Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

O&G > Chronic Gynae > Flashcards

Chronic Gynae Flashcards

1
Q

What is menopause, who does it affect and why does it occur?

A

Absence of menses for >12 months (retrospective diagnosis)
Average age = 51y, but can be 45-55y. If <40 then –> POI

Due to the depletion of oocytes –> reduction in ovarian production of progesterone, oestradiol and testosterone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How may a woman undergoing the menopause present? How many women get Sx?

A

note: approximately 75% women get symptoms, and these can last for around 7 years

Sx:

  • Persistent amenorrhoea (often initial oligomenorrhoea and/or shortened cycles)
  • Vasomotor symptoms –> hot flushes, night sweats, palpitations
  • Urogenital - vaginal dryness, dyspareunia, frequency, dysuria, recurrent UTI
  • Psychological - tiredness/lack of sleep, mood disturbances/swings, reduced libido (these present first)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What investigations would you do in a woman with suspected menopause?

A

Ix:

  • Clinical diagnosis so no further Ix required if symptoms fit the picture
  • Pregnancy test as amenorrhoea in sexually active woman
  • if under 45 or POI then can do FSH/oestradiol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How would you manage a patient with the menopause? What is important when counselling treatment? What are CI to HRT?

A

Mx: Firstly do they have a uterus?

  • Yes –> Oestrogen+Progesterone treatment to protect against endometrial carcinoma
  • No –> systemic oestrogen (oral/implant) but think about CI such as DVT (other options are transdermal/topical)

1st line: LIFESTYLE CHANGES

  • weight loss (for flushes)
  • exercise (light = yoga, aerobic = running, swimming, walking) but NOT late at night
  • alcohol, caffeine (vasomotor) and stress reduction
  • sleep hygiene - reducing blue light exposure before bed, good wind down routine, relaxation techniques

2nd line: HRT

Oestrogen alone (Elleste Solo) - only in post-hysterectomy 1

  • Oral Oestrogen (standard tx)
  • Transdermal patch (if BMI>30 due to lower VTE risk)
  • Can also get oestrogen only combined with a Mirena coil

O+P (Elleste Duet)
- Oral, Implant, Transdermal, vaginal creams/gel (last 2 have reduced clot risk)

CYCLICAL pattern (peri-menopausal) =

  • -> Monthly (for those with regular periods and menopause symptoms): oestrogen everyday of the month with progesterone in last 14 days
  • -> 3-monthly (for those with IRRegular periods and menopause symptoms): oestrogen everyday for 3 months and progesterone for last 14 days
CONTINUOUS pattern (post-menopausal)
---> Oestrogen + Progesterone everyday

absolute CI:

  • Hx of VTE
  • undiagnosed vaginal bleeding
  • pregnancy
  • prev breast cancer
  • severe liver disease
  • current thrombophillia

OTHER THERAPIES:

  • Vasomotor Sx –> SSRIs i.e. fluoxetine (1st line) –> citalopram, venlafaxine –> gabapentin, alpha agonists such as clonidine but many anti-ach side effects
  • Vaginal dryness - lubricants/gels
  • Oesteoprosis treatments e.g. bisphosphonates

COUNSELLING:

  • If <60 then HRT is definitely beneficial i.e. in POI ensure you stress this!
  • Acts to improve symptoms (vasomotor, libido) and also protects against CVD and osteoporosis
  • HRT best effects when started within 10y
  • O+P have small increase in breast cancer, O alone = risk of endometrial
  • Transdermal O with micronised P looks to be the optimal treatment especially for CVD patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the benefits of HRT? What are the risks of HRT?

A

benefits of HRT = improved menopause symptoms (vasomotor, sleep + UG sx), prevention of osteoporosis

risks of HRT = combined–> breast cancer, Oes= breast and endometrial cancer; VTE (2-4x higher - 2/1000 people taking HRT in 7.5y)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the SE’s of HRT?

