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Obs and Gynae > Gynae > Flashcards

Gynae Flashcards

1
Q

Describe the hypothalamic-pituitary axis

A

The hypothalamus produces GnRH which stimulates release of FSH and LH from anterior pituitary. FSH and LH stimulate Oestrogen from the ovary.
- oestrogen has a negative feedback effect on both hypothalamus and anterior pituitary

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2
Q

What is function of oestrogen

A
  • development of secondary sexual characteristics:
  • breast development
  • growth of pubic hair and development of female sex organs at puberty
  • development of endometrium
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3
Q

What are the phases of the Ovarian cycle

A

FOL(d) M(a)PS
Ovarian cycle:
Follicular, Ovulation, Luteal phase

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4
Q

What are the phases of the menstrual cycle

A

FOL(d) M(a)PS
Menstrual cycle:
Menstrual flow, proliferative phase, secretory phase

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5
Q

What occurs during the follicular phase

A
  • Low oestrogen/progesterone
  • rising levels of FSH + LH
  • Developing follicles release oestrogen
  • Inhibits FSH -> leads to one dominant follicle
  • Oestrogen levels then cause positive feedback leading to LH surge and Ovulation
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6
Q

What occurs during the Luteal phase

A
  • After ovulation, follicle forms the corpus luteum
  • secretes progesterone which maintains endometrial lining
  • Unless fertilisation which results in HCG that maintains, regresses to corpus albicans
  • fall in progesterone and oestrogen causes endometrium to break down and menstruation to occur.
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7
Q

When does menstrual phase occur

A
  • at end of luteal phase, corpus luteum degenerates + decreased progesterone.
  • endometrium sheds
  • day 1-5. Varies.
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8
Q

What happens during proliferative phase

A
  • endometrium exposed to increasing levels of oestrogen (result of FSH and LH stimulating production)
  • Oestrogen causes repair and growth of endometrial layer
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9
Q

What happens during secretory phase

A
  • after ovulation has occurred
  • progesterone produced by corpus luteum
  • prepares for embryo to implant
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10
Q

Which phase is constant in women and what is its length

A
  • luteal phase

- always 14 days duration from ovulation to menstruation

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11
Q

What is the mnemonic for 9 main categories of causes of abnormal uterine bleeding

A 
- PALM-COEIN (palm coin)
(structural causes)
- Polyps 
- Adenomyosis
- Leiomyomas/Fibroids
- Malignancy + hyperplasia
(non-structural)
- Coagulopathy - often VWD
- Ovulatory dysfunction - PCOS, hypothyroidism, hyperprolactinemia
- Endometrial - endometriosis and other endometrial problems
- iatrogenic - IUD, drugs
- Not yet classified - pregnancy, PID
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12
Q

What are most common causes of heavy menstrual bleeding/menorrhagia

A
  • dysfunctional uterine bleeding (no identifiable cause)
  • fibroids
  • polyps - endometrial + cervical
  • adenomyosis
  • PID
  • ovarian tumour
  • hypothyroidism, VWD (FH of bleeding after surgery/trauma)
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13
Q

Ix of HMB

A
  • speculum + bimanual (fibroids, cancers)
  • FBC + Hb (IDA), thyroid (hypothyroidism), coagulation screen
  • PVUS/TVUS (PALM - structural causes)
  • Outpatient Hysteroscopy (suspect submucosal fibroids, cancer)
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14
Q

Medical Mx of HMB

A
  • Exclude underlying pathology -> anaemia, fibroids, bleeding disorders, cancer.
  • When contraception acceptable:
    1. 1st line = Mirena (progesterone) IUS coil.
    2. COCP (21 days, 7 day break)
    3. Progestogen only pill (every day, no break) or depo injection/implant
  • When does not want contraception, symptomatic relief:
    Tranexamic acid (antifibrinolytic - reduces bleeding) or Mefenamic acid, NSAIDs
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15
Q

Surgical Mx of HMB

A
  • endometrial ablation -> burns endometrial lining
  • hysteroscopic polyp removal
  • myomectomy
  • hysterectomy
  • uterine artery embolisation
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16
Q

