gynae Flashcards
atrophic vginitis
inflammation of the vagina due to environmental changes e.g infection, inflammation or from atrophy - hormonal deficiency.
lack of oestrogen due to menopause.
affects up to 50% of post menopausal women.
atrophy can lead to reduced secretions and a change in the PH.
Ix: vaginal PH testing- if greater than 5 indicative of atrophy, vaginal maturation index.
speculum exam.
Rx: vaginal oestrogen- in any form.- contraindicated if prev oe+ breast cancer.
congenital adrenal hyperplassia
autosomal recessive genetic deficiency in 21-hydroxylase.
this shifts production of adrenals to androgen, away from cortisol/ aldosterone.
salt wasting, metabolic issues, ambiguous genitals.
either picked up at birth in newborn screenings, or at puberty where 2’ sex diff doesn’t happen (irregular periods, large clitoris)
under virilisation may occur in XY males
Ix: measure serum 17-OHP(alpha-hydroxyprogsterone). this is usually high.- if +ve- check again + electrolyte panel.
neonate screening programs have tightly bound normal values.
hpoglycaemia (hypocortisol)
hyperkalaemia
hyponatraemia- both hypoaldosterone.
treatment of Congenital adrenal hyperplasia
glucocorticoids (steroids)- to provide sugar retention.
mineralocorticoids- to retain salt
testosterone/ oestrogen at puberty if deficient.
provide enough to stop the adrenals hyperplasing.
hypogonadism
a clinical syndrome in males which combines low testosterone with clinical symptoms (reproductive/ clinical symptoms or bone health, fatigue etc)
consider in any man who has lost morning erections.
can be from birth, or acquired.
causes: 1’- age, kleinfelters (XXY), cryptorchidism, obesity, infection, drugs, trauma, toxins (heavy metals, pesticides)
2’: combined pituitary deficiency, prolactinoma, congenhypogonadotrophic hypogonadism, drugs, irradiation, REDS.
hypogonadism ix and rx.
Ix: early morning serum testosterone
less than 10.4 is significant.
then order serum LH + FSH to determine if primary or 2’.
Rx: if non-gonadal- treat cause e.g obesity- lifestyle
give testosterone to return to normal physiologic levels.
IVF/ sperm injection if desiring fertility.
If due to prolactinoma- dopamine agonists (cbergoline 1st
bromocriptine 2nd).
menopause
cessation of menstruation for 12 months or more, not caused by other processes.
S+S: hot flush, sleep disturbance, mood disturbance, vaginal symptoms, sleep disturbances.
Rf: 40-60
cancer rx, smoking, ovarian surgery.
Ix: pregnancy test
FSH testing, if under 45, if elevated consider meno.
Rx: lifestyle changes
If still has a uterus- oestrogen and progesterone
if no uterus- oestrogen
2nd line ssri
complications of HRT
breast cancer: oestrogen alone- no risk
oestrogen and progesterone - slight inc risk
VTE: low risk, lower with.
pelvic inflammatory disease
general term for infection of the upper genital tract.
gen affects sexually active, young women.
chlaymdia and gonorrhoea are the main culprits, but can be caused by other things. – mixed infections are common due to natural flora also getting involved.
RF: unprotected sex, multiple partners, recent instrumentation of the cervix, or break in muscoal barrier.
S+S: recent-onset pelvic or lower abdominal pain, deep dyspareunia, secondary dysmenorrhoea, abnormal vaginal bleeding or mucopurulent discharge, systemic symptoms
complications: subsequent ectopic pregnancy.
pelvic peritonitis/ sepsis.
tubo-ovarian abscess
perihepatitis
tubal facor infertility
chronic pelvic pain due to scarring/ adhesions.
pelvic inflammatory disease Ix +RX.
Ix:
a clinical diagnosis but may want to–>
pregnancy test, vaginal swabs for STI testing + blood tests such as inflammatory markers and HIV and syphilis serology.
Rx: admit if severe or pregnant.
1st line: mild - 500mg IM ceftriaxone
severe: ceftriaxone 2g IV/24hr.
In addition to the above- always give
ofloxacin 400 PO 12hrly
metronidzole 400mg PO 12hrly for 14/7
premenstrual syndrome
psychological, physical and behavioural symptoms that occur in the luteal (post ovulation) phase.
depression, anxiety, irritability, loss of confidence, and mood swings.
Bloating, breast pain.
aggression, reduced cognitive abililty.
diagnosis is supported by timings rather than particular symptoms- luteal phase, rather than days before period only.
Diagnosis: physical exam, symptoms diary of at least 2-3 cycles. - resolves with menses, symptoms free for at least 1/52.
Rx: lifestyle advice
moderate symptoms- COCP
severe/ wanting to be pregnant- SSRI.
severe form is premenstrual dysphoric disorder- need 5 of 11 symptoms on the checklist.
gets easier in pregnancy and after menopause, but not spontaneously.
toxic shock syndrome
acute onset illness,
fever, hypotension, multi-organ dysfunction, sunburn like rash- capillary leak is significant.
ulceration of vaginal mucosa/ strawberry tounge also could be present.
associated with medical/ sanitary products that are then colonised by bacteria (tampons)- reduced since ultra absorbant tampons taken off the market
staph aureus, or strep pyogenes- causitive organisms
Superantigens bypass normal T cell regulation and lead to massive inflammatory cascades.
Ix: bloods- inflammatory– signs of multy organ dysfunction (elevated CK 2x normal, coagulation issues)
measure calcium and replace- can be life threatening.
Rx: probably in the ICU
aggressive IV fluids + Ceftriaxone + clindamycin.
if mrsa add vanc.
try and culture and treat with sensitivites.
uterine prolapse
loss of anatomical support for the uterus- resulting in it coming out of where it was in
S+S: visible prolapse, vaginal bulging, pelciv pressure, urinary frequency, dyspareunia, incomplete bladder empty/ bowel empty.
RF: vaginal delivery, age, bmi, prev prolapse surgery, genetics, white.
Ix: diagnosis is made on vaginal examination at rest + valsalva.
Rx: asymptomatic- observation + pelvic muslce rehab.
Symptomatic–> pessary
2’-> reconstructive surgery- uterosacral ligament repair/ sactospinous ligament repair. can add mesh too. – often done with hysterectomy also.
PRog: does not get better on own. likely to reoccur even with surgery (30%)
vulvar and glandular epithelium cancers
squamous cell carcinoma mostly. 0.3% of all cancer types in US.
presents as erythematous lesion or ill defined mass
RF: age(65-74), HPV infection, smoking, inflammatory conditions of the vulva, prior pelvic radiation, and immunodeficiency
60% of diagnosis localised–> 85% 5 year survival.
Ix: tissue biopsy
Rx: surgical excision.
chaemo/ radio but not mainstay.
HPV inactivates TP53 and RB proteins- unregulated prolif.
OR
Inflammatory changes, cells interact with TP53.
first lymph nose is the superficial inguinal lymph.
what can be seen on transvaginal ultrasound
LLM
leiomyoma (fibroid)
polyps
adenomyosis
malignancy
management of fibroids
based around 3cm size.
3> removal
less than 3 - non
if causing problem remove.