A

SE =

  • breast tenderness
  • nausea
  • headaches (oestrogenic)
  • fluid retention
  • mood swings, depression (progestognenic)
  • unscheduled vaginal bleeding (common in 1st 3 months of HRT) more so in sequential HRT but Ix if continues after 6mo OR after a spell of amenorrhoea)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What else must women experiencing the menopause also take?

A

Contraception requirement until 1y amenorrhoeic if 50+, 2y amenorrhoeic if <50.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is dysfunctional uterine bleeding (DUB)? Who does it affect and what are some RFs? What are the 2 types?

A

Abnormal uterine bleeding in the absence of organic pathology

  • Affects ~10% women
  • Res = extremes of reproductive age, obesity

Types:

  • Anovulatory (90%) - failure of follicular development –> no increase in progesterone –> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation –> cyclical heavy bleeding
  • Ovulatory (10%) - prolonged progesterone secretion –> irregular shedding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How may women with DUB present? What are some causes of DUB?

A

Sx:

  • Bleeding - IMB, dysmenorrhoea (painful periods), menorrhagia (as quantified by pt)
  • Signs+sx of anaemia
  • Signs+sx of cause e.g. relation to menstrual cycle, fertility issues, compression symptoms, cervical screening Hx…

Causes can be remembered by PALM COEINS

  • Polyps
  • Adenomyosis
  • Leiomyoma
  • Malignancy
  • Coagulopathy - vWD
  • Ovulation - PCOS, hypothyroid
  • Endometriosis
  • Iatrogenic
  • Not classified
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What Ix would you do in a patient with DUB?

A

Ix:

  • Full Hx and exam (anaemia signs or of cause)
  • Bimanual examination (e.g. bulky, fibroids)
  • Speculum examination (e.g. cervical ectropion) - NOTE if menorrhagia with no other related symptoms e..g persistent IMB, pelvic pain or pressure sx, then consider treatment without examination)
  • Bloods - FBC, TFTs, clotting screen if primary menorrhagia or FHx
  • 2nd line = TVUSS (PCOS, fibroids, malignancy)
  • 3rd line = OPD hysteroscopy or laparoscopy +/- biopsy for endometriosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How would you manage DUB?

A

Mx:
- If no identified pathology/ fibroids <3cm/ suspected/diagnosed adenomyosis

1st line
= If contraception required (hormonal) then LNG-IUS Mirena but may not be possible in large fibroids distorting uterus

2nd line
= If fertility required/1st line declined or unsuitable then:
–> BLEED Sx = Tranexamic acid 1g TDS (CI in renal impairment or thrombotic disease)
–> PAIN = Mefenamic acid NSAIDs (CI in IBD)
OR Contraception required
–> COCP
–> Cyclical oral progestogens e.g. Norethisterone 5mg TDS for 10d if bleeding acutely but when you stop taking, it causes a heavy bleed

Surgical

  • Endometrial ablation - will require continued contraception
  • Hysterectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is endometriosis and who does it affect? What are RFs for it?

A

Presence and growth of endometrial tissue outside of the uterus

  • Affects 1/10 women of reproductive age, mainly ~30-45y
  • RFs = early menarche, FHx, nulliparity, prolonged menstruation (>5d), short menstrual cycles
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are some cancer associations with endometriosis? What is Sampson’s theory?

A

Clear cell ovarian carcinoma&raquo_space;> endometrioid ovarian carcinoma

Sampson’s theory = endometriosis arises due to the retrograde flow of menstruation and implantation, with spill of endometrial cells on to the ovary and other sites in the pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How may women with endometriosis present?

A

Sx:

  • Cyclical or chronic pelvic pain occurring before or during menstruation = dysmenorrhoea (but no menorrhagia as this indicates more -> fibroids)
  • [Deep] dyspareunia
  • Dyschezia (pain on defecation)
  • Subfertility
  • Sx of extra-uterine endometriosis i..e rectal pain, bleeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How would you Ix a woman with suspected endometriosis? What is diagnostic?

