Gynae Flashcards
Follicular Stage ~ 14 days
Hormone Changes
FSH: Stim Follicles -> second Follicles (surrounded by Granulosa cells)
(Granulosa cells release Oestrogen: => Decrease in GnRH/FSH/LH)
LH: Surge (Past certain point Oestrog (+) feedbacks)
=> Release of Ovum
Luteal Stage = 14 day
Hormone changes
If Ovum Fertilised/Non-Fert
Empty Follicle - > Corpus Luteum (Prod Oestrog + Prog)
If ovum fertilised:
-> Embryo (produces hCG -> maintains Corpus Luteum)
If ovum not fertilised: (Degeneration of corpus Luteum):
Reduced Oestrog + Prog -> Increased GnRH (+FSH/LH)
Breakdown of endometrium (-> Menstruation)
Menstrual Cycle Stages + Def
Follicular Stage:
Maturation of Follicle
Luteal Stage:
Movement of Follicle/Ovum +/- Menstruation
Hypogonadotropic/Hypergonadotropic Prim Amenorrhoea causes
Hypogonadotropic: (Loss of LH/FSH)
Damage to hypothalamus/ant Pit, Hypo-Pit
Chronic condition (CF, IBD)
Excessive exercise/diet
Hypergonadotropic: (Lack of Resp to LH/FSH)
Damage to Gonads (Torsion, cancer, Inf), Congen Absence of Ovaries
Turners Synd (45, XO – Growth Def in girls)
CAH (21-Hydroxylase Def => Overproduct of Androgens)
AIS (Fail to Resp to Test => No descent of Testis)
Sx of Structural Causes of Prim Amenorrhoea
No Menses => Cyclical Abdo pain
Abnormal Genitalia/Pelvic Organs
(Normal Second sex Charact: Hair, Breasts, Growth)
Primary Amenorrhoea Ix - 7
Invest:
bhCG - Pregnancy test
FBC (+ Fe) – Anaemia
U+Es – CKD
Anti-ttG – Coeliac D
TFTs, PRL – Prolactinoma (+/- MRI), LH/FSH, IGF-1 – GH Def
Testosterone – Raised w/: PCOS, CAH, AIS
Physical Ex/USS (If abnormal: Karyotype)
(X-ray Bone age – Develop delay)
Prim Amenorrhoea Mx
Conservative
Hypogonadotropic
Hypergonadotropic
Conservative:
Wait, Reduce Stress, Increase BMI, CBT
Hypogonadotropic: Pulsatile GnRH (Restores menses, no contraception) COCP (Restores menses w/ contraception)
Hypergonadotropic:
COCP
Second Amenorrhoea Def + causes - 5
Cessation of Reg menses > 3 months or Irreg menses > 6 months
Pregnancy, Menopause, Premature Ovarian Fail, Hormonal contraception
Prolactinoma (Hyper-PRL => Panhypo-Pit + Hypogonadotropic hypogonadism)
Thyroid D (HypoTh)
PCOS
Stress (Low BMI/Excessive Exercise, Chronic cond -> Reduced GnRH)
Second amenorrhoea Ix - 6
bhCG (Pregnancy test)
LH/FSH (Raised LH: PCOS, Raised FSH: Prim Ovarian Fail)
Testosterone (Raised w/: PCOS, CAH, AIS)
PRL (Prolactinoma), MRI (Pit adenoma)
TFTs
Pelvic USS
PMS Diagnosis + Timing Rules
Cyclical Sx spanning > 2 cycles
(If Sx severe: Premenstrual Dysphoric Disorder)
Timing:
Sx not present before menarche, during pregnancy, after menopause
Can occur in response to HRT/COCP
Can occur after surgery/hysterectomy (Ovaries cont to function)
Menorrhagia Mx:
Contra not Req
Contra Req
Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid
Contraception required: Mirena Coil (IUS) COCP POP (Referral for Endometrial Ablation, Hysterectomy)
Fibrioids Def
Benign, Oestrog-Sens, SM Tumours – Leiomyomas
Fibrioids Mx:
Contra not Req
Contra Req
Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid
Contraception required:
