Gynae Flashcards
causes of menorrhagia
endometriosis
adenomyosis
polyps
fibroids
coagulation disorders
thyroid issues
IUD
Malignancy
Causes of amenorrhoea
primary - no periods by 15. Turners, anorexia, imperforate hymen, congenital adrenal hyperplasia
secondary - 3-6months no period. Pregnancy, menopause, primary ovarian insufficiency, hypothyroidism, IUS, sheehans, excessive exercise, PCOS
Causes of dysmenorrhoea
primary - occurs in 50% of women, No cause identified. Treat with NSAIDs like mefanamic acid
secondary - endometriosis, adenomyosis, fibroids, PID, IUD
what is adenomyosis and features
deposition of endometrial tissue in myometrium resulting in dysmenorrhoea, menorrhagia and a boggy uterus
first line investigation for adenomyosis
TVUSS
rx of adenomyosis
definitive - hysterectomy
Otherwise can give tranexamic acid and GnRH agonists
causes of post coital bleeding
cervical or vaginal cancer
cervical ectropion
vaginal atrophy
trauma
rx of vaginal atrophy
vaginal lubricants and moisturisers. If doesn’t work, can give topical oestrogen cream
risk factors for cervical cancer
HPV!! (16,18,33)
age <40
multiple sexual partners
high parity
early first intercourse
lower socioeconomic status
HIV
cervical cancer screening
smear tests offered between ages 25-64 to detect HPV. Cytology offered if positive
25-49 - 3 year screening
49-64 5 year screening
cervical cancer screening and pregnancy
wait until 3 months post party
cervical screening - what to do if
- negative for HPV
- positive for HPV
- inadequate sample
- recall to normal screening
- perform cytology. If positive - colposcopy. If negative - repeat at 12 months
- repeat sample in 3 months. I still inadequate, refer for colposcopy
Rx of CIN
LLETZ - large loop excision of transformation zone
Rx of cervical cancer
what about if want to maintain fertility
Gold standard - hysterectomy
Cone biopsy if want to maintain fertility
Can also do radiotherapy
Complications of hysterectomy/cone biopsy
Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies
Radical hysterectomy may result in a ureteral fistula
Risk factors of endometrial cancer
Unopposed oestrogen - early menarche, late menopause, nulliparous, oestrogen only HRT
Metabolic syndrome - obesity, diabetes
PCOS
Tamoxifen
Post menopausal
protective factors for endometrial cancer
multiparty
smoking
COCP
Referral criteria for endometrial cancer
> 55 with post menopausal bleeding
first line ix for suspected endometrial cancer
Rx of cancer
TVUSS for endometrial thickness. <4mm is good
hysterectomy ± radiotherapy
what does endometrial hyperplasia present like
- presents with abnormal bleeding eg PCB, IMB, PMB
Rx of typical endometrial hyperplasia and rx of atypical
typical - high does prog. May use levonorgestrel IUS
atypical - hysterectomy
Features of endometriosis
dysmenorrhoea
chronic pelvic pain
infertility
deep dysparaunia
Non gynae - dysuria, haeamturia, urgency, Dyschezia - painful bowel movements
Pelvic exam findings endometriosis
tender posterior fornix
reduced organ motility
Gold standard Ix for endometriosis
laparoscopy
first line rx of symptoms of endometriosis
what if doesn’t help
what if want to maintain fertility
NSAIDs or paracetamol
If not help - COCP or progesterones
If doesn’t help - GnRH analogues to induce pseudomenoause
If want to maintain fertility - endometrial ablation
rx of menorrhagia - if want contraception and if don’t want contraception
if want contraception - mirena first line, COCP second line
if not want contraception - use mefanamic acid or tranexamic acid starting on first day of periods
common side effects of HRT
breast tenderness, nausea, fluid retention and weight gain
complications of HRT
VTE risk
Oestrogen only - endometrial cancer in women with a uterus. Needs to be combined
Breast cancer - increased risk with combined HRT
Stroke risk
IHD risk if taken for >10yrs
2 first line investigations for infertility
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21
interpreting day 21 serum progesterone
high level indicates ovulation has occurred
lifestyle advice for infertility
aim for bmi 20-25
folic acid
regular sex every 2-3 days
smoking/drinking advice
symptoms of menopause inc long term complications
irregular periods, dysfunctional uterine bleeding
vasomotor sx - hot flushes, night sweats
vaginak dryness and atrophy, urinary frequency
anxiety and depression
Long term - osteoporosis, IHD
Rx of menopause
- lifestyle
- HRT
- non - HRT
Lifestyle - exercise, weight loss, sleep hygiene
HRT - combined if have uterus or oestrogen only if not
Non - HRT - vaginal lubricants or oestrogen cream. For vasomotor sx - fluoxetine or citalopram, CBT
Contraindications of HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
RF of ovarian cancer
many ovulations - nulliparous, early menarche, late menopause
BRCA1 or 2
Features of ovarian cancer
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
main ix for ovarian cancer
Rx of it
Ca125 and ultrasound
Mostly palliative as advanced disease at presentation
features of complex cyst.
