Gynae Flashcards
Bartholin’s cyst / abscess
Fluid filled sac in one of Bartholin’s glands
Gland blocked - mucus build up - cyst
Infected - abscess - E coli, MRSA, STIs
Bartholin’s cyst / abscess Px
Cyst
- soft, fluctuant, non-tender mass
- vulvar pain walking / sitting
- superficial dyspareunia
- sudden relief (rupture)
Bartholin’s cyst / abscess Ix
Clinical dx
> 40yo biopsy - r/o cancer
Endocervical + high vagina; swabs - STI
Bartholin’s cyst / abscess Mx
Small - warm baths may stimulate rupture
Word catheter - incise, insert catheter, leave for 4-6wks, tract forms (not for deep cysts)
Marsupialisation - cut into, suture up - under GA
Also silver nitrate cautery, needle aspiration, CO2 laser
Abscess - abx
Stress incontinence
Involuntary leakage of urine with increased intra-abdo pressure
Stress incontinence Px
Urine leakage on exertion
Coughing, sneezing, exercise
Stress incontinence Ix
R/o UTI - urine dip + culture
Freq/vol chart
Urodynamic studies - r/o detrusor overactivity
Stress incontinence Mx
Wt loss, reduce caffeine, stop smoking
Pelvic floor muscle training
Surgical- Tension free vaginal tape
Duloxetine - enhanced contraction of urethral sphincter- if women decline surgical procedure
Urge incontinence
Overactive bladder - freq, urg, nocturia - detrusor overactivity
Urge incontinence Px
Urgency, frequency, nocturia
Urge incontinence Ix
R/o UTI
Freq/vol chart - shows increased freq
Urodynamic studies
Urge incontinence Mx
reduce fluids, caffeine
Bladder retraining
Anticholinergics - oxybutynin / solifenacin / tolterodine
Mirabegron
Botox
Surgical mx (detrusor myomectomy) if debilitating sx
Pelvic organ prolapse
Descent of pelvic organs into vagina - from weakness / lengthening of ligaments / muscles
Uterine prolapse - uterus descends
Vault prolapse - post-hysterectomy - top of vagina descends
Rectocele - defect in posterior vaginal wall - rectum prolapses
Cystocele - defect in anterior vaginal wall - bladder prolapses
urethrocele - urethra prolapses
Pelvic organ prolapse Px
Dragging sensation, something coming down
Urinary sx - incontinence, urgency, freq, weak stream, retention
Bowel sx - incontinence, constipation, urgency
Sexual dysfunction - pain, altered sensation
Lump / mass in vagina
Pelvic organ prolapse exam
Use Sim’s speculum, empty bladder / bowel first
Pelvic organ prolapse Mx
Pelvic floor exercises, wt loss…
Pessaries
Surgery
Lichen sclerosus
Chronic inflammation (?autoimmune) of genitalia usually
more common in elderly F
Atrophy of epidermis + white plaques
Increased vulvar SCC risk
Lichen sclerosus Px
White patches
Scarring
Itch
Dyspareunia, dysuria
Sx worse with friction (Koebner)
Lichen sclerosus Ix
Clinical
Biopsy if atypical, ?malignancy, no tx response
Lichen sclerosus Mx
Topical steroids - clobetasol
Emollients
Ovarian cysts
Fluid filled sac in ovary
Common, benign mostly
Simple - fluid only
Non-neoplastic - no malignant potential
Neoplastic - malignant potential
Ovarian cysts / tumours RFs
Nulliparity (more ovulations), early menarche, late menopause, smoking, obesity, HRT with oestrogen only
BRCA 1+2 - breast, ovarian ca
HNPCC - colorectal, endometrial, ovarian ca
Ovarian cysts / tumour protective factors
Multiparity, combined contraception, breastfeeding
Ovarian cysts Px
- Asym
