Clinical Flashcards
what is primary amenorrhoea ?
failure to start menstruating. it needs investigation in a 16-year old, or in a 14 year old who has no signs of puberty
what is secondary amenorrhoea?
this is when periods stop for >6 months other than due to pregnancy. occurs after periods were previously occuring.
what is oligomenorrhoea?
infrequent periods - common at the extremities of reproductive life when regular ovulation often does not occur
what is menorrhagia?
excessive menstrual blood loss -
what is dysmenorrhoea?
painful periods (+/- nausea or vomiting)
primary dysmenorrhoea - pain without organ pathology - often starting with anovulatory cycles after the menarche
secondary dysmenorrhoea - pain with associated with pathology e.g. adenomyosis, endometriosis, pelvic inflammatory disease
what is intermenstrual bleeding?
vaginal bleeding (other than postcoital) at any time may follow after a mid-cycle fall in oestrogen production
what is postcoital bleeding?
non-menstrual bleeding that occurs immediately after sexual intercourse
causes: cervical trauma, polyps; cervical, endometrial and vaginal carcinoma and vaginitis
what is postmenopausal bleeding?
bleeding occuring >1yr after the last period.
what is the main cause of postmenopausal bleeding?
endometrial carcinoma - always this unless proven otherwise
what are the causes of inter menstrual bleeding?
pregnancy related
hormonal contraception
infection: chlamydia and PID
cervical ectropian, polyps and carcinoma
what are other causes of postmenopausal bleeding?
oestrogen withdrawal
atrophic vaginitis
cervical polyps
cervical malignancy
endometrial polyps
what are the causes of primary amenorrhoea?
1.Physiological causes:
Constitutional delay — no anatomical abnormality
Pregnancy
2.Genito-urinary malformations:
Imperforate hymen - cyclical pain
Transverse septum.
Absent vagina or uterus.
3.Endocrine disorders:
Hypothyroidism.
Hyperthyroidism.
Hyperprolactinaemia
Cushing’s syndrome.
Polycystic ovary syndrome (a rare cause of primary amenorrhoea).
Androgen insensitivity syndrome (rare, previously known as ‘testicular feminization’).
4.Causes of primary amenorrhoea in those with no secondary sexual characteristics (such as breast development) include:
Primary ovarian insufficiency (POI) due to:
Chromosomal irregularities (for example Turner’s syndrome [46XO] and gonadal agenesis [46XX or 46XY]).
5.Hypothalamic dysfunction due to:
Stress, excessive exercise, and/or weight loss
- Chronic systemic illness (such as uncontrolled diabetes, severe renal and cardiac disorders, coeliac disease, cancer, and infections [for example tuberculosis]).
- Causes of ambiguous genitalia:
5-alpha-reductase deficiency.
Androgen-secreting tumours.
Congenital adrenal hyperplasia.
what are the causes of secondary amenorrhea
1.hypothalamic-pituitary ovarian causes: most common
mainly causes by stress, increase in exercise and weightloss
- The female athlete triad : low energy availability menstrual dysfunction, and low bone density e.g. athletes - 40% of female athletes have amenorrhoea
2. physiological causes:
pregnancy
lactation
menopause
- hyperprolactinaemia - 30% have galactorrhoea
- severe systemic disease e.g. renal failure, thyroid disease, pituitary disease and haemochromatosis
- Polycystic ovarian syndrome - common
how do you diagnose amenorrhea?
Examine:
- Measure height and body weight, and calculate body mass index (BMI) for weight-related causes of amenorrhoea
- Turner’s syndrome features (short stature, web neck, shield chest with widely spaced nipples, wide carrying angle, and scoliosis).
- Features of Cushing’s syndrome features (striae, buffalo hump, significant central obesity, easy bruising, hypertension, and proximal muscle weakness).
- Hirsutism and acne (suggesting PCOS, especially in those with a high BMI).
testing
- βhcg e.g. urinary - excludes pregnancy
- FSH/LH - will be low in hypothalamic-pituitary causes but may be normal if weight loss or excessive exercise is the cause. will be raised
- Prolactin - increased by stress, hypothyroidism,prolactinomas and drugs
- Genetics - karotyping for turners
- Thyroid function tests
- tesosterone level - will be raised in androgen secreting tumor
Imaging:
MRI head for suspected pituitary tumour
how do you manage amenorrhea?
- manage the underlying cause
- lifestyle changes - applies to secondary amenorrhea caused by weight loss, excessive exercise, stress, or chronic illness
- contraception pills - as ovulation may occur at any time
- assisted conception if she wants to be pregnant
- manage risk for osteoporosis:
For women with premature ovarian failure (younger than 40 years of age), hypothalamic amenorrhoea, or hyperprolactinaemia (women with amenorrhoea associated with low oestrogen levels who are at increased risk of developing osteoporosis):
Treat the underlying cause, if possible.
