Female Health FCM Flashcards
What is amenorrhoea?
What are the 2 types?
the absence or cessation of menstruation
- PRIMARY = failure to establish menstruation by the time of expected menarche
- SECONDARY = cessation of menstruation in women with previous menses
What is the causes Primary amenorrhoea?
- constitutional delay
- pregnancy
- genito-urinary malformations
- endocrine disorders
- androgen insensitivity syndrome
What are the causes of secondary amenorrhoea?
- primary ovarian insufficiency - PCOS
- hypothalamic dysfunction
- ambiguous genitalia
What are the risk factors associated with amenorrhoea?
excessive exercise obesity/overweight Family history of amenorrhoea Genetics eating disorders
List the signs and symptoms of primary amenorrhoea
not established menstruation by age of 13 alongside having no secondary sexual characteristics
not established menstruation by age of 15 but has developed secondary sexual characteristics.
List the signs and symptoms of secondary amenorrhoea
cessation of menstruation for 3-6months for a women who previously had normal and regular menses
cessation of menstruation for 6-12months for a women who previously has oligomenorrhoea (irregular)
what investigations/exams are done in primary amenorrhoea?
physical pelvic exam
pelvic ultrasound
bloods - serum prolactin, TSH, FSH, LH and total testosterone
what investigations/exams are done in secondary amenorrhoea?
bloods
- FSH, LS, prolactin level, total testosterone, TSH
Ultrasound scan done is PCOS suspected
How is primary amenorrhoea managed?
referral to secondary care specialist - either gynae or endocrinologist
manage certain obvious causes by
- encouraging weight gain or refer to dietician if required
- advise reducing exercise, increasing caloric intake and weight gain
- stress-related amenorrhoea would require measures of manage and improving coping strategies for stress.
if amenorrheoa persists for 12months, consider whether osteoporosis prophylaxis is required - this may involve HRT or COC pill.
How is secondary amenorrhoea managed?
manage the following causes of secondary amenorrhoea in primary care
- PCOS
- Hypothyroidism
- Menopause
- pregnancy
similar to primary amenorrhoea
- weight gain and reduce exercise
- stress relief/improving coping mechanisms
- manage chronic illnesses
- hypothalamic/pituitary causes e.g. tumour
what warrant a referral to gynae in amenorrhoea?
- persistent raised LH and FSH
- recent urterine/cervical surgery
- infertility
- suspected PCOS
what warrants a referral to endocrinologist?
- hyperprolactinaemia
- low FSH and LH
- increased testosterone not explained by PCOS
What is Dysmenorrhoea?
painful cramping, usually in the lower abdomen which occurs shortly during or before menstruation or both.
What are the 2 types of Dysmenorrhoea?
Primary Dysmenorrhoea - no underlying pathology but is caused by uterine production of prostaglandins during menstruation
Secondary Dysmenorrhoea- after several years of painless periods caused by an underlying pelvic pathology or IUD
what are the risk factors associated with Dysmenorrhoea?
Primary Dysmenorrhoea
- early age of menarche
- heavy menstrual flow
- nulliparity
- Family history
- stress
- smoking
- poor diet & obesity
Secondary Dysmenorrhoea
- dependent on the underlying cause
What are the signs and symptoms of Dysmenorrhoea?
- cramping/pain in the lower abdomen
- lower back pain
- nausea and vomiting
- lethargy and fatigue
What investigations/exams are done for Dysmenorrhoea?
physical abdo exam - fibroids/other masses
physical pelvic exam
consider ultrasound - to rule out fibroids, adenexal pathology and endometriosis or asses an IUD
consider high vaginal and endo-cervical swabs - if pt at risk of STI (any associated vaginal discharge/abnormal bleeding)
pregnancy test - exclude ectopic
How is primary Dysmenorrhoea managed?
- offer NSAID unless contraindicated
- either ibuprofen, naproxen, mefanamic acid etc
- paracetamol if NSAID contraindicated - if the pt doesn’t wish to concieve then consider prescribing a 3-6month trial of hormonal contraceptive as a first-line alternative
- if the response to individual treatments is insufficient then a combination of simple analgesia and hormonal contraception may be considered.
- consider recommending local application of heat or transcutaneous electrical nerve stimulation (TENS) to help reduce pain
- is symptoms don’t respond to initial treatment within 3-6months of there is doubt in diagnosis - refer to gyanecologist
How is secondary Dysmenorrhoea managed?
dependent on the underlying cause
suspect a serious secondary cause and refer urgently if any ‘red flags’ are present such as
- ascites and/or a pelvic/abdominal mass
- an abnormal cervix on examintion
persistent IMB, PCB with associated features of PID
- an ultrasound suggestive of cancer
What is premenstrual syndrome?
PMS is a condition characterised by psychological, physical, behavioural symptoms occurring in the luteal phase of the normal menstrual cycle.
What causes PMS?
Exact cause is unknown.
likely to be related to hormonal
- sensitivity to changes in progesterone levels
- oestrogen and progesterone also have an impact on neurotransmitters including GABA and serotonin
What are risk factors for PMS?
- presence of periods
- family history of PMS
- mood disorders
- cigarette smoking
- alcohol intake
- sexual abuse +/- trauma
- weight gain
- stress
What are the signs and symptoms of PMS?
psychological
mood swings, irritability, depressed/anxious, poor concentration
physical
breast tenderness, bloating, headaches, backaches, weight gain
behavioural
reduced visio-spatial and cognitive ability and aggressive
what are the investigations/exams done for PMS?
a physical exam
record of daily symptom in a diary
How is PMS managed?