- Chronic pain - frequency, constipation, bloating, dyspareunia
- Acute pain - bleed / rupture / torsion
- PV bleed
- Wt loss - cancer
- Abdo mass, ascites
- Adnexal masses, cervical excitation
Ovarian cysts Ix
CA125
USS
Calculate risk of malignancy index (RMI) - menopausal status + US findings + CA125 level
<40yo - bloods for ?germ cell tumour - LDH, alpha-fetoprotein, hCG
Ovarian cyst Mx
Pre-menopause
- Monitor with rpt US / CA125
- Persistent / >5cm - laparoscopic cystectomy / oophorectomy
Post-menopause
- RMI <25, <5cm - 1yr follow up with USS + CA125
- RMI 25-250 - oophorectomy / hysterectomy / omentectomy / lymphadenectomy
- RMI >250 - staging laparotomy
Meig’s syndrome
Benign ovarian fibroma (mass) + pleural effusion + ascites
Typically older women
Remove tumour - effusion + ascites resolve
Ovarian cancer
Malignant tumour of ovary
Can be surface derived, germ cell, sex-cord stromal, mets
Ovarian cancer Px
Abdo / pelvic pain
Abdo distension / bloating
Urinary sx - urgency
Diarrhoea
Early satiety, weight loss, anorexia
Abdo mass
Ovarian cancer Ix
Bloods, inc CA125, (aFP + hCG if <40yo)
Abdo / pelvic USS
CT / CXR - staging
FIGO staging Ovarian cancer
1 - ovary
2 - spread to pelvis
3 - spread to abdo
4 - spread past abdo
Ovarian cancer Mx
Surgery - staging laparotomy
Chemo
Follow up for 5yrs
PCOS
Excess androgens + multiple immature follicles (cysts) in ovaries
PCOS Patho
- Multifactorial cause
- Excess LH (from ant pit) -> ovaries produce excess androgens
- Insulin resistance - high insulin - supresses hepatic production of sex hormone binding globulin (SHBG) - higher levels of free androgens
- androgens suppress LH surge + ovulation
- follicles develop in ovary, arrested at early stage - remain as cysts
PCOS Px
- Oligomenorrhoea, amenorrhoea
- Infertility
- Hirsutism
- Obesity
- Chronic pelvic pain
- Depression
- Acne, acanthosis nigricans, male pattern hair loss, HTN
PCOS DDx
Hypothyroid
Hyperprolactinaemia
Cushing’s
PCOS Dx - Rotterdam Criteria
Dx if 2/3 of:
- Oligo +/-anovulation
- clinical / biochemical signs of hyperandrogenism
- polycystic ovaries on imaging
PCOS Ix
- Testosterone raised, SHBG low, LH raised, FSH normal, progesterone low
- LH:FSH raised
- TFTs, serum prolactin
- Pelvic USS - peripheral ovarian follicles - string of pearls appearance
- OGTT
PCOS Mx
Oligomenorrhoea
- With anovulation - low progesterone -> unopposed oestrogen => endometrial hyperplasia + malignancy risk - need to induce bleeds to prevent this:
- cOCP
- Dydrogesterone (progesterone analogue)
Infertility
- Clomifene +/- metformin -> induce ovulation
- Laparoscopic ovarian drilling
- Gonadotrophins
Hirsutism
- Cosmetic
- Anti-androgens - cyproterone, spironolactone, finasteride
- Eflornithine - cream for facial hair
Obesity
- Diet, exercise
- Orlistat
Adenomyosis
Growth of endometrial tissue in myometrium - benign
tends to be multiparous, older women
Adenomyosis Px
- Dysmenorrhoea - cyclical -> daily
- Menorrhagia
- Deep dyspareunia
- Irregular bleeding
- Symmetrically enlarged, boggy uterus
Adenomyosis Ix
TVUS
MRI
Histology after hysterectomy - definitive
Adenomyosis Mx
NSAIDs, TXA + mefenamic acid for sx
Hormone therapy for cycle control - cOCP, progestogens, GnRH agonist, aromatase inhibitor
Hysterectomy - curative