What should they be referred on for
multiloculated, solid, irregular, >5cm. Any post menopausal woman with cyst should be referred to gynae
should be biopsied to exclude malignancy
RF of ovarian torsion
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
features of ovarian torsion
Sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
USS of ovarian torsion
whirlpool sign
life threatening complication of ovarian induction for infertility (particularly associated with PCOS)
Ovarian hyperstimulation syndrome - causes fluid shift resulting in Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
main causes of PID
top is chlamydia trachomatis
Neisseria gonorrhoea
Mycoplasma genitalium
Mycoplasma hominis
Features of PID
deep pelvic pain
dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
fever
IX of PID
high vaginal swab for gonorrhoea and chlamydia
pregnancy test
Rx of PID
Abx - combination of:
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Complications of PID
perihepatitis - fitz hugh curtis
chronic pelvic pain
infertility
increased risk of ectopic pregnancy
Rotterdam criteria for PCOS
2 out of 3 of:
- infrequent or no ovulation
- clinical and/or biochemical signs of hyperandrogenism (hirsutism, acne, elevated levels of total or free testosterone)
- polycystic ovaries on ultrasound scan >12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm3)
Features of PCOS
subfertility and infertility
menstrual disturbances: oligomenorrhoea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
hyperinsulinaemia
Ix of PCOS
USS
FSH, LH, testosterone (testosterone raised, raised FSH:LH ratio)
Sex Hormone Binding Globulin (low in PCOS)
Rx of PCOS
- general
- hirsutism
- infertility
General - weight loss, COCP
Hirsuitism - cocp, topical eflornithine
Infertility - clomiphene first line, may add in metformin as well
rx of endometrial hyperplasia
dilatation and curettage
definition of premature ovarian insufficiency
onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
causes of premature ovarian insufficiency
idiopathic - most common
bilateral oophorectomy
radiotherapy
chemotherapy
infection: e.g. mumps
autoimmune disorders
rx of premature ovarian insufficiency
HRT - but won’t cover for contraception in case spontaneous ovarian activity resumes
rx of PMS
mild - lifestyle - exercise, weight loss, smoking, alcohol
moderate - COCP
severe - SSRI
rx of urge incontinence
bladder retraining for at least 6 weeks - diary, monitoring input and output, resisting urge etc
1st line drug: oxybutynin or mirabegron in ‘frail old ladies’
rx of stress incontinence
pelvic floor training - 8 contractions 3 times per day for a min of 3 months
Surgery
Duloxetine - stimulates muscles within the sphincter so stays closed
RF of prolapse
obesity
multiparous
increasing age
presentation of prolapse
pressure, heaviness, bearing down
incontinence, frequency, urgency
Fibroids presentation
may be asymptomatic
menorrhagia - may cause iron-deficiency anaemia
bulk-related symptoms - lower abdominal pain, bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
Ix of fibroids
TVUSS
Rx of fibroids
- asymptomatic
- menorrhagia
- shrink/remove fibroids
- no treatment other then periodic review
- LNG-IUS, mefanamic acid, tranexamic acid
- GnRH agonists, myomectomy, uterine artery embolisation
What is red degeneration of fibroids
haemorrhage into tumour - commonly occurs during pregnancy
features of candidiasis
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions
rx of candidiasis
oral fluconazole 150 mg as a single dose first-line
or clotrimazole pessary if contraindicated (eg in pregnancy)
compare dischare in candida, BV and trichomonas
candida - Cottage cheese’ discharge, Vulvitis
Itch
BV - Offensive, thin, white/grey, ‘fishy’ discharge
Trich - Offensive, yellow/green, frothy discharge, vulvovaginitis, s trawberry cervix
RF of vulval carcinoma
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
Presentation of vulval carcinoma
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
ix for urnary incontinence
bladder diaries
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
when can expectant management be used for an ectopic
An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Indicatiion for medical management in ectopic and what is it
<35mm
unruptured
nonsignificant pain
no heart beat
bHCG <1500
Give methotrexate, must be willing to come back for follow up
indication for surgical management in ectopic pregnancy and what is it
> 35mm
ruptured
pain
fetal heartbeat
bHCG >5000
salpingectomy if no other risk factors for infertility
slpingotomy if risk factors eg contralateral tube damage
primary ovarian insufficiency blood results
Raised FSH and LH
Low oestrogen
COCP missed pill rules
- if one pill
- if 2 pills
if one - take when remember, no other measures needed
0-7 days - emergency contraception + barrier for 7 days
wk 2 - take missed + 7 day barrier
wk 3 - take missed. omit pill interval. + barrier for 7 days
