GOSH Flashcards
Laparatomy
a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery
Laparoscopy
a small tube with a camera is put into the stomach area
hysteroscopy
a TRANSVAGINAL procedure used to examine the inside of the womb (uterus). It’s carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end.
fibroids/leimyomata definition and RF
benign tumours of myometrium
if they have a pendunculated stalk ==> a polyp
RF: afro-carribean and FHx. injectable progestogens and COCP are protective!
fibroids/leimyomata aeitiology
Grow in response to oestrogen (and progesterone) therefore shrink after meno pause and variable changes during preg
Sx of fibroids/leimyomata
usually site dependent rather than size, and usually asymptomatic
- menorrhagia
- dysmenorrhoea
- IMB
- They only cause pain if torsion or red degeneration
NB/ if big e/n, may cause bladder retention or frequency
red degeneration
Result of an inadequate blood supply - pain and uterine tenderness. Common in preg
fibroids/leimyomata complications
torsion, degenerations, malignancy
fibroids/leimyomata ix
USS but MRI or laparoscopy may be required to distinguish the fibroid from an ovarian mass
Need to differentiate fibroids and adenomyosis w MRI
fibroids/leimyomata tx
small - no tx
large - serially measured by examination or USS (?malig)
MEDICAL Mx = GnRH agonists cause temporary amenorrhoea and fibroid shrinkage but nto for F trying to conceive. SURGICAL Mx = hysteroscopic resection hysterectomy Uterine artery embolisation
Adenomyosis definition
aka endometriosis interna
= presence of endometrium within the myometrium
Adenomyosis associations
40yo
asso/w endometriosis and fibroids (need to differentiate from fibroids!)
Usually asx but can present w painful, regular, heavy menstruation. O/E mildly enlarged and tender uterus. Sx subside after menopause
Ix: MRI
MEDICAL Mx = IUS or COCP w or w/o NSAIDs to control menorrhagia and dysmenorrhoea
SURGICAL Mx = hysterectomy
Endometritis aeitiology
often secondary to STI, instrumentation of uterus (eg. surgery, IUD), pregnancy/miscarriage/TOP (RPOC)
infx in postmenopausal –> malignancy
Endometritis sx
- persistent and heavy PV bleed + pain
- tender uterus
- open os
Tx = broad sepc abx and ERPC if req
Intrauterine polyps
benign tumours in the uterus
40-50yo when oestrogen levels v high or postmenopausal F on tamoxifen for breast carcinoma
cause menorrhagia, IMB, and may prolapse through the cervix
Tx = resection or diathermy can cure bleeding problems
Endometrial carcinoma RF and PC
90% ADENOCARCINOMA
RF: exogenous oestrogen w/o progesterone obesity PCOS nulliparity and late menopause ovarian tumours Tamoxifen is a oestrogen agonist in the uterus!
Hx of COCP and pregnancy is protective
Presents w PCB +/- abnormal smears
Endometrial carcinoma ix and tx
USS
endometrial bx w Pipelle or hysteroscopy
MRI and CXR (to exclude rare pulmonary spread) req
NB/ staging is only possible following a hysterectomy
Mx of Endometrial carcinoma:
1. hysterectomy + bilateral salpingooophrectomy (BSO) –> XRT for pt w high risk LN involvement
‘Only XRT’ is for those w high risk of extrauterine and evidence of wide spread disease.
