General Flashcards
Primary Amenorrhoea - Causes
- Chromosomal 50%
- Hypothalamic 20%
- Mullarian 15%
- Anatomic 5%
- Pituitary 5%
- Other 5%
Primary amenorrhoea - Definition
- No menses by 15 with normal secondary sex characteristics
- No menses by 13 without secondary sex characteristics
Hypergonadotrophic primary amenorrhoea - Causes
Turner’s syndrome Structurally abnormal X chromosome Pure gonadal dysgenesis Enzyme deficiencies Mosaicism
Hypogonadotrophic primary amenorrhoea - Causes
Physiological delay
Kallmans syndrome
CNS tumours
Chronic disease
Amenorrhoea with secondary sex characteristics
ANATOMIC: - Hymen - AIS -True Hermaphrodite NON-ANATOMIC - Ovarian insufficiency - Iatrogenic - Autoimmune - Glalactoaemia - Savage syndrome (Gonadotrophin resistant ovary)
Secondary amenorrhoea - Causes
- Pregnancy
- Ovarian 40% (PCOS, prem insufficiency [chemorad/turners/autoimmune/fragile x premutation])
- Hypothalamic 35% (functional, infiltrative)
- Pituitary 20% (prolactinoma, sella mass, sheehans, radiation)
- Uterine 5%
- Thyroid dx
Delayed puberty
- Anatomic - Rokitanski, obstruction
- Hypergonadotropic
- Gonadal dysgenesis (turner’s, 46XX, 46 XY)
- Early gonadal failure - Hypogonadotrophic
- Constitutional
- infiltrative lesion
- Kallmans (anosmia and colour blindness)
- chemorad
- hypothyroidism
- drugs
- Chronic disease
Precocious puberty - Causes
- CENTRAL
- Idiopathic
- Tumours
- Infection
- Trauma
- Congenital abn e.g. hydrocephalus - PERIPHERAL
- HYPOgonadotrophic
* isosexual = oestrogenic neoplasm (e.g. McCune albright [fibrous dysplsia, cafe au lait patches and hyperfunctioning endocrinopathies])
* heterosexual = androgenic tumour or CAH
- HYPERgonadotropic
* GnRH or BHCG [similar to LH] secreting tumour
*** Premature adrenarche may be the first sign of PCOS
Precocious puberty - Definition
Development of secondary sex characteristics earlier than expected i.e. 2SD < mean. Usually 8 in girls and 9 in boys.
Endometriosis - Level A evidence for Infertility
- Rx grade I/II with excision or ablation
- No role for hormonal therapy (either primary or adjunct to surgery)
- Endometriomas:
- no benefit to remove if >3cm in ART context
- if removing cystectomy is better than drainage
Endometriosis - Other levels of evidence for Infertility
B:
- GnRH for 3-6/12 prior to ART improves clinical pregnancy
C:
- Stage III/IV laser coat better than monopolar in sport pre rates
- IUI and ovarian hyperstim increases live birth rates )Stage I/II)
- Recurrence not increased by IVF/ICSI
Endometriosis - Level A evidence for Pain
- Progestagens and antoprogestagens effective
- GnRH antagonists (Groerelin) + add back effective
- Endometrioma:
- COCP for secondary prevention
- cystectomy > drainage
- Surgery:
- No role for preop or post op hormonal Rx
- DO NOT use LUNA
- Mirena 1-2y secondary prevention dysmenorrhoea
- Presacral neurotomy is difficult but effective
Endometriosis - Other levels of evidence for Pain
B:
- COCP
- Mirena IUD
- Surgery for deep end, but 2% intro complication rate
- Aromatoase inhibitors (w Prog, COCP or GnRH ant)
- Endometrioma - excision lower recurrence rate
C:
- Ring or patch
GPP:
- Hysterectomy for those who’ve completed their family and have failed medical therapy
Components of the prognostic scoring system for persistent trophoblastic disease
- Age = old worse
- BHCG level = higher worse
- Outcome of index pregnancy = term worse than MC worse than molar preg
- Time from index pregnancy = longer has worse outcome
- Size of residual tissue = bigger is worse
- Metastatic disease = liver/brain worse than GIT worse than spleen/kidneys worse than lungs
- Previous CTX (double agent worse than single)
Will guide decision of MTX or EMA-CA or EMA-EP +/- RTx.
XY Females
- AIS (no androgen receptors so no hair)
- Gonadal dysgenesis (NO secondary sex characteristics)
- 5 alpha reductase deficiency (No DHT so no prostate/penis, but male secondary sex characteristics)
Requirements for Gillick Competence
- Unable to convince parents
- Likely to engage in sexual activity regardless of contraception
- Able to understand advice given
- Contraception required for physical or mental health
- In the patients best interest
- No lower age limit
PCOS - Rotterdam Criteria
2/3: *need all 3 in adolescents
- Polycystic ovaries (>11 follicles in EACH ovary, 2-9mm, OR >10mL)
- Hyperangrogenism (clinical or biochemical)
- Oligoamenorrhoea
Present in 15% of women.
