General Gynaecology Flashcards
what are some causes of secondary dysmenorrhoea?
endometriosis ovarian cysts leiomyoma uterine polyps IUD copper PID adenomyosis foreign body cervical stenosis (cyclical pain without period)
what are some causes of abnormal uterine bleeding?
gynaecological causes: e.g. fibroids/PID/adenomyosis/pregnancy related
non-gynae causes think BED
BLOOD- haematological malignancies, coagulopathies, ITP (platelet dysfunction)
ENDOCRINE- prolactinoma, PCOS, hyper/hypothyroidsm
DRUGS- anticoagulants, OCP, steroids, HRT, chemotherapy
how to treat trichomonas vaginalis?
metronidazole
what are the symptoms of trichomonas vaginalis?
frothy green vaginal discharge
dyspareunia
‘strawberry cervix’
or asymptomatic
where would you find mittlesmertz pain usually?
in the iliac fossa
Describe dysmenorrhoea pain
cramping pain during/before/post menstruation in the suprapubic area sometimes radiating to the back or down the thigh
Describe endometriosis triad of symptoms
- cyclical menstrual pain or chronic pelvic pain worse during periods
- Pain is provoked- deep dyspareunia, pain with insertion of tampon
- infertility
in what age group is adenomyosis prominent?
middle aged 30-40s women
what are the symptoms of adenomyosis
heavy menstrual bleeding
dysmenorrhoea
what are the risk factors for adenomyosis?
increasing age
multiparous
define menopause?
period in which a woman’s menstrual period ceases and they no longer can bear children- generally diagnosed 1 yr after last menstrual period
or simply, the final menstrual period
average age of menopause
50 yrs (range 45-55yrs)
define premature menopause
menopause in women less than 40 yrs
what are some symptoms of menopause?
reduced libido atrophic vaginitis mood changes hot flushes sleep disturbance tender breasts
what are some things you want to exclude with irregular or heavy bleeding in an older woman?
endometrial hyperplasia/cancer
fibroids
polyps
define early menopause?
menopause in 40-45 yrs old
If a menopausal woman still has their uterus and is about to commence HRT therapy, what hormones are used and why?
Cyclical oestrogen + progesterone because unopposed oestrogen causes endometrial hyperplasia
Risks of HRT
cardiovascular risk
increased risk of breast cancer
increase of breakthrough bleeding (leading to unnecessary ix)
increased risk of cholecystitis
what are the contraindications to HRT?
Absolute: oestrogen dependent neoplasms (endometrial/breast Ca), vascular issues (IHD, recurrent thromboembolism).
Relative: Hx of CAD, HTN, vaginal bleeding, active liver disease, active SLE
what are some causes of premature menopause?
iatrogenic- surgery/radiotherapy/chemotherapy
genetic- turners/fragile x/etc
autoimmune causes
unknown
how long should HRT be used for premature menopause?
until 51 yrs
define post menopausal bleeding?
any vaginal bleeding more than 1 yr after last menstrual period
what are some common causes of post menopausal bleeding
endometrial or cervical cancer atrophic vaginitis exogenous oestrogen polyps and fibroids endometrial hyperplasia
what are some rarer causes of post menopausal bleeding?
ovarian cancer
prolapse
what are some questions we should ask during an interview regarding post menopausal bleeding
check for trauma
check for night sweats
check for abnormal vaginal discharge
check for abnormal weight loss
check for change in bladder bowel function
check medications- tamoxifen and other meds
check FMH of endometrial cancer
what is a key risk factor for endometrial cancer
obesity
what are some non-pharmacological ways of managing hot flushes?
Lifestyle changes such as stopping smoking, reducing alcohol/caffeine intake and losing weight may reduce symptoms in some women. Regular exercise and avoiding triggers (eg hot drinks) may also help.
describe your pharmacological mx of dysmenorrhoea?
NSAIDs like mefanamic acid = first line
OCP
in a healthy 45+ yr old woman with signs of menopause, do you need to do a FSH to confirm?
no
generally dx clinically based on 1 yr since FMP and menopausal symptoms
in a woman who has at a hysterectomy, how might we determine menopause?
FSH serum concentration
at what age can we use the OCP up to?
age 50-51
risk factors for endometrium hyperplasia?
obesity, PCOS, nulliparity, infertility, tamoxifen use
What should we do for a woman who has had a Pap smear showing a lower grade squamous lesion?