A

Ix:

  • Bimanual and speculum examination = reduced mobility, tender nodularity in posterior vagial fornix
  • TVUSS = may show endometriomas
  • Diagnostic laparoscopy is GOLD STANDARD = red vesicles or punctate marks on peritoneum indicate active lesions, white scars and brown spots show less active endometriosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How would you manage endometriosis?

A

Mx - can initiate if clinical examination/TVUSS is normal (no need for laparoscopy) but if no symptomatic relief in 3-6m, then DL should be undertaken

1st line = 3m trial of paracetamol +/- NSAIDs (inhibit PG synthesis which cause pain)

  • avoid opiates due to often co-existing constipation
  • can add TXA adjunct

2nd line = 3m trial of COCP or progesterone (POP, implant, injectable or LNG-IUS)

  • provides cycle control and contraception whilst alleviating symptoms of endometriosis (take for 21d, 7d off OR tricycle)
  • progesterone induces amenorrhoea in those where COCP is contraindicated

2nd line (surgical) = laparoscopic ablation (mild endometriosis superficially) or hysterectomy with BSO (radical surgery)

  • ablation has a high recurrence rate of 30% so supplement with COCP
  • GnRH e.g. leuprorelin can induce a ‘pseudo-menopause’ used to shrink endometriosis in approach to surgery however don’t use for over 6m as inhibits oestrogen release (osteoporosis risk + menopause SEs)
  • If presenting with sub fertility = laparoscopic ablation +/- endometrioma cystectomy and no hormonal treatment if trying to conceive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are complications of endometriosis?

A
  • Subfertility

- Co-existing conditions e.g. IBS and constipation (up to 80%) should also be treated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the difference between primary and secondary dysmenorrhoea?

A

Primary - cramping pain during or just before menstruation, onset in ADOLESCENCE, ~90% incidence

Secondary - painful menstruation due to recognised pathology e.g. endometriosis

19
Q

What are fibroids and the 3 types? What 3 changes can they undergo? What are some i) RFs? ii) protective factors?

A

Fibroids are benign tumours arising from the myometrium (leiomyoma). Types:

  • Submucosal
  • Intramural
  • Subsclerosal

Changes they undergo:

  • > Hyaline degeneration
  • > Calcification (post-menopausal)
  • > Red degeneration - coagulative necrosis in pregnancy

RFs = ‘BONE’ = black women (+/- FHx), obesity, nulliparity and expecting (pregnancy)

Protective = smoking, grand multiparity, COCP

20
Q

How do fibroids grow? How common are they? How may women present with fibroids?

A

Hormone dependent growth - contain many oestrogen and progesterone receptors and so enlarge during pregnancy (+shrink in menopause)
- Affects 1/3 women of reproductive age

Sx:

  • Asymptomatic
  • May have palpable pelvic masses, uterine enlargement
  • DUB
  • Miscarriage, sub-fertility
  • Abdominal swelling, pressure symptoms on bowel and bladder
21
Q

How would you Ix suspected fibroids?

A

Ix:
- Similar to DUB investigations:

  • Full Hx and exam
  • Bimanual examination (e.g. bulky, fibroids)
  • Speculum examination (e.g. cervical ectropion) - NOTE if menorrhagia with no other related symptoms e..g persistent IMB, pelvic pain or pressure sx, then consider treatment without examination)
  • Bloods - FBC, TFTs, clotting screen if primary menorrhagia or FHx
  • 1st LINE = TVUSS
  • OPD hysteroscopy if >4mm when not expected
22
Q

How would you manage fibroids?