Mirena Coil (IUS)
COCP
POP
Fibrioids Mx: Surg
Surg: (GnRH Agonist => Reduce Fibroid size):
Small (< 3cm): Endometrial Ablation, Resection, Hysterectomy
Large (> 3cm): Uterine A Embolization, Myomectomy, Hysterectomy
Endometriosis + Adenomyosis Def
Ectopic Endometrium,
Adenomyosis: Ectopic Endometrium w/in Myometrium
Endometriosis Mx
HRT (Sx control):
COCP, POP, Prog Inj, Prog Implant, IUS
GnRH Agonists (Induce Menopause)
Surg (Increase Fertility):
Lap (+/- Biopsy, Ablate/Excise, Remove Adhesions)
Hysterectomy + Bilat Salpingoopherectomy
Adenomyosis Mx:
Contra not Req
Contra Req
Surg
Contraception not required:
No pain: Tranexamic Acid
Pain: Mefenamic Acid
Contraception required: Mirena Coil (IUS) COCP POP Surg: Endometrial Ablation, Uterine A Embolization, Hysterectomy
Fibrioids vs Endometriosis vs Adenomyosis
Fibrioids: Cyclical pain, Menorrhagia, Enlarged/Firm/Tender Uterus
Endometriosis: Cyclical/Chronic (Cont) pain, Menorrhagia
Adenomyosis: Pain, Menorrhagia, Enlarged/Tender Uterus
Menorrhagia Ix
Pelvic/Abdo Ex (Fibroids, Ascites, Cancer) FBC + Fe (Anaemia) Hysteroscopy Pelvic/Trans-vag USS Lap +/- Biopsy (Endometriosis) Hysterectomy w/ Histology (Adenomyosis)
Menopause Def
Premature Menopause Def + Criteria
Menopause: Permanent end to Menses (> 12 months)
Premature: Ovarian Fail/Insuff (Menopause < 40yo)
Women < 40yo w/ typical menopausal Sx + Raised FSH
Premature Menopause Mx:
w/w/out Uterus
w/w/out Menses
Supp
HRT until Menopause Age: 50:
w/ Uterus: Oestrog + Prog (Req for Endometrial Protection)
(COCP not recommended; increased VTE risk)
w/out Uterus: Oestrogen-only HRT (Patch)
w/ Menses: Cyclical w/ Reg Breakthrough bleeds
w/out Menses: Continuous HRT
Vag Lubricants, Oestrogen pessaries/gel
CBT, SSRi, Mood stabilisers
(Testosterone => Increase Libido)
Premature Menopause Patho + Sx
Reduced Ovarian follicles -> Reduced Oestrogen =>
Increase in FSH/LH =>
Anovulation/Amenorrhea/Irreg menses
Perimenopausal Sx
PCOS Criteria
Oligoovulation/Anovulation
Hyperandrogenism (Hirsuitism, Acne, Weight Gain)
Polycystic ovaries on USS (String of pearls: > 12, Ovarian Vol > 10cm3)
(+/- Infertility, Insulin-resistance)
PCOS Ix
Hormone assay:
Increased: Testosterone (excess androgens), LH/FSH, Insulin
PRL (Hypopituitarism), TFTs (HypoTh)
Pelvic/Transvag USS:
Ovarian Vol > 10cm3
> 12 developing follicles on an ovary (string of pearls around Periph)
OGTT (screen for DM):
Glu > 11mmol 2hrs after drink (Impaired tolerance)
PCOS Mx
Weight loss, Statins, Orlistat (Lipase Inhib: Reduce Absorption of fat w/in Intestines)
Mirena Coil (oppose Oestrogen)
COCP (Dianette: Anti-androgenic Effects)
Ovarian Cysts Ix
Pelvic USS:
If simple: < 5cm: No f/up Req,
If Complex: > 5cm: Tumour Markers
Tumour Markers: aFP, LDH, hCG, CA-125
Meigs Synd
Ovarian Fibroma (Benign), Pleural Effusion, Ascites
Ovarian signs on USS:
Ruptured Cyst
Torsion
Ruptured Cyst: Free fluid w/in Peritoneum
Torsion: Free fluid w/in Peritoneum, Whirlpool Sign, Ovarian Oedema
Ashermans Syndrome Def + Sx
Adhesions w/in Uterus (Inf, Trauma, Surg)
Sx:
Lighter periods, Second Amenorrhea