PCOS - Pathogenesis
Incompletely understood
Complex hormonal and biochemical alterations
- Genetics (70%) and environmental
- Increased LH and LH pulse frequency, and enhanced ovarian sensitivity to LH
- Increased insulin resistance > increased androgens and decreased SHBG
Pregnancy risks of PCOS
GDM (~50%)
Miscarriage (mostly secondary to obesity)
PIH
SGA
Long term risks of PCOS
- Endometrial cancer RR 2.7
- Type II DM RR 4
- CV disease
- OSA
- Anxiety/depression
Differential diagnoses for PCOS
- Hyperprolactinaemia
- Cushings disease
- late onset CAH
- Hypothyroidism
- Androgen secreting adrenal tumour
Congenital Adrenal Hyperplasia - Presentation
- Classical
- Virilised female baby
- Hyponaturamia and hyperkalaemia secondary to aldosterone deficiency - Non-classical
- Precocious or normally times heterosexual puberty
- PCOS like syndrome
Congenital adrenal hyperplasia - Mechanism
21-hydroxylase is the most commonly affected enzyme
Usually converts 17-OH-progesterone to 11-deoxycortisol > cortisol (and aldosterone). (17-OH-P is also the substrate for androstenedione).
Without cortisol no negative feedback, so higher ACTH and more substrates into androstenedione.
Congenital adrenal hyperplasia - Rx
Dexamethasone/Prednisone for pathway supression
COCP
Ovulation induction if required
When should AN thromboprophylaxis start?
As early in pregnancy as practically possible.
Women w one previous unprovoked DVT without any thrombophilia?
Close surveillance only AN.
Consider 6/52 post partum.
Which thombophilias need AN thromboprophylaxis?
Antithrombin III
Factor V Leiden homozygotes or compound heterozygotes
More than one thrombophilia
Prevalence of post hysterectomy vault prolapse
12% if hysterectomy for prolapse
2% if performed for other indications
Prevention of vault prolapse at the time of hysterectomy
- McCall culdoplasty at the time of hysterectomy (approximating the USL)
- sacrospinous fixation if the vault descends to the introits during hysterectomy
Reversible causes of urinary incontinence
DIAPPERS Delirium Infection Atrophy Psychological Pharmacological Excessive urine production Restricted mobility Stool impaction
Cause of urinary urge incontinence
Idiopathic
Neurogenic e.g. DM, MS, CVA
Conservative Rx urge incontinence
- Lifestyle modification (fluid, ETOH, caffeine, constipation, mobility, toilet access)
- Bladder training
- Supervised physiotherapy
- Electrical stimulation w TENS
- Pessary of large cystocoele present
Pharm Rx urge incontinence
Oestrogen (improved symptoms, improved UDS)
Anticholinergics (15% greater than placebo) e.g Ditropan, Detrusitol
TCA (anticholinergic and LA) e.g. Imipramine
Intravesical botox
Surgical Rx urge incontinence
Hydrodistention
Sacral nerve stimulation
What is the PALM COEIN classification and it’s components?
Classification system of abnormal uterine bleeding.
4 structural
4 other
1 underfined
Polyp
Adenomyosis
Leiomyoma (submucosal, other)
Malignancy and hyperplasia
Coagulopathy
Ovulatory
Endometrial
Iatrogenic
Not yet classified
What is the risk of miscarriage by maternal age?
45 95%
GTG
What are the diagnostic criteria for APLS?
Antibodies - postivie x 2 at least 10 weeks apart
Anticardiolipin
Lupus anticoagulant
B2 glycoprotein
and. ..
- 3 1st trimester losses
- 1 > 10/40 loss w a morpholgically normal foetus
- Delivery <34/40 for placental disease
OR hx thrombotic disease
How does APLS cause adverse pregnancy outcomes?
- Inhibition of trophoblast function and differentiation
- Activation of complement at the materno-foeto interface resulting in local inflammation
- Thrombosis at the materno foetal interface (later effect)
(first 2 reversed by Heparin!)
Preconception or 1st AN Ix in prepreg DM
- UEC
- Urine MCS
- HbA1c
- TSH
- 24h urine protein/ PCR
- Opthal consult
- ECG
- Assessment of exercise tolerance and CV disease
How effective is the Fluvax?
~50%, thus still need to Rx women w Oseltamivir
Is 80% effective at preventing hospitalisation
