Gynae Flashcards
1
Q
Polycystic Ovarian Syndrome
definition of anovulation
A
absence of ovulation
2
Q
Polycystic Ovarian Syndrome
definition of oligoovulation
A
irregular, infrequent ovulation
3
Q
Polycystic Ovarian Syndrome
definition of ammenorrhoea
A
absence of menstrual periods
4
Q
Polycystic Ovarian Syndrome
definition of androgens
A
male sex hormones such as testosterone
5
Q
Polycystic Ovarian Syndrome
definition of hyperandrogenism
A
effects of high levels of androgens
6
Q
hirsutism
A
the growth of thick dark hair
7
Q
Polycystic Ovarian Syndrome
definition of insulin resistance
A
lack of response to insulin, resulting in high blood sugar levels
8
Q
Polycystic Ovarian Syndrome
what criteria is used to make a diagnosis
A
the Rotterdam Criteria
9
Q
Polycystic Ovarian Syndrome
diagnosis (rotterdam criteria)
A
2/3 of:
- oligoovulation or anovulation: irregular or absent
- hyperandrogenism: hirsutism + acne
- polycystic ovaries on US (or ovarian volume of >10cm3)
10
Q
Polycystic Ovarian Syndrome
presentation
A
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism
- Acne
- Hair loss in a male pattern
11
Q
Polycystic Ovarian Syndrome
other features and complications
A
- Insulin resistance and diabetes
- Acanthosis nigricans
- CVD
- Hypercholesterolaemia
- Endometrial hyperplasia and cancer
- Obstructive sleep apnoea
- Depression and anxiety
- Sexual problems
12
Q
Polycystic Ovarian Syndrome
what is Acanthosis nigricans
A
thickened, rough skin typically found in the axilla and on the elbows
It has a velvety texture
occurs with insulin resistance
13
Q
Ddx of hirsutism
A
- medications
- ovarian or adrenal tumours that secrete androgens
- cushing’s syndrome
- congenital adrenal hyperplasia
14
Q
Polycystic Ovarian Syndrome
why does insulin resistance result in higher levels of androgens
A
When someone is resistant to insulin, their pancreas has to produce more insulin
Insulin promotes the release of androgens from the ovaries and adrenal glands.
15
Q
Polycystic Ovarian Syndrome
what does sex hormone-binding globulin (SHBG) do
A
binds to androgens and suppresses their function
16
Q
Polycystic Ovarian Syndrome
what does insulin do to sex hormone-binding globulin (SHBG)
A
suppresses it
which promotes hyperandrogenism
17
Q
Polycystic Ovarian Syndrome
why is there anovulation and multiple partially developed follicles
A
The high insulin levels contribute to halting the development of the follicles in the ovaries
18
Q
Polycystic Ovarian Syndrome
what can help reduce insulin resistance
A
diet, exercise and weight
19
Q
Polycystic Ovarian Syndrome
which blood tests to diagnose PCOS and exclude other pathology
A
- Testosterone
- Sex hormone-binding globulin
- LH
- FSH
- Prolactin (may be mildly elevated in PCOS)
- TSH
20
Q
Polycystic Ovarian Syndrome
what will hormonal blood tests show
A
- raised LH
- raised LH to FSH ratio **
- raised testosterone
- raised insulin
- normal or raised oestrogen levels
21
Q
Polycystic Ovarian Syndrome
what is the gold standard for visualising the ovaries
A
transvaginal US
22
Q
Polycystic Ovarian Syndrome
US: what does it mean by string of pearls
A
The follicles may be arranged around the periphery of the ovary
23
Q
Polycystic Ovarian Syndrome
diagnostic criteria on US
A
either:
- 12 or more developing follicles in one ovary
- Ovarian volume of more than 10cm3
24
Q
Polycystic Ovarian Syndrome
what is the screening test of choice for diabetes in pts with PCOS
A
2-hour 75g oral glucose tolerance test (OGTT)
25
Polycystic Ovarian Syndrome
general mnx to reduce risks associated with obesity, T2DM, hypercholesterolaemia, CVD
- WEIGHT LOSS
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
- Antihypertensive medications where required
- Statins where indicated (QRISK >10%)
26
Polycystic Ovarian Syndrome
what may be used to help weight loss in women with a BMI>30
orlistat
27
Polycystic Ovarian Syndrome
what is orlistat
a lipase inhibitor that stops the absorption of fat in the intestines
28
Polycystic Ovarian Syndrome
why is there a risk of endometrial cancer
women have many of the RFs:
- obesity
- diabetes
- insulin resistance
- amenorrhoea
+ ENDOMETRIAL HYPERPLASIA
29
Polycystic Ovarian Syndrome
why is there endometrial hyperplasia
do not produce sufficient progesterone (infrequent ovulation so corpus luteum doesn't produce it)
continued oestrogen production
endometrial lining continues to proliferate without regular shedding during menstruation
similar to giving unopposed oestrogen
30
Polycystic Ovarian Syndrome
inx if >3m between periods or abnormal bleeding
pelvic ultrasound to assess the endometrial thickness
Cyclical progestogens should be used to induce a period prior to the ultrasound scan.
If endometrial thickness > 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
31
Polycystic Ovarian Syndrome
Options for reducing the risk of endometrial hyperplasia and endometrial cancer
- Mirena coil: continuous endometrial protection
```
- Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
```
COCP
32
Polycystic Ovarian Syndrome
what is the initial step for improving fertility
weight loss
33
Polycystic Ovarian Syndrome
Infertility: options where weight loss fails
- Clomifene
- Laparoscopic ovarian drilling
- IVF
34
Polycystic Ovarian Syndrome
Infertility: what is ovarian drilling
laparoscopic surgery
punctures multiple holes in the ovaries using diathermy or laser therapy
can improve the woman’s hormonal profile and result in regular ovulation and fertility
35
Polycystic Ovarian Syndrome
mnx of hirsutism
- Co-cyprindiol (Dianette): licenced for hirsutism + acne
| - Topical eflornithine
36
Polycystic Ovarian Syndrome
hisutism: disadvantage of Co-cyprindiol (Dianette)
significantly increased risk of VTE
usually stopped after three months of use.
37
Polycystic Ovarian Syndrome
1st line for acne in PCOS
COCP
38
Asherman’s Syndrome
what is it
adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
39
Asherman’s Syndrome
when does it usually occur after
after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth)
after uterine surgery
after several pelvic infection
40
Asherman’s Syndrome
how does Endometrial curettage (scraping) cause it
it can damage the basal layer of the endometrium
heals abnormally, creating adhesions
41
Asherman’s Syndrome
presentation
after recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea (absent periods)
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
- It may also present with infertility.
42
Asherman’s Syndrome
gold standard inx
Hysteroscopy
43
Asherman’s Syndrome
other inx for diagnosis other than hysteroscopy
- Hysterosalpingography: contrast is injected into the uterus and imaged with xrays
- Sonohysterography: uterus is filled with fluid and a pelvic ultrasound is performed
- MRI scan
44
Asherman’s Syndrome
mnx
dissecting the adhesions during hysteroscopy.
45
Hormone Replacement Therapy
why do women experience sx peri/postmenopausal
decline in oestrogen levels
46
Hormone Replacement Therapy
why does progesterone need to be given in addition to oestrogen to women with a uterus
to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
47
Hormone Replacement Therapy
choosing the HRT: woman without a uterus
oestrogen-only HRT
48
Hormone Replacement Therapy
choosing the HRT: Women that still have periods
cyclical HRT
| and regular breakthrough bleeds
49
Hormone Replacement Therapy
choosing the HRT: Postmenopausal women with a uterus and >1y without periods
continuous combined HRT
50
Non-Hormonal Treatments for Menopausal Symptoms
- lifestyle changes
- CBT
- Clonidine
- SSRIs
- Venlafaxine (SNRI)
- Gabapentin
51
menopausal sx: which sx is clonidine useful in
vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT
52
menopausal sx: how does clonidine act
act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain.
