Gynae 1 Flashcards
(42 cards)
1
Q
What is adenomyosis?
A
When the endometrium grows into the myometrium
Similar to endometriosis but not the same:
Endometriosis = endometrial cells existing outside of the uterus
2
Q
What are the S/S of adenomyosis?
A
- Menorrhagia ± dysmenorrhoea
- Chronic pelvic pain (more so during menstruation)
3
Q
When does adenomyosis present?
A
Most women are in their later childbearing years, between 35 and 50
The major symptoms go away after menopause.
4
Q
What are the investigations for adenomyosis?
A
- Bimanual: Bulky and sometimes tender ‘boggy’ uterus (enlarged, soft, and tender uterus / more flaccid than expected)
- USS: Haemorrhage-filled, distended endometrial glands, may show an irregular nodular development (similar to fibroids)
- MRI pelvis: GOLD STANDARD - thickening of junctional zone exceeding 12 mm
5
Q
What is the management of adenomyosis?
A
Adenomyosis often goes away after menopause, so treatment might depend on how close you are to that stage of life.
- 1st line = LNG-IUS ± NSAIDs
- Hysterectomy is the only definitive treatment
If amenorrhoea induced, ectopic endometrium becomes quiescent
+DUB/fibroids management pathway
6
Q
What are the causes of primary amenorrhoea?
A
- Turner’s syndrome
- Androgen insensitivity (testicular feminisation)
- Congenital adrenal hyperplasia
- Congenital malformations of the genital tract
- Imperforate hymen
7
Q
What are the causes of secondary amenorrhoea?
A
- Hypothalamic amenorrhoea (e.g. secondary to stress, excessive exercise, anorexia)
- Polycystic ovarian syndrome (PCOS)
- Hyperprolactinaemia
- Premature ovarian failure
- Thyrotoxicosis (hypothyroidism)
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
8
Q
What is an imperforate hymen?
A
A condition in which the hymen covers the entire opening of the vagina, blocking the vaginal opening
- All other sexual characteristics developed, but has amenorrhoea and cyclical pelvic pain
- USS will show haematometra (a collection or retention of blood in the uterus)
9
Q
What are the investigations for amenorrhoea?
A
- Serum/urine b-HCG (exclude pregnancy)
- Bloods: FBC, U&Es, TFTs, coeliac screen
- Gonadotrophins: Low levels indicate hypothalamic cause, raised levels indicate ovarian problem (e.g. POI) or gonadal dysgenesis (e.g. Turner’s syndrome)
- Prolactin (prolactinoma)
- Androgens (raised in PCOS)
10
Q
What is Asherman’s syndrome?
A
Presence of intrauterine adhesions that may partially or completely occlude the uterine cavity.
11
Q
What is the aetiology of Asherman’s syndrome?
A
- Damage to endometrium involving the basal layer, owing to factors such as trauma (from instrumentation, surgery, dilatation and curettage) or infection
- Leads to fibrosis and adhesion formation
12
Q
What are RFs for Asherman’s syndrome?
A
- Endometrial resection
- Excessive curettage (e.g. following miscarriage, termination)
- Surgery (myomectomy, C-section)
- Endometriosis
13
Q
What are the S/S of Asherman’s syndrome?
A
- Amenorrhoea
- Cyclical abdominal pain
- Subfertility
- Often no external physical signs
14
Q
What are the investigations for Asherman’s syndrome?
A
- sHCG
- Bloods: TFTs, FSH, LH, prolactin, oestradiol - normal
- Hysterosalpingogram - irregular, scattered contour of contrast within endometrial cavity
- Pelvis USS
- Hysteroscopy - gold standard diagnostic
15
Q
What is the management of Asherman’s syndrome?
A
Hysteroscopic adhesiolysis
Post procedure:
- Copper IUCD placed in cavity to prevent adhesions forming
- PO oestrogens (induce endometrial proliferation)
- Reassess cavity after 2-3 months after treatment
16
Q
What is atrophic vaginitis?
A
Vaginal irritation caused by thinning of the vaginal epithelium.
17
Q
What is the aetiology of atrophic vaginitis?
A
- Caused by a reduction in circulating oestrogen levels
- Leads to loss of glycogen in epithelial cells and increases vaginal pH
18
Q
What are RFs for atrophic vaginitis?
A
- Menopause
- Prolonged lactation
19
Q
What are the S/S of atrophic vaginitis?
A
- Vaginal irritation
- Dyspareunia
- Superficial dysuria
- Discharge – may be bloody
- O/E: pale, thin vaginal walls with loss of rugal folds, cracks or fissures
20
Q
What are the investigations for atrophic vaginitis?
A
Clinical diagnosis
- Swabs may be taken for superimposed infection.
- Any suspicious lesions warrant exclusion of malignancy.
- Presentation with bleeding may necessitate investigation as per PMB
21
Q
What is the management of atrophic vaginits?
A
- Systemic HRT (systemic progesterone + PV oestrogen)
- Bleeding on intercourse > water-based moisturisers and lubricants
22
Q
What are the complications of atrophic vaginitis?
A
- Increased incidence of superinfection due to increase vaginal PH
- Prognosis – substantial relief can be achieved with treatment
23
Q
What are the investigations for a vaginal infection?