Menorrhagia definition and tx
heavy menstrual bleed (subjectively or objectively >80ml)
Tx:
1st line = IUS
2nd line = Tranexamic acid (antifibrinolytics) or mefanamic acid (NSAIDs = PG inihibitors)
3rd line = COCP
4th line = high dose progestogens or GnRH analogues –> amenorrhoea
When to do an endometrial bx (Pipelle or hyseroscopy)
>10mm in pre-menopausal, >4mm in post-menopausal >40yo menorrhagia w IMB USS suggests polyp prior to endometrial ablation/diathermy before insertion of IUS if irreg cycles
causes of PCB
cervical Ca
cervical ectropion
cervical polyps
cervicitis/vaginitis
Ambiguous development and intersex
A) increased androgen fx in a genetic F
- Congenital adrenal hyperplasia is recessively inherited. Usually presents at birth w ambiguous genitalia. Tx = mineralcorticoid and cortisol replacement
B) reduced androgen fx in a genetic M
- appears to be female and dx is when ‘she’ presents w amenorrhoea
- absent uterus and rudimentary testes
PMS sx and tx
cyclical nature
tension, irritability, loss of control, bloatedness
GI upset and breast pain
tx = SSRI
cervical ectropion/erosion
= is when the columnar epithelium of the endocervix is visible as a red area around the os
Normal in preg, younger F or if on COCP
PC: PV d/c and PCB
Tx = cryotherapy AFTER smear (and colposcopy) has excluded Ca
Cervicitis
usually from STI
Cervical polyps
= benign tumours of endocervical epithelium
> 40yo
asx or cause IMB/PCB
Mx of abnormal smear
normal –> repeat every 3 years
mild dyskaryosis/borderline changes –> repeat in 6 months. if still present then colposcopy
mod dyskaryosis –> colposcopy
severe dyskaryosis –> urgent colposcopy
cervical glandular –> colopscopy, if abnormality not found then hysteroscopy
prevention of cervical Ca
- HPV vaccination
2. barrier contraceptive education
prevention of invasive cervical Ca
- LLETZ aka diathermy loop excision (complications incl: post-op haemorrhage and increased risk of pre-term delivery)
cervical Ca sx (if any)
MOST ARE SQUAMOUS CELL CARCINOMAS (some are adenocarcinomas)
- PCB
- offensive vaginal d/c
- IMB
(- PMB)
pain is NOT an early feature
tx of cervical Ca
- microinvasive ie.stage 1Ai –> cone bx (A cone biopsy is done less often than LLETZ. It: is a minor operation to cut out a cone-shaped piece of tissue containing the abnormal cells. only tends to be used if a large area of tissue needs to be removed.)
- -> simple hysterectomy - stage 1Aii-1Bi –> laparoscopic lymphadenectomy initially and if positive then straight to chemo-XRT.
Radical trachelectomy is for F who wish to preserve fertility.
NB/ Wertheine’s hysterectomy involves pelvic node clearance - other stage 1&2A: if LN -ve –> radical hysterectomy
if LN involved –> chemo-XRT - stage 2B+ or +ve LN –> chemo-XRT alone
Indications for chemo-XRT
o LN+ve on MRI or after lymphadenectomy
o alternative to radical hysterectomy even when LN -ve
o surgical margins unclear
o palliative XRT for bone pain or haemorrhage
Ovarian cyst accidents
= rupture of ovarian cyst contents into peritoneal cavity
- intense pain, esp w demoid cyst and endometrioma. Also caused by haemorrhage into a cyst or the peritoneal cavity (if severe e/n can cause hypovolaemic shock). As does torsion of pedicle
Common ovarian masses- pore and post menopausal
PREMENOPAUSAL OVARIAN MASS - benign epithelial tumour, follicular/lutein cysts, dermoid cysts, endometriomas
POSTMENOPAUSAL OVARIAN MASSES - benign epithelial tumour, malignancy
Endometriotic cyst/endometriomas = blood-filled chocolate cysts if seen in the ovaries, that are characteristic of endometriosis
Functional cysts = follicular (persistently enlarged follicles) and lutein cysts (persistently enlarged corpora lutea) are only in pre-menopausal F. COCP protects against functional cysts by inhibiting ovulation. Risk of malig so if >5mm for more than 2 months then CA125 levels measured and laparoscopy considered to remove or drain the large cyst
ovarian Ca
SILENT killer Ca presenting at stage 3-4;
- abdo distention/palpable mass
- pain or abnormal bleeding
- Breast and GI sx - commonly secondary ovarian met from breast or GIT Ca
RF = FHx, nulliparity, early menarche, late menopause
NB/signet ring = Krukenberg tumours
ovarian Ca mx