53
menopausal sx: what does clonidine do
lowers BP and reduced HR and also an antihypertensive
54
menopausal sx: common SEs of clonidine
- dry mouth
- headaches
- dizziness
- fatigue
55
menopausal sx:
| what can sudden withdrawal of clonidine result in
rapid increases in BP and agitation
56
alternative remedies intended to manage vasomotor sx such as hot flushes
- Black cohosh
- Dong quai
- Red Clover
- Evening primrose oil
- Ginseng
57
what is evening primrose oil linked with
- significant drug interactions
- clotting disorders
- seizures
58
Hormone Replacement Therapy
indications for HRT (4)
- Replacing hormones in premature ovarian insufficiency, even without symptoms
- Reducing vasomotor symptoms such as hot flushes and night sweats
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
59
Hormone Replacement Therapy
benefits
- Improved vasomotor and other symptoms of menopause
- Improved QoL
- Reduced risk of osteoporosis and fractures
60
Hormone Replacement Therapy
risks (5)
- breast cancer
- endometrial cancer
- VTE
- stroke + coronary artery disease
- ovarian cancer (minimal)
61
Hormone Replacement Therapy
benefits of oestrogen-only HRT (only given to women without a uterus)
- lower risk of breast cancer
| - no increased risk of coronary artery disease
62
Hormone Replacement Therapy
way to reduce risk of VTE
using patches rather than pills
63
Hormone Replacement Therapy
CIs to consider in pts wanting to start
- Undiagnosed abnormal bleeding
- Endometrial hyperplasia or cancer
- Breast cancer
- Uncontrolled hypertension
- VTE
- Liver disease
- Active angina or MI
- Pregnancy
64
Hormone Replacement Therapy
assessment before initiating HRT
- check no CIs
- FH: breast/endometrial cancer and VTE
- BMI + BP
- cervical + breast screening up to date
- encourage lifestyle changes
65
Choosing HRT
Step 1: local or systemic sx
local: topical oestrogen cream
systemic: go to step 2
66
Choosing HRT
Step 2: does woman have uterus
no uterus: continuous oestrogen-only HRT
uterus: combined HRT and got to step 3
67
Choosing HRT
Step 3: Have they had a period in the past 12 months?
Yes (perimenopausal): cyclical combined HRT
No (postmenopausal): continuous combined HRT
68
Hormonal Replacement Therapy
when is the transdermal route (patches or gel) more suitable than tablets
- women with poor control on oral treatment
- higher risk of VTE
- CVD and headaches.
69
Hormonal Replacement Therapy
when is continuous progesterone used
when the woman has not had a period in the past:
- 24 months if under 50 years
- 12 months if over 50 years
70
Hormonal Replacement Therapy
whare are the options for delivering progesterone for endometrial protection
- Oral (tablets)
- Transdermal (patches)
- Intrauterine system (e.g. Mirena coil)
71
Types of Progesterone
what are progestogens
any chemicals that target and stimulate progesterone receptors
72
Types of Progesterone
what is progesterone
the hormone produced naturally in the body
73
Types of Progesterone
what is progestins
synthetic progestogens
74
Types of Progesterone
what are the 2 significant progestogen classes used in HRT
- C19 progestogens
- C21 progestogens
(refers to number of carbon atoms in the molecule)
75
Types of Progesterone
what are C19 progestogens
derived from testosterone: more 'male' in their effects
helpful if reduced libido
76
Types of Progesterone
what are C21 progestogens
derived from progesterone, and are more “female” in their effects
helpful if depressed mood or acne
77
Types of Progesterone
examples of C19 progestogens
- norethisterone
- levonorgestrel
- desogestrel
78
Types of Progesterone
examples of C21 progestogens
- dydrogesterone
| - medroxyprogesterone
79
Hormone Replacement Therapy
why is the Mirena coil the best way of providing progesterone
added benefits of contraception and treating heavy menstrual periods
won't experience progestogenic side effects
80
Hormone Replacement Therapy
what is Tibolone
- used as a form of continuous combined HRT
- a synthetic steroid
- stimulates oestrogen, progesterone and androgen receptors.
- can be helpful if reduced libido
81
Hormone Replacement Therapy
when do you follow up after initiating HRT
3months
82
Hormone Replacement Therapy
how long does it take to gain full effects
3-6m so it is worth persisting or at least 3m with each regime
83
Hormone Replacement Therapy
what is an indication for referral to a specialist
problematic or irregular bleeding
84
Hormone Replacement Therapy
when should you stop oestrogen-containing contraceptives or HRT before major surgery
4w
85
Hormone Replacement Therapy
does HRT act as contraception
no, use mirena or POP (in addition to HRT)
86
Hormone Replacement Therapy
oestrogenic SEs
- Nausea + bloating
- breast swelling
- breast tenderness
- headaches
- leg cramps
87
Hormone Replacement Therapy
Progestogenic SEs
- Mood swings
- Bloating
- Fluid retention
- Weight gain
- Acne and greasy skin
88
Androgen Insensitivity Syndrome
how is it passed on genetically
X-linked recessive genetic condition
caused by a mutation in the androgen receptor gene on the X chromosome
89
Androgen Insensitivity Syndrome
what is it
cells are unable to respond to androgen hormones due to a lack of androgen receptors
Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics
90
Androgen Insensitivity Syndrome
are patients genetically male or female
genetically male, with XY sex chromosome
but female phenotype externally.
91
Androgen Insensitivity Syndrome
why does the uterus, upper vagina, cervix, fallopian tubes and ovaries not develop
the testes (in the abdomen or inguinal canal) produce anti-Müllerian hormone
92
Androgen Insensitivity Syndrome
are patients fertile
no
93
Androgen Insensitivity Syndrome
how would partial androgen insensitivity syndrome present as
micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.
94
Androgen Insensitivity Syndrome
how does it often present in infancy
inguinal hernias containing testes
95
Androgen Insensitivity Syndrome
how does it often present in puberty
primary amenorrhoea
96
Androgen Insensitivity Syndrome
hormone test results:
- LH
- FSH
- testosterone
- oestrogen
- LH: raised
- FSH: normal or raised
- testosterone: normal or raised (for a man)
- oestrogen: raised (for a man)
97
Androgen Insensitivity Syndrome
medical and surgical input
Bilateral orchidectomy: avoid testicular cancer
oestrogen therapy
vaginal dilators or vaginal surgery: create adequate vaginal length
98
Androgen Insensitivity Syndrome
general mnx
- raised as female, but this is sensitive and tailored to the individual
- counselling to promote their psychological, social and sexual wellbeing.
99
Lichen Sclerosis
what is it
a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin.
autoimmune
100
Lichen Sclerosis
where does it effect women
labia, perineum and perianal skin
can affect axilla, thighs
101
Lichen Sclerosis
dx
usually clinically
if in doubt, a vulval biopsy can confirm dx
102
what does lichen refer to
a flat eruption that spreads
103
what is lichen simplex
chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin.
presents with excoriations, plaques, scaling and thickened skin
104
what is lichen planus
an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
105
woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva.
what is it
Lichen Sclerosis
106
Lichen Sclerosis
sx
- Itching
- Soreness and pain possibly worse at night
- Skin tightness
- superficial dyspareunia
- Erosions
- Fissures
107
Lichen Sclerosis
what is Koebner phenomenon
when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus
108
Lichen Sclerosis
how can it be made worse
tight underwear that rubs the skin,
urinary incontinence
scratching.