Uterine artery embolisation - short term to preserve fertility (block blood supply to adenomyosis)
Endometrial cancer
Tumour of endometrium
Mostly adenocarcinoma
From unopposed oestrogen (no progesterone)
Endometrial cancer RFs
Obesity, nulliparity, early menarche, late menopause
Unopposed oestrogen (so add progesterone to HRT to prevent)
DM, tamoxifen, PCOS
HNPCC- hereditary non-polyposis colorectal carcinoma- also known as lynch syndrome
cOCP + smoking + multiparity - protective
Endometrial cancer Px
PMB - post-menopausal bleeding
Intermenstrual bleeding (IMB) (pre-menopause)
Pain, discharge
Abdo pelvic masses, vaginal atrophy
Endometrial cancer Ix
All women >55 with postmenopausal bleeding should be referred
TVUS - endometrial thickness should be <4mm
Pipelle biopsy
Hysteroscopy, endometrial biopsy
FIGO endometrial cancer staging
1 - in uterus
2 - spread to cervix
3 - spread to pelvis
4 - bladder/bowel/further
Endometrial cancer Mx
Hysterectomy + bl salpingo-oophorectomy
Chemo / radio if mets
Progesterone therapy - if frail / not fit for surgery
Endometrial hyperplasia
Abnormal PV bleed - eg IMB
Progestogens (eg Mirena), rpt sample 3-4mo
Surgery if atypical hyperplasia - dilatation + curettage
Endometriosis
Growth of endometrial tissue outside uterus
Tissue is sensitive to oestrogen - cyclical sx
Endometriosis Px
- Cyclical pelvic pain - at menstruation
- secondary dysmenorrhoea - pain days after bleeding
- Deep dyspareunia
- Subfertility
- Non-gynae sx - dysuria, urgency, haematuria, dyschezia…
Pelvic exam
- fixed retroverted uterus, tender nodularity in posterior fornix, visible lesions
Endometriosis Ix
Laparoscopy
US not useful
Endometriosis Mx
NSAIDs +/- paracetamol
cOCP, progesterones
GnRH analogues - reduce oestrogen, induce pseudomenopause
Surgical laparoscopic excision, laser tx, hysterectomy
Uterine fibroids
Benign smooth muscle tumours of uterus - leiomyomas
Intramural, submucosal, subserosal
RFs - Afro-Carribean, obesity, early menarche, FHx
Develop in response to oestrogen
Fibroids Px
- Asym
- Heavy menstrual bleeding (HMB), anaemia
- Lower abdo pain
- Bloating
- Urinary frequency
- Subfertility
- Polycythaemia rarely
- Solid mass / enlarged uterus on examination
Fibroids Ix
TVUS
Hysteroscopy
MRI (if ?malignancy)
Fibroids Mx
Medical
- TXA, mefenamic acid
- Hormonal contraception - control HMB
- GnRH analogue - suppress ovulation
Surgical
- Endometrial ablation
- Fibroid resection
- Myomectomy
- Uterine artery embolisation
- Hysterectomy
Fibroids Cx
Regress after menopause
Red degeneration
- Ischaemia, infarction, necrosis of fibroid - disrupted blood supply
- Abdo pain, fever, tachycardia, vomiting
- Supportive mx
Heavy menstrual bleeding (HMB)
Excessive menstrual blood loss which interferes with QoL
Abnormal uterine bleeding (AUB) causes
PALM - structural
- Polyp - endometrial / cervical
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy, hyperplasia
COEIN - non-structural
- Coagulopathy
- Ovulatory dysfunction - PCOS, hyperthyroid, anorexia, athletes
- Endometrial
- Iatrogenic - hormonal contraception, HRT, post-surgery
- Not yet classified - PID, endometriosis, trauma, FB
HMB
- miscarriage / ectopic
- as above
HMB Px
Excessive PV bleed at menstruation
Fatigue
COB
?pallor, assess for inflamed cervix, pelvic masses….
