Gynae 1 Flashcards
What is premenstrual syndrome (PMS)?
- Distressing psychological, physical and/or behavioural symptoms in the absence of organic/psychiatric disease
- Occurs during luteal phase with significant improvement of symptoms with onset / during period
- (if had hysterectomy with ovarian conservation = occurs cyclically)
How many people suffer from PMS?
15% asymptomatic
80% mild-moderate
5% severe
What are the signs/symptoms of severe PMS (DSM IV criteria)?
5+ symptoms present for most of late luteal phase
Remission within a few days from onset of menses
Absence of symptoms in the week post menses (must be at least 1 from first 4):
- Depressed mood, feelings of hopelessness or self-deprecation
- Anxiety / tension
- Affective lability (feeling suddenly sad or tearful)
- Anger / irritability
- Decreased interest in usual activities
- Subjective sense of difficulty in concentrating
- Lethargy
- Change in appetite, overeating or specific food cravings
- Hypersomnia or insomnia
- Subjective sense of being overwhelmed or out of control
- Other physical symptoms (breast tenderness or swelling, headaches, joint or muscle pain, bloating, weight gain)
What investigations are done for PMS?
Mostly self-diagnosed - symptom diary filled in over 2 cycles
NB important to exclude organic disease or significant psychiatric illness
What are some hormonal management options of PMS?
Progesterone and progestrogens
- Mirena coil
- Depot injection
Ovulation suppression agents:
- COCP
- Danazol
- Oestrogen
- GnRH analogues +/- addback HRT
NB addback HRT reduces risk of bone demineralisation
What are some non-hormonal managements of PMS?
- SSRI/SNRI - can take continuously or just during luteal phase
- Total hysterectomy
- CBT
What are some self-help techniques for PMS?
- Diet alterations i.e. less fat, sugar, salt, caffeine
- Dietary supplements - Vit B6 10mg OD
- Exercise
- Stress reduction
What defines a polycystic ovary?
Polycystic ovary = a characteristic transvaginal US appearance of multiple (12+) small follicles (2-8mm) in an enlarged ovary (>10mL volume)
What is the criteria used for diagnosing PCOS called?
The Rotterdam criteria 2003
What are the features of the Rotterdam criteria?
2 / 3 of:
1) Irregular or absent periods (>35 days apart)
2) Clinical/biochemical features of hyperandrogegism:
- Acne
- Hirsutism
- Alopecia
- Raised serum testosterone
3) Polycystic ovaries on TVUS
What is the pathophysiology of PCOS?
Not fully understood but likely to be multifactorial
Excess androgens produced by theca cells of ovaries (either due to hyperinsulinaemia or increased LH levels)
Raised LH from anterior pituitary (in 40% women)
Insulin resistance (often caused by weight gain) leads to hyperinsulinaemia
Insulin resistance leads to:
- Increased androgen production (multiple mechanisms)
- Reduced production of sex hormone-binding globulin (SHBG) in liver leading to raised levels of free testosterone
How common is PCOS?
Most common endocrine disorder in women:
6-10% prevalence of women at childbearing age
Responsible for 80% of anovulatory subfertility
USS evidence of PCO in 20-30% women
What are some risk factors for PCOS? (2)
Family history - genetic
Metabolic syndrome
- Obesity (particularly central obesity)
- Insulin resistance
- Hypercholesterolaemia
What are some signs/symptoms of PCOS?
· Oligomenorrhoea (can be amenorrhoea too)
· Hirsutism – excessive male pattern hair growth
· Acne vulgaris
· Androgenic alopecia
· Infertility – due to chronic anovulation
· Obesity/signs of metabolic syndrome
· Acanthosis nigricans
· Voice change may occur in severe forms of PCOS but it typically suggests a different underlying cause of hyperandrogenism
What are some long term health consequences of PCOS? (4)
· Gestational diabetes – should screen in pregnancy at 24-48 weeks
· Type 2 diabetes
· Cardiovascular disease
· Endometrial cancer – aim for 3-4 monthly withdrawal bleeds to reduce risk
What blood hormone levels are investigated in PCOS?
· Increased testosterone – both total and free
· Increase LH (LH:FSH ratio > 2:1) - a reversed LH:FSH ratio of around 3:1 is characteristic
· Oestrogen - normal/slightly elevated
List some ddx for PCOS
1) Ovarian failure
2) Hypothalamic disease
3) Prolactinoma
4) Secondary cause of amenorrhoea
5) Congenital adrenal hyperplasia
What are the 4 broad categories of medical management of PCOS?