109
Lichen Sclerosis
appearance of affected skin
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
110
Lichen Sclerosis
how often is it followed up
every 3 – 6 months by an experienced gynaecologist or dermatologist.
111
Lichen Sclerosis
trx
Potent topical steroids: clobetasol propionate 0.05% (dermovate)
emollients
112
Lichen Sclerosis
directions of use of steroids
- initially OD for 4w
- gradually reduced to alternate days then twice weekly
- flares: go back to topical steriods daily
113
Lichen Sclerosis
cancer complication
5% risk of developing squamous cell carcinoma of the vulva
114
Lichen Sclerosis
other complications
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
115
Endometriosis
what is it
ectopic endometrial tissue outside the uterus.
116
Endometriosis
what are endometrioma
A lump of endometrial tissue outside the uterus
117
Endometriosis
what are chocolate cysts
Endometriomas in the ovaries
118
Endometriosis
aetiology theories
- retrograde menstruation
- Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus
- lymphatic spread of endometrial cells
- metaplasia (from typical cells of that organ into endometrial cells)
119
Endometriosis
why may there be blood in urine or stools
Deposits of endometriosis in the bladder or bowel
120
Endometriosis
usually presents with cyclical pain, when may it be non-cyclical
Localised bleeding and inflammation can lead to adhesions --> chronic, non-cyclical pain
121
Endometriosis
why may the woman have reduced fertility
- adhesions around the ovaries and fallopian tubes
| - Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.
122
Endometriosis
symptoms
- cyclical abdo/pelvic pain
- deep dyspareunia
- dysmenorrhoea
- infertility
- cyclical bleeding from other sites (haematuria)
123
Endometriosis
what may examination reveal
- endometrial tissue visible in the vagina on speculum
- fixed cervix on bimanual exam
- tenderness in vagina, cervix and adnexa
124
Endometriosis
what may pelvic US show
may reveal large endometriomas and chocolate cysts
125
Endometriosis
what is the gold standard inx for diagnosis
Laparoscopic surgery: get a biopsy from it
126
Endometriosis
hormonal mnx options (before establishing a definitive diagnosis with laparoscopy)
- COCP back to back
- POP
- Medroxyprogesterone acetate injection (e.g. Depo-Provera)
- Nexplanon implant
- Mirena coil
- GnRH agonists
127
Endometriosis
surgical mnx
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy
128
Endometriosis
what may improve fertiltiy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
129
Endometriosis
why may cyclical pain be treated with hormonal medication
stop ovulation and reduce endometrial thickening
130
Endometriosis
why may GnRH agonists like goserelin (Zoladex) or leuprorelin (Prostap) help
induce a menopause-like state
shut down the ovaries temporarily and can be useful in treating pain
131
Heavy Menstrual Bleeding
aka
menorrhagia
132
Heavy Menstrual Bleeding
what is classed as excessive blood loss
>80ml
changing pads every 1 – 2 hours
bleeding lasting >7d
passing large clots
133
Heavy Menstrual Bleeding
what is dysfunctional uterine bleeding
no identifiable cause of menorrhagia
134
Heavy Menstrual Bleeding
causes
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- PID
- Contraceptives: copper coil
- Anticoagulants
- Bleeding disorders (VWd)
- Endocrine (DM, hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- PCOS
135
Heavy Menstrual Bleeding
initial inx
- speculum and bimanual: fibroids, ascites, cancer
| - FBC: anaemia
136
Heavy Menstrual Bleeding
when should outpatient hysteroscopy be performed
if there is:
- suspected submucosal fibroids
- suspected endometrial pathology, e.g. hyperplasia or cancer
- persistent intermenstrual bleeding
137
Heavy Menstrual Bleeding
when should pelvic and TVUS be arranged
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
138
Heavy Menstrual Bleeding
mnx for woman who does not want contraception and there is no pain
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
139
Heavy Menstrual Bleeding
mnx for woman who does not want contraception and there is pain
Mefenamic acid
| (NSAID – reduces bleeding and pain)
140
Heavy Menstrual Bleeding
mnx when contraception is wanted
1. mirena
2. COCP
3. cyclical PO progestogens
141
Heavy Menstrual Bleeding
when to refer to secondary care
- trx unsuccessful
- severe sx
- fibroids >3cm
142
Heavy Menstrual Bleeding
what is the final option when medical mnx has failed
endometrial ablation and hysterectomy.
143
Atrophic Vaginitis
what is it
dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
aka genitourinary syndrome of menopause
144
Atrophic Vaginitis
pathophysiology
menopause --> decrease in oestroegen --> mucosa becomes thinner, less elastic and more dry
tissue more prone to inflammation
change in vaginal pH and microbial flora can contribute to localised infections
145
Atrophic Vaginitis
what can a lack of oestrogen cause
- Atrophic Vaginitis
- pelvic organ prolapse
- stress incontinence.
146
Atrophic Vaginitis
presentation
in postmenopausal women:
- itchy
- dry
- dyspareunia
- bleeding due to localised inflammation
147
postmenopausal women with recurrent UTIs, stress incontinence or pelvic organ prolapse. Which condition?
atrophic vaginitis
148
Atrophic Vaginitis
examination findings
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
149
Atrophic Vaginitis
mnx
- vaginal lubricants (Sylk, Replens and YES)
| - topical oestrogen: cream, pessary, tablet, ring
150
Atrophic Vaginitis
what are the contraindications to topical oestrogen
breast cancer, angina and venous thromboembolism
151
Fibroids
what are they
benign tumours of the smooth muscle of the uterus
152
Fibroids
aka
uterine leiomyomas
153
Fibroids
which ethnic group is it more common in
black women
154
Fibroids
are they oestrogen sensitive
yes, they grow in response to oestrogen
155
Fibroids
types
- intramural
- subserosal
- submucosal
- pedunculated
156
Fibroids
what does intramural mean
within the myometrium
157
Fibroids
what does subserosal mean
just below the outer layer of the uterus. These fibroids grow outwards and can become very large
158
Fibroids
what does submucosal mean
just below the lining of the uterus (the endometrium).
159
Fibroids
what does pedunculated mean
on a stalk
160
Fibroids
presentation
- heavy menstrual bleeding
- prolonged menstruation (>7d)
- abdo pain, worse during menstruation
- bloating/feeling dull in abdo
- urinary/bowel sx
- deep dyspareunia
- reduced fertility
161
Fibroids
what will abdo and bimanual exam reveal
a palpable pelvic mass
or enlarged firm non-tender uterus
162
Fibroids
initial inx for submucosal fibroids presenting with heavy menstrual bleeding
hysteroscopy
163
Fibroids
inx of choice for larger fibroids
pelvic US
164
Fibroids
what inx may be considered before surgery where more info about the fibroid is needed
MRI scanning
165
Fibroids
medical mnx for fibroids <3cm
1st line: mirena
- NSAIDs
- tranexamic acid
- COCP
- cyclical PO progestogens
166
Fibroids
surgical mnx for fibroids <3cm with heavy menstrual bleeding
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
167
Fibroids
medical mnx for fibroids >3cm
refer to gynae
- NSAIDs, tranexamic acid
- mirena
- COCP
- cyclical PO progestogens
168
Fibroids
surgical mnx for fibroids >3cm
- uterine artery embolisation
- myomectomy
- hysterectomy
169
Fibroids
what may be used to reduce the size before surgery
GnRH agonist e.g. goserelin (Zoladex) or leuprorelin (Prostap)
170
Fibroids
how do GnRH agonists work
inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid
171
Fibroids
what is a myomectomy
surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy
172
Fibroids
complications
- red degeneration
- torsion
- leiomyosarcoma (malignant)
- iron deficiency
- reduced fertility
- miscarriages, premature, obstructive delivery
- constipation
- urinary outflow obstruction + UTIs
173
Fibroids
what is red degeneration
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
174
Fibroids
who is red degeneration more likely to occur in
occurs in fibroids >5cm during 2nd and 3rd trimester of pregnancy.
