Gynae Flashcards
Describe the hypothalamic-pituitary axis
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
What is function of oestrogen
- development of secondary sexual characteristics:
- breast development
- growth of pubic hair and development of female sex organs at puberty
- development of endometrium
What are the phases of the Ovarian cycle
FOL(d) M(a)PS
Ovarian cycle:
Follicular, Ovulation, Luteal phase
What are the phases of the menstrual cycle
FOL(d) M(a)PS
Menstrual cycle:
Menstrual flow, proliferative phase, secretory phase
What occurs during the follicular phase
- 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
What occurs during the Luteal phase
- 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.
When does menstrual phase occur
- at end of luteal phase, corpus luteum degenerates + decreased progesterone.
- endometrium sheds
- day 1-5. Varies.
What happens during proliferative phase
- endometrium exposed to increasing levels of oestrogen (result of FSH and LH stimulating production)
- Oestrogen causes repair and growth of endometrial layer
What happens during secretory phase
- after ovulation has occurred
- progesterone produced by corpus luteum
- prepares for embryo to implant
Which phase is constant in women and what is its length
- luteal phase
- always 14 days duration from ovulation to menstruation
What is the mnemonic for 9 main categories of causes of abnormal uterine bleeding
- 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
What are most common causes of heavy menstrual bleeding/menorrhagia
- dysfunctional uterine bleeding (no identifiable cause)
- fibroids
- polyps - endometrial + cervical
- adenomyosis
- PID
- ovarian tumour
- hypothyroidism, VWD (FH of bleeding after surgery/trauma)
Ix of HMB
- speculum + bimanual (fibroids, cancers)
- FBC + Hb (IDA), thyroid (hypothyroidism), coagulation screen
- PVUS/TVUS (PALM - structural causes)
- Outpatient Hysteroscopy (suspect submucosal fibroids, cancer)
Medical Mx of HMB
- 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
Surgical Mx of HMB
- endometrial ablation -> burns endometrial lining
- hysteroscopic polyp removal
- myomectomy
- hysterectomy
- uterine artery embolisation
Causes of irregular menstruation/intermenstrual bleeding
- anovulatory cycles (common in early and late reproductive years)
- fibroid, polyps, adenomyosis, ovarian cysts, PID
- cancer (ovarian, endometrial, cervical)
What is primary amenorrhea
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
When does normal puberty start in girls and what happens
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
Causes of primary amenorrhea
- (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)
What is definition of secondary amenorrhoea?
- no menstruation for more than 3 months after previous regular menstrual periods
What are the causes of secondary amenorrhea
- (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
Causes of postcoital bleeding
- cervical carcinoma
- cervical ectropion
- cervical polyps
- > when cervix is not covered in healthy squamous epithelium is more likely to bleed after mild trauma.
What is dysmenorrhea?
- painful menstruation
Causes of primary dysmenorrhea, how to manage?
- no organic cause is found. Very common - contraction of endometrium and uterine ischaemia
- pain usually responds to NSAIDs or ovulation suppression (e.g. COCP)
What is secondary dysmenorrhea, what is suggestive of it? Causes?
- pain due to pelvic pathology
- when simple medical treatment for primary fails
- fibroids, adenomyosis, endometriosis, PID, ovarian tumours
What is precocious puberty?
Menstruation occurs before age of 9 or other secondary sexual characteristics present before 8
Causes of precocious puberty?
- most cases no cause found
- increased GnRH secretion from meningitis, encephalitis, CNS tumour
- increased oestrogen secretion from tumours of ovary or adrenal glands
How to manage precocious puberty
GnRH agonist/anologue (suppress ovulation by stopping pulsatile release of GnRH)
What is premenstrual syndrome
- psychological, emotional and physical symptoms that occur prior to the onset of menstruation.
- resolve once menstruation begins
- caused by fluctuation in oestrogen and progesterone
Px of premenstrual syndrome
Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido
What are the 2 anatomical positions of the uterus
- 80% women are anteverted -> tilts up towards the abdominal wall
- 20% women it is retroverted -> tilting back into the pelvis
What is a leiomyoma
- 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
Types of fibroid
- 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
Px of fibroids
- often asymptomatic
- HMB (most frequent symptom)
- IMB
- Dysmenorrhea, abdo pain
- Urinary symptoms if pressing on bladder
- impaired fertility
Ix for fibroids
- abdo + bimanual may have palpable pelvic mass or enlarged firm non-tender uterus
- PVUS for large fibroids
- Hysteroscopy for submucosal fibroids
Mx for fibroids
- 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.
Complications of fibroids
- 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
What are the signs of outflow tract obstruction causing amonnhorea
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.
What is Ashermans syndrome
- adhesions form within the uterus
- complication of uterine surgery (e.g. RPOC, myomectomy)
Px of Ashermans syndrome
- Typically following curettage (scraping at ERPC/D&C), surgery
- secondary amenorrhoea
- lighter periods
- dysmenorrhoea
- +/- infertility
What is Adenomyosis
- Presence of endometrial tissue within myometrium
- more common in later reproductive years and those that are multiparous
- hormone dependent, symptoms resolve after menopause
Px of Adenomyosis
- Menorrhagia
- Dysmenorrhoea
Ix of Adenomyosis
- TVUS is 1st line
- MRI is clearer
Mx of Adenomyosis
- IUS 1st line
- NSAIDs and tranexamic acid if trying to conceive
- Hysterectomy
What are uterine polyps
- small, benign tumours that grow into uterine cavity
Px of polyps
- menorrhagia
- IMB
Dx of polyps
- TVUS
- hysteroscopy
Mx of polyps
- resection of polyp
What is endometriosis + where
- growth of endometrial tissue outside in uterus - commonly ovaries, fallopian tube. Rarely in abdomen
- Causes inflammation with progressive fibrosis and adhesions
Px of endometriosis
- 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
Ix of endometriosis
- Pelvic US: may reveal large endometriomas and chocolate cysts. Often unremarkable
- Laparoscopic surgery + biopsy = gold standard
Mx of endometriosis
- 1st line ->