- offer lifestyle advice such as regular sleep and exercise, minimise stress, smoking cessation and alcohol reduction
- NSAIDs for any pains - consider COC
- arrange a CBT referral and consider SSRIs
- review in 2 months after to assess the effectiveness of treatment
What is PCOS?
A heterogenous condition/endocrine disorder that appears to emerge at puberty
What causes PCOS?
exact cause isn’t fully known but it is likely to be both a genetic predisposition alongside environmental factors.
associated with hyperinsulinaemia as it reduces SHBG in the liver which increases androgen production.
Hormonal imbalance os common in women PCOS
What are the investigations/exams done for PCOS?
Total testosterone SHBG free androgen index LH, FSH, prolactin, TSH Abdominal Ultrasound
How is PCOS managed?
- encourage lifestyle modifications
- offer screening for impaired glucose tolerance test and T2DM and CVD risk factors.
- screen for depression and anxiety & consider psychosexual problems/ body image and eating disorders
- if pregnant or considering pregnancy - oral glucose tolerance test & consider changes to metformin and hormonal treatment
- manage clincial features of PCOS - consider COC alone if not contraindicated
How does vaginitis present?
changes in colour/odour of discharge
vaginal itching/irritation
pain/soreness around the vulva causing either dysuria or dyspareunia
some light bleeding/spotting
How is vaginitis examined/investigated?
pelvic examination
vaginal swabs
How is vaginitis managed/treated?
dependent on the cause
bacterial infections - metronidazole/clindamycin
fungal/yeast like infections - antifungal cream/suppository
vaginal atrophy/dryness can be treated with oestrogen creams (lidocaine), tablets or rings (pessarys)
which type of cancer is common in the vagina?
vaginal squamous cell carcinoma
What does presentation of a vaginal neoplasms involve?
unusual vaginal bleeding - PMB, IMB, PCB watery vaginal discharge lump/mass in the vagina dysuria/urinary frequency pelvic pain constipation
How is vaginal neoplasm examined/investigated?
pelvic exam
colposcopy & biopsy
vaginal swab/smear
What does management of vaginal neoplasms entail?
dependent on stage and type of cancer
typically involves surgical removal - using vaginectom
radiation therapy is often given alongside this
what is a cystocele?
anterior vaginal prolapse - bladder droops into the vagina due to weakened muscles
How does a cystocele present?
bulging sensation/ feeling of fullness/heaviness
difficulty passing urine - more frequent
dyspareunia
problems inserting tampons/applicators
frequent UTIs
investigations for suspected cystocele?
start off with a pelvic exam
urine tests - rule out any UTIs etc
cytoscopy
how is cystocele managed?
mild/asymptomatic may not require treatment
Tx options include
- weight loss
- kegel exercises/pelvic floor strengthening
- pessary to hold vagina
- HRT - replace oestrogen - more for symptoms
- surgical intervention
What is a rectocele and how does it present?
herniation/buldge of rectum onto the posterior wall of the vagina
presents
- difficulty with bowel movement
- rectal pressure/fullness
- feeling of incomplete emptying of bowels
- sexual concerns - discomfort
What investigations/exams are done when this is suspected?
mainly based on pelvic exam
sometimes using Ultrasound
What does management of rectocele involve?
Asymptomatic = no Tx required
symptomatic - initially a pessary may be given to help hold/support the vaginal walls
surgical repair of prolapse - removal of weakened tissue /insertion of mesh patch to provide support.
How does bartholin’s cyst present?
often asymptomatic when small - small painless lump
larger growths/cysts - may make movement slightly more difficult - look for change in gait
swelling of labia
obvious collection of pus/abscess present
fevers may also occur when cysts enlarges with erythema and heat.
What is a breast abscess and what causes it?
a painful build-up of pus in the breast caused by an infection.
if located in the upper outer quadrant of the breast = lactational
if located in the central of lower quadrants = non-lactation
usually as a complication of mastitis/cellulitis which wasn’t adequately controlled by antibiotics
how does a breast abscess present?
localised, painful inflammation of the breast
associated fever
malaise
mass - fluctuant, tender, palpable - erythematous/warm to touch
generally diagnosed on physical breast exam can used and using US
How is a breast abscess managed?
confirmed abscess via US is then drained using US-guided needle aspiration or surgical drainage
culture from fluid produced by abscess - give abx accordinging to culture
advise lactating women to continue breastfeeding if they could/ express until they can resume breastfeeding
How does breast fibroadenoma present?
firm rubbery painless lump
easily movable
can enlarge/shrink on their own
How are breast adenomas investigated?
Ultrasound
core biopsy needed definitive diagnosis
How are breast fibroadenomas managed?
usually no treatment/follow up required
sometimes surgery is considered - excisional biopsy/lumpectomy or cyroablation
What is fibrocystic disease? How does it present?
Breast composed of lumpy tissue - nodular/glandular tissue
presents:
- severe localised pain in sudden onset
- some may experience pain in armpits
What is done to manage fibroblastic disease?
most don’t require any invasive treatment
OTC pain relievers can usually relieve pain/discomfort
wear supportive bra and use warm/cold compresses
How does mastitis present?
painful breast
fever or general malaise
tender, red, swollen and hard are of the breast - wedge shaped
investigated milk culture
How is the mastitis managed?
relieve pain and discomfort with simple analgesia - advise cold/warm compress
prescribe oral antibiotic if infectious/ systemic signs are present - co-amoxiclav TDS 10-14 days