Assess their fragility fracture risk.
Advise maintaining a healthy lifestyle to optimize bone health. This involves doing weight-bearing exercises, avoidance of smoking, eating a balanced diet, and maintenance of normal body weight.
Correct vitamin D deficiency, and ensure an adequate calcium intake.
Consider offering hormone replacement therapy (HRT) or the combined oral contraceptive (COC) pill (both off-label use) if amenorrhoea persists for more than 12 months.
what is polycystic ovarian syndrome (PCOS)?
consists of:
hyperandrogenism
oligomenorrhoea
polycystic ovaries on Ultrasound
cause is unknown
what is polycystic ovarian syndrome associated with?
obese
metabolic syndromes - hypertension, dyslipidaemia, insulin resistance, and visceral obesity
higher prevalence of T2DM and sleep apnoea
how do you diagnose Polycystic ovarian syndrome?
Rotterdam criteria (2 out of 3 must be present) :
- polycystic ovaries (12 or more follicles or ovarian volume >10cm3 on US)
- oligo-ovulation or anovulation
- clinical and/or biochemical signs of hyperandrogenism
same diagnosis as amenorrhea
imaging - pelvic ultrasound
oral glucose tolerance - for T2DM
fasting lipid panel
how do patients with PCOS present?
oligomenotthea with or without hirsutism, acne and subfertility
How do you manage PCOS?
Lifestyle management - weight loss and exercise are the mainstay of treatment and increase insulin sensitivity (metformin).
encourage smoking cessation
monitor + manage for - diabetes, hypertension,dyslipidaemia and sleep apnoea
fertility management:
clomifene citrate - induces ovulation
metformin as an alternative to clomifene- may improve menstrual disturbance and ovulatory function but does not have a significant on hirsutism or acne
use ovarian drilling if patient is not reacting to clomifene
gonadotrophins
IVF
hirsutism - treated cosmetically or with antiandrogen e.g. cyproterone
what are the causes of menorrhagia
- dysfunctional uterine bleeding (DUB) - heavy/ irregular bleeding without the absence of recognizable pelvic pathology - diagnosis of exclusion
- IUCD
- fibroids
- endometriosis
- adenomyosis
- pelvic infection
- polyps
- hypothyroidism
- coagulation disorders
- increasing age
- cooper coil
- endometrial cancer
what are the signs and symptoms of menorrhagia?
heavy prolonged vaginal bleeding
often worse at the extremes of reproductive life
dysmenorrhoea
symptoms of anaemia, pallor
enlarged uterus - suggests fibroids or adenomyosis
how do you diagnose menorrhagia?
exclude pregnancy
PV exam
Bloods: FBC, TFT, LFT, coagulation screen
Imaging:
US first line
hysteroscopy and endometrial sampling
how do you manage menorrhagia?
fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
A LNG-IUS - first-line treatment e.g. mirena IUS
- pharmacological treatment should be considered: non-hormonal
tranexamic acid
nonsteroidal anti-inflammatory drug
hormonal
combined hormonal contraception
cyclical oral progestogens
- Secondary care treatment : pharmacological options not already tried, uterine artery embolization,
surgery
myomectomy
hysterectomy
second-generation endometrial ablation
what is premenstrual syndrome (PMS)?
condition which manifests with distressing physical, behavioral and psycho social symptoms in the absence of organic or psychiatric disease, regularly occuring during the luteal phase of the menstrual cycle.
significant improvement by the end of menstrual cycle
what are the signs and symptoms of PMS?
mood swings
irritability
depression
bloating
breast tenderness
headache
reduced
visuospatial ability
increase in accidents
how do you diagnose PMS?
physical examinatio indicated by the woman’s age and routine gynaecological and medical recommendations
patient record daily symptom diary for two or three cycles
how do you manage PMS
1. Offer lifestyle advice that includes: Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates. Regular exercise. Regular sleep. Stress reduction. Smoking cessation (if applicable). Alcohol restriction (if applicable).
- if the predominant symptom is pain (for example headache or generalized aches and pains), prescribe a simple analgesic
- For women with moderate PMS symptoms:
Consider prescribing a new-generation combined oral contraceptive (COC)
CBT
- for women with severe PMS:
Consider prescribing a selective serotonin reuptake inhibitor (SSRI)
what is the menopause?
time of waning fertility leading up to the last period.
it is a retrospective diagnosis having said to have 12 months after the last perioid
average age is 52 yrs
what is peri-menopause?
transition phase from pre to post menopausal and the time in which symptoms are experienced.
what are the symptoms of menopause?