A

Mx:
-> TVUSS: No pathology identified/ fibroids <3cm or suspected adenomyosis then DUB Mx

Fibroids >3cm:

  • 1st line non-hormonal (not contraceptive)
  • -> TXA 1g TDS (CI in renal impairment and thrombotic disease)
  • -> Mefenamic acid/NSAIDs (CI in IBD)
  • 1st line hormone (contraceptive)
  • -> COCP
  • -> Cyclical oral progestogens

Other/Surgical/radiological treatment:

  • > Injectable GnRH agonists short-term to shrink fibroids but stops oestrogen production (menopause SEs such as vaginal dryness, hot flushes, sweating and osteoporosis). Usually used before surgery
  • > Ulipristal acetate OD short-term (6m) to shrink fibroids and reduce bleeding. Not as effective as GnRH agonists but doesn’t induce menopausal state but not widely used clinically and long-term use associated with liver injury
  • > Transcervical resection of fibroids - surgery for small submucosal or polypoid
  • > Myomectomy - best for improving fertility, may be open or laparoscopic. Power morcellation used to shrink fibroids for removal. More likely to require CS for birth in future due to uterine rupture and small risk of big bleed
  • > Hysterectomy
  • > Endometrial ablation
  • > Radiological uterine artery embolisation - can preserve fertility but risk of ovarian failure, embolises both uterine arteries to infarct fibroids. As effective as myomectomy for alleviating fibroid DUB and pressure Sx
23
Q

What are the complications of fibroids? What syndrome is associated with leiomyosarcomas?

A
  • > Pregnancy:
  • Red degeneration during pregnancy (low fever, vomiting :Mx is conservative and resolves in 4-7d)
  • Miscarriage, malpresentation and transverse lie, PTL, PPH
  • > 10y recurrence rate after myomectomy is 20%
  • > After menopause fibroids regress and calcify
  • > Risk of very rare cancer, leiomyosarcoma, is <1/100,000 - associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)
24
Q

What is a urogenital prolapse and 5 different types? Who does it affect and what are some RF’s?

A

Descent of the pelvic organs, caused by weakness of pelvic floor muscles
Types:
-> Uterine: prolapse of the uterus into the vagina
-> Cystocele: prolapse of the anterior vaginal wall involving the bladder
-> Rectocele: prolapse of the lower posterior vaginal wall involving the anterior wall of the rectum
-> Enterocele: prolapse of the upper posterior vaginal wall containing loops of small bowel
-> Vault prolapse: prolapse of the vaginal vault after hysterectomy

Affects 30-50% women aged 50+ years
- 9.3% incidence of pelvic organ prolapses

RF’s:

  • Increasing age
  • Parity
  • Menopause
  • Pelvic surgery
  • Heavy lifting, chronic cough, high impact sports
  • Spinal cord injury, muscular atrophy
25
Q

How may women with urogenital prolapses present?

A

Sx:

  • Feelings of heaviness of descent PV
  • Recurrent UTI
  • Back pain
  • Dysparaeunia
  • Urinary symptoms if cystocele (FUNDHIPS)
26
Q

What are some grading systems associated with urogenital prolapse? How would you Ix it?

A

Grading:

  • POP-Q = NICE reccomended, uses anatomical landmarks in relation to the hymen
  • Shaw’s = more commonly used, looks at extent of prolapse, 1st degree is descent into the introitus, 2nd is extends to the introitus but descent past the introitus on straining and 3rd is prolapse past through the introitus
  • Baden-Walker = similar to Shaw’s but uses the hymen as a reference point

Ix:

  • Examination and Speculum for grading and severity
  • MC&S for urine infections
  • Uroynamics testing (incontinence)
27
Q

What is the Mx of urogenital prolapse? How may you counsel patients (PACES)?

A 
Mx:
1st line/asymptomatic = conservative
-> Weight loss
-> Minimise weight lifting and stop smoking
-> Treat constipation
-> +/- Pelvic floor exercises (16w)

2nd line/symptomatic

  • > Pessary (ring, shelf and gellhorn -> Gehrung -> cube pessaries for advanced prolapses + f/u to see if improvement (ring changed every 6m)
  • > Topical oestrogen, if vaginal erosion occurs and remove ring until healed
  • > SE’s = unpleasant discharge, irritation, UTI, interference with sex (sex is not possible with a shelf pessary)

3rd line/surgery:

  • > Vault prolapses = sacrocolplexy (+mesh)
  • > Anterior/posterior prolapse = anterior/posterior colporrhaphy
  • > Uterine prolapse = hysterectomy or sacrospinous hysteropexy

PACES:

  • > Explain what has happened - organs descended down due to poor pelvic muscle strength -> RFs/common in women over 50, obesity and multiparty, heavy lifting
  • > Explain conservative managements (WL, smoking cessation, no lifting, pelvic floor exercise)
  • > Explain ring pessary
28
Q

What are 5 types of incontinence and their aetiology and how may they vary in their history?

