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Phase 3a > Gynae 1 - Reproduction > Flashcards

Gynae 1 - Reproduction Flashcards

1
Q

What induces ovulation?

A

Biphasic LH surge

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2
Q

What are the four phases of the endometrial cycle?

A

Menstrual, repair, proliferative, luteal/secretory

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3
Q

What kind of feedback does oestrogen have on FSH?

A

Negative

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4
Q

What is the function of FSH?

A

Maturation of follicle

Stimulates ovaries to release oestrogen

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5
Q

A mutation in which gene causes androgen insensitivity syndrome (AIS)?

A

Androgen receptor gene

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6
Q

What are the two types of AIS?

A

Complete or partial

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7
Q

What is the presentation of CAIS individuals?

A

Female external genitalia
Short blind-ended vagina
Absent uterus and tubes

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8
Q

What is the spectrum of disease in PAIS?

A

Almost normal female phenotype with clitoral enlargement

To morphologically normal male with hypospadias

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9
Q

What occurs in the embryo in AIS?

A

Testis develop normally
Testosterone-dependent Wolffian structures do not develop normally
Regression of Mullerian structures occurs

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10
Q

Where are testes likely to be found in AIS?

A

Inguinal hernias
Labial swellings
Somewhere in the pelvis

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11
Q

What are the other symptoms of AIS?

A

Breast development
Scanty pubic/axillary hair
Amenorrhoea

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12
Q

How is AIS diagnosed?

A

Karyotyping - XY

Pelvic ultrasound to locate testis

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13
Q

What is the condition of enzyme defects in the adrenal steroidogenesis pathways?

A

Congenital adrenal hyperplasia

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14
Q

What mutation occurs with CAH?

A

Cyp21 on C6

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15
Q

What enzyme is deficient in CAH?

A

21-hydroxylase

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16
Q

What is the pathophysiology of CAH?

A

Cortisol deficiency, increased ACTH secretion, increased androgen production

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17
Q

What are the presentations of CAH?

A

Females - ambiguous genitalia and virilization
Males - precocious puberty
Both - Salt losing crisis at 1-3 weeks of age, with hypoglycaemia. Reduced fertility, with less natural fertility in salt losers

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18
Q

How is CAH diagnosed?

A

Increased plasma 17-hydroxyprogesterone levels
24h urinary steroid analysis
Polycystic ovaries

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19
Q

What is the treatment of CAH?

A

Hydrocortisone
Fludrocortisone if salt-losing type
Sodium chloride in first 6-12m of life
Adult women may need female hormones via the COCP or flutamide

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20
Q

How is CAH prevented in subsequent pregnancies?

A

Dexamethasone with a positive pregnancy test.

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21
Q

Define precocious puberty?

A

Onset and signs of puberty before age 8

Menarche before age 10

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22
Q

What is the consequence of precocious puberty?

A

Early accelerated linear growth with premature epiphyseal closure, resulting in decreased final height

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23
Q

What are some causes of precocious puberty?

A 
Idiopathic
Ovarian cysts
Primary hypothyroidism
McCune-Albright syndrome
Congenital adrenal hyperplasia
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24
Q

What is the average age for menarche?

A

12.7 years

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25
Q

What staging is used for puberty?

A

Tanner’s staging

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26
Q

What investigations are required in precocious/delayed puberty?

A 
Bone age from hand radiograph
FSH/LH/Oestradiol/17-hydroxyprogesterone/testosterone
TFTs
Pelvic USS/Cranial MRI
Karyotyping
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27
Q

What is the treatment of idiopathic precocious puberty?

A

GnRH analogue injections e.g. leuprorelin

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28
Q

Define delayed puberty

A

Absence of menstruation and secondary sexual characteristics by age 14
Absence of menstruation by age 16

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29
Q

Give three causes of delayed puberty

A

Constitutional delay
Low BMI/high levels of physical exertion
Chronic systemic disease
Ovarian failure - Turner’s

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30
Q

How can puberty be induced?

A

Boys: PO/IM testosterone
Girls: Oestrogen, gradually increasing doses with cyclical progesterone

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31
Q

Define primary and secondary amenorrhoea

A

Primary - lack of menstruation by 16y

Secondary - absence of menstruation for 6m

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32
Q

Give some causes of primary amenorrhoea

A

Constitutional delay
GU malformation e.g. imperforate hymen
AIS
Ovarian failure

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33
Q

Give some causes of secondary amenorrhoea

A

PCOS
Cushing’s
Premature ovarian failure
Post-pill

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34
Q

What laboratory findings indicate premature ovarian failure?

