Gynae Flashcards
Menopause
Retrospective diagnosis - no periods for 12 months - permanent end to menstruation
Usually at ~51 years
Premature ovarian insufficiency + diagnostic test
Menopause before 40 y/o
- aka premature menopause
Diagnosis confirmed with 2 raised FSH levels 4-6 weeks apart (+ clinical presentation and ruling out hypothyroidism, hyperprolactinaemia, and pcos)
Menopause pathophys
- Declining devlopment of ovarian follicles
- Reduced production of oestrogen + progesterone
- Normally, Oestrogen has negative feedback to pituitary -> reduced LH and FSH produce.
- In menopause there is less negative feedback as oestrogn is low so LH and FSH keep getting higher
- Ovulation doesn’t occur (anovulation) -> irregular menstrual cycle
- Endometrium doesn’t develop without enough oestrogen so AMENORRHOEA
- Perimenopausal Sx
Perimenopausal Sx
Vasomotor:
- Hot flushes
- Night sweats
Sexual dysfunction:
- Vaginal dryness and atrophy
- Reduced libido
- Problems with orgasm
- Dyspareunia
Psych:
- Emotional lability or low mood
- Anxiety
- Lethargy
- Reduced conc.
Other:
- Premenstrual syndrome (tender breasts, fatigue, irritibality, cravings)
- Irregular periods
- Joint pains
- Heavier or lighter periods
-
Complications of menopause
- CVD + Stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
Caused by reduced oestrogen
Menopause/perimenopause Dx
- Women OVER 45 YEARS
- Typical Sx
Clinical Dx
FSH blood test in:
- Women UNDER 40 with SUPSECTED Early menopause
- Women 40-45 with Sx / change in menstrual cycle
Menopause Mx
No treatment may be needed
- HRT (both oestrogen + progesterone (for endometrial protection from oestrogen))
- cyclically if still having periods; otherwise continuous
- Increased risk of breast + endometrial cancer if only taking oestrogen; VTE - Testosterone - can improve libido
Non-hormonal:
- Lifestyle measures: activity, avoiding triggers, sleep
- SSRIs / SNRIs
- Clonidine (Alpha-2 adrenergic receptor agonist)
- CBT
- Vaginal moisturisers
Polycystic Ovarian Syndrome (PCOS)
Heterogenous endocrine disorder characterised by:
- Hyperandrogenism (oligomenorrhoea, hirsutism, acne)
- Ovulation disorders
- Polycystic ovarian morphology
PCOS epid
Affects 1/3 of females of childbearing age
PCOS aet
Unkown.
Hyperandrogenism, Insulin resistance, HIgh LH + Raised oestrogen - implicated
PCOS Sx
- Oligomenorrhoea
- In/Subfertility
- Hirsutism + Acne
- Obesity (in ~ 70% of ppl)
- Mood changes
- MALE PATTERN BALDNESS
- Acanthosis nigricans (from INSULIN RESISTANCE)
PCOS DDx
- Menopause
- Congenital adrenal hyperplasia
- Hyperprolactinoma
- Androgen secreting tumours
- Cushing’s
PCOS Dx criteria
ROTTERDAM CRITERIA - at least 2 of the following are needed to Dx:
- Oligo / Anovulation
- Hyperandrogenism
- Polycystic ovaris on USS - >12 cysts / ovaries >10cm^3
+ need to exclude other causes
PCOS Ix
Bloods:
- Testosterone (normal / raised)
- Sex hormone-binding globulin
- Luteinizing Hormone (raised)
- Follicle-stimulating Hormone (LH:FSH ratio = high - >2 ; FSH is lower than LH)
- Prolactin (may be slightly raised in PCOS too)
- TSH / TFTs
- Fasting + oral glocuse tolerance to check for Insulin resistance (Raised)
- DHEA-S + free androgen index (androgen secreting tumours)
- 24hr urine cortisol (Cushing’s)
Scan = TRANSVAGINAL USS OF PELVIS (Transabdominal is also fine)
- Increased ovarian volume + multiple cysts
- Follicles arranged around edge of ovary -> ‘string of pearls’
Dx criteria for PCOS on scan
- 12 or more developing follicles in one ovary
- Ovarian volume > 10cm3
PCOS Mx
Advice:
- Weight loss + exercise
- Education on Increased risk of CVD, DIABETES + ENDOMETRIAL CANCER
- Encourage low sugar, calorie-coltrolled diet
- Smoking ceassation
- Statins + anti-HTN if needed
Asses for complication
Pharm (if not planning preg):
- cOCP - decreases irregular bleeding + reduce risk of endometrial cancer
- Metformin - helps regularise menstruation, hirsutism + acne
- 2nd line - Co-cyprindrol - reduces hirsutism + promotes regular menstruation (VTE risk so can’t use any other hormonal contraception alongside - same as with most oral contraception)
Preg promoting pharm:
- Clomiphene (ovulatory stimulant) - induces ovulation + enhances conception rates
- Metformin (esp in combination with clomiphene) - improves conception rates
- Ovarian drilling - 2nd line (laproscope to damage ovarian hormone-producing cells)
- Gonadotrophins - 2nd line to induce ovulation
Significance of weight loss for PCOS Mx
- Can result in ovulation + restore fertility + regular menstruation
- Improves insulin resistance
- Reduces hirsutism
- Reduces risk of associated conditions
If obese (BMI > 30) - may use Orlistat
- A lipase inhibitor (stops fat being absorbed in intestines)
Pathphys of why PCOS can lead to Endometrial cancer
- Usually the CORPUS LUTEUM releases PROGESTERONE AFTER OVULATION
- In PCOS there is no/irregular ovulation so reduced progesterone to counteract effects of systemic oestrogen
- Oestrogen continues to be released -> Uncontrolled endometrial prolifereation -> hyperplasia + significant risk of cancer
When should a pelvic USS for endometrial thickness be done? What needs to be done prior to the USS?
- If there are extended gaps (> 3 months) between periods
- Give Cyclical progesterones before scan to induce a period
Endometrial thickness >10mm -> refer for biopsy
Tx to reduce risk of endometrial cancer in menopause
- Mirena coil - releases progesterone so acts as continuous protection in HRT (must be replaced after 6 yrs if used for HRT)
- Inducing withdrawal bleed - just need to have at least 3 a year (1 every 3-4 months)
- cOCP (go off it for the week you want the period)
- Cyclical progesterones (need 10mg once a day for 14 days)
RFx for endometrial cancer
- Obesity
- Diabetes
- Insulin resistance
- Amenorrhoea
What is the main side effect of co-cyprindiol
Significantly rised risk of VENOUS THROMBOEMBOLISM as it is anti-androgen
- Usually stopped after 3 MONTHS
Fibroids
Benign smooth muscle tumours in uterus (uterine leiomyomas) - OESTROGEN SENSITIVE (contain more ostrogen receptors than normal uterine cells)
Fibroid epid
- affect 40-60% in later reproductive years
- esp in 40s
- Esp in BLACK women