General Gynaecology Stuff Flashcards
What is a fixed retroverted uterus a sign of?
Endometriosis
Deposits of ectopic tissue on the utero-sacral ligament pull the uterus from anteverted to retroverted position
What are the features of imperforate hymen?
The hymen does not have an opening, hence the blood cannot flow out during menstruation.
This leads to primary amenorrhoea even with development of secondary sexual characteristics and cyclical pain
At what age can someone consent to sexual intercourse?
A child under the age of 13 is always considered to be unable to consent for sexual intercourse
What blood tests are done for amenorrhoea?
HCG - Rule of pregnancy Gonadotrophins Oestrodiol Prolactin Androgens - Raised in PCOS TFT
What are the different methods of abortion?
Less than 9 weeks: Mifepristone (anti-progestogenic) followed 48 hours later by prostaglandins (misoprostol) to stimulate uterine contractions
Less than 13 weeks: Surgical dilation and suction of uterine contents
More than 15 weeks: Surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
What is used for incomplete/missed miscarriage?
Misoprostol alone
What is the definition and types of precocious puberty?
Early onset of puberty
8 in a girl
9 in a boy
Causes:
Central - Gonadotrophin dependent
Peripheral - Gonadotrophin independent
Peripheral is always pathological. Normally the result of exogenous ingestion of oestrogen or a hormone-producing tumour
What is the definition of delayed onset of puberty?
No secondary sexual characteristics by the age of 14
What is the definition of Amenorrhoea?
Primary amenorrhoea - No periods by the age of 16
Secondary amenorrhoea - No periods for more than 6 months after previously having periods
Oligomenorrhoea - Period cycles longer than 35 days with <9 periods a year
What are causes of hypogonadotrophic hypogonadism?
• Hypothalamic Disorders
§ Excessive exercise, weight loss and stress
§ Lesions (craniopharyngioma, glioma)
§ Head injuries
§ Kallmann’s syndrome (Lack of GnRH)
§ Sarcoidosis, TB
§ Progestogens, HRT, dopamine antagonists
• Pituitary Disorders
§ Adenomas (prolactinoma is most common)
§ Pituitary necrosis (e.g. Sheehan’s syndrome)
§ Iatrogenic (surgery, radiotherapy)
§ Congenital failure of pituitary development
What is the cause of hypergonadotrophic hypogonadism?
Polycystic ovarian syndrome
What is Asherman syndrome?
Secondary amenorrhoea due to endometrial scarring
What are investigations for amenorrhoea/oligomenorrhoea?
○ A pregnancy test should be carried out if the patient is sexually active
○ Blood can be taken to measure hormone levels
§ Raised LH + raised testosterone –> PCOS
§ Raised FSH –> POF
§ Raised prolactin –> prolactinoma
§ Thyroid function if clinically indicated
○ Ultrasound would be useful to visualise polycystic ovaries
○ MRI can be used to visualise the pituitary gland
○ Other investigations include:
§ Hysteroscopy - Asherman syndrome, cervical stenosis
§ Karyotyping - Turner’s and other chromosomal abnormalities
What are the clinical features of polycystic ovarian syndrome?
Rotterdam consensus criteria: 2/3 of the following:
• Amenorrhoea/Oligomenorrhoea
• Clinical/Biochemical Hyperandrogenism
• Polycystic ovaries on ultrasound
Other features: • Acne • Acanthosis nigricans • Hirsutism • Subfertility • Obesity • Risk of T2DM • Risk of cardiovascular event
What is the management of polycystic ovarian syndrome?
COCP to regulate menstruation
Cyclical oral progesterone to regulate withdrawal bleed
If fertility an issue, clomiphene to induce ovulation
Lifestyle advice - Diet and exercise
Ovarian drilling - May prompt ovulatory cycles
Treatment of hyperandrogenism:
• Cyproterone acetate (antiandrogen)
• Topical eflornithinecream
What are the clinical features of premenstrual syndrome?
Psychological, behavioural and physical symptoms that begin during the luteal phase and resolve by the end of menstruation
Symptoms: • Irritability • Depression • Bloating • Abdominal pain • Mastalgia • Headache
What is the management of premenstrual syndrome?
1st line (Mild-Moderate) = Conservative management
• Exercise
• Diet
• Stress management (Consider counselling)
• Reduced alcohol/caffeine
2nd line (Moderate-Severe) = COCP or SSRIs if severe CBT for depression
Last line = Hysterectomy plus bilateral salpingo-oophorectomy
What are the symptoms of menopause?
- Dysmenorrhoea
- Hot flushes
- Vaginal dryness
- Weight gain
- Mood changes
- Night sweats
What biochemical changes are seen in menopause?
Normally menopause is a clinical diagnosis, however if unsure, investigations include:
* Serial FSH measurements = Raised * Serial oestradiol measurements = Low * Vaginal exam = Vaginal atrophy
What is the management of menopause?
Hormone replacement therapy
• Normally used till symptoms of menopause subside (1-2 years)
• Taken orally
• Combination of oestrogen + progesterone
• Transdermal implant available if oral not possible
• Should be used for 3 months before concluding ineffective
What additional considerations must be made with regards to HRT?
- If they have had a hysterectomy, oestrogen-only HRT is given
- If they are perimenopausal, cyclical HRT is given (Oestrogen every day, but progesterone only for last 14 days)
- If they only have local symptoms (vaginal dryness), they can be given vaginal oestrogen cream or a pessary
What are the causes of secondary amenorrhoea/oligomenorrhoea?
Premature ovarian insufficiency
PCOS
Hyperprolactinaemia
What are the clinical features of premature ovarian syndrome?
Menopause before the age of 40
Investigations:
- FSH/LH (Rise)
- Oestrogen (Falls)
What is the management of premature ovarian syndrome?
Most causes treated with COCP
After 40, switch to HRT
What are contraindications to HRT?
- Suspected malignancy
- Breast cancer
- Endometrial cancer
- Thrombophilia (Factor V Leiden)
- Current VTE
What are the risks of HRT?
- Increased risk of breast cancer
- Increased risk of ovarian cancer
- Increased risk of CVD/Stroke in older women
- Increased risk of VTE
What is Ovarian Hyperstimulation Syndrome?
Typically during IVF, when excess hormone therapy is given, which results in multiple luteinised cysts that secrete oestrogen, progesterone and vascular endothelial growth factor. This leads to increased membrane permeability and fluid loss.
Stages:
Mild - Abdominal pain/bloating
Moderate - +N&V, Ascites on ultrasound
Severe - +Clinical ascites, hypoproteinaemia, oliguria
Critical - +DVT, ARDS, Anuria, Tense ascites
How do you differentiate VIN from vulval carcinoma?
VIN is typically white and plaque-like. It also does not infiltrate the basement membrane
Vulval carcinoma is typically red and ulcerated. It invades the basement membrane