Causes of irregular menstruation/intermenstrual bleeding

A
  • anovulatory cycles (common in early and late reproductive years)
  • fibroid, polyps, adenomyosis, ovarian cysts, PID
  • cancer (ovarian, endometrial, cervical)
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17
Q

What is primary amenorrhea

A

absence of menstruation: by 13 years when there is no other evidence of pubertal development.
by 15 years where there are other signs of puberty, such as breast bud development

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18
Q

When does normal puberty start in girls and what happens

A

8-14 years, lasting about 4 years. Earlier growth spurt than boys. Puberty starts with breast bud development, then pubic hair and finally menstrual periods

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19
Q

Causes of primary amenorrhea

A
  • (increased BHCG) -> pregnancy
  • (increased/decreased TSH) -> hyper/hypothyroid
  • (increased prolactin) -> hyperprolactinaemia
  • FSH,LH:
    (Low FSH/LH) = hypogonadotrophic hypogonadism -> constitutional delay in puberty, damage to HPA axis from surgery/ radiotherapy, excessive exercise/dieting, kallman syndrome
    (High FSH/LH) = hypergonadotrophic hypogonadism -> turners syndrome (45XO), Mullerian agenesis (46XX + abnormal uterus), previous damage to the gonads (torsion, cancer, infections)
  • Outflow obstruction/structural pathology: Imperforate hymen, transverse vaginal septum
  • 46XY androgen insensitivity (male karyotype with female phenotype)
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20
Q

What is definition of secondary amenorrhoea?

A
  • no menstruation for more than 3 months after previous regular menstrual periods
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21
Q

What are the causes of secondary amenorrhea

A
  • (increased BHCG) -> pregnancy
  • (abnormal TSH, PRL) -> thyroid, hyperprolactinoma [MRI]
  • (increased androgens ) -> PCOS (high LH or LH:FSH ratio, testosterone) , androgen insensitivity (high FSH, testosterone)
  • (increased FSH, LH) hypergonadotropic hypogonadism -> menopause, premature ovarian failure
  • (decreased FSH,LH) hypogonadotropic hypogonadism -> weight loss, exercise, chronic illness
  • hormonal contraception
22
Q

Causes of postcoital bleeding

A
  • cervical carcinoma
  • cervical ectropion
  • cervical polyps
  • > when cervix is not covered in healthy squamous epithelium is more likely to bleed after mild trauma.
23
Q

What is dysmenorrhea?

A
  • painful menstruation
24
Q

Causes of primary dysmenorrhea, how to manage?

A
  • no organic cause is found. Very common - contraction of endometrium and uterine ischaemia
  • pain usually responds to NSAIDs or ovulation suppression (e.g. COCP)
25
Q

What is secondary dysmenorrhea, what is suggestive of it? Causes?

A
  • pain due to pelvic pathology
  • when simple medical treatment for primary fails
  • fibroids, adenomyosis, endometriosis, PID, ovarian tumours
26
Q

What is precocious puberty?

A

Menstruation occurs before age of 9 or other secondary sexual characteristics present before 8

27
Q

Causes of precocious puberty?

A
  • most cases no cause found
  • increased GnRH secretion from meningitis, encephalitis, CNS tumour
  • increased oestrogen secretion from tumours of ovary or adrenal glands
28
Q

How to manage precocious puberty

A

GnRH agonist/anologue (suppress ovulation by stopping pulsatile release of GnRH)

29
Q

What is premenstrual syndrome

A
  • psychological, emotional and physical symptoms that occur prior to the onset of menstruation.
  • resolve once menstruation begins
  • caused by fluctuation in oestrogen and progesterone
30
Q

Px of premenstrual syndrome

A 
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment 
Clumsiness
Reduced libido
31
Q

What are the 2 anatomical positions of the uterus

A
  • 80% women are anteverted -> tilts up towards the abdominal wall
  • 20% women it is retroverted -> tilting back into the pelvis
32
Q