175
Fibroids
why does red degeneration occur
the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
kinking in the blood vessels as the uterus changes shape and expands during pregnancy
176
Fibroids
presentation of red degeneration
- severe abdo pain
- low grade fever
- tachycardia
- vomiting
177
Fibroids
mnx of red degeneration
supportive: rest, fluids, analgesia
178
Primary Amenorrhoea
definition
not starting menstruation
- by 13y + no signs of pubertal development
- or by 15y + signs of puberty
179
Primary Amenorrhoea
when does puberty start in girls
8-14y
180
Primary Amenorrhoea
when does puberty start in boys
9-15y
181
Primary Amenorrhoea
progression of puberty in girls
- breast buds
- then pubic hair
- then periods
182
Primary Amenorrhoea
a lack of oestrogen + testosterone can cause delay in puberty. what are the 2 reasons for this
- Hypogonadotropic hypogonadism
| - Hypergonadotropic hypogonadism
183
Primary Amenorrhoea
what is hypogonadotropic hypogonadism
deficiency of LH and FSH, leading to deficiency of oestrogen
184
Primary Amenorrhoea
what could hypogonadotropic hypogonadism be due to
- hypopituitarism
- damage to hypothalamus or pituitary e.g. radiotherapy
- chronic conditions: CF, IBD
- excessive exercise or dieting
- constitutional delay in growth + development
- endocrine: GH deficiency, hypothyroidism, cushing's, hyperprolactinaemia
- Kallman's syndrome
185
Primary Amenorrhoea
what is hypergonadotropic hypogonadism
the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH)
186
Primary Amenorrhoea
causes of hypergonadotropic hypogonadism
- previous damage to gonads (torsion, cancer, mumps)
- congenital absence ovaries
- Turner's syndrome (XO)
187
Primary Amenorrhoea
what is Kallman Syndrome associated with
hypogonadotrophic hypogonadism, with failure to start puberty.
reduced or absent sense of smell (anosmia)
188
Primary Amenorrhoea
what is androgen insensitivity syndrome
tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop.
It results in a female phenotype, other than the internal pelvic organs.
189
Primary Amenorrhoea
structural pathology which can cause primary amenorrhoea
- Imperforate hymen
- Transverse vaginal septae
- Vaginal agenesis
- Absent uterus
- Female genital mutilation
190
Primary Amenorrhoea
what is the threshold for initiating inx
no evidence of pubertal changes in a girl aged 13
can also be considered when there is some evidence of puberty but no progression after 2y
191
Primary Amenorrhoea
initial inx (assess for underlying medical conditions)
- FBC + ferritin for anaemia
- U&E for CKD
- Anti-TTG or anti-EMA antibodies for coeliac
192
Primary Amenorrhoea
what hormonal blood tests would you order
- FSH + LH
- TFTs
- insulin-like growth factor I (screening test for GH deficiency)
- prolactin
- testosterone
193
Primary Amenorrhoea
what genetic testing would you do
microarray test for Turner's (X0)
194
Primary Amenorrhoea
what imaging would you do
- xray wrist: constitutional delay
- pelvic US
- MRI brain
195
Primary Amenorrhoea
mnx
treat the underlying cause
196
Primary Amenorrhoea
mnx of hypogonadotrophic hypogonadism such as hypopituitarism or Kallman syndrome
pulsatile GnRH can be used to induce ovulation and menstruation.
pregnancy not wanted? COCP
197
Secondary Amenorrhoea
definition
no menstruation for >3m after previous regular menstrual periods
198
Secondary Amenorrhoea
when to consider assessment + inx
after 3-6m
In women with previously infrequent irregular period: after 6-12m
199
Secondary Amenorrhoea
what is the most common cause
pregnancy
200
Secondary Amenorrhoea
causes
- pregnancy
- menopause + premature ovarian failure
- hormonal contraception
- Hypothalamic or pituitary pathology
- Ovarian causes: PCOS
- Uterine pathology: Asherman’s syndrome
- Thyroid pathology
- Hyperprolactinaemia
201
Secondary Amenorrhoea
hypothalamus causes
hypothalamus reduces the production of GnRH in response to significant stress
- Excessive exercise (e.g. athletes)
- Low body weight and eating disorders
- Chronic disease
- Psychological stress
202
Secondary Amenorrhoea
pituitary causes
- pituitary tumours: prolactin secreting prolactinoma
| - pituitary failure: trauma, radio, surgery, Sheehan
203
Secondary Amenorrhoea
why does hyperprolactinaemia cause amenorrhoea
High prolactin levels act on the hypothalamus to prevent the release of GnRH --> no release of LH + FSH
204
Secondary Amenorrhoea
trx of hyperprolactinaemia
Dopamine agonists such as bromocriptine or cabergoline
205
Secondary Amenorrhoea
assessment
- hx + examination
- hormonal blood tests
- US: PCOS
206
Secondary Amenorrhoea
what hormone tests would you do
- bHCG: pregnancy
- high FSH: primary ovarian failure
- high LH: PCOS
- prolactin then MRI
- TFTs
- high testosterone: PCOS, AIS, CAH
207
Secondary Amenorrhoea
why do women with PCOS need a withdrawal bleed every 3-4m
to reduce the risk of endometrial hyperplasia and endometrial cancer.
208
Secondary Amenorrhoea
what can be used to stimulate a withdrawal bleed in PCOS
Medroxyprogesterone for 14d, or regular use of the COCP
209
Secondary Amenorrhoea
what are pts with amenorrhoea at increased risk of
osteoporosis
210
Secondary Amenorrhoea
when to start trx to reduce the risk of osteoporosis
when amenorrhoea lasts more than 12 months
211
Secondary Amenorrhoea
what trx is used to reduce the risk of osteoporosis
- ensure adequate vit D and Ca intake
| - HRT or COCP
212
Premenstrual Syndrome
what is it
the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation
213
Premenstrual Syndrome
symptoms are not present when?
- before menarche
- during pregnancy
- after menopause
214
Premenstrual Syndrome
cause
fluctuation in oestrogen and progesterone hormones during the menstrual cycle
thought to be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA
215
Premenstrual Syndrome
common sx
```
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
```
216
Premenstrual Syndrome
what is progesterone-induced premenstrual disorder
sx in response to COCP or cyclical HRT containing progesterone
217
Premenstrual Syndrome
what is the term used for when features are severe and have a significant effect on QoL
premenstrual dysphoric disorder
218
Premenstrual Syndrome
diagnosis is made based on what?
- based on a sx diary spanning 2 menstrual cycles
219
Premenstrual Syndrome
definitive dx
GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.
220
Premenstrual Syndrome
mnx initiated in primary care
- healthy lifestyle changes
- COCP
- SSRIs
- CBT
221
Premenstrual Syndrome
1st line COCP
containing drospirenone e.g. Yasmin
222
Premenstrual Syndrome
what does drospirenone do
has some antimineralocortioid effects, similar to spironolactone.