TAH w bilateral salpingo-oophrectomy (BSO) at staging laparotomy
Debulking all advanced tumours
Follow up w chemo (unless bordlerline or stage 1A)
Do not offer routine ‘second-look’ laparoscopy, but can monitor relapse using CA125 and CT
Causes of pruritus vulvae
o Candidiasis o vulval warts o pubic lices, scabies o derm eg.eczema, psoriaisis, lichen simplex [long hx of itching and soreness, inflamed labia majora, thickened w hyper/hypopigmentation, Avoid irritants such as soapUse emollients and steroid creams], lichen planus [causes irritation w flat, papular, purplish lesions in anogenital area, also affects hair, nails and mucous mem. Tx = high potency steroid creams], lichen sclerosis [Usually post-menopausal. ?AI co-existing w thyroid disease and vitiligo, soreness and pruritus, pink-white papules which coalesce to form skin resembling old-scribe papers w fissures. Can be ass/w malignancy, Tx = ultra potent topical steroids], contact dermatitis o Ca or premalignant stage
Bartholin’s glands if blocked –> cyst and abscess formation
If infx occurs (Staph and E.Coli) - acutely painful and large tender red swelling near the inner wall (because bartholin glands are behind the labia minora)
tx = incision and drainage, marsupialization
Congenital cysts
commonly arise in vagina
smooth white appearance
can be golf ball size and often mistaken for prolapse
tx = only excise of sx eg.dyspareunia
Vulval Ca causes
MOST ARE SQUAMOUS CELL CARCINOMAS
premalignant disease is VIN = presence of atypical cells in the vulval epithelium. 2x types of VIN
a) caused by HPV - responsible for the rare Ca in <45yo. Warty and basaloid lesion b) lichen sclerosis - major cause in >45yo, lesion is keratinizing
Although VIN is premalignant, vulval Ca often arises de novo and is ass/w lichen sclerosis, immunosuppression, smoking and Paget’s disease of vuvla
Vulva Ca sx, ix and tx
Primary vaginal Ca mainly in older F (PC = bleeding, d/c, mass, ulcer)
Clear cell adenocarcinoma of vagina in late teenage years
PC - pruritus, bleeding, d/c, mass
ix - bx
1A –> wide local excision w/o lymphadenectomy
others –> wide local excision w separate groin node dissection
post op XRT if LN +ve, or pre-op to shrink or for palliation
Prolpase RF and sx
RF = childbirth, vaginal birth, oestrogen deficiency, obesity and chronic cough, congenital weakness, pelvic masses
dragging/lump sensation - worse at end of day
o severe prolapse may interfere w sexual intercourse, bleed, d/c or ulcerate. Cystocele –> urinary freq and incomplete bladder emptying.Rectocele –> difficulty defecating.
BACK PAIN IS UNUSUAL
Prolapse mx
conservative - weight loss, stop smoking,
(Ring usually, shelf if severe) pessaries for those unfit for surgery; they act like artificial pelvic floor, changed yearly
uterine prolapse –> vaginal hysterectomy (sacrohysteroplexy if want to maintain fertility)
Cystocele –> anterior repair
Rectocele –> posterior repair NB/cystoceles and rectoceles are collectively known as vaginal wall prolapses
Vault prolapse –> sacrocolpoplexy
‘Tape’ surgery for genuine stress incontinence
Genuine stress incontinence definition
= involuntary loss of urine when bladder pressure exceeds maximum urethral pressure in the absence of detrusor contraction
dx only confirmed after ruling out overactive bladder using cystometry
SUI RF
Hx: ask about faecal incontinence as well! ADL - ask pt to prioritise the sx as tx varies!
pregnancy vaginal delivery (esp prolonged or instrumental labour) obesity incr age prolapse commonly co-exists previous hysterectomy
Mx of SUI
conservative - weight loss, stop smoking, treat chronic cough or constipation
1, PFE +/- vaginal cones for at least 3 months
- cystometry to exclude OAB
- ‘Tape’ surgery
- Surgery = Open Burch Colposuspension
- Medical = Duloxetine (serotonin reuptake inhibitor)
Genuine stress incontinence vs SUI
GSI = a DISORDER diagnosed only after cystometry, of which stress incontinence is the major sx
stress incontinence is a SYMPTOM, can be due to GSI, OAB or overflow incontinence
OAB definition
= urgency w or w/o urge incontinence, usually w freq or nocturia in the absence of proven infx. SUI is common. Leakage at night or at orgasm. Faecal urgency. Hx of childhood enuresis. High caffeine/energy drink intake.