- Hot flushes/night sweats (vasomotor symptoms)
- Cognitive impairment and mood disorder
- Urogenital symptoms (genitourinary syndrome of menopause)
- Altered sexual function
- Sleep disturbance
- atropy of oestrogen- dependent tissues (genitalia, breasts) and skin
- vaginal atrophy - atrophic vaginitis
- osteoporosis
- increased risk of cardiovascular and cerebrovascular disease
how do you diagnose the menopause?
- clinical
2. investigation 2 consecutive: FSH level (more than 30 IU/L)
how do you manage the menopause?
- diet and exercise can relieve symptoms
- Hormone replacement therapy (HRT)
- vaginal dryness - oestrogen cream
- menorrhagia responds to mirena coil
what are the main routes of administration of Hormone replacement therapy?
- oral
- transdermal patch
- injection
- intra uterine (mirena)
- intra vaginal (pessary ring)
when do you prescribe oestrogen only HRT?
Oestrogen-only preparations are given to women without a uterus
unopposed oestrogen is a risk factor for endometrial cancer
when do you prescribe combined HRT?
combined oestrogen and progestogen preparations are given to women with an intact uterus
routes - oral, patch, mirena coil
what type of HRT do you prescribe for women who are having periods, or who are 12 months of a period? (perimenopausal)
Oestrogen and cyclical progestogen
what type of HRT do you prescribe for postmenopausal woman ?
monthly or 3-monthly cyclical regimens, or a continuous combined regimen may be used.
what are the adverse effects of HRT?
Oestrogen-related adverse effects: Fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, dyspepsia, oestrogen-dependent cancer
Progestogen-related adverse effects: Fluid retention, breast tenderness, headaches or migraine, mood swings, premenstrual syndrome-like symptoms, depression, acne vulgaris, lower abdominal pain, and back pain.
Venous thromboembolism (VTE)
Vaginal bleeding problems - common
dementia
endometrial cancer - risk only seeen in use of oestrogen only in women
what are the benefits of HRT?
- reduction of vasomotor symptoms
- improvement in urogential symptoms and sexual
- reduced risk of colorectal cancer
- prevention and treatment of osteoporosis
what is the latest date for a termination?
24 weeks unless for medical reasons
what are the 2 main common grounds for termination of pregnancy?
• CLAUSE C – up to 23+6 weeks “the pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”
• CLAUSE E – no gestational limit “there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped”
can a doctor refuse to carry out an abortion?
yes, HCPs the right to refuse to participate in abortion care
however it Limits are:
• Does not apply in emergency or life-threatening situations
• Should not delay or prevent a patient’s access to care
• Does not apply to ‘indirect’ tasks associated with abortion e.g. administrative,
supervision of staff etc
how do you carry out medical termination?
<9 weeks:
vaginal misoprostol only - prostaglandin analogue
advise them to contact doctor if bleeding hasn’t started in 24 hrs
what document certifies a termination and who signs it?
Certified on HSA1 form
(“Certificate A”) - 2 doctors sign
what categories of medical termination are there?
early - <9weeks
Late 9-13 weeks
mid trimester/late 13-24
how do you assess termination of pregnancy?
Clinical
• Estimated by LMP +/- date of +ve UPT
• Palpable uterus ( > 12 wks)
Ultrasound • Abdominal or transvaginal (< 6wks) • Frequently used for all pre-COVID • Now via risk assessment (~1/3) • Symptoms or risk factors for ectopic • Uncertainty about dates • Before STOP in some areas
how is surgical method of termination of pregnancy is carried out?
Removal of pregnancy via surgical procedure (under anaesthesia)
• Cervical priming via misoprostol or osmotic dilators
< 14wks
• Electric vacuum aspiration (GA)
• Manual vacuum aspiration (up to 10wks; LA)
> 14wks
• Dilatation and evacuation
what are the contraindications of abortions?
Haemorrhage +/- blood
transfusion
Failed/incomplete
abortion
Infection
Uterine perforation
(surgical risk only)
Cervical trauma (surgical risk only)
where are endometriotic deposits normally found?
in the pelvis
on the ovaries
peritoneum
uterosacral ligaments
pouch of Douglas
myometrium - this type of endometriosis is called adenomyosis
what is subfertility?
Infertility is defined as the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented.
happens 1/7 couples
what are the main causes for infertility?
- Male factor (25%)
- anovulation (21%) - may be caused by premature ovarian failure, turner syndrome, surgery or chemotherapy, CPOS, excessive weight loss or weight loss
- tubal factor (15-20%)
- unexplained (28%)
- endometriosis (6-8%)
what are the risk factors of infertility
smoking
obesity
occupational risks
excessive alcohol consumption
drug use.