223
Premenstrual Syndrome
what is required for endometrial protection against endometrial hyperplasia when using oestrogen
cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.
224
Premenstrual Syndrome
what can be used in severe cases
GnRH analogues to induce a menopausal state
225
Premenstrual Syndrome
what should you take with GnRH analogues and why
HRT to add back hormones to mitigate osteoporosis SE
226
Premenstrual Syndrome
mnx when all medical mnx has failed
Hysterectomy and bilateral oophorectomy + HRT
227
Premenstrual Syndrome
medical mnx for cyclical breast pain
Danazole and tamoxifen (initiated by breast specialist)
228
Premenstrual Syndrome
what may be used to treat the physical sx (breast swelling, water retention, bloating)
Spironolactone
229
Adenomyosis
what is it
endometrial tissue inside the myometrium (muscle layer of the uterus).
230
Adenomyosis
presentation
- dysmenorrhoea (painful)
- menorrhagia (heavy)
- dyspareunia (sex)
231
Adenomyosis
examination findings
enlarged and tender uterus (softer than a uterus containing fibroids)
232
Adenomyosis
1st line inx
TVUS
MRI + transabdo US if not available
233
Adenomyosis
gold standard inx
histological examination of the uterus after a hysterectomy (obviously not a suitable way to establish dx)
234
Adenomyosis
mnx when contraception is wanted or acceptable
1st line: mirena
2: COCP
3: cyclical PO progestogens
235
Adenomyosis
mnx for when women do not want contraception
- tranexamic acid
| - mefenamic acid (when there is associated pain)
236
Adenomyosis
in pregnancy, what is adenomyosis associated with
- infertility
- miscarriage
- preterm birth
- small for gestational age
- preterm premature rupture of membranes
- malpresentation
- c-section
- postpartum haemorrhage
237
Menopause
what is it
a retrospective diagnosis, made after a woman has had no periods for 12 months
menopause is the point at which menstruation stops
238
Menopause
define postmenopause
12 months after the final menstrual period onwards
239
Menopause
define perimenopause
the time leading up to the last menstrual period, and the 12 months afterwards
240
Menopause
define premature menopause
menopause before the age of 40
it is the result of premature ovarian insufficiency
241
Menopause
pathophysiology
- no growth of ovarian follicles
- reduced oestrogen
- increased LH + FSH due to -ve feedback
- failing follicular development
- anovulation
- also no oestrogen --> endometrium doesn't develop --> amenorrhoea
242
Menopause
what causes the perimenopausal sx
a lack of oestrogen
243
Menopause
perimenopausal sx
- Hot flushes
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier or lighter periods
- Vaginal dryness and atrophy
- Reduced libido
244
Menopause
risks due to lack of oestrogen
- CVD + stroke
- osteoporosis
- pelvic organ prolapse
- urinary incontinence
245
Menopause
A diagnosis of perimenopause and menopause can be made in women over __
45y with typical sx without performing any inx
246
Menopause
when should you consider an FSH blood test to help w/ dx
- <40y w/ suspected premature menopause
| - 40-45y w/ menopausal sx or a change in menstrual cycle
247
Menopause
how long should women use contraception for after their last menstrual period
- 2y if <50y
| - 1y if >50y
248
Menopause
good contraceptive options (UKMEC1: no restrictions)
- Barrier methods
- Mirena or copper coil
- Progesterone only pill
- Progesterone implant
- Progesterone depot injection (<45y)
- Sterilisation
249
Menopause
key side effects of the progesterone depot injection (e.g. Depo-Provera
- weight gain
| - osteoporosis (why it's unsuitable for >45y)
250
Menopause
contraceptive option (UKMEC 2 after 40y: advantages generally outweigh risk)
COCP containing norethisterone or levonorgestrel in women >40y due to lower risk of VTE
251
Menopause
mnx of perimenopausal sx
- none
- HRT
- Tibolone
- Clonidine
- CBT
- SSRIs
- Testosterone
- Vaginal oestrogen
- Vaginal moisturisers
252
Menopause
what is tibolone
synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
253
Menopause
what is clonidine
agonists of alpha-adrenergic and imidazoline receptors
254
Premature Ovarian Insufficiency
definition
menopause before the age of 40
255
Premature Ovarian Insufficiency
what will hormonal analysis show
- raised FSH
| - low oestradiol levels
256
Premature Ovarian Insufficiency
cause
- idiopathic (>50%)
- iatrogenic: chemo, radio, surgery
- autoimmune: coeliac, T1DM, thyroid
- genetic: turner's
- infection: mumps, TB, CMV
257
Premature Ovarian Insufficiency
presentation
- irregular periods
- lack of menstrual periods
- hot flushes, night sweats, vaginal dryness
258
Premature Ovarian Insufficiency
dx
<40
+ typical menopausal sx
+ FSH>25 on 2 consecutive samples separated by >4w
259
Premature Ovarian Insufficiency
mnx
- traditional HRT
| - COCP
260
Premature Ovarian Insufficiency
does HRT given before 50y increase risk of breast cancer
no (as women would ordinarily produce the same hormones at this age)
261
Premature Ovarian Insufficiency
is there an increased risk of VTE with HRT in women <50y?
may be increased so this can be reduced by using transdermal methods (patches)
262
Ovarian cysts
presentation
often found incidentally on pelvic USS
- pelvic pain
- bloating
- fullness in abdo
- palpable pelvic mass
263
Ovarian cysts
when may they present with acute pelvic pain
if there is ovarian torsion, haemorrhage or rupture of the cyst
264
Ovarian cysts
what are functional cysts
related to the fluctuating hormones of the menstrual cycle,
265
Ovarian cysts
name 2 functional cysts
1. follicular cysts
| 2. corpus luteum cysts
266
Ovarian cysts
what is a follicular cyst
the most common
the developing follicle which fails to rupture and release the egg
harmless
267
Ovarian cysts
what are corpus luteum cysts
corpus luteum fails to break down and instead fills with fluid
may cause pelvic discomfort, pain or delayed menstruation
often seen in early pregnancy
268
Ovarian cysts
other types (apart from functional)
- serous cystadenoma
- mucinous cystadenoma
- endometrioma
- dermoid cysts/germ cell tumours
- sex cord-stromal tumours
269
Ovarian cysts
what are serous cystadenomas
benign tumours of the epithelial cells
270
Ovarian cysts
what are mucinous cystadenomas
benign tumour of the epithelial cells
can become huge, taking up lots of space in the pelvis and abdomen
271
Ovarian cysts
what are endometriomas
lumps of endometrial tissue within the ovary, occurring in patients with endometriosis
can cause pain + disrupt ovulation
272
Ovarian cysts
what are dermoid cysts/germ cell tumours
benign ovarian tumours
they are teratomas: come from germ cells, may contain skin , teeth, hair + bone
273
Ovarian cysts
what are dermoid cysts/germ cell tumours associated with
ovarian torsion
274
Ovarian cysts
what are sex cord-stromal tumours
rare benign or malignant tumours
arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)
275
Ovarian cysts
name some types of Sex Cord-Stromal Tumours
Sertoli–Leydig cell tumours and granulosa cell tumours
276
Ovarian cysts
features that may suggest malignancy
- Abdominal bloating
- Reduce appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
277
Ovarian cysts
RFs for ovarian malignancy
- Age
- Postmenopause
- Increased number of ovulations
- Obesity
- HRT
- Smoking
- Breastfeeding (protective)
- Family history and BRCA1 and BRCA2 genes
278
Ovarian cysts
protective factors
Factors that will reduce the number of ovulations:
- later onset of periods
- early menopause
- any pregnancies
- COCP
279
Ovarian cysts
inx for premenopausal women with a simple ovarian cyst < 5cm on US
none
280
Ovarian cysts
inx for women <40y with a complex ovarian mass
tumour markers for possible germ cell tumour:
- LDH
- α-FP
- HCG
281
Ovarian cysts
causes of raised CA125
- epithelial cell ovarian cancer
- Endometriosis
- Fibroids
- Adenomyosis
- Pelvic infection
- Liver disease
- Pregnancy
282
Ovarian cysts
mnx for possible ovarian cancer (complex cysts or raised CA125)
2 week referral to gynae oncology specialist
283
Ovarian cysts
mnx for possible dermoid cysts
referral to a gynaecologist for further investigation and consideration of surgery
284
Ovarian cysts
mnx of simple ovarian cyst <5cm
almost always resolve within three cycles.
