Gyn Flashcards
1
Q
Chlamydia background
A
Epidemiology
- most common bacterial infection
- > more common in women
- risk factors
- > young adult (<25yrs)
- > new/multiple sex partner
- > partner with chlamydia
- > infrequent condom use
- > previous STD
- > urban
- coinfection common
- > gonorrhoea
- > trichomonas
- > m genitalium
Aetiology
- sexual transmission
- > cervix < - > urethra (approx 75% partners affected)
- > urethra < - > rectum (transmission rate much lower)
- infects
- > columnar epithelial cells cervix
- > urethra
- > bartholins glands
- > fallopian tubes
- > anus
- does not infect squamous cells of vagina
Pathophys
- structure
- > gram negative bacteria
- > obligate intracellular organism
- life cycle
- > spore like elementary body attaches to epithelium
- > enter and surround by vacuole (inclusion)
- > transforms to larger/metabolically active reticulate body
- > replicates over 3 days
- > transforms back into elementary bodies
- > cell rupture and spread
- incubation period up to 2 weeks
2
Q
chlamydia syndrome
A
Women
- cervicitis
- > vast majority asymptomatic
- urethritis
- > 50% of infections
- PID and sequelae
- pregnancy
- > premature rupture of membranes
- > preterm birth
- > low birth weight
- > chorioamnionitis
Men
- urethritis
- epididymitis
- > unilateral pain/tenderness
- > hydrocele
- > swollen epididymis
Common to men and women
- conjunctivitis
- > by direct inoculation with genital secretions
- > erythematous injection of conjunctiva
- > non purulent
- reactive arthritis
- > acute onset several weeks post infection
- > asymmetric, oligoarticular
- > enthesitis
- > dactylitis
- > inflammatory lower back pain
- reiters syndrome (classic triad)
- > arthritis
- > conjunctivitis/uveitis
- > urethritis/cervicitis
- proctitis
- > pain
- > discharge
- > bleeding
- > tenesmus
- > constipation
3
Q
gonorrhoea background
A
Epidemiology
- approx 5/10,000 gen pop
- > 200 times more common in ATSI
- risk factors
- > ATSI
- > MSM
- > under 25yrs
- > new/multiple sex partners
- > partner with STD
- > inconsistent condom use
- > past STD
Aetiology
- penetrative sex
- > oral
- > vagina
- > rectum
- transmission rate
- > male to female = 60%
- > female to male = 25%
Pathophys
- attaches to mucosal epithelium
- chromosomal plasticity
- > evades immune system
- > high rate of antimicrobial resistance
- > reinfection common
- incubation period
- > approx 3 days in men
- > longer in women
4
Q
gonorrhoea syndromes
A
Women
- cervicitis
- > most common
- > usually asymptomatic
- urethritis
- > almost always with cervicitis
- > usually asymptomatic
- PID and sequelae
- bartholinitis
- > with cervicitis
- > perilabial pain and discharge
- > oedematous/tender labia
- pregnancy
- > PPROM
- > premature delivery
- > low birth weight
- > chorioamnionitis
Men
- urethritis
- prostatitis
- > lower back pain
- > dysuria
- > frequency/urgency
- epididymitis/orchitis uncommon
Both
- proctitis
- > pain
- > discharge/bleeding
- > tenesmus/constipation
- pharyngitis
- > oral sex
- > pharyngitis
- > exudate
- > cervical lymphadenopathy
- conjunctivitis
- > by direct inoculation with anogenital secretions
- > hyperacute (symptoms within 12 hrs)
- > copious purulent discharge
- > red and irritated
- > chemosis/swollen eyelids
- > preauricular lymphadenopathy
- > sight threatening
- purulent arthritis (disseminated disease)
- > acute onset
- > distal/asymmetric/oligoarticular arthritis)
- > otherwise well
- arthritis-dermitis syndrome (disseminated disease)
- > several weeks post infection
- > flu like illness with fever
- > asymmetric, migratory polyarthritis
- > tenosynovitis
- > pustular/vesicular lesions on extremities
5
Q
causes cervicitis
A
Infectious
- endocervix
- > chlamydia (most common overall)
- > gonorrhoea
- ectocervix
- > HSV
- > trichomonas
- other
- > tuberculosis
- > mycoplasma genitalium
- > GAS
Non infectious
- mechanical
- > condoms/diaphragms/tampons
- > surgical instrumentation
- chemical
- > latex
- > douching
- > spermicides
- systemic disease
- > bechets
- > lichen planus
6
Q
evaluation cervicitis
A
Hx
- mucopurulent discharge
- abnormal bleeding
- > post coital
- > intermenstrual
- dyspareunia
- vulvovaginal irritation/pruritis/burning
- with concomitant urethritis
- > dysuria
- absence
- > abdo/pelvic pain
- > fever
- presence of risk factors
Exam
- abdo
- > tenderness?
