Gynae Flashcards
Benign ovarian tumours:
- when should they be biopsied?
- 2 physiological?
- 1 germ cell?
- 2 epithelial?
If complex/multi-loculated on USS
Physiological:
- Follicular: commonest, non-rupture of dominant follicle or failure of atresia, regress after several cycles
- Corpus luteum: failure to breakdown of corpus luteum, may fill with fluid/blood, more likely to cause intraperitoneal bleeding than follicular
Germ cell:
- Dermoid (mature): lined with epithelium, may contain hair and teeth. Most common ovarian tumour <30, usually asymptomatic but may cause torsion
Epithelial:
- Serous cystadenoma: commonest benign epithelial tumour, bilateral in 20%
- Mucinous cyst adenoma: second commonest, typically large and may become massive, can rupture to cause pseudomyxoma peritonei
How long after TOP can pregnancy tests remain positive?
4 weeks
If still positive at this point it suggests incomplete abortion or persistent trophoblast
Investigations for heavy menstrual bleeding?
FBC in all women
If intermenstrual/postcoital bleeding, pain/pressure symptoms, or exam findings (e.g. bulky tender uterus suggesting adenomyosis), refer for routine TVUSS
Management of menorrhagia if requires contraception?
If doesn’t require contraception?
Requires contraception:
- Mirena
- COCP
- Long-acting progestogen (Depo-provera)
Doesn’t:
- Tranexamic acid or mefanamic acid (NSAID)
Subfertility primary care Ix?
Primary care:
- chlamydia screen
- Day 2-5 FSH/LH
- TSH, PRL, testosterone and rubella Ig (vaccinate if not immune)
- Mid-luteal progesterone (luteal phase always 14 days so 7 days before period due)
- semen analysis: repeat in 3 months if abnormal - make lifestyle changes, start taking zinc, selenium and VitC supplements
Subfertility secondary care Ix?
TVUSS - rule out masses, fibroids or polyps
Hyspetosalpingogram - dye injected and XR - confirm tubal patency (dye can cause tubal spasm -> false positive)
Laparoscopy and dye test gold standard - do if HSPG abnormal - pelvic pathology can be treated at the same time
Semen analysis - what to look for?
Must be 3-5 days since last ejaculation and be at lab within an hour
Volume >1.5ml pH >7.2 Conc >15 million/ml >4% normal morphology >32% motile >58% live
Key counselling points if couple struggling to conceive but <1 year?
Folic acid
BMI 20-25
Regular intercourse every 2-3 days
Smoking/drinking
Management of endometriosis?
1st line - NSAIDs and/or paracetamol
2nd line - add in COCP
Secondary care:
- GnRH analogues (lower oestrogen, induce ‘pseudomenopause’)
- Surgery - laparoscopic excision and laser treatment of endometriotic ovarian cysts
(unfortunately drug treatment has very little impact on fertility)
Complications of hysterectomy with antero-posterior repair?
- enterocoele
- vaginal vault prolapse
Urinary retention may occur acutely following operation but not usually a chronic complication
What happens during follicular phase?
- Initial fall in oestrogen and progesterone triggering menstruation
- steady increase in FSH and LH, and steady increase in oestrogen
FSH and LH complete first meiotic division to form secondary follicle
Oestrogen thins cervical mucus and stimulates endometrial thickening
As it nears completion, control of FSH/LH by oestrogen switches to positive feedback and there is a surge
- LH - greatest and stimulates ovulation
- FSH - occurs 12-36 huours after LH surge
What happens during luteal phase?
Always 14 days
Fall in FSH, LH and oestrogen, increase in progesterone which increases endometrial glandular secretions and vascularity (preparing it for implantation)
If fertilisation doesn’t occur, corpus luteum degenerates and progesterone decreases
If fertilisation occurs, embrue produces hCG which maintains corpus luteum, which maintains endometrium
Causes of menorrhagia?
Obesity
Non-organic: DUB, contraception
Pregnancy (miscarriage, ectopic etc)
Systemic: hypothyroid, diabetes, adrenal disease, ITP, von Willebrand, renal, liver disease
Local:
PID, trauma, fibroids, IUD/IUS, cervical ectropion/polyps, cervical/endometrial malignancy, endometrial: hyperplaisia, endometriosis, adenomyosis, polyp
What is DUB?
Anovulatory?
Ovulatory?
Abnormal bleeding in the absence of any underlying pathology
Anovulatory:
Seen at extremes of fertility, assoc w irregular cycles - endometrium not being regularly shed so when bleeds happen they tend to be heavy
Ovulatory:
Poor quality egg and follicle which fails to produce enough progesterone, causing failure to fully shed endometrium
Ix DUB?
It is a diagnosis of exclusion
PV exam
FBC, TFT, LFT, coag
USS, hysteroscopy or endometrial sampling if Hx suggests
Management of DUB?
Symptoms:
- tranexamic acid - bleeding
- mefanamic acid - pain
Periods: 1st - mirena 2nd - COCP 3rd - IM progestogens 4th - GnRH analogues/Danazol - dampen HPA axis and induce menopause
Surgical:
endometrial ablation
hysterectomy
Primary/secondary amenorrhoea?
Causes of each?
Prim: no period by 15, or by 13 in girls with no secondary sex characteristics
- imperforate hymen (normal developement)
- Turner’s (short stature 45XO)
- Testicular feminisation (female phenotype, male genotype)
- anorexia, exercise etc
Secondary: cessation of periods for 3-6 months when previously normal, no pregnancy
- Pregnancy, menopause
- PCOS
- drugs: withdrawal from COCP, recreational, steroids
- stress, weight loss, over exercising, obesity
- Kallman, Turner, Prader Willi
- THYROID, renal, pituitary, haemochromatosis
Causes of oligomenorrhoea?
PCOS
Menopause
Withdrawal from contraception, recreational, steroids
Stress, weight loss, exercise, obesity
Ix a/oligo-menorrhoea?
PREGNANCY
FSH, LH, oestrogen, progesterone, prolactin, TFT, U&E, coeliac
Low FSH/LH = pituitary cause
High = ovarian cause
Rotterdam criteria?
Oligomenorrhoea and/or anovulation
Hyperandrogenism (acne, hirsutism, acanthosis nigricans)
Ovaries:
- 12+ follicles in each ovary (2-9mm diameter) or ovarian volume >10ml
Tests to do for PCOS?
Normal amenorrhoea tests
Plus:
- fasting glucose/OGTT
- fasting lipids
- pelvic USS
Menegement PCOS hirsutism?
PCOS infertility?
General: Lifestyle & monitor for diabetes, HTN, hyperlipidaemia
Hirsutism:
- COCP
- topical eflornithine
Infertility:
- weight reduction
- Letrozole or Clomifene (stimulates ovulation)
- Metformin
- gonadotrophins
- IVF
Causes of intermenstrual bleeding?
Pregnancy
Hormonal contraception
Infection (chlamydia/PID)
Cervical (ectropion, polyps, carcinoma)
Causes of post-coital bleeding?
Vaginitis (any cause)
Infection (chlamydia)
Endometrial (carcinoma)
Cervical (ectropion, polyp, malignancy)