They should have her repeat test at 12 months and if it again shows low grade squamous intraepithelial lesion and they should be referred for a colposcopy
If they are aged 30 years or more than they should be offered ever pay Pap smear at six months or a colposcopy
How might we follow up a woman who’s had a previous high-grade squamous intraepithelial lesion?
Cervical cytology plus HPV testing should be performed 12 months post treatment and annually thereafter until both tests are negative on 2 consecutive occasions
what is the relationship between fragile x and premature menopause?
primary ovarian insufficiency
a menopausal woman complains of menopausal symptoms. what treatment would you consider and what must you find out about the patient first?
HRT but need to know whether the patient has a uterus or not. This will indicate whether oestrogen+ progesterone or oestrogen alone is given
define dypsareunia
pain with sexual intercourse (superficial or deep)
define endometriosis?
presence of endometrial stroma and glands outside the uterus; oestrogen dependent condition
what is the gold standard ix for confirming endometriosis?
Gold standard ix= laparoscopy to look and to get histology
what are some management options for endometriosis?
- Drugs- analgesics- not narcotics
- Drugs to suppress hormonal activity e.g. continuous OCP, Progestins, GnRH analogues
- Surgery- ablate or excise endometriosis via laparoscopy
- Radical surgery- hysterectomy + oophrectomy= definitive management
- Warn that it may not fix pain esp if central sensitisation is present
• Plan pregnancies sooner rather than later
-Early move to IVF if required
what is adenomyosis?
endometrial glands and stroma in the myometrial layer of uterus
what is the gold standard ix for adenomyosis?
histology from hysterectomy
(so very hard to diagnose)
sometimes we can use u/s but not very specific or sensitive
what is primary dysmenorrhoea and what must we consider?
dysmenorrhoea with unknown cause
but must consider adenomyosis (bc can only be diagnosed with a hysterectomy)
what is abnormal uterine bleeding?
overarching term used to describe any bleeding that is abnormal with regard to timing/frequency/volume
what is heavy menstrual bleeding?
subjective term reported by women who have periods that are excessively heavy
-impacts on QOL and functioning
what is prolonged menstrual bleeding?
bleeding >8 days on a regular basis
what are some causes of superficial dyspareunia?
• Thrush • Dermatitis • Vestibulodynia • Atrophic vaginitis Lichen sclerosis
what are some causes of deep dyspareunia?
• Endometriosis
• Adenomyosis
• Adhesions
Ovarian cysts
Define metrostaxis
acute heavy volume menstrual bleed
what are the two types of dysfunctional uterine bleeding?
ovulatory and anovulatory
what is the pathophysiology of anovulatory uterine bleeding?
as there is NO ovulation, CL does NOT produce progesterone.
Endometrium thickens due to unopposed E2 and then outgrows its blood supply, causing necrosis and subsequent shedding.
what is the difference between ovulatory and anovulatory histology of the endometrium?
ovulatory= secretory endometrium anovulatory= proliferative endometrium
what are some longterm consequences of dysfunctional uterine bleeding?
Fe deficiency anaemia
Infertility
Endometrial hyperplasia + Ca in DUB anovulatory type
on bimanual examination, you notice that the uterus is FIXED and retroverted. what must you consider?
endometriosis or PID
what does a positive test for cervical excitation during gynae examination often indicate?
blood or infection in the pelvis
what is the gold standard test to diagnose exclude endometrial hyperplasia/carcinoma?
hysterotomy, dilation and curettage
however, NOT first line ix. (really should be using pipelle)
risks of performing endometrial sampling?
risk of uterine perforation, infection, gas embolism
what is your line of action (in terms of ix) with a 58 year old post menopausal woman who presents with vaginal bleeding?
working diagnosis- endometrial cancer
- transvaginal u/s and endometrial sampling pipelle
- if both normal, watch and wait
- if abnormal then proceed to hysterotomy, D and C
what is normal endometrial thickness on transvaginal u/s?
less than 4mm
what is the commonest cause of menorrhagia amongst teenage girls?
anovulatory dysfunctional uterine bleeding
what is the difference between mefanamic acid and tranexamic acid?
mefanamic acid= prostaglandin inhibitor
tranexamic acid= anti-fibronolytic agent (inhibits clot breakdown)
what are some treatment/management options for heavy menstrual bleeding?
prostaglandin inhibitor, antifibronolytic agents
OCP
Depot provera
Mirena
surgical- endometrial ablation or hysterectomy
what are some causes of intermenstrual bleeding in a young woman?