- speculum
- > erythematous/oedematous vulva (may be normal)
- > erythematous/tender vagina
- > oedematous/erythematous/friable cervix with discharge
- typical lesions
- > strawberry cervix = trichomoniasis
- > ulcerations/vesicles = HSV
- bimanual to exclude PID
- > cervical motion/uterine/adnexal tenderness?
Investigations
- b HCG
- NAAT
- > men = first catch urine/urethral swab
- > women = first catch urine/self swab/endocervical swab
- Culture (gonorrhoea sensitivity)
- > thayer martin/charcoal enriched swab
- > male = clinician urethral
- > female = endocervical
- Gram stain (provisional dx from gram -ive diplococci)
- > male urethritis only (clinician collected)
- Consider if typical lesions
- > HSV serology
- Consider if high risk/STI confirmed
- > HIV
- > syphilis
- > Hep B/C
Empiric management
- if concern for PID in high risk
- > empiric PID treatment
- if high risk
- > consider empiric chlamydia treatment
Gonorrhoea management
- targeted antibiotics
- > ceftriaxone 500mg IM single dose
- test of cure unnecessary
- contact tracing/prophylactic treatment
- > sexual partners for past 2 months
- avoid sex for 7 days
- > post treatment of index patient and partner
Chlamydia management
- targeted antibiotics
- > azithromycin 1g oral single dose
- > doxycycline 100mg oral BD 1 week
- test of cure at 3 weeks
- > pregnant
- > PID
- contact tracing/prophylactic treatment
- > sexual partners for past 6 months
- avoid sex for 7 days
- > post treatment of index patient and partner
7
Q
PID background
A
Epidemiology
- most common gynaecological reason for hospitalisation
- risk factors
- > under 25
- > multiple partners/new partner
- > infrequent condom use
- > previous STD/partner with STD
Aetiology
- majority
- > chlamydia
- > gonorrhoea
- occassionaly
- > mycoplasma genitalium
- > gram negative enterics
- > haemophilus influenzae
Pathophys
- infection of cervix with chlamydia/gonorrhoea
- > disruption of protective barrier
- > ascent of micro-organisms
- complications
- > recurrence
- > chronic pain
- > tuba-ovarian abscess
- > hydro-salpinx
- > ectopic pregnancy
- > infertility (<20%)
- > fitz-hugh curtis syndrome
8
Q
PID evaluation
A
Hx
- may be asymptomatic
- lower abdo pain
- > often bilateral
- > worse with jarring movements
- > may have RUQ pain
- nausea/vomiting
- abnormal vaginal bleeding
- > intermenstrual
- > post-coital
- > menorrhagia
- mucopurulent discharge
Exam
- fever
- abdo
- > tenderness (bilateral)
- > rebound tenderness/bowel sounds?