A

Incontinence:

  • Stress [commonest] = increased pressure on the bladder causing small losses of incontinence (e.g. laughing, coughing) - weakness of pelvic floor and sphincter muscles
  • Urge = strong urge to urinate and often accidents occur (large losses) - overactivity of detrusor muscle/overactive bladder
  • Mixed = 2/+ types; often stress and urge together
  • Overflow = difficulty emptying bladder –> filling and then incontinence
  • Functional = can’t get to the toilet in time e.g. mobility issues
29
Q

How would you investigate incontinence in a female?

A

Ix:

  • Speculum: exclude pelvic organ prolapse - ask patient to cough and assess any fluid leakage
  • Bimanual: squeeze against fingers = ability to contract muscles (Kegel exercises) +
  • 1st line = urine dipstick, urine MC+S to rule out DM and UTI
  • 1st line = Bladder diaries for at least 3d
  • 2nd = urodynamic testing (if mixed incontinence) where 3 pressures are measured from inside rectum and urethra
30
Q

What are some RFs for incontinence?

A

Stress:

  • Age, post menopausal
  • Birth
  • Traumatic delivery
  • Pelvic surgery
  • Obesity

Urge:

  • Age, post menopausal
  • Smoking
  • Obesity
  • FHx
  • DM
31
Q

How would you manage stress incontinence?

A

Mx:

  • > May require specialist referral
  • > 1st = lifestyle advice: reduce caffeine and alcohol intake, WL if BMI > 30 and pelvic floor exercises (8 contractions, 3x a day for 3m; can be referred to physio for this). Consider if any medications are worsening e.g. diuretics
  • > 2nd line = surgical treatment or Duloxetine, SNRI. Surgery includes Burch colposuspension or rectus fascial sling
32
Q

How would you manage urge incontinence? What are some CIs for these options?

A

Mx:

  • > May require specialist referral
  • > 1st = lifestyle advice: Reduce caffeine and alcohol intake, WL if BMI > 30.
  • BLADDER RETRAINING for 6w progressively hold off going to the toilet. Also avoid fizzy drinks as carbonic acid can stimulate detrusor, and control DM well. Consider if any medications are worsening e.g. diuretics
  • > 2nd line = antimuscarinic drugs such as darfienacin, oxybutinin and tolterodine (DOT), or ADH analogues (desmopressin)
  • -> Notify of SEs i.e. dry eyes and mouth, constipation, retention. Also risk of cognitive decline and memory problems
  • -> Do NOT give oxybutynin to old, frail women as increased fall risk
  • -> DO NOT give in patients with closed angle glaucoma
  • > 3rd line = Mirabegron (b3 agonist), used if concerns about using anticholinergics in older, frail women
  • -> BUT contraindicated in uncontrolled HTN
  • > 4th line = surgery (botox injection, sacral nerve stimulation, urinary diversion and augmentation cystoplasty
  • -> However, if want botox, there is a ~10% risk of OVER-relaxing the muscles and so can cause retention. Therefore, women must be willing to learn how to empty their bladder themselves (self-catheterisation). Lasts about 6m.
33
Q

How would you manage overflow incontinence?

A

OVERFLOW Mx:

  • Due to difficulty emptying bladder/obstruction
  • Referral to specialist urogynaecologist
  • 1st line = timed voiding
34
Q

What cause would you suggest in a woman with a Hx of prolonged labour presenting with dribbling incontinence? How would you confirm this?