Female fertility declines with age; the effect of age on male fertility is less clear
what investigations can be carried out primary care for infertility?
unable to conceive after 1 year of regular unprotected sexual intercourse
men:
chlamydia screening
semen analysis - repeat in 3 months if abnormal
plasma FH is raised in testicular failure
karotype - exclude 47 xxy
female:
mid-luteal phase progesterone levels - in all women to confirm ovulation - day 21 progesterone >30nmol/L is indicative of ovulation
serum gonadotrophins levels - only with women who have irregular cycles
TFTS
prolactin measurement
chlamydia screening
rubella immunity
what imaging do you carry out for infertility
Transvaginal ultrasound
Hysterosalpingogram (HSG) uses x-ray and contrast injected through a small cannula in the cervix
laparoscopy and dye test - gold standard procedure for assessing tube patency but 2nd line to HSG or HYCOSY
what are the causes of female infertility?
- Ovulatory
Group I ovulation disorders: also known as hypogonadotrophic hypogonadism) are caused by hypothalamic pituitary failure e.g. hypothalamic amenorrhea and hypogonadotrophic hypogonadism
Group II ovulation disorders: dysfunctions of the hypothalamic-pituitary ovarian axis e.g. (PCOS) and hyperprolactinaemic amenorrhoea
Group III ovulation disorders caused by ovarian failure
hyperthyroidism and hypothyroidism
Cushing’s syndrome and congenital adrenal hyperplasia
- Tubal, uterine, and cervical factors:
STIs and PIDs
Endometriosis
Cervical mucus defect or dysfunction.
Submucosal fibroids
- Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Spironolactone
what are the causes of male infertility?
- Primary spermatogenic failure
e.g. Anorchia (absence of testes). Testicular dysgenesis Trauma. Testicular torsion. Post-inflammatory forms varicocele tumours
- Genetic disorders:
Klinefelter’s syndrome with karyotype 47, XXY
- Obstructive azoospermia (defined as the absence of both spermatozoa and spermatogenic cells in semen and post-ejaculate urine due to bilateral obstruction of the seminal ducts).
e.g. Ejaculatory duct obstruction
Vas deferens obstruction
Epididymal obstruction
- other:
erectile dysfunction
Sulfasalazine — can cause infertility and oligospermia
Androgens and anabolic steroids
what is the normal semen analysis?
semen volume - 1.4 ml
total sperm number (million per ejaculate) - 39
sperm concentration (million per ml) -16
total motility - 42
progressive motility -30
vitality -54
sperm morphology - 4%
what is azoospermia?
no sperm in ejaculate
what asethenozoospermia?
% progressive motile sperm below reference limit
what is oligozoospermia?
total number / concentration of sperm below reference limit
What is teratozoospermia?
% morphologically normal sperm below reference limit
what is oligoasthenozoospermia?
combination of: Asthenozoospermia (reduced sperm motility) and Oligozoospermia (low spermatozoon count)
oligoteratozoospermia?
combination of teratozoospermia and azoospermia
how do you manage subfertility?
- ovulation induction
A. clomifene citrate - 1st line
50-100-150 mg tab days 2-6
alternative is letrozole
B. gonadotrophin injections - recombinant FSH
can cause multiple pregnancy/ overstimulation
C. laparoscopic ovarian drilling
- surgical techniques
Tubal microsurgery in women with mild tubal disease
Surgical ablation, or resection of endometriosis plus laparoscopic adhesiolysis in women with endometriosis.
men:
Surgical correction of epididymal blockage in men with obstructive azoospermia
IVF
intrauterine insemination (IUI)
intracytoplasmic sperm injections (ICSI)
what is ovarian hyperstimulation syndrome?
complication of ovulation induction or superovulation. this is a systemic disease and vasoactive products are central to its pathophysiology
what are the characteristics of ovaria hyperstimulation syndrome?
- ovarian enlargement
- fluid shift from intravascular to extravascular space
- this leads to the accumulation of fluid in peritoneal and pleural spaces
- intravascular volume depletion causes haemoconcentration are hypercoagulability
what are the risk factors of ovarian hyperstimulation syndrome?
young age
Low BMI
polycystic ovaries
previous OHSS
what is the presentation of OHSS?