- Lowering insulin levels
- Restoring fertility
- Treatment of hirsutism and acne
- Restoration of regular menstruation with prevention of endometrial hyperplasia and cancer
What is the average age of menopause?
52 years
What is menopause?
The permanent cessation of menstruation resulting in the loss of ovarian follicular activity
Natural menopause = 12 months of amenorrhoea in women > 50 or 24 months after LMP in women < 50
What is perimenopause?
= Menopause transition
The time period from the first instance of climacteric symptoms to multiple years post-menopause (average length = 4 years)
What is premenopause?
Time period from first occurrence of climacteric irregular menstruation cycles to the last menstrual period; characterised by increasingly infrequent menstruation
What is postmenopause?
Time period beginning 12 months after last menstrual period
What is climacteric?
The phase encompassing the transition from reproductive state to the non-reproductive state
ie menopause is a specific event occurring during the climacteric, just as menarche is an event that occurs during puberty
What is the physiology of menopause?
- The number of ovarian follicles decreases with age
- This decreases ovarian function
- Therefore, oestrogen and progesterone levels fall
- This causes a loss of negative feedback to the gonadotropic hormones
- Therefore, there is an increase in GnRH levels
- This increases the levels of FSH and LH in the blood
- This increases the frequency of anovulatory cycles
- The end result is ovarian function eventually stops
What are some short-term signs/symptoms of menopause? (3 broad groups)
Vasomotor symptoms:
- Hot flushes
- Night sweats
Atrophic features:
- Vulvovaginal atrophy - dryness, pruritus, dyspareunia (due to decreased oestrogen = can cause dyspareunia)
- Breast tissue atrophy
- Urinary atrophy - dysuria, frequency, urgency, UTIs
Psychological symptoms:
- Depressed mood
- Anxiety
- Irritability
- Mood swings
- Lethargy
- Loss of libido
- Sleep disturbance
What are some long-term signs/symptoms of menopause? (3)
- Osteoporosis = inc risk of fracture (esp Colles’, hip, vertebrae)
- Cardiovascular disease
- Breast cancer
Menopause is primarily a clinical diagnosis. However, what investigations may be required?
- FSH levels - only helpful if ?diagnosis (eg <40yr) and levels in menopausal range (raised FSH is not diagnostic for menopause but a high level indicates a lack of ovarian response)
- Testosterone + prolactin - normal range
- TFTs to rule out hyperthyroidism
- Blood glucose - diabetes can cause similar symptoms
- DEXA scan
UNHELPFUL TESTS = LH, estradiol, progesterone
How can you manage the various symptoms of menopause?
· Hot flushes - avoid triggers, regulate environmental temperature, fluoxetine/citalopram
· Insomnia - exercise, relaxation techniques
· Osteoporosis - smoking cessation, vitamin D intake, weight-bearing exercise
· Vaginal dryness - lubricants/moisturisers
Vaginal atrophy - topical oestrogen creams (estriol)
What is defined as premature menopause?
How common is it?
Menopause <40 year
20% of women
What are some causes of premature menopause?
Often no cause found (idiopathic)
Primary ovarian insufficiency:
- Chromosome abnormalities
- FSH receptor gene polymorphism /PCOS
- Enzyme deficiencies
- Autoimmune disease
- Smoking - major risk factor
- Infectious diseases
Secondary causes:
- Chemo / radiotherapy
- Bilateral oophorectomy or surgical menopause
- Hysterectomy without oopherectomy
What is are some signs/symptoms of premature menopause?
Most commonly amenorrhoea or oligomenorrhoea (+/- hot flushes)
Coexisting disease may be detected eg hypothyroidism, Addison’s disease, DM, chromosomal abnormalities
What is the management of premature menopause?
Oestrogen replacement needed until after average age of menopause - HRT, COCP
May have reduced fertility and require assisted conception
What are the main indications for HRT? (3)
1) Short term treatment of menopausal symptoms where risk:benefit ratio is favourable
2) For women with early menopause until the age of natural menopause (51/52yr) even if they are asymptomatic
3) For women under 60 yrs who are at risk of an osteoporotic fracture in those where non-oestrogen treatments are unsuitable
Starting HRT is not recommended in those >60yr
What combinations of hormones are used in HRT depending on the patient?
Oestrogen + progestogen if no hysterectomy
Oestrogen alone if previous hysterectomy
Progesterone is added if patient has a uterus to prevent endometrial proliferation
Others:
- Tibolone = a synthetic steroid hormone that is converted to metabolites with oestrogenic, progestogenic and androgenic actions
- Testosterone (patches and implants) to improve libido
What oestrogens are commonly used in HRT?
Estradiol
Estrone
Estriol
Conjugated quine oestrogen