Whereas…
Detrusor overactivity is a urodynamic dx char by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked by coughing
OAB mx
- conservative - if excessive, reduce caffeine/fluid intake
Commence bladder training for at least 6 weeks (void by the clock at regular intervals rather than at desire). Stop smoking and reduce weight. - medical - antimuscarinic eg. oxygbutynin or tolterodine
- Botox lasts for 6 months or sacral nerve stimulation
Acute urinary retention
pt unable to pass urine for 12hr; it is painful and catheterisation is maintained for 48hr while the cause is treated
Painful bladder syndrome
and interstitial cystitis
PBS = pt experiences suprapubic pain related to bladder filling, accompanied by freq and nocturia, in the absence of proven pathology
Interstitial cystitis is confined to pt w painful bladder sx who have characteristic cystoscopic and histological features. Tx = TCA, baldder trainig, analgesics.
Endometriosis
result of retrograde menstruation
= growth of endometrial tissue outside the uterus; oestrogen dependent therefore regresses after the menopause and during pregnancy
accumulated altered blood is dark brown –> chocolate cysts aka endometrioma in the ovaries
Endometriosis can cause inflammation, progressive fibrosis and adhesions (serious enough to render all pelvic organs to be immobile!)
Endometriosis sx
- Chronic pelvic pain - CYCLICAL
- dysmenorrhoea (painful periods) before onset of menstruation…may be relieved by period
- DEEP dyspareunia
- subfertility
- dyschezia (the ectopic tissues can be anywhere!) during menses
- subfertility (due to the adhesions! if v severe, may req IVF)
Rupture of a chocolate cyst (blood filled sac) can cause acute pain
O/E: tenderness and thickening behind the uterus or in the adnexa on VE. Uterus may be retroverted and immobile (due to adhesions)
Endometriosis ix
can only be diagnosed w visualisation (laparoscopy) +/- bx. Active lesions are red vesicles or punctate marks on the peritonium.
TVUS to exclude ovarian endometrioma
MRI to exclude adenomyosis
Endometriosis ddx
Adenmyosis
Chronic PID
Chronic pelvic pain
IBS
Endometriosis mx
asx –> no tx
Can just use analgesics. OR
Trial of hormonal drug to suppress ovarian activity (based on the evidence that sx regress during pregnancy [prescribe COCP or progestogens eg, ED pill or IUS], post-menopausally [GnRH analogues induces a temporary menopausal state] or androgenic [danazol but rarely used due to severe SE]).
NB/COCP is often taken back-to-back w/o a break to reduce the freq of painful w/d bleeds.
MEDICAL TX DOES NOT IMPROVE FERTILITY|!!!
Surgical - Ablation (using either diathermy, laser, microwave or balloon) can be used at time of laparoscopy (‘see and treat’) - this improves fertility! Laser ablation +/- adhesiolysis
Other radical surgeries are dissection of adhesions and removal of ovarian endometriomata, or even a hysterectomy w BSO (LAST RESORT - usually if severe and older F!)
Progestogens
Progesterone is the natural type of progestogen, which is a class of hormones that also includes all of the other synthetic progestogens
systemic progestogen SE
fluid retention
erratic bleeding
PMS
weight gain
Chronic pelvic pain
= intermittent or constant pain in lower abdo or pelvis of at least 6 months, not occurring exclusively w menstruation or intercourse
- migraine
- low back pain
Exclude endometriosis, adenomyosis, IBS [trial of antispasmodics], psych factors. Prescribe analgesic. F w cyclical pain –> COCP or GnRH for 3-6 months before diagnostic laparoscopy.