- abdominal discomfort
- nausea
- vomiting
- abdominal distention
usually lasts 3-7 days after hcg administration or 12-17 days if pregnancy has ensured
how do you manage OHSS?
mild - moderate:
analgesia - avoid NSAIDs
drink to thirst not to excess
avoid strenuous activities and intercourse due to risk of ovarian torsion
continue progesterone luteal support - avoid hCG
severe:
analgesia and antiemetics
check FBCs, LFTs. U&E and albumin
strict fluid balance
check for ascites and thrombosis
urinary catheter
thromboprophylaxis with compression stockings and LMWH
what is a prolapse?
occurs when the weakness of the supporting structures allows the pelvic organs to protrude within the vagina.
what types of prolapses are there?
cystocele: anterior wall of the vagina and the bladder attached to it, bulge
urethrocele: lower anterior wall is location of lump. v similar to cystocele
Rectocele: lower posterior wall which is attached to rectum may bulge through weak levator ani.
enterocele - bulges of the upper posterior vaginal wall may contain loops of intestine from the pouch of Douglas.
uterine prolapse : protrusion of the uterus downwards into the vagina, taking with it the cervix and upper vagina.
how do you grade prolapses?
1st degree - lowest part of the prolapse descends halfway down the vaginal axis to the introitus
2nd degree - lowest part of the prolapse extends to the level of the introitus and through the introitus on straining
3rd degree: lowest part of the prolapse extends through the introitus and outside the vagina.
Procidentia: refers to 4th degree uterine prolapse - uterus lies outside the vagina
what are the risk factors of prolapse?
- congenital
- prolonger labour
- trauma from instrumental delivery
- lack of postnatal pelvic floor exercise
- obesity
- chronic cough
- constipation
- smoking
what are the symptoms of prolapse?
- can be asymptomatic
- dragging sensation
- discomfort
- sensation o heaviness or pulling in the vagina
- feeling of a lump coming down
- dyspareunia - painful intercourse
- backache
- urinary incontinence or retention
what investigations do you carry out for prolapses?
- Bimanual to exclude pelvic masses
- Pelvic organ prolapse quantification system (POP-Q)
patient straining - 6 specific sites are evaluated
patient at rest - 3 sites
measure each site in relation to the hymenal ring. if a site is above the hymen then give a negative number
if a site is below the hymen then give a positive number
- urodynamic studies if urinary continence
- pelvic ultrasounds
how do you manage prolapses?
- conservative:
avoid heavy lifting
lose weight
stop smoking
vaginal oestrogens: only if symptomatic atrophic vaginitis
Pessaries:
useful for women unfit for surgeries.
Relief symptoms whilst awaiting surgery
further pregnancies planned or pregnant
diagnostic test for prolapse
- surgery:
Cystocele/ uretrocele - anterior colporrhaphy
Rectocele/ entereocele - posterior colporrhaphy
uterine/ vaginal vault - sacrospinous ligament fixation or hysterectomy
give example of contraception methods.
- combined pill (hormonal method)
- condoms (barrier method)
- DMPA injection
- patch (hormonal method)
- contraceptive implant (hormonal method)
- copper coil (intrauterine method)
- diaphragm (barrier methods)
- IUS (intrauterine method)
- The ring (hormonal method)
- mini pill (hormonal method)
- surgical sterilisation (permanent method)
what are the three types of mechanisms for contraception?
- prevention of ovulation
- prevention of fertilisation
- prevention of implantation
Give examples of Long acting reversible contraception (LARC)?
- IUS
- IUD either levo
- Nexplanon
What is the mechanism of LARC?
prevention of ovulation
apart from hormone coil and traditional Progesterone only pill
how long do LARCs provide contraceptive cover for?
12-14 weeks
what are the contraindications for LARC?
- Pregnancy
- Breast cancer
- severe cardiac disease
- undiagnosed vaginal bleeding
- submucosal fibroids
- uterine malformation
what are the side effects of LARC?
weight gain
increased risk of osteoporosis
risk factor for ectopic pregnancy
delay in return of fertility
irregular bleeding
What is a VLARC?
very long acting resisting contraceptive
give an example of a VLARC?
Copper coil - non hormonal IUD
IUS: mirena coil
Implant
what is the mechanism of action for copper coil?
prevention of fertilisation
how long does a copper coil stay in the uterus for?
5-10 years
what are contraindications for copper coils?
peptic ulcer disease
current pelvic infection
abnormal uterine anatomy
history or current endometrial or cervical cancer
pregnancy - increased risk of ectopic pregnancy and second trimester miscarriage
when should you insert a copper coil ?
first 7 days of period
anytime if reasonably certain they are not pregnant
up to 5 days UPSI for emergency contraception
immediately after termination of pregnancy
what are the side effects copper coil?
Side effects: heavy, prolonged periods
problems with insertion: pain, increased risk of infection, uterine perforation, expulsion of device
what type of mechanism of action does the IUS have?
prevention of implantation
how long can a IUS be used for?