do not require a follow-up scan
285
Ovarian cysts
mnx of simple ovarian cyst 5-7cm
routine referral to gynaecology
and yearly ultrasound monitoring.
286
Ovarian cysts
mnx of simple ovarian cyst >7cm
consider MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound
287
Ovarian cysts
mnx of cysts in postmenopausal women
CA125 result and referral to a gynaecologist
288
Ovarian cysts
mnx of cysts in postmenopausal women with a raised CA125
two-week wait suspected cancer referral
289
Ovarian cysts
mnx of cysts in postmenopausal women that are <5cm and a normal CA125
US every 4-6m
290
Ovarian cysts
surgical mnx
laparoscopy: ovarian cystectomy (removal of cyst) with possible oophorectomy
291
Ovarian cysts
complications
torsion
haemorrhage
rupture
292
Ovarian cysts
what is the triad of Meig's Syndrome
1. ovarian fibroma
2, pleural effusion
3. ascites
293
Ovarian cysts
what signs on US point towards a benign diagnosis
- uniocular cysts
- solid components
- no blood flow
294
Ovarian Torsion
what is it
ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
295
Ovarian Torsion
what is it usually due to
an ovarian mass >5cm such as a cyst or tumour
296
Ovarian Torsion
why does it happen with normal ovaries in younger girls before menarche
girls have longer infundibulopelvic ligaments that can twist more easily
297
Ovarian Torsion
why is it an emergency
Twisting of the adnexa and blood supply to the ovary leads to ischaemia.
If the torsion persists, necrosis will occur, and the function of that ovary will be lost
298
Ovarian Torsion
presentation
- sudden onset severe unilateral pelvic pain
- N+V
(not always severe and can take a milder, prolonged course)
299
Ovarian Torsion
what may examination show
- localised tenderness
| - maybe a palpable mass
300
Ovarian Torsion
initial inx of choice
TVUS
301
Ovarian Torsion
what may US show
- “whirlpool sign”
- free fluid in pelvis
- oedema of the ovary
302
Ovarian Torsion
what may Doppler studies show
a lack of blood flow
303
Ovarian Torsion
inx for definitive diagnosis
laparoscopic surgery
304
Ovarian Torsion
mnx
emergency
laparoscopic surgery to either:
- detorsion
- oopherectomy
305
Ovarian Torsion
complications if not treated
- loss of function in that ovary (other ovary can usually compensate)
- if other ovary loses function too --> infertility, menopause
- infection --> abscess --> sepsis
- rupture --> peritonitis --> adhesions
306
Cervical Ectropion
aka
cervical ectopy or cervical erosion
307
Cervical Ectropion
pathophysiology
columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix)
308
Cervical Ectropion
why is postcoital bleeding a presentation
the endocervix (columnar epithelial cells) are more fragile and prone to trauma
309
Cervical Ectropion
who is it more common in and why
associated w/ higher oestrogen levels:
- younger women
- COCP
- pregnancy
310
Cervical Ectropion
what is the transformation zone
the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).
311
Cervical Ectropion
presentation
- postcoital bleeding
- dyspareunia
- increased vaginal discharge
- vaginal bleeding
312
Cervical Ectropion
on examination
transformation zone: well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the endocervix.
313
Cervical Ectropion
are they associated with cervical cancer
no
314
Cervical Ectropion
mnx if asymptomatic
none: will typically resolve as the patient gets older, stops the pill or is no longer pregnant.
315
Cervical Ectropion
is having a cervical ectropion a contraindication to the COCP
no
316
Cervical Ectropion
mnx if there is problematic bleeding
- cauterisation of the ectropion using silver nitrate
| - or cold coagulation during colposcopy
317
Nabothian Cysts
what are they
fluid-filled cysts often seen on the surface of the cervix
318
Nabothian Cysts
aka
nabothian follicles or mucinous retention cysts
319
Nabothian Cysts
are they related to cervical cancer
no
320
Nabothian Cysts
pathophysiology
The columnar epithelium of the endocervix (the canal) produces cervical mucus.
When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst.
321
Nabothian Cysts
when can it form
- after childbirth
- minor trauma to cervix
- cervicitis secondary to infection
322
Nabothian Cysts
sx
- asymptomatic
| - feeling of fullness in pelvis if very large
323
Nabothian Cysts
on examination
speculum:
- smooth rounded bumps on cervix, usually near to os
- ranged from 2mm-30mm
- whitish or yellow
324
Nabothian Cysts
mnx if diagnosis is clear
reassure pt, no trx
325
Nabothian Cysts
mnx if diagnosis is uncertain
- refer for colposcopy
| - occasionally they may be excised or biopsied
326
Pelvic Organ Prolapse
what causes it
weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
327
Pelvic Organ Prolapse
name 4 types
- uterine prolapse
- vaginal vault prolapse
- rectocele
- cystocele
328
Pelvic Organ Prolapse
what is a uterine prolapse
the uterus itself descends into the vagina
329
Pelvic Organ Prolapse
what is a vault prolapse
occurs in women that have had a hysterectomy
the top of the vagina (vault) descends into the vagina
330
Pelvic Organ Prolapse
what is a rectocele
rectum prolapses forward into the vagina
because of a defect in the posterior vaginal wall
331
Pelvic Organ Prolapse
presentation of rectocele
faecal loading --> constipation, urinary retention, palpable lump in vagina
332
Pelvic Organ Prolapse
which type is it if woman uses finer to press lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels
rectocele
333
Pelvic Organ Prolapse
what is a cystocele
caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
prolapse of the urethra is also possible (urethrocele)
334
Pelvic Organ Prolapse
what is a prolapse of both bladder and urethra called
cystourethrocele
335
Pelvic Organ Prolapse
RFs
- multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
336
Pelvic Organ Prolapse
presentation
- “something coming down” in the vagina
- dragging or heavy sensation in the pelvis
- Urinary sx: incontinence, urgency, freq, weak stream, retention
- Bowel sx: constipation, incontinence, urgency
- Sexual dysfunction: pain, altered sensation, reduced enjoyment
337
woman identifies lump and often pushes it back up. Worse on straining or bearing down. What is t
pelvic organ prolapse
338
Pelvic Organ Prolapse
what should pts do before examination
empty bladder and bowels
339
Pelvic Organ Prolapse
When examining, what various positions may be attempted
the dorsal and left lateral position.
340
Pelvic Organ Prolapse
what special speculum can be used for examination
Sim’s speculum
- U-shaped, single-bladed speculum
- supports the anterior or posterior vaginal wall while the other vaginal walls are examined.