Candidiasis/thrush
= infx w Candida Albicans (fungus). NON-sexually transmitted
RF = pregnancy, DM, abx use
- asx or cottage cheese d/c w vulval irritation and itching
- superficial dyspaneuria and dysuria might occur
- inflamed and red vagina/vulva
tx = topical imidazoles eg.Canesten or oral fluconazole
Bacterial Vaginosis (BV)/ Gardnerella/anaerobic vaginosis
= overgrowth of mixed vaginal flora incl anaerobes eg.Gardnerella and mycoplasma hominis. NON-sexually transmitted
- grey white d/c
- fishy odour (from amines released by bacteria)
- vulva and vagina NOT red NOR itchy
dx by raised pH, fishy grey white d/c, positive ‘whiff’ test, clue cells on microscopy
tx = metronidazole or clindamycin cream
chlamydia trachomatis
= a bacterial infx
- usually asx but can cause urethritis and vaginal d/c
dx = NAAT or PCR, NOT seen on microscopy
chlamydia -> PID (tubal damage, subfertility,chronic pelvic pain)
-> Reiter’s syndrome (urethritis, conjunctivitis, arthritis)
tx = doxycycline or azithromycin
Neisseria Gonorrhoeae
= a bacterial infx
- usually asx but can cause urethritis, vaginal d/c, bartholinitis, cervicitis
dx = gram - diplococcus on microscopy + endocervical swabs
gonorrhoeae -> bacteraemia
-> acute septic arthritis
tx = penicillin, ciprofloxacin, or CEFTRIAXONE
Genital warts/Condylomata acuminata
= HPV 6&11 viral infx
- can range from looking like tiny flat patches on vulval skin to cauliflower (papilliform) swellings
tx = podophyllin or imiquimod cream
cryotherapy or electrocautery for resistant warts
high reccurence rate
Genital herpes
= herpes simplex virus type 2 infx (type 1 causes cold sores)
- primary infx w MULTIPLE small PAINFUL vesicles and ulcers around the introitus
- local lymphadenopathy
- dysuria
- systemic sx
- reactivation w secondary infx is less painful and preceeded by localised tingling
tx = aciclovir
Syphilis
= Spirochaete infx by treponema pallidum
- primary Syphilis is a Solitary painleSS vulval lucer (chancre)
- untreated secondary syphilis may develop weeks later w a rash, flu-like sx, warty genital or perioral growths (condylomata lata)
- Latent syphilis follows, as does tertiary/neurosyphilis
tx = parenteral (usually IM) penicillin
Trichomoniasis
= flagellate protozoan infx of trichomonas vaginalis
- offensive grey-green d/c
- vulval irritation
- superficial dyspareunia
- cervicitis w a punctate erythematous ‘strawberry’ appearance
tx = metronidazole
genital ulcer causes
herpes (HSV type 2) syphilis chancroid (haemophilus ducreyi) lymphogranuloma venereum (subtype of chlamydia trachomatis) donovanosis/granuloma inguinale
HIV RF
NB/ CD4 <200 or development of opportunistic infx/Ca eg.cervical is diagnostic of AIDS
multiple sexual partners partners and self from high prevalence countries partner w known HIV status failure to use barrier contraception presence of other UTIs CSW or been paid for sex IVDU sexual contact w high risk men eg.MSM
Acute pelvic infx or PID
RF = younger, sexually active nuliliparous F
is an inflammatory and infectious disease, and is a complication of a sexually transmitted disease; ascending infx of the bacteria in the vagina and cervix - usually chlamydia
Endometritis usually co-exists, as might bilateral salpingitis
- perihepatitis presents w RUQ pain (due to adhesions)
- asx (esp chlamydial)
- bilateral lower abdo pain
- vaginal d/c
- signs of lower abdo peritonism w bilateral adnexal tenderness and cervical excitation
- fever, raised WCC and raised CRP
Acute PID ix
Endocervical swab for chlamydia
blood cultures if signs of infx
pelvic USS to exclude abscess or ovarian cyst
laparoscopy w fimbrial bx and culture is gs
Acute PID tx
- parenteral cephalosporin eg. IM ceftriaxone
- followed by doxycyclin/oflaxcin + metronidazole
- analegesic
febrile pt should be admitted for IV therapy. Pelvic absecess may req draining
compl of PID -> abscess formation or pyosalpinx
- > tubal obstruction and subfertility, chronic pelvic infx, chronic pelvic pain - > ectopic pregnancy
causes of vaginal d/c
physiological candidiasis BV atrophic vaginitis cervical eversion and ectropion
chronic PID
results of untreated/inadequately treated acute PID
- dense pelvic adhesions and obstructed fallopian tubes, possibly dilated w fluid or pus
- chronic pelvic pain
- dysmenorrhoea
- deep dyspareunia
- heavy and irregular menstruation
- chronic vaginal d/c
- subfertility
- OE similar to endometrosis w abdo and adnexal tenderness and a fixed retroverted uterus
tx = analgesics, sometimes adhesiolysis and salpingectomy is required
subfertility definition
conception has not occured after a year of regular unprotected intercourse
PCOS
many PCOS pt have fhx of T2DM: peripheral insulin resistance and insulin incr androgen production.