3- 5 years insertion
what are the contraindications of IUS?
peptic ulcer disease
current pelvic infection
abnormal uterine anatomy
history or current endometrial or cervical cancer
pregnancy - increased risk of ectopic pregnancy and second trimester miscarriage
not used as a method of emergency contraception
when is an IUS suitable for insertion?
within first 7 days of period
<48 hrs or >4 weeks post partum
immediately after termination of pregnancy
What is the mechanism of action for the implant?
inhibition of ovulation
how long does the implant stay in the body for?
3 years - needs to be changed more regularly if obese
when should you put an implant in?
- within first 5 days of cycle
- on or before day 21 post partum
- up to 5 days post first or second trimester abortion
- starting after last active pill taken
when will condom cover be required for implants?
started an other time in the cycle
used a s a quick start for emergency contraception
switching from POP, mirena, IUD
what are the side effects of Implants?
irregular bleeding, weight gain, acne
problems with insertion: nerve damage and pain on insertion
what do short acting combined hormonal contraception contain?
both oestrogen and progesterone
what is the mechanism of action for short acting combined hormonal contraception?
inhibition of ovulation
give examples of short acting combined hormonal contraception?
transdermal patch
combined oral contraceptive pill
short acting single hormonal contraception
vaginal ring
how does the transdermal patch last for?
single patch is applied for one week at a time for three weeks
what are the problems for transdermal patch?
if the woman is obese it reduces efficacy
breast pain, nausea and painful periods more common than with other combined preparations
increased thrombotic risk
How long does a vaginal ring last for?
21 days
followed by a 7day ring free period
How long do you need to take a combined oral contraceptive pill for?
pill taken for 21 consecutive days
when do you start taking the contraceptive pill?
if taken on first 5 days of cycle - no cover required
if taken after first 5 days of cycle - 7/7 condoms
emergency contraception: immediately after levonelle, 5 days after ellaone
what are the side effects of contraceptive pill?
vomiting - take again if this happens within 2 hours
diarrhoea - take again if this happens within 24 hrs
what happens if they miss taking a pill between 24<48 hrs?
take missed pill and continue with rest of pack as normal
what happens if you miss 2 pills >48 hrs
week 1 - take most recent pill use 7/7 condom cover and consider emergency contraception
week 2: take most recent pill, 7/7 condom cover
week 3: take most recent pill, 7/7 condom cover and omit break
what happens if you miss >2 pills?
emergency contraception if in first week
continue with rest of the pack and omit break
what are the benefits of combined pill?
improves acne
improves pre menstrual symptoms
protects against ovarian, endometrial and colorectal cancer
what are the side effects of combined pill?
- increased VTE
- increased CVD and stroke risk
- increased risk of breast and cervical cancer
- increased BP
- mood swings
- nausea and vomiting
- irregular bleeding
what are the contraindications for combined pill?
- migraine with aura- recurring headache that strikes after or at the same time as sensory disturbances called aura.
- smoking >15 cigarettes if >35 yo
- history of breast cancer
- anti phospholipid syndrome
what is a progesterone only pill?
pill which only contains progesterone e.g. etonogestrel or levenogestrel
what is the mechanism of action for POP?
thickens cervical mucus
how many times do you take POP?
take pill everyday at same time
when do you prescribe POP?
to women who are usually contraindicated for combined one
- breast feeding
> 35 and smoking
what are the side effects of POP?
DUB
Weight gain
headaches
where is incontinence in women maintained in the body?
urethra by the external sphincter and pelvic floor muscles
what is incontinence?
involuntary leakage of urine which is divided into urge, stress and mixed urinary incontinence
what is continuous urinary leakage most commonly associated with?
vesicovaginal fistula or congenital abnormality e.g. ectopic ureter
what investigations do you carry out for incontinence?
Urinalysis
Imaging - use US to exclude incomplete bladder emptying and define any pelvic mass . NOT routinely used however
cystoscopy - used to visualise urethra bladder,mucosa, trione and ureteric orifices. Biopsies can be taken
urodynamics - a combination of tests which lok at the ability of bladder to store and void urine. Uroflowmetry screens for voiding difficulties.
What is stress urinary incontinence? (SUI)
involuntary leakage of urine on effort or exertion, or on sneezing or coughing
mainly due to urethral sphincter weakness
what is urge urinary incontinence?
is the involuntary leakage of urine with a strong desire to pass urine.
commonly coexists with frequency and nocturia and forms overactive bladder syndrome
What is mixed urinary incontinence?
is the combination of stress and urge incontinence and usually one symptom will predominate (treat that first)
what is overflow incontinence?
usually due to injury or insult
what is the main common type of incontinence in women?
stress urinary incontinence
what is the pathophysiology of stress urinary incontinence?
when detrusor pressure exceeds the closing pressure of the urethra
what investigations do you carry out for stress urinary incontinence?