Dysmenorrhea
(Infertility, Recurrent miscarriages)
Ashermans Syndrome Invest + Mx
Invest: Hysteroscopy (w/ Dissection) Hysterosalpingography (X-ray w/ contrast) Sonohysterography (Pelvic USS w/ Fl) MRI
Mx:
Dissection during hysteroscopy
Incontinence Ix
Ex: (Pelvic tone, Cough Impulse) Bladder diary Urin dipstick Post-void Bladder scan Urodynamic tests
Incontinence Mx (Conservative)
Lifestyle changes:
Reduce Caffeine/Alcohol
Reduce BMI
Stop Meds (Diuretics)
Stress Incontinence Mx
Pelvic floor exercises
Surg (mesh, stitches, bulking)
Duloxetine (SNRi AntiD)
Urge Incontinence Mx
Bladder retraining (Increase time btw voids)
Anti-cholinergics (Oxybutynin)
Mirabegron (Beta3 Agonist)
COCP UKMEC4 - 7
Uncontrolled HT, IHD/AF/Cardiomyopathy Vasc D/Stroke, Hx of VTE Migraine w/ Aura Age > 35 + Smoking > 15/day Maj Surg w/ prolonged Immobility Liver Cirrhosis/Tumours SLE, Anti-phospholipid Synd
Rules governing contra for Adolescents
Refer to Fraser guidelines and ensure patient is gilick competent:
Understands advice
Encouraged to involve parents
(-) physical/mental effect if advice/treatment withheld
Action is in best interests
Methods of Postpartum Contra
Emergency contraception only needed past 21 days
1): Lactational amenorrhoea:
Anovulation since delivery,
Fully breastfeeding,
Infant < 6 months
2) : POP/implant (safe whilst breastfeeding)
3) : COCP (Avoid while breastfeeding, UKMEC2 after 6wks)
4) : IUD/IUS (Inserted w/in 48hrs or > 4wks – otherwise expulsion likely)
IUD/IUS lost threads Invest, Timing
Pregnancy test Exploration w/ narrow A forceps USS, AXR Hysteroscopy, Lap surg (Excl: Expulsion, Pregnancy, Uterine perforation)
IUD: (Lasts 5-10yrs)
IUS: (Lasts 5yrs)
Emergency Contra
IUD (wait 5 days)
IUS/Mirena (w/in 72hrs)
Ulipristal Acetate (w/in 120hrs/5 days):
(Avoid Bfeeding for 1wk, Avoid in Asthma, Delay COCP/POP for 5 day)
Missed Pill Rules
If miss pill/DnV => Take extra pill
If +/- 5 days from Day 14 seek Emergency Contra
If miss multiple pills => Skip pill-free period + take extra contraception
COCP SE:
Breast tenderness,
Headaches,
N+V
VTE Risk, Breast Ca Risk
Prog SE:
Breast tenderness, Headaches, N+V Weight gain Acne Abnormal Bleeding (Pill: 1/3, Inj/Implant: Problematic - COCP)
IUD/IUS SE
Problematic Bleeding (COCP)
Pelvic Pain
Expulsion
Increased risk of Ectopics
Coil Contras
PID/STI
Pregnancy
Pelvic Ca
Uterine distortion (Fibroids)
IUD: Wilsons D
IUS: Cervical/Endometrial Ca
HPV => Cerv Ca Patho
HPV 16/18 infects cervix + releases:
E6: Inhibs p53
E7: Inhibs pRb
Cerv Screening (Smear)
Smear: Collection of cells tested for HPV + Cytology (Assess Dyskariosis: Pre-cancerous changes)
If 25-49: Every 3yrs
If 50-65: Every 5yrs
(If Preg: Wait 12wks)
Inadequate sample: Repeat after 3 months
HPV(-): Continue normal screening
HPV(+) w/ normal cytology: Repeat after 12 months
HPV(+) w/ abnormal cytology: Refer for Colposcopy
Cerv Screening (Colposcopy)
Biopsy taken + sent for Histopathological grading of Dysplasia:
CIN 1: Mild (1/3)
CIN 2: Mod (2/3)
CIN 3: Severe (+/- => Cancer)
Cervical Ca FIGO Staging
S1: Confined to cervix