- speculum
- > discharge at endocervix
- bi-manual
- > cervical motion tenderness
- > uterine tenderness
- > adnexal tenderness
- Beta HCG
- Vaginal discharge wet mount
- > absence of WCC has negative predictive value
- Endocervical swab
- > NAAT for gonorrhoea/chlamydia
- > culture for gonorrhoea
- FBC
- CRP/ESR
- Consider
- > blood cultures
- > US of fallopian tubes/ovaries/endometrium (severe)
- > CT (peritonitis/equivocal US)
- > laparoscopy (complicated/resistant/ddx suspected)
- If high risk
- > HIV/HBV/HCV/syphilis
9
Q
PID management
A
Empiric management
- criteria
- > high risk
- > lower abdo pain/positive bi-manual
- regime
- > cetriaxone 500mg IM single dose
- > azithromycin 1g oral single dose
- > metronidazole 500mg BD for 10 days
Additional
- Analgesia
- Patient education
- > causes/risks/prevention
- > prognosis/complications
- > avoid intercourse for 7 days post treatment
- Insufficient evidence for removal of IUD
- Disposition
- > generally outpatient
- > inpatient if resistant/severe/complications
- Safety net
- > reassess in 24-48hrs
- > present to hospital if its gets worse
- Contact tracing
- > any partner within 60 days = investigation
- > no partner within 60 days = last partner
- > consider empiric treatment
- Test of cure
- > repeat chlamydia/gonorrhoea within 3 months
10
Q
PCOS background
A
Epidemiology
-approx 10% of women of reproductive age
Aetiology
- unknown
- heritability = approx 75%
- > multiple genes contributing small risk
- environmental
- > obesity and hyperinsulinaemia
- > congenital adrenal hyperplasia and androgenism
Pathophys
- Functional ovarian hyperandrogenism
- > dysregulated LH driven thecal androgen production
- > causes hirsutism
- > high androgens = increased primary follicle recruitment
- > increased synergism with FSH = premature luteinization
- > increased recruitment + premature luteinization = PCOM + oligo-anovulation
- Insulin resistant hyperinsulinism
- > causes and worsened by obesity
- > sensitises theca cells to LH = increased androgens
- High LH
- > androgen excess disturbs sex steroid inhibition of LH
- > high insulin decreases SHBG by liver
- Excess adrenal androgens
- > enhanced responsiveness to ACTH
- > similar action to ovarian androgens
11
Q
PCOS evaluation
A
Hx
- often presents in puberty
- hirsutism/acne/alopecia
- oligo-anovulation
- > primary amenorrhoea (no menarche by 15)
- > secondary amenorrhoea (no menses for three cycles)
- > oligomenorrhoea = <9 menses/year (less during puberty)
- > AUB = menses <21 apart/ >7 days long/ very heavy
- weight gain
- infertility
- medications associated with hirsutism?
Exam
- HTN
- hyperandrogenism
- > male hair growth/loss
- > acne
- > deep voice/clitoromegaly/increased muscle mass
- obesity
- acanthosis nigricans
- abdo exam
- > adrenal tumour
- pelvic exam
- > ovarian tumour
Investigations
- Androgens (day 3 follicular phase)
- > total and free (SHBG) testosterone
- > dehydroepiandrosterone sulfate (DHEA-S)
- > androstenedione (A4)
- 17 hydroxyprogesterone
- > early morning during (day 3 follicular phase )
- > anytime if amenorrhea
- > low rules out non classic congenital adrenal hyperplasia
- Luteal phase (7 days before menses) progesterone
- > high levels = ovulation
- Rule out other causes oligomenorrhoea/anovulation
- > b HCG = pregnancy
- > prolactin = prolactinoma
- > TSH = hypothyroidism
- > LH:FSH = >3 in PCOS, low in hypothalamic disease
- Tranvaginal ultrasound (if criteria not already met)
- > PCOM = ovarian volume >10mL/12 follicles in either
- Additional tests
- > GTT
- > lipids