341
Pelvic Organ Prolapse
how can the severity of the uterine prolapse be graded
the pelvic organ prolapse quantification (POP-Q) system
342
Pelvic Organ Prolapse
POP-Q: grade 0
normal
343
Pelvic Organ Prolapse
POP-Q: grade 1
lowest part is >1cm above the introitus
344
Pelvic Organ Prolapse
POP-Q: grade 2
lowest part is within 1cm of the introitus (above or below)
345
Pelvic Organ Prolapse
POP-Q: grade 3
lowest part is >1cm below the introitus, but not fully descended
346
Pelvic Organ Prolapse
POP-Q: grade 4
Full descent with eversion of the vagina
347
Pelvic Organ Prolapse
what is the term for a prolapse extending beyond the introitus
uterine procidentia
348
Pelvic Organ Prolapse
what are the 3 options for mnx
1. conservative
2. vaginal pessary
3. surgery
349
Pelvic Organ Prolapse
who is conservative mnx suitable for
- able to cope with mild sx
- do not tolerate pessaries
- not suitable for surgery
350
Pelvic Organ Prolapse
conservative mnx
- physio: pelvic floor exercises
- weight loss
- lifestyle: reduce caffeine, incontinence pads
- vaginal oestrogen cream
- treat related sx: eg anticholinergics for stress incontinence
351
Pelvic Organ Prolapse
how do vaginal pessaries work
inserted into the vagina to provide extra support to the pelvic organs
352
Pelvic Organ Prolapse
types of pessaries
- ring
- shelf + Gellhorn
- cube
- donut
- hodge (rectangular)
353
Pelvic Organ Prolapse
advice to give about pessaries
- try the right one for you
- remove + clean or change every 4m
- can cause vaginal irritation + erosion over time
- oestrogen cream helps protect vaginal wall from irritation
354
Pelvic Organ Prolapse
what is the definitive trx option
surgery
355
Pelvic Organ Prolapse
complications of pelvic organ prolapse surgery
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
356
Pelvic Organ Prolapse
complications of mesh repairs
- chronic pain
- altered sensation
- dyspareunia
- abnormal bleeding
- urinary or bowel problems
357
Urinary Incontinence
what are the types
- urge
- stress
- mixed
358
Urinary Incontinence
what is urge incontinence caused by
overactivity of the detrusor muscles of the bladder
359
Urinary Incontinence
urge incontinence is aka?
overactive bladder
360
Urinary Incontinence
presentation of urge incontinence
- suddenly feeling the urge to pass urine
| - having to rush to the bathroom and not arriving before urination occur
361
Urinary Incontinence
what are the 3 canals through the centre of the female pelvic floor
urethral, vaginal and rectal canals
362
Urinary Incontinence
what is stress incontinence due to
weakness of the pelvic floor and sphincter muscles
which allows urine to leak at times of increased pressure on the bladder
363
Urinary Incontinence
presentation of stress incontinence
urinary leakage when laughing, coughing or surprised
364
Urinary Incontinence
what is mixed incontinence
combination of urge and stress
identify which is having more significant impact
365
Urinary Incontinence
when can overflow incontinence occur
when there is chronic urinary retention due to an obstruction to the outflow of urine
incontinence occurs without the urge to pass urine
366
Urinary Incontinence
causes of overflow incontinence
- anticholinergic meds
- fibroids
- pelvic tumours
- neuro: MS, diabetic. spinal cord
367
Urinary Incontinence
mnx for women with suspected overflow incontinence
referred for urodynamic testing and specialist management
368
Urinary Incontinence
RFs
- Increased age
- Postmenopausal status
- Increase BMI
- Previous pregnancies and vaginal deliveries
- Pelvic organ prolapse
- Pelvic floor surgery
- Neuro conditions: MS
- Cognitive impairment and dementia
369
Urinary Incontinence
modifiable lifestyle factors that can contribute to symptoms
- caffeine
- alcohol
- medications
- BMI
370
Urinary Incontinence
what to ask for when assessing severity
- Frequency of urination
- Frequency of incontinence
- Night time urination
- Use of pads and changes of clothing
371
Urinary Incontinence
what to examine for
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- ask pt to cough and assess leakage
372
Urinary Incontinence
how to assess strength of the pelvic muscle contraction on examiantion
asking the woman to squeeze against the examining fingers in bimanual examination
373
Urinary Incontinence
what grading system can be used to assess the strength of the pelvic muscle contraction
modified Oxford grading system:
374
Urinary Incontinence
modified Oxford grading system
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
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Urinary Incontinence
inx
- bladder diary
- urine dipstick
- bladder scan
- urodynamic testing
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Urinary Incontinence
what does a bladder scan measure
Post-void residual bladder volume to assess for incomplete emptying
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Urinary Incontinence
when can urodynamic testing be used
to investigate patients with:
- urge incontinence not responding to 1st line meds
- difficulties urinating
- urinary retention
- previous surgery
- unclear diagnosis
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Urinary Incontinence
what do urodynamic tests do
objectively assess the presence and severity of urinary symptoms
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Urinary Incontinence
what do pts need to do before urodynamic tests
- stop taking any anticholinergic and bladder related med 5d before
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Urinary Incontinence
what happens in urodynamic tests
- thin catheter inserted into bladder
- another inserted into rectum
- they measure the pressures in the bladder and rectum for comparison
- bladder filled with liquid
- various outcome measures are taken
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Urinary Incontinence
urodynamic tests: what does cystometry measure
the detrusor muscle contraction and pressure
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Urinary Incontinence
urodynamic tests: what does uroflowmetry measure
the flow rate
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Urinary Incontinence
urodynamic tests: what is leak point pressure
the point at which the bladder pressure results in leakage of urine.
pt asked to cough, move or jump when the bladder is filled to various capacities.
This assesses for stress incontinence.
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Urinary Incontinence
urodynamic tests: what does post-void residual bladder volume test for
incomplete emptying of the bladder
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Urinary Incontinence
urodynamic tests: what does video urodynamic testing involve
filling the bladder with contrast and taking xray images as the bladder is emptied.
(not part of routine part of urodynamic testing
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Urinary Incontinence
conservative mnx for stress incontinence
- avoid caffeine, diuretics + overfilling of bladder
- avoid excessive or restricted fluid intake
- weight loss
- supervised pelvic floor exercises
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Urinary Incontinence
how long should pelvic floor exercises be done before surgery
3 months
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Urinary Incontinence
what should women aim for in pelvic floor exercises
at least 8 contractions TDS
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Urinary Incontinence
medical mnx for stress incontinence
Duloxetine (SNRI antidepressant)
| used 2nd line where surgery is less preferred
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Urinary Incontinence
surgical options for stress incontinence
- tension-free vaginal tape
- autologous sling procedures
- colposuspension
- intramural urethral bulking
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Urinary Incontinence
what is tension-free vaginal tape
mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
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Urinary Incontinence
what is Autologous sling procedures
Similar to TVT but a strip of fascia from the patient’s abdominal wall is used rather than tape
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Urinary Incontinence
what it colposuspension
stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
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Urinary Incontinence
what it intramural urethral bulking
injections around the urethra to reduce the diameter and add support
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Urinary Incontinence
Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, what operation may be done
artificial urinary sphincter: pump inserted into labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.