HMB Ix
- Pregnancy test
- Bloods - FBC, TFT, hormones (PCOS), coag, vWF…
- TVUS
- Cervical smear
- Swabs - infection - high cervical + endometrial
- Pipelle endometrial biopsy - if persistent bleed, >45yo
- Hysteroscopy + biopsy
HMB Mx
- Mirena - thin endometrium, shrink fibroids
- TXA / mefenamic acid / cOCP
- Progesterone only - POP, depo, implant - oral on d5-26 of cycle, not acting as contraception
Surgical
- endometrial ablation (if no longer wanting to conceive)
- hysterectomy
Primary dysmenorrhoea
Painful periods / lower abdo pain, no underlying pathology
Prostaglandins -> spiral artery vasospasm, myometrial contractions => pain
Secondary dysmenorrhoea
Painful periods associated with pathology
Endometriosis, adenomyosis, PID, intrauterine devices, fibroids
Primary dysmenorrhoea Px
Lower abdo / pelvic pain - starts just before period
Malaise, N+V, diarrhoea, dizzy
Examination unremarkable
Primary dysmenorrhoea Ix
R/o pathology - eg swabs for infection, TVUS
Primary dysmenorrhoea Mx
Stop smoking, analgesia
Monophasic cOCP
Mirena
Water bottles, heat patch
TENS - transcutaneous electrical nerve stimulation
Post-coital bleeding causes
50% no pathology
Cervical ectropion (more common on cOCP)
Cervicitis - infections
Cancer
Polyps
Trauma
Post-menopausal bleeding (PMB)
PV bleed after >12mo amenorrhoea
PMB causes
- Vaginal atrophy
- endometrial hyperplasia
- endometrial / cervical / ovarian / vaginal / vulval cancer
- Trauma
PMB Ix
- PMB >55yo -> TVUS <2wks for ?endometrial cancer (<5mm thickness acceptable)
- Hysteroscopy + biopsy if uncertain / anything found
PMB Mx
Tx cancer
Change HRT
Tx vaginal atrophy
Cervical polyps
Benign growths on inner surface of cervix, malignant potential
Cervical polyps Px
Asym
PV bleed, discharge
Rarely block os - infertility
May project through os - see on speculum
Cervical polyps Ix
Triple swabs - r/o infection - endocervical + high vaginal
Cervical smear - r/o CIN
Biopsy - definitive
Cervical polyps Mx
Remove - polypectomy forceps / in colposcopy clinic
Cervical ectropion
Eversion of endocervix - columnar epithelium (bleeds easily)
Commonly seen when taking oestrogen contraceptives
Cervical ectropion Px
Asym
PV bleed - post-coital, IMB
Discharge
Speculum - red appearance
Cervical ectropion Ix
Clinical dx
pregnancy test, triple swabs, cervical smear
Cervical ectropion Mx
No tx unless sx
Stop cOCP
Ablation of tissue
Cervical cancer
Cancer of cervix
70% SCC, 15% ACC, 15% mixed
Develops from cervical intraepithelial neoplasia (CIN)
Majority caused by HPV
Mets to lung, liver, bone, bowel
Cervical intraepithelial neoplasia (CIN)
Dyskaryosis - cell mutations in transformational zone of cervix, (cells already transforming from squamous -> columnar)
Tx - large loop excision of transformational zone (LLETZ)
HPV in cervical cancer
HPV 16 + 18 high risk, 6 + 11 low risk
Vaccinate to prevent
Cervical cancer RFs
HPV
Smoking
STIs
>8yrs cOCP use
Immunodeficiency
Cervical screening
Speculum, brush transformational zone, send for HPV screen, liquid based cytology for dyskaryosis
24.5yo - first invitation
25-49yo - 3yrly screening
50-64yo - 5yrly screening
> 65yo - if recent smear / no screening since 50yo
Cervical screening results
HPV -ve - continue as routine
HPV +ve, normal smear - rpt smear 12mo - if still HPV +ve + normal smear - rpt again in 12mo - if still HPV +ve normal smear at 24mo - colposcopy - if HPV -ve at 24mo test - back to routine
If HPV +ve, abnormal smear - colposcopy
If inadequate smear - rpt 3mo - if still inadequate - colposcopy
Include transgender men / non-binary individuals in screening
Pregnant women - delay screening until 12wks post-partum
Cervical cancer Px
- Asym
- Abnormal PV bleed
- PV discharge
- Dyspareunia
- Pelvic pain
- Wt loss
- Local invasion - oedema, loin pain, PR bleed, radiculopathy, haematuria, urinary retention
- Pelvic mass on bimanual
Cervical cancer Ix
- Colposcopy - magnify cervix, take biopsy
- Premenopause - Ix + Tx for chlamydia - if sx ongoing, for colposcopy
- Post-menopause - urgent colposcopy + biopsy
CT / MRI / PET
Examination / biopsy under GA
Cervical cancer FIGO staging
0 - in situ
1 - cervix
2 - pelvis
3 - vagina
4 - bladder, rectum, mets
Cervical cancer Mx
Surgery
- Trachelectomy - remove cervix + upper vagina - preserve fertility
- Laparoscopic hysterectomy + pelvic lymphadenectomy
- Remove all organs
Radiotherapy
Chemotherapy
Vulval carcinoma
Rare, 90% SCC, rest BCC…