A
Always do speculum before bimanual (lubrication in bimanual ruins speculum swabs)
1. pH:
- Lateral wall of vagina (avoid cervix) > normal pH 3.5-4.5 (due to lactobacilli in vagina)
- Low pH = candida (or normal)
- Raised pH = contamination (blood, semen, lubrication), BV, TV
2. Swabs: 1st endocervical; 2nd high vaginal…
Double swabs:
- Endocervical (or VVS) NAAT swab - gonorrhoea, chlamydia
- High vaginal charcoal swab - (fungal and bacterial) BV, TV, candida, GBS
Triple swabs:
- Endocervical NAAT (or VVS) swab - chlamydia/gonorrhoea
- Endocervical charcoal swab - gonorrhoea
- High vaginal charcoal swab - fungal and bacterial (BV, TV, candida, GBS)
3. Bloods:
- HIV, syphilis
24
Q
What are the RFs for BV?
A
- Smoking
- Vaginal Douching
- Bubble Bathing
- Sexual activity (sexually associated, not sexually transmitted)
- New sexual partner
- Other STIs
- Copper IUD
- Vaginal pH increase
25
What are protective factors for BV?
- Condoms
- Circumcised partner
- COCP
26
What is the pathophysiology of BV?
- Overgrowth of anaerobic bacteria (Gardnerella vaginalis, Prevotella spp., Mycoplasma hominis, Mobiluncus spp.)
- Loss of lactobacilli > increased pH > increased likelihood of BV
- Gardnerella commonly found but commensal in 30-40% women
27
What are the investigations for BV?
Diagnosis = clinical + microscopy > offensive, fishy-smelling discharge (no soreness or irritation), high pH
- HVS – microscopy (clue cells– vaginal epithelium cells coated with lots of bacilli)
- Hay-Ison criteria or Amsel’s criteria
28
What is Amsel's criteria?
3 out of 4 of…
- Thin, white, homogenous discharge
- Clue cells on microscopy
- Vaginal pH >4.5 (only BV and TV)
- Fishy odour on adding 10% KOH
29
What is Hay-Ison criteria?
applied to gram stain
Grade 3 = BV
30
What is the management of BV?
*Does not need to be treated if asymptomatic*
- 1st line – metronidazole, PO, 400mg BD, 7 days
- 2nd line – intravaginal clindamycin PV cream, 5g 2%, 7 days
- Avoid vaginal douching, shower gel, use of shampoo in bath
31
What are the complications of BV?
- Associated with late miscarriage, preterm birth, PROM and postpartum endometritis
- Increases risk of acquiring and transmitting STI
32
What is TV?
**Trichomonas vaginalis (Flagellated protozoan)**
- More common in developing countries
- Sexually transmitted
33
What are the S/S of TV?
*Asymptomatic in 50%*
**Symptomatic:**
- Green/yellow “frothy” vaginal discharge
- Vulval itch or vaginal soreness
- Offensive odour
- Lower abdominal pain and dysuria
- Dyspareunia
- O/E = strawberry cervix
34
What are the investigations for TV?
- High vaginal swab > direct microscopy (wet mount of vaginal fluid shows flagellated organism in the middle)
- Endocervical swabs for other STIs
- pH >4.5
- Whiff test
- Culture and gram stain
- HIV test, NAAT, VDRL
35
What is the management for TV?
- 1st line = Metronidazole, 400mg BD, PO, 7 days
- 2nd line = Metronidazole, 2g, PO STAT
- Contact tracing and treatment of partners in last 4 weeks
- Abstinence for 7 days
- Follow-up to check resolution of symptoms
36
What are the complications of TV?
- Pregnancy = PTL, LBW, PPROM
- Enhance HIV/STI transmission
37
What is candidiasis?
**Causative organism = Candida albicans (90%)** or Candida glabrata (5%)
- Can be spontaneous or secondary to disruption of normal vaginal flora (2nd most common infection after BV)
- Classification = Oral (local invasion of oral tissue) or Invasive (systemic invasion of sterile sites)
38
What are the RFs for candidiasis?
- Oestrogen exposure (more common in pregnancy, reproductive years)
- Immunocompromise (HIV)
- Diabetes (poorly controlled)
- Recent ABx (i.e. for a UTI)
- Intercourse
39
What are the S/S of candidiasis?
vulva itching, soreness, irritation, ‘cottage-cheese’-type discharge
40
What are the investigations for candidiasis?
*No investigations usually required*
- pH low/normal (<4.5) > if high, consider BV or TV
- Diagnostic = HVS – microscopy, culture and gram stain (speckled gram +ve spores, pseudohyphae)
- Other = MSU (UTIs), HbA1c (diabetes)
*N.B. pseudohyphae ONLY in C. albicans*
41
What is the management of candidiasis?
- 1st line – fluconazole (150mg, PO, STAT) - repeat after 72hrs if severe
- 2nd line (if oral contraindicated) – clotrimazole pessary (500mg, PV, STAT) + 1% clotrimazole cream (BD, topical)
- If pregnant, only use topical treatment
**General advice:**
- Avoid tight fitting synthetic clothing
- Avoid local irritants (perfume)
- Do not wash female area with soap/shower gels (or wash >1 day)
- Do not douche
- Use simple emollients to moisturise
**Recurrent:**
- ≥4 proven symptomatic episodes
- Check adherence, recheck initial diagnosis
- Tx with induction and maintenance fluconazole
42
What are the complications of candidiasis?
- Hepatotoxicity associated with systemic azole antifungal therapy – monitor LFT
- Oesophageal candidiasis or disseminated candidiasis in immunocompromised