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Urinary Incontinence
conservative mnx (1st line) for urge incontinence
bladder retraining for at least 6w
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Urinary Incontinence
medical mnx for urge incontinence
- anticholinergics: oxybutynin, tolterodine, solifenacin
| - or mirabegron
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Urinary Incontinence
side effects of anticholinergics like oxybutynin, tolterodine, solifenacin
dry mouth, dry eyes, urinary retention, constipation and postural hypotension
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Urinary Incontinence
why should anticholinergics be problematic in older, more frail pts
they can lead to cognitive decline, memory problems and worsening of dementia,
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Urinary Incontinence
Mirabegron is CI'd in?
uncontrolled HTN
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Urinary Incontinence
how does mirabegron lead to a hypertensive crisis
works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure
402
Urinary Incontinence
invasive mnx of urge incontinence
- botulinum toxin type A
- percutaneous sacral nerve stimulation
- augmentation cystoplasty
- urinary diversion
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Urinary Incontinence
what is percutaneous sacral nerve stimulation
implanting a device in the back that stimulates the sacral nerves
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Urinary Incontinence
what is augmentation cystoplasty
using bowel tissue to enlarge the bladder
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Urinary Incontinence
what is urinary diversion
redirecting urinary flow to a urostomy on the abdomen
406
Bartholin’s Cyst
what are the Bartholin's glands
a pair of glands located either side of the posterior part of the vaginal introitus
they produce mucus to help with vaginal lubrication
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Bartholin’s Cyst
what is it
when the ducts of the Bartholin's glands become blocked, they can swell and become tender
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Bartholin’s Cyst
presentation
a fluid filled cyst between 1-4cm
unilateral
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Bartholin’s Cyst
presentation of a Bartholin’s abscess (infected cysts)
hot, tender, red and potentially draining pus.
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Bartholin’s Cyst
dx
clinically with a history and examination
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Bartholin’s Cyst
mnx
- good hygiene
- analgesia
- warm compressions
- incision generally avoided as cyst will reoccur
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Bartholin’s Cyst
inx if vulval malignancy needs to be excluded
biopsy
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Bartholin’s Cyst
inx for Batholin's abscess
- swab of pus for culture
| - send specific swabs for chlamydia + gonorrhoea
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Bartholin’s Cyst
what is the most common cause of Bartholin's abscess
e.coli
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Bartholin’s Cyst
mnx of Bartholin's abscess
- abx
- or surgery may be required:
Word catheter
Marsupialisation
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Bartholin's Cyst
Word catheter procedure
- local
- incision to drain pus
- inflate catheter with saline into abscess space
- fluid can drain around catheter, preventing cyst or abscess reoccurring
- tissue heals around catheter leaving a permanent hole
- catheter deflated and carefully removed at a later date once epithelisation of the hole has occurred
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Bartholin's Cyst
what does Marsupialisation involve
- GA in a surgical theatre
- incision to drain
- sides of abscess are sutured open
- allowing continuous drainage
418
Female Genital Mutilation
what is it
surgically changing the genitals of a female for non-medical reasons
a form of child abuse + safeguarding issue
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Female Genital Mutilation
Female genital mutilation is illegal as stated in ____
the Female Genital Mutilation Act 2003
legal requirement for healthcare professionals to report cases of FGM to the police
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Female Genital Mutilation
which countries have high rates
- Somalia
- Ethiopa
- Sudan
- Eritrea
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Female Genital Mutilation
how many types are there
4
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Female Genital Mutilation
Type 1
Removal of part or all of the clitoris
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Female Genital Mutilation
Type 2
Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
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Female Genital Mutilation
Type 3
Narrowing or closing the vaginal orifice (infibulation).
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Female Genital Mutilation
Type 4
All other unnecessary procedures to the female genitalia.
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Female Genital Mutilation
2 key RFs to bear in mind
- from a community that practise FGM
| - having relatives affected by FGM.
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Female Genital Mutilation
scenarios where it is worth considering the risk of FGM
- Pregnant women with FGM with a possible female child
- Siblings or daughters of women or girls affected by FGM
- Extended trips with infants or children to areas where FGM is practised
- Women that decline examination or cervical screening
- New patients from communities that practise FGM
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Female Genital Mutilation
immediate complications
- Pain
- Bleeding
- Infection
- Swelling
- Urinary retention
- Urethral damage and incontinence
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Female Genital Mutilation
long term complications
- Vaginal infections e.g. BV
- Pelvic infections
- UTIs
- Dysmenorrhea
- Sexual dysfunction and dyspareunia
- Infertility and pregnancy-related complications
- psychological issues
- Reduced engagement with healthcare and screening
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Female Genital Mutilation
mnx if U18
- mandatory to report all cases to the police
contact
- social serves + safeguarding
- paediatrics
- specialist gynae or FGM services
- counselling
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Female Genital Mutilation
mnx if >18
- careful consideration about whether to report cases to the police or social services
- risk assessment tool on gov.uk
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Female Genital Mutilation
surgical mnx for type 3
de-infibulation
| - aims to correct the narrowing or closure of the vaginal orifice
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Female Genital Mutilation
what is re-infibulation
(re-closure of the vaginal orifice) could be requested after childbirth. Performing this procedure is illegal.
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Congenital Structural Abnormalities
where do the upper vagina, cervix, uterus and fallopian tubes develop from
the paramesonephric ducts (Mullerian ducts)
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Congenital Structural Abnormalities
in a male fetus, what is produced which suppresses the growth of the Mullerian ducts
anti-Mullerian hormone
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Congenital Structural Abnormalities
what is bicornuate uterus
where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance
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Congenital Structural Abnormalities
dx of bicornuate uterus
pelvic US
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Congenital Structural Abnormalities
complications of bicornuate uterus
Miscarriage
Premature birth
Malpresentation
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Congenital Structural Abnormalities
what is imperforate hymen
where the hymen at the entrance of the vagina is fully formed, without an opening.
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Congenital Structural Abnormalities
typical presentation of imperforate hymen
discovered when girl starts to menstruate
cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding
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Congenital Structural Abnormalities
trx of imperforate hymen
surgical incision
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Congenital Structural Abnormalities
what could imperforate hymen lead to
retrograde menstruation could occur leading to endometriosis.
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Congenital Structural Abnormalities
what is transverse vaginal septae
an error in development, where a septum (wall) forms transversely across the vagina.
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Congenital Structural Abnormalities
in transverse vaginal septae, the septum can either be ____
perforate (with a hole) or imperforate (completely sealed).
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Congenital Structural Abnormalities
presentation of transverse vaginal septae (perforated)
girls will still menstruate, but can have difficulty with intercourse or tampon use
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Congenital Structural Abnormalities
presentation of transverse vaginal septae (imperforated)
present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation
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Congenital Structural Abnormalities
complications of transverse vaginal septae
infertility and pregnancy-related complications
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Congenital Structural Abnormalities
dx of transverse vaginal septae
examination, ultrasound or MRI
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Congenital Structural Abnormalities
trx of transverse vaginal septae
surgical correction
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Congenital Structural Abnormalities
main complication of surgery for a transverse vaginal septae
vaginal stenosis and recurrence of the septae
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Congenital Structural Abnormalities
what is vaginal hypoplasia
abnormally small vagina
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Congenital Structural Abnormalities
what is vaginal agenesis
absent vagina
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Congenital Structural Abnormalities
why does vaginal hypoplasia and agenesis occur
due to failure of the Mullerian ducts to properly develop
and may be associated with an absent uterus and cervix.
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Congenital Structural Abnormalities
in vaginal hypoplasia and agenesis, are the ovaries affected
no, so normal female sex hormones (except AIS where they are testes)
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Congenital Structural Abnormalities
mnx of vaginal hypoplasia and agenesis
- vaginal dilator over a prolonged period to create an adequate vaginal size
- or vaginal surgery