What is a leiomyoma

A
  • Fibroids
  • benign tumours of the myometrium (smooth muscle of the uterus).
  • more common in later reproductive years
  • growth is oestrogen and progesterone dependent - regresses after menopause
33
Q

Types of fibroid

A
  • intramural -> within the myometrium
  • subserosal -> just below outer layer of uterus. Can grow into abdominal cavity
  • submucosal -> just below lining of the uterus (endometrium)
  • Pedunculated -> means on a stalk
34
Q

Px of fibroids

A
  • often asymptomatic
  • HMB (most frequent symptom)
  • IMB
  • Dysmenorrhea, abdo pain
  • Urinary symptoms if pressing on bladder
  • impaired fertility
35
Q

Ix for fibroids

A
  • abdo + bimanual may have palpable pelvic mass or enlarged firm non-tender uterus
  • PVUS for large fibroids
  • Hysteroscopy for submucosal fibroids
36
Q

Mx for fibroids

A
  • only require tx when cause symptoms
  • IUS 1st line for small fibroids with no distortion of uterus
  • GnRH may shrink fibroid
  • surgery:
    1. hysteroscopic surgery with resection for smaller fibroids
    2. Myomectomy via laparoscopic or open surgery in those with fertility issues
    3. Radical hysterectomy +/- ovary removal
  • other:
    uterine artery embolisation -> surgical alternative for larger fibroids. Starves fibroid of oxygen.
    Endometrial ablation -> burning endometrial lining.
37
Q

Complications of fibroids

A
  • torsion of pedunculated fibroid
  • red degeneration of fibroid (ischaemia, infarction and necrosis of fibroid due to disrupted blood supply - hx of fibroids, severe abdominal pain and low-grade fever)
  • malignancy change to leiomyosarcoma
38
Q

What are the signs of outflow tract obstruction causing amonnhorea

A

patient who has developed secondary sex characterstics and is experiencing cyclical abdominal pain but no bleeding.
- may also have bloating - build up of menstrual blood in vagina.

39
Q

What is Ashermans syndrome

A
  • adhesions form within the uterus

- complication of uterine surgery (e.g. RPOC, myomectomy)

40
Q

Px of Ashermans syndrome

A
  • Typically following curettage (scraping at ERPC/D&C), surgery
  • secondary amenorrhoea
  • lighter periods
  • dysmenorrhoea
  • +/- infertility
41
Q

What is Adenomyosis

A
  • Presence of endometrial tissue within myometrium
  • more common in later reproductive years and those that are multiparous
  • hormone dependent, symptoms resolve after menopause
42
Q

Px of Adenomyosis

A
  • Menorrhagia

- Dysmenorrhoea

43
Q

Ix of Adenomyosis

A
  • TVUS is 1st line

- MRI is clearer

44
Q

Mx of Adenomyosis

A
  • IUS 1st line
  • NSAIDs and tranexamic acid if trying to conceive
  • Hysterectomy
45
Q

What are uterine polyps

A
  • small, benign tumours that grow into uterine cavity
46
Q

Px of polyps

A
  • menorrhagia

- IMB

47
Q

Dx of polyps

A
  • TVUS

- hysteroscopy

48
Q

Mx of polyps

A
  • resection of polyp
49
Q

What is endometriosis + where

A
  • growth of endometrial tissue outside in uterus - commonly ovaries, fallopian tube. Rarely in abdomen
  • Causes inflammation with progressive fibrosis and adhesions
50
Q

Px of endometriosis

A
  • cyclical or chronic pelvic pain (6+ months) : cyclical, dull, burning pain -> localised bleeding + inflammation = adhesions -> chronic, non-cyclical pain that can be sharp
  • Dysmenorrhoea
  • Deep dyspareunia
  • Infertility
  • Painful bowel movements / urinary sypmtoms
51
Q

Ix of endometriosis

A
  • Pelvic US: may reveal large endometriomas and chocolate cysts. Often unremarkable
  • Laparoscopic surgery + biopsy = gold standard
52
Q

Mx of endometriosis

A
  • 1st line ->

Obs and Gynae (1 decks)

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