Exclude UTI
A frequency/ volume chart shows normal frequency and functional bladder capacity
urodynamics when surgery is considereed
check for detrusor overactivity
check for voiding dysfunction - woman with poor flow rate is at risk fo long - term urinary retention
what are the risk factors of SUI?
vaginal delivery
oestrogen deficiency from menopause
radiotherapy
congenital weakness
trauma from radical pelvic surgery
how do you manage SUI?
Lifestyle advise - weight loss, smoking cessation, treatment of chronic cough
Pelvic floor exercise (muscle training) for at least 3 months
Surgery:
Peri urethral injections of bulking agents
if they reject surgery then - duloxetine
tension- free vaginal tapes
What is overactive bladder syndrome (OAB)?
chronic condition affecting women and implies underlying detrusor overactivity (DO)
what are the causes of OAB?
incidence increases with age
idiopathic - main cause
rare caues:
MS
spina bifida
secondary to pelvic or incontinence surgery
what can provoke symptoms of OAB?
cold weather
opening the front door
coughing
sneezing
what are the symptoms of OAB?
stress incontinence symptoms
how do you diagnose OAB?
detrusor overactivity - diagnosed via urodynamic testing
exclude UTI
frequency/ volume chart typically shows increased diurnal frequency and nocturia
urodynamics shows involuntary detrusor contractions during filling - done when there is a doubt about diagnosis
how do you manage OAB?
bladder retraining
pharmacology:
anticholinergics e.g. oxybutynin, solifenacin or mirabegron
side effects include dry mouth, constipation and nausea
intravaginal oestrogen cream can help in those with vaginal atrophy
what are the causes of vulval lumps?
local varicose veins
boils
sebaceous cysts
bartholins cyst or abscess
uterine prolapse or polyp
inguinal hernia
varicocele
carcinoma
viral warts
what are vulval warts?
genital warts caused by HPV
spread via sexual contact
incubation is weeks
what body parts can be affected by vulval warts?
vulva
perineum
anus
vagina
cervix
which HPV causes vulval warts?
HPV 6 and 11
which HPV causes vulval and cervical intraepithelial neoplasia?
16,18 and 33
what can vulval warts cause?
anal carcinoma
how do you manage vulval warts?
warts can be destroyed via the following:
cryotherapy
trichloroacetic acid
electrocautery
only treat a few warts at a time to avoid toxicity
self application:
podophyllotoxin cream
what type of cancers can HPV 6 and 11 may cause in offspring of affected mothers with vulval warts??
laryngeal or respiratory papilomas
what is urethral caruncle?
This is a small red swelling at the urethral orifice.
what is the main cause of urethral caruncle?
meatal prolapse
when can urethral caruncle cause pain?
on micturition
how do you manage urethral caruncle?
excision or diathermy
what is a bartholin’s cyst and abscess?
if the bartholin’s duct and glands are blocked a painless cyst forms however if this becomes infected it can become extremely painful - basically cannot sit down
a hot red labium is seen
how do you manage bartholin’s cyst and abscess?
abscess should be incised and permanent drainage ensured by marsupialisation
what tests might you do for batholin’s cyst and abscess?
exclude gonococcus
what is vulvitis?
vulval inflammation may due to infections e.g. candida, herpes simplex, chemicals
often associated with vaginal discharge
what are the causes of vulval ulcers?
syphilis - main cause
herpes simplex - common in young
carcinoma
chancroid
TB
Behcet syndrome
crohns disease
granuloma inguinale
what is herpes simplex?
Herpes is an enveloped DNA virus.
what types of herpes are there?
HSV 1
HSV 2
which herpes causes genital infection?
both do
HSV 2 more common though
what is the primary infection of Herpes simplex?
usually the most severe
starts with the prodrome (itching of affected skin)
flu- like illness
progresses to vulvitis pain and small vesicles on the vulva
urinary retention may occur due to autonomic nerve dysfunction
recurrent attacks are usually less severe and may be triggered by illness, stress, sexual intercourse and menstruation
how do you manage herpes simplex?
strong analgesia
lidocaine gel
anti viral - aciclovir orally shorten symptoms. dont give topical cream
what is the clinical presentation of carcinoma of the vulva?
lump : as an indurated ulcer which may not be noticed unless it causes pain and bleeding hence often presenting late
how do you manage carcinoma of the vulva?