A

Increased FSH and LH

Endometrial atrophy

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35
Q

What laboratory findings indicate pituitary failure?

A

Decreased T4 and TSH

Increased prolactin

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36
Q

Fusion of the two Mullerian ducts produces…

A

Uterus, upper 2/3 vagina, cervix, uterine body

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37
Q

FSH and LH are released by which gland?

A

Anterior pituitary

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38
Q

A cycle longer than 32 days is known as…

A

Oligomenorrhoea

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39
Q

Give three causes of oligomenorrhoea

A

PCOS
Borderline low BMI
Incipient POF - ovarian resistance leading to anovulation

40
Q

What is a consequence of unopposed oestrogen in PCOS?

A

Endometrial hyperplasia

41
Q

How are regular cycles attained in oligomenorrhoea?

A

COCP

42
Q

What is the condition where excessive facial and body hair grows in women?

A

Hirsuitism

43
Q

What is virilization?

A

Presence of cliteromegaly, balding, deep voice, male body habitus, in a woman

44
Q

What is a common ovarian cause for hirsuitism?

A

PCOS

45
Q

Give three other causes for hirsuitism

A

CAH
Acromegaly
Cushing’s syndrome

46
Q

What kind of hair is seen in women with hirsuitism, and where is it found?

A

Terminal

Face, chest, abdomen, back, thighs

47
Q

What does virilization usually indicate?

A

Androgen-secreting tumour

48
Q

What score is used to grade hirsuitism?

A

Ferriman-Gallwey score >8

49
Q

What investigations are required in hirsuitism?

A

Testosterone
DHEAS
OGTT
17-OHP

50
Q

What is the treatment of hirsuitism (other than treating the cause)?

A

Weight loss and cosmetic approaches
COCP e.g. co-cyprindiol (Dianette) or Yasmin
Anti androgens: Flutamide, finasteride, topical eflornithine

51
Q

Give three causes of pelvic pain in adolescents

A

Ovarian or fallopian tube torsion
Primary dysmenorrhoea
Endometriosis
Rare Mullerian abnormalities

52
Q

What is the aetiology of endometriosis?

A

Retrograde menstruation with adherence
Systemic/lymphatic spread
Family history

53
Q

What are the common sites for ectopic endometrial tissue?

A

Pouch of Douglas
Uterosacral ligaments
Ovarian fossae

54
Q

What are endometriomas?

A

Ovarian endometrial cysts filled with old blood

55
Q

What is the presentation of endometriosis?

A 
Infertility
Cyclical/constant pelvic pain
Dysmenorrhoea
Dyspareunia
Bowel symptoms e.g. constipation, dyschezia
Fatigue
56
Q

How is endometriosis diagnosed?

A

Bimanual pelvic examination for adnexal tenderness and masses
TVUSS for endometriomas
Laparoscopy gold standard

57
Q

What are the treatments of endometriosis?

A

Mefenamic acid or NSAIDs
COCP - conventional, then tricycling
Mirena IUS

Refer if no improvement in 3-6 months/trying to conceive:
GnRH agonists
Surgery
Endometrial ablation

58
Q

What is PCOS a disorder concerning?

A

Hyperandrogenism

59
Q

What are the features of PCOS?

A

Oligomenorrhoea
Hirsuitism/acne
Obesity
Infertility

60
Q

What is required for the Rotterdam criteria diagnosis of PCOS?

A

Need 2/3 of:
Oligomenorrhoea/amenorrhoea
Polycystic ovaries on TVUSS (>12 antral follicles on 1 ovary)
Clinical or biochemical signs of hyperandrogenism

61
Q

What hormone is increased in PCOS?

A

Testosterone

Maybe LH

62
Q

How is PCOS managed (woman not wanting to get pregnant)?

A

Weight loss, low GI diet
Improve menstrual regularity with COCP
Metformin
Co-cyprindiol or eflornithine: hirsuitism

63
Q

What is the treatment of subfertility secondary to PCOS?

A

Weight loss
Metformin, clomifene, or a combination
Ovarian drilling

64
Q

What are women with PCOS at higher risk of?

A

Diabetes and endometrial hyperplasia

65
Q

What are three causes of secondary dysmenorrhoea?

A

Endometriosis/adenomyosis
PID/STI
Pelvic adhesions
Congenital abnormalities causing genital tract obstruction

66
Q

What are the management options in dysmenorrhoea?