Diagnosis
- 2/3 (all three for puberty) of Rotterdam criteria
- > oligo/an-ovulation (present for 2yrs if pubertal)
- > PCOM
- > clinical or biochemical hyperandrogenism
- exclude other causes
12
Q
Hirsutism ddx
A
PCOS + CODEIN
- Cushings
- > disease (corticotroph adenoma)
- > syndrome (adrenocortical tumour)
- Ovarian tumour
- > sertoli-leydig
- > theca-granulosa
- Drugs
- > phenytoin
- Endocrine
- > hypothyroidims
- > prolactinoma
- > acromegaly
- Idiopathic
- Non classical congenital adrenal hyperplasia
13
Q
primary amenorrhoea background
A
Epidemiology
-<0.1%
Aetiology
- Hypothalamus
- > constitutionally delayed growth and puberty
- > idiopathic hypogonadotropic hypogonadism
- > Kallman’s syndrome
- Pituitary
- > prolactinoma
- Ovaries
- > PCOS
- > primary hypogonadism (Turner’s/injury/insult)
- > androgen insensitivity syndrome
- Uterus/cervix/vagina
- > mullerian agenesis
- > transverse vaginal septae
- > imperforate hymen
- Adrenal
- > NCCAH
- Thyroid
- > hypothyroidism
- Systemic (functional hypothalamic amenorrhoea)
- > anorexia nervosa
- > excessive weight gain/loss
- > stress
- > female athlete triad
14
Q
primary amenorrhoea evaluation
A
Hx
- no menarche by age 15 +/- pubarche
- Hypothalamus
- > pubertal development (constitutional delay)
- > stress/weight gain and loss/eating/ exercise
- > anosmia
- Pituitary
- > headaches
- > blurred/loss vision or diplopia
- > galactorrhea
- Ovaries
- > stature relative to family (Turners)
- > hirsutism/acne/weight (PCOS)
- Uterus
- > cyclical pelvic pain (anatomical abnormality)
- Adrenals
- > neonatal crisis (NCCAH)
- Additional
- > family hx of delayed puberty (constitutional)
- > medications
Exam
- height/weight/BMI
- inspect
- > acne/hirsutism/pigmentation/virilisation
- > syndromic features
- > pubertal development
- > outflow tract abnormalities
- consider
- > neuro exam for pituitary mass
- > bi manual for outflow tract abnormalities
bHCG
TSH
prolactin
FSH and estradiol
-high FSH/low estradiol = primary ovarian failure (Turners)
-low FSH/low estradiol = hypothalamic failure
Ultrasound pelvis
-presence/absence of uterus/ovaries/cervix
Consider
- Karyotyping
- > if uterus present/high FSH = Turners
- > if uterus absent = 46 XX (genesis)/46XY (androgen insensitivity syndrome)
- Androgens (PCOS)
- > presence of hirsutism/acne/virilisation
- MRI brain (sellar mass)
- > if uterus present/low FSH/no breast development
- > no mass = constitutional/functional hypothalamic/idiopathic hypogonadotropic hypogonadism
15
Q
secondary amenorrhoea background
A
Epidemiology
-approx 3%
Aetiology
- Hypothalamus
- > weight loss/athlete triad/anorexia
- Pituitary
- > prolactinoma (inhibits GnRH)
- Thyroid
- > hypothyroid (high TRH increase prolactin release)
- Ovaries
- > PCOS
- > premature ovarian failure (radiation/chemo/fragile X/autoimmunity)
- Uterus
- > pregnancy
- > ashermans
Hx
- pregnancy risk/symptoms
- hypothalamus
- > stress/eating/exercise
- > medications (COCP/antipsychotics/metaclopramide)
- pituitary
- > headache/vision changes/galactorrhoea
- ovaries
- > hirsutism/acne/virilisation
- > menopause symptoms
- uterus
- > bleeding/infection/curretage
Exam
- height/weight/BMI
- inspect
- > virilisation/pigmentation
- > galactorrhoea
- > vaginal atrophy
bHCG FSH and estradiol ->both low = hypothalamus/pituitary disease ->FSH high/estradiol low = POI prolactin TSH
Consider
- PCOS testing
- karyotyping if FSH high
- MRI brain if FSH/estradiol low
- progestin challenge if normal labs
- > 10mg medroxyprogesterone for 10 days
- > absence of bleeding supports ashermans