2 out of 3:
o PCO = 12+ follicles in an enlarged ovary, on USS
NB/PCO is genetic
o irregular periods = >35 days apart
o hirsutism = clinically w acne or XS body hair, OR biochemically w raised serum testosterone
PCOS sx
- subfertility (one of the PCOS criteria is irregular periods)
- oligomenorrhoea oe amenorrhoea
- hrisutism (acne or XS body hair)
- obesity
- m/c
PCOS ix
TVUS
Anovulation is investigated w FSH (raised in ovarian failure, low in hypothalamic diesase, normal in PCOS)
LH (not much use), TSH
low luteal phase progesterone if anovulatory
prolactin (to exclude prolactinoma)
hirsutism is investigated w serum testosterone levels (raised in androgen secreting tumour or congenital adrenal hyperplasia)
fasting lipids and glucose to screen for complications
PCOS complications
infertility
obesity
m/c
LONG TERM RISKS
T2DM
Endometrial Ca (if persistent amenorrhoea/anovulation due to unopposed oestrogen action)
PCOS symptomatic tx (other than subfertility)
weight reduction
balanced diet
COCP will regulate menstruation and treat hirsutism, at least 3-4 bleeds/yr
antiandrogen acetate or spironolactone for hirsutism
metformin reduces insulin levels therefore reducing levels of androgens and hirsutism
Causes of anovulation
PCOS
Premature ovarian failure (no ovarian folllicles present; bone protection w HRT or COCP req)
hypothalmic hypogonadism (reduction in GnRH release which reduces stimulation of pit gland to produce FSH and LH) - common in AN
hyperprolactinaemia (in turn reduces GnRH release)
thyroid disease
Advice for induction of ovulation
normal weight
stop smoking
folic acid and risk of multiple pregnancies w ovulation induction
tx of specific causes
PCOS tx (re: ovulation induction)
- Clomifene (max 6 month use) - for ovulation induction; = anti-oestrogen at the hypothalamus and pit gland therefore incr release of FSH and LH. Need USS monitoring in case of multiple follicle maturation
If clomifene resistance…
- Metformin (insulin sensitising drug)
- gonadotrophins
- Laparosocopic ovarian diathermy
- IVF
hypothalamic hypogonodism tx (re: ovulation induction)
reduce weight
if weight normal, then gonaotrophins
hyperprolactinaemia (re: ovulation induction)
bromocriptine or cabergoline
Azoospermia
NO sperm present
ix = examine for presence of vas deferens, check karyotype eg.Klinefelter’s 47XXY, CF, hormone profile
tx = surgical sperm retrieval then IVF + ICSI or donor insemination
Oligospermia
reduced sperm count
tx = intrauterine semination, IVF +/- intracytoplasmic sperm injection (ICSI)
Asthenospermia
astheno = w/o strength
poor motility sperm
Teratospermia
terato = monster
morphologically defective sperms
leucospermia
infection
semen analysis
last ejaculation 2-7 days ago
if abnormal, repeat after 70 days, examine the scrotum, reduce smoking, drinking, drug use eg.sulfasalazine for RA or anabolic steroids
reduce exposure to industrial chemicals
wear loose clothing and testicular cooling
Causes of fertilization failure
tubal damage
- infx eg.PID from chlamydia –> adhesiolysis and salpigostomy (incr rate of ectopic!)