- E2 falls during the menstrual cycle causing a mini E2 withdrawal bleed
- Structural cause: Polyps/endometriosis
what might persistent post-coital bleeding indicate?
cervical dysplasia or cervicitis
What is the most common cause of post-coital bleeding?
cervical ectropium
what causes cervical ectropium?
increase E2 levels during puberty
size of ectropium may be increased by OCP and multiparity
what are two things we need to consider before deciding to treat endometriosis?
plans for fertility
patient’s symptoms
what is the medical management of endometriosis?
NSAIDs, and hormone therapy mainly contraceptives such as Mirena, COCP, implanon etc
how is an endometrial biopsy taken?
through a suction pipelle inserted through the cervix to sample fragments of endometrial tissue
what are some characteristic u/s results that might indicate ovarian torsion?
U/s doppler- reduction of blood flow to the ovary; ring of oedema around the ovary
what is the most common coagulopathy which can cause abnormal uterine bleeding
VWF deficiency
what is the mechanism by which hypothyroidism causes abnormal uterine bleeding?
low thyroid levels –> increase CORT levels –> induces E2 –> irregular bleeding/growth of endometrium
what do we mean by ‘dysfunctional ovarian bleeding’?
Endometrial disorders in the absence of pelvic pathology
what medication is transexamic acid?
anti-fibrinolytic agent
define primary amenorrhoea?
Primary amenorrhoea is defined as the failure of spontaneous menstruation to commence by 16 years of age, or by 15 years of age if there is an absence of secondary sex characteristics.
define secondary amenorrhoea?
Secondary amenorrhoea is the absence of menstruation for greater than 6 months’ duration in a woman who has previously menstruated.
what are some possible causes of intermenstrual bleeding?
Cervical malignancy • Cervical ectropion • Endocervical polyp • Atrophic vaginitis • Pregnancy • Irregular bleeding related to the contraceptive pill
what does PALM COEIN stand for in terms of heavy menstrual bleeding?
Polyps
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy i.e. ITP, leukaemia Ovulatory dysfunction Endometrial dysfunction/endocrine cause Iatrogenic Not otherwise classified
a lady comes in with a history of heavy menstrual bleeding. what ex do you want to do?
General appearance= pallor, haemodynamically stable?, jaundice, bruising
Abdominal palpation of the uterus, assessing for any masses
Other included BP, Cardiac/Resp
+/- bimanual for uterus size
+/- speculum examination if pap smear not up to date
an endometrial thickness of ?__mm is highly suspicious in a premenopausal woman and should be investigated. Fill in the gap.
> 16mm
what is the risk of endometrial ablation?
adenomyosis i.e. painful periods
what is the risk of uterine artery embolisation?
risk of menopause if ovaries are accidentally involved
what are the management options for a woman who has heavy menstrual bleeding?
- Nothing/watch and wait
- Mefanamic acid (ponstan), tranexamic acid
- Hormonal- COCP/Depot/implanon
- IUD- Mirena
- Treat underying cause e.g. removal of polyps, myomectomy
- Interventional radiology: uterine artery embolisation, MR guided focused u/s to ablate blood supply to the fibroid.
- Endometrial ablation
- Hysterectomy
what are the possible mechanisms of infertility in endometriosis?
mechanical-obstruction
functional- dyspareunia
inflammatory- hostile environment
define dysfunctional uterine bleeding
Excessive heavy, prolonged or frequent bleeding that is not due to pregnancy or any recognizable pelvic or systemic disease
dx of exclusion
what are some focused hx questions for heavy menstrual bleeding?
• Ask about hirsutism, increased BMI, acne
• Ask about irregular cycles or long cycle lengths
• Ask about symptoms of anaemia
• Ask about symptoms of hypothyroidism (low mood, weight gain, cold intolerance, constipation)
• Ask about symptoms of coagulopathy- any bruising, gum bleeding, ecchymoses, FMH of coagulopathy
• Ask about cancer- FMH of bowel cancer or tamoxifen use for previous breast cancer
• Ask about parity–> whether nulliparous or multiparous
• Ask about dyspareunia and dysmenorrhoea
• Ask about pap smears and if any were abnormal
Ask about impact on life