A

Mefenamic acid 500mg TDS each period

COCP or Depot/Mirena IUS

67
Q

What are the management option of refractory dysmenorrhoea?

A

Tricycle COCP
Refer to a gynaecologist-
GnRH analogues

68
Q

Define dysfunctional uterine bleeding

A

Any abnormal uterine bleeding in the absence of pregnancy, genital tract pathology, or systemic disease

69
Q

What are the symptoms of DUB?

A

Heavy/prolonged bleeding including clots and flooding
Dysmenorrhoea
Anaemia and disruption to life

70
Q

What are the red flags for cervical or endometrial pathology?

A

Totally erratic bleeding
IMB
Post-coital bleeding

71
Q

What may be seen on TVUSS in DUB?

A

Fibroids
Polyps
Endometrial thickening

72
Q

What is the treatment for regular DUB?

A

Tranexamic acid
COCP
Mirena IUS

73
Q

What is the treatment of irregular DUB?

A

Tranexamic acid and mefenamic acid
COCP
Mirena IUS

74
Q

What is adenomyosis and what are the risk factors?

A

Presence of ectopic endometrial tissue in the myometrium

CS, surgical TOP, pregnancy

75
Q

What medication is used in PCOS?

A

Co-cyprindiol (Dianette)

Anti-androgen, regulates cycle

76
Q

What does metformin do in PCOS treatment?

A

Reduces insulin resistance which decreases androgens

77
Q

How does tranexamic acid work?

A

Anti-fibrinolytic, decreases blood loss by 50%

78
Q

What are the three main indications for mirena IUS?

A

Contraception
Primary menorrhagia
Endometrial protection during HRT

79
Q

What is the medical management of menorrhagia?

A

1) Mirena IUS
2) Tranexamic acid. Combine tranexamic acid with mefanemic acid if pain is also a problem
3) COCP/POP

80
Q

What is the surgical management of menorrhagia?

A

Myomectomy and uterine artery embolization are fertility sparing
Non fertility sparing - endometrial ablation/hysterectomy

81
Q

What are the gradings of utero-vaginal prolapse?

A

1- half way down to introitus
2- as far as introitus
3- procidentia - beyond introitus

82
Q

When should you refer or arrange investigations for a patient with menorrhagia?

A

If the history or examination suggests that there may be fibroids, other pelvic masses, ascites, or anaemia

83
Q

What are three red flag gynaecological symptoms?

A

Intermenstrual bleeding
Post-coital bleeding
Post-menopausal bleeding

84
Q

What are the causes of intermenstrual bleeding?

A

Under 45 - chlamydia
Over 45 - exclude endometrial cancer
All - exclude a cervical cause

85
Q

What does postcoital bleeding suggest?

A

A cervical cause

86
Q

What are the causes of post-menopausal bleeding?

A

Endometrial cancer
Atrophic vaginitis
Fibroids or polyps

87
Q

Which lymph nodes drain the ovary?

A

Para-aortic lymph nodes

88
Q

What is a trachelectomy?

A

Removal of cervix and pelvic lymph nodes with preservation of body and uterus for fertility in cervical cancer

89
Q

Define premature ovarian failure

A

The onset of menopausal symptoms and elevation of gonadotrophins before the age of 40 years

90
Q

When is methotrexate appropriate management for ectopic pregnancy?

A

No symptoms
bHCG<1500IU
Small (<35mm) unruptured ectopic with no visible heartbeat

91
Q

When is laparoscopy and salpingectomy appropriate management for ectopic pregnancy?

A

Symptomatic
bHCG>1500IU
Large >35mm or ruptured ectopic, visible heart beat

92
Q

What is the test used to find out if a woman is ovulating?

A

Day 21 mid-luteal progesterone

Day 5 FSH

93
Q

How is tubal patency checked?

A

Hysterosalpingo contrast sonography (HyCoSo)

Hysterosalpingogram, laparoscopy and dye test

94
Q

What tests should be done in a woman failing to get pregnant?

A 
FSH/TSH, LH
Prolactin
Testosterone
OGTT
STI screen
95
Q

What is the mode of action of the COCP, and the implant?

A

Inhibit ovulation - primary MoA

Thicken cervical mucus and prevent proliferation of the endometrium (on the side)

96
Q

What is the main mode of action of the POP?

A

Thickens cervical mucus

97
Q

What is the main mode of action of the IUS?

A

Prevents endometrial proliferation

On the side - thickens cervical mucus

Phase 3a (18 decks)

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