- endometriosis –> laparoscopic surgery to remove endometriotic deposits
- adhesions from surgery
cervical problems
sexual problems
Detection of tubal damage in subfertility
- Firstly hysteroscopy needs to be performed first to assess the uterine cavity for abnormalities
- Laparoscopy and dye test allows visualisation and assessment of fallopian tubes. methylene blue dye is injected through the cervix from the outside and can see if it enters or spills from the tubes to test if they are patent
- hysterosalpingogram - w/o anaesthetic radio-opaque contrast is injected through the cervix to look for spillage using XR. A variant of this is HyCoSy where TVUS and US opaque liquid is used instead, reserved for F w no RF for tubal disease
Indications for assisted conception
when all other methods have failed unexplained subfertility male factor subfertility [ICSI] tubal blockage [IVF] Genetic disorders
Assisted conception methods
intrauterine insemination IVF intracytoplasmic sperm injection oocyte or sperm donation surrogacy
can offer preimplantation genetic diagnosis to >37yo F
Complication of assisted conception
Superovulation leading to multiple pregnancies
egg collection can lead to intraperitoneal haemmorhage and pelvic infx
incr risk of ectopic preg
PCOS tx overview
if infertility –> clomifene, +metformin, ovarian diathermy, , gonadotrophins, IVF
if menstrual problems –> COCP
if acne/hirsutism –> cosmetic tx, COCP +/- cyproterone acetate, spironolactone, eflornithine facial cream
Common progestogenic SE
BREAST TENDERNESS mood changes like depression erratic bleeding or amenorrhoea acne weight gain reduced libido
Common oestrogenic SE
nausea
headache
BREAST TENDERNESS
fluid retentino and weight gain
COCP missed pill rule
vomit w/i 2hr –> take another pill and follow MPR
severe diarrhoea –> continue pills and follow MPR
MPR =
one or two missed pills anywhere in the cycle is ok.
take the missed pill asap, even if 2 at the same time. then continue the pack as normal.
if more than 2 pills missed then use condoms for 7 days.
COCP and pre-op
stop 4 weeks before surger due to prothrombotic risks
COCP complications
VTE CVA - MI and strokes HTN focal migraines jaundice liver, cervical and breast Ca
risk is increased by smoking, incr age and obesity
absolute CI to COCP
- hx of VTE
- inherited thrombophilia
- > 35yo smoker >15/day
- BMI>40
- DM w vascular complications
- hx of MI/stroke, IHD, severe HTN
- migraine w aura
- active breast/endometrial Ca
- active/chronic liver problems
Relative CI to COCP
age >40yo chronic inflammatory disease renal impairment, DM BMI 35-40 BF and upto 6 months post partum (because lactation is partly suppressed so the piil in CI in puperium is relative CI upto 6 months post partum)
common minor SE to COCP
nausea, headache, BREAST TENDERNESS
breakthrough bleeding in firth few months but tends to settle shortly
Benefits to COCP
3 per 1000 women get pregnant
regular, less painful and lighter periods
improves acne and hirsutism
protects again ovarian, endometrial and bowel Ca
POP (progestogen-only pill)/ED pill/ mini pill
An alternative to COCP because no CI ;D
same time every day w/o a break
common SE: period changes (erratic or amenorrohoea), weight gain, mood changes eg.depression or PMS, breast tenderness
MPR = take next one as soon as possible. if >3hr late, use condoms for 2 days
complications of intrauterine devices
E and the 6P’s
expulsion - usually w/i 1st month
Perforation - of uterine wall at time of insertion
Pain
Period changes - heavier or more painful (except w progestogenic devices)
PID incr risk
Pregnancy more like to be ectopic
Progestogenic effects on period…
LIGHTER! But may be heavier or more erratic
Absolute CI to intrauterine devices
Endometrial or cervical Ca
undiagnosed PV bleed
Active/recent pelvic infx
current breast Ca (for progestogenic IUS only)
Relative CI to intrauterine devices
Previous ectopic preg
young/nuliparous
immunocompromised incl HIV +ve
Depot progestogens
IM depo-provera every 3 months
S= progestogenic + prolonged amenorrhoea and reversible bone loss
IUD
prevents implantation
can be kept in upto 10 years, but replaced b/t 5-10yr
cause of PMB
endometrial Ca endometrial hyperplasia +/- atypia and polyps cervical Ca atrophic vaginitis cervicitis ovarian Ca Cervical polyps
menopause
Premature menopause
permanent cessation of menstruation; 12 consecutive months of amenorrhoea
premature if <40yo
PMB ix
bimanual
speculum
cervical smear
TVUS
Early menopause effects
Psychological sx eg.depression, mood swings
vasomotor sx eg.hot flushes, night sweats –> sleep disturbance,
Intermediate menopause effects
skin atrophy
hair thinning
vaginal atrophy can cause burning, itching or pain during sex
urinary sx eg.freq, urgency, nocturia, recurrent infx
Late menopause effects
CVA eg. MI and strokes (due to oestrogen deficiency) and cardiac disease
osteoporosis ie. weak bones that predispose to an incr risk of fracture (osteopenia = weak bones)