depends on size of tumor
if <2cm wide and <1mm deep then lymph node excision is not needed
if >1mm deep do triple incision surgery = wide
radiotherapy may be used preoperatively to shrink tumours if sphincters are affected
chemoradiation is used in people unsuitable for surgery to shrink large tumours preoperatively and for relapses
what are the signs and symptoms of cervical cancers?
cervical smear showing invasion
incidental finding on treatment of CIN
postcoital and or postmenopausal bleeding watery vaginal discharge
advance disease includes:
heavy vaginal bleeding
ureteric obstruction
weight loss
bowel disturbance
vesicovaginal fistula
pain
what would you see when examining the cervix if there was cervical cancer?
colposcopy shows an irregular cervical surface abnormal vessels and dense uptake of acetic acid
bimanual examination:
the cervix feels roughened and hard and if disease is advanced there is loss of the fornices and the cervix is fixed
speculum examination:
shows an irregular mass that often will bleed on contact
what investigations should you do for cervical cancer?
FBC , U&E LFTs Punch biopsy for histology
large loop excision of the transformation zone (LLETZ) is contraindicated
CT abdomen and pelvis for staging
MRI pelvis helps with staging and identifying lymph nodes
examination under anaesthetic helps staging
what are the causes of cervical cancer?
HPV 16 and 18 are main causes
what are the risk factors of cervical cancer?
HPV particularly 16 and 18
inadequate cervical screening
- risk of HPV infection depends on:
number of sexual partners
age at first sexual intercourse
no condom use
- woman with HPV the following factors increase risk of progression to cervical cancer
other STIs e.g. herpes simplex, chlamydia or gonococcal infections
smoking
high parity
family history in a first degree relative
oral contraceptive pill for longer than 5 years
- immunosuppresed women
how do you manage cervical cancer?
1.prevention
NHS screening (offered 25 - 640
HPV vaccination - girls at 12-13
use of condoms
- Management
depends on stage:
- CIN
colposcopy
biopsy and histological analysis
moderate to severe abnormalities are found: excision or ablation
- Stage IA1 (microinvasive disease)
conservatively - no need for lymphadenectomy
- Stage IA2 (early stage disease)
tumour <4cm - radical hysterectomy with lymphadenectomy
Tumour >4cm - chemoradiation
- Stage IIB (locally advanced disease)
chemoradiation
- Stage IVB (metastatic disease)
combination chemotherapy is the treatment of choice
single agent therapy and palliative care also option
what is cervical intraepithelial neoplasia (CIN)?
precursor lesion of invasive carcinoma
diagnosis is made via biopsy
what is a dyskaryosis
cytological term used to describe cervical smears
the change of appearance in cells that cover the surface of the cervix
high false positives and negatives so colposcopy is required
what is colposcopy?
examination of the cervix via a colposcope
two stains are used : iodine or acetic acid
Iodine - abnormal areas don’t change colour
Acetic acid - abnormal areas turn white
what do you do if there is high grade colposcopy?
suggests CIN II - III therefore intervene
do colposcopy detect adenocarcinomas of the cervix?
nope
define CIN I,II,III
CIN I - 1/3rd of the thickness of the cervical surface layer is affected. Regresses spontaneously in 60% of cases with no treatment
CIN II- 2/3rds of the thickness of the surface layer is affected. progresses to cancer in 5% of cases
CIN III - high grade dysplasia. full thickness of the surface layer is affected 20-30% of cases in CIN III progress to cervical cancer.
how do you manage CIN?
LLETZ - large loop excision of the transformation zone
occurs with colposcopy clinic local anaesthetic using loop diathermy - 90% cure rates in one treatment
what is CGIN?
cervical glandular intraepithelial neoplasia it can coexist with CIN or be a sole finding
difficult to manage as the endocervical epithelium extends into the cervical canal and therefore not completely visible at colposcopy
associated with high risk HPV and higher skip lesions
manage with cylindrical LLETZ ,cone biopsy or hysterectomy if she doesn’t want kids
what are the stages of cervical cancer?
stage I - tumours confined to cervix :1A microscopic 1B macroscopic
Stage 2 - have extended locally to pper 2/3 of the vagina IIb to parametria
Stage 3 - spread to lower 1/3 of vagina IIIa or pelvic wall
stage 4 - spread to bladder or rectum 1
how common are vaginal cancers?
extremely rare <1% of gynaecological malignancies
what is the clinical presentation of vaginal cancers?
most are squamous in origin
usually in older women
commonest in the upper 1/3rd of vagina
bleeding
how do you manage vaginal cancers?
radiotherapy
prognosis is poor
what is the cause of endometrial cancer?
related to excessive exposure to oestrogen unopposed to progesterone