A

Dribbling incontinence post-prolonged labour would suggest a vesico-vaginal fistula
–> Ix: urinary dye studies

35
Q

How would you counsel a patient with urinary incontinece?

A

PACES:

  • > Explain diagnosis and RFs (i.e if stress: weak muscles OR urge: overactive bladder)
  • > Explain conservative management - lifestyle measures such as avoiding caffeine, alcohol, smoking, WL if applicable, controlling fluid intake
  • > Explain first line Mx = pelvic floor exercises for 3m (stress) or bladder diary and retraining for 6w + gradually inc time in-between going to the toilet (urge)
  • > Explain other options such as medicines and surgical options
36
Q

What is PCOS and how may it present in women? How common is it?

A

Common metabolic and reproductive condition in females characterised by the presence of 2 of the following triad [Rotterdam criteria]

  • > Oligovulation/Anovulation (>2y - infrequent, irregular cycles or absence)
  • > Hyperandrogenism (biochemical or clinical i.e. acne, hirsutism)
  • > Polycystic ovaries on USS (12+ in at least 1 ovary measuring 2-9mm or >10cm^3 ovarian volume)

Sx:

  • > Amenorrhoea/Oligomenorrhoea
  • > Hirsuitism (growth of thick hair in a traditionally male pattern - face, upper lips, lower abdomen)
  • > Subfertility
  • > Weight gain (obesity in ~70%)
  • > Acne
  • > Insulin resistance (acanthosis nigricans), CVD, hyperlipidaemia
37
Q

Why do PCOS patients get insulin resistance? Why does this make their symptoms worse? How can the insulin resistance be treated?

A

Androgens may worsen insulin resistance in PCOS patients - + means they must produce more insulin to achieve the same response

Insulin promotes androgen release from the ovaries and adrenal glands –> higher androgen/testosterone levels
Insulin also suppresses SHBG production in the liver, therefore enabling more free androgens to circulate.

This therefore worsens the hyperandrogegism in PCOS patients
The raised insulin also contributes to stopping follicle development in the ovaries –> an ovulation and multiple partially developed follicles seen on USS

Tx: Diet, weight loss and exercise

38
Q

How would you investigate suspected PCOS?

A

Ix:
[NICE recommends the following bloods to diagnose PCOS and rule out other conditions]

  • Bloods = Testosterone, SHBG, LH, FSH, Prolactin (may be mildly raised) and TSH –> RAISED LH and RAISED LH:FSH ratio (2-3 :1), raised testosterone and insulin with normal/raised oestrogen levels
  • Pelvic TVUSS –> often has a ‘string of pearls appearance’ with either 12/+ ovarian follicles in 1 ovary OR ovarian volume >10cm3
    NOTE: USS isn’t reliable in adolescents for the diagnosis of PCOS

ALSO:

  • OGTT at diagnosis for those BMI 25/+, non-caucasian and if >40, FHx DM/GDM and DM monitoring
  • CVD monitoring (lipid profile, BP, diet/exercise/WL)
39
Q

How would you generally manage PCOS?

A

General Mx:

  • aims to reduce risks associated with T2DM, obesity, CVD and hypercholesteraemia
  • > Weight loss*
  • > Low GI, calorie controlled diet
  • > Increased exercise
  • > Smoking cessation
  • > Antihypertensives and statins where indicated (e.g. Q-risk over 10%)
  • > Monitoring for complications such as endometrial hyperplasia and cancer, infertility, acne, OSA, depression/anxiety

*Weight loss is a significant part of management of PCOS - can actually result in ovulation, restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and risks of other conditions

40
Q

How would you specifically manage i) anovulation in PCOS ii) infertility iii) hirsutism iv) acne ?