S2: Invades uterus/upper Vag
S3: Invades Pelvic wall/lower Vag
S4: Invades pelvic organs (Bladder, Rectum, Pelvis)
Cerv Ca Mx + Prevention
CIN, S1: LLETZ, Cone Biopsy
S1 – 2a: Radical Hysterectomy (+ removal of L.Ns)
S2b – 4: Surg, Radio/ChemoTx, Palliative
(Adv cancer: Pelvic Exenteration:
Rad Surg to Remove all pelvic organs: Vag, Cervix, Uterus, Fallopian tubes, Ovaries, Bladder, Rectum)
Prevention: Gardasil (HPV Vaccine)
Endometrial Hyperplasia Def, Risk F + Mx
Pre-cancerous condition w/ 2 types:
Hyperplasia w/ out Atypia
Atypical hyperplasia
(Risk F: Unopposed oestrogen)
Mx:
IUS (Mirena coil)
PO Prog
Endometrial Ca Referral
PM bleeding (> 12 months since LMP) => 2 week wait
Unexplained Vag discharge/Visible Haematuria in women > 55yo => Trans-Vag USS
Endometrial Ca Ix
TV-USS (Nomal Endo Thickness: < 4mm)
Pipelle Biopsy (w/ Speculum)
Hysteroscopy (w/ Endometrial Biopsy)
Endometrial Ca FIGO Staging
S1: Confined to Uterus
S2: Invades Cervix
S3: Invades Ovaries/Fallopian tubes/Vag/LN’s
S4: Invades other Pelvic Organs
Endometrial Ca Mx
S1+2: TAH + BSO (+/- Radio/ChemoTx)
+/- Prog: Slow Cancer
Ovarian Ca Referral
Ascites, Abdo/Pelvic masses: 2wk-wait
Change in bowel habit, Weight loss, Bloating, Pelvic pain, Urin Sx: CA-125
Ovarian Ca Ix
(RMI: Risk of Malig Index):
Menopausal Status
USS Findings
CA-125 level (> 35 IU/ml)
(Women < 40yo w/ complex ovarian mass: (GCs): aFP, hCG )
Ovarian FIGO Staging
S1: Confined to Ovaries
S2: Spread, w/in Pelvis
S3: Spread, w/in Abdo
S4: Dist Metastasises
Ovarian Ca Mx
Surg + Chemo
Vulval Ca/VIN Risk F
Adv Age (> 75yo),
Immunosuppression,
HPV Inf
Lichen Sclerosus
VIN Mx
(Diagnosed via Biopsy) Watch+wait Wide Local Excision Imiquimod cream (Immune modulator) Laser Ablation
Vulval Ca Ix + Mx
2wk-wait w/ Biopsy (Incl Sentinel LN’s)
(Staging CT Abdo/Pelvis)
Wide-local Excision +/- LN dissection
Chemo/RadioTx
BV Features
Discharge w/ Fish smell Vag swab (Clue cells, pH > 4.5) Mx: Metronidazole
Candidiasis Features
Thick discharge, Itch + Pain
Mx: Vag/Top Cotrimoxazole, PO Fluconazole
Chlamydia Features
Abnormal discharge/bleeding, Pain
Mx: PO Doxy 100mg BD 7 days
Chlamydia Complication
LGV (Lymphogranuloma Venereum)
=> Painless Ulcer, Lymphadenitis, Proctitis/Proctocolitis
Mx: PO Doxy 100mg BD 21 days
Gonorrhoea Features
Green/Yellow Discharge, Pain
Mx: IM Ceftriaxone 1g
Mycoplasma Genitalum Features
Urethritis (Excl Gonnorhoea: NAAT Vag swab)
Mx: Doxy 100mg 7 days, Azithromycin 1g and 500mg OD 2 days
Trichomonas Features
Frothy discharge, Itch/Pain +/- Smell
(Strawberry Cervix, pH >4.5)
Mx: Metronidazole
HSV Features
Reg Aciclovir
Sores: Instillagel
Syphilis Features
Painless Ulcer, Rash, Lymphadenopathy
(Ab testing for T. Pallidum)
Mx: Deep IM Benzylpenicillin, Full STI Screen
Disseminated Gonococcal Inf Triad
Tenosynovitis
Migratory Polyarthritis
Dermatitis
Prim Amenorrhoea Def
Fail to menstruate by 15yo (w/ normal Second Sex characteristics) or by 13yo (w/ no Second Sex characteristics) or no progress for > 2yrs
Dysmenorrhea Mx
NSAID (Mefenamic Acid), Paracetamol
COCP
POP/Implant
IUS