A

I) Anovulation
- Increased risk of endometrial hyperplasia and cancer as PCOS women don’t produce enough progesterone and so lining isn’t shed
[alr increased risk due to obesity, DM and insulin resistance]

Mx:
–> Women with extended gaps between periods (>3m) or abnormal bleeding should have a pelvic USS to assess endometrial thickness. Cyclical progestergens should be used to induce a period PRIOR to the USS. IF >10mm then they are
referred for a biopsy
Reducing EH/EC risk:
–> Mirena coil for continuous endometrial protection
–> Cyclical progestogens or COCP to induce a withdrawal bleed every 3-4m

ii) Infertility
1) Weight loss is the initial step (if applicable)

Specialists may initiate next options:
2) Clomiphene (+Metformin after 3 failed clomiphene cycles; SERM)
3) Surgery - Laparoscopic ovarian drilling [diathermy/laser holes in ovaries to help hormonal profile]
- IVF, gonadotrophin (risk of ovarian hyperstimulation syndrome or OHSS = pain and bloating)
[Metformin and letrozole may be useful but evidence not clear]

iii+iv) Hirsutism and acne

Acne = COCP 1st line (but increased VTE risk)
Other = topical adapalene (retinoids), Abx (Clindamycin 1%), azelaic acid 20% and oral tetracycline

Hirsutism =
–> Weight loss may improve symptoms
–> Co-cyprindiol (Dianette) is a COCP licensed for hirsutism and acne treatment which has an anti-androgenic effect
However, due to VTE risk it is stopped after 3m of use
–> Topical eflornithine (takes 6-8w to see an improvement, hirsutism returns within 2m of stopping cream)
–> Other options reccoemnded by specialists include laser hair removal, electrolysis, finasteride (5-a reductase inhibitor) etc

41
Q

What are the complications of PCOS?

A

Complications:

  • Metabolic syndrome (DM, cholesterol)
  • Cardiovascular disease
  • Obstructive sleep apnoea
  • Endometrial hyperplasia and cancer
  • Subfertility/infertility
42
Q

What is POI and how common is it? What are some causes? How does it present?

A

POI = premature ovarian insufficiency
-> Affects 1% of women (FHx is a risk factor)

Onset of menopause before the age of 40 years

Causes:

  • > Idiopathic
  • > AI/Unknown (Addison’s disease - autoantibodies, coeliac, T1DM, thyroid disease associations)
  • > Iatrogenic e.g. Oopherectomy
  • > Genetic (FHx)
  • > Infections (mumps, TB or CMV)

Presents:
[Menopause Sx]
- Secondary amenorrhoea
- Vasomotor sx = hot flushes, sweating/night sweats, palpitations, headaches
- Urogenital = Dyspareunia, dryness, frequency, dysuria, recurrent UTI
- Psychological = poor concentration, lethargy, mood disturbance reduced libido (these Sx present first)

43
Q

How would you Ix suspected POI?

A

Ix:

  • Pregnancy test!
  • Bloods - LH, FSH (will be high, unopposed), low estradiol [others = prolactin, TFTs)
  • TVUSS - endometrial/ovarian cancer

NICE Dx requires =

  • > age <40
  • > typical menopause symptoms
  • > elevated FSH (>25 IU/L on 2 consecutive samples, separated by more than 4w)
44
Q

How would you manage POI? How would you manage fertility complications associated with POI?

A

Mx:
HRT is very important, if they have concerns ensure to emphasise thats more for older women but as younger there are more risks/longer (CVD, osteoporosis, stroke, dementia/parkinsonism)
-> HRT reduces all these risks above, but small risk of pregnancy still so still need contraception
-> HRT recommended until at least normal age of menopause
-> ALSO, HRT before age 50 is not considered to increase breast cancer risk compared to general population [note for menopause, only small risk if u take combined, oestrogen only has no inc risk)
-> Increased risk of VTE but can use transdermal options which have a reduced risk (avoid immobility etc)

  • IF do have a womb, then consider combined progertone and oestrogen HRT or COCP (COCP also acts as contraception but traditional associated with lower BP)
  • IF have NO womb, then consider oestrogen-only (wary of risks of EC, VTE etc)

Fertility options:

  • Donor oocyte IVF - or surrogacy and adoption
  • Only 5-10% POI women can get pregnancy without fertility treatment

O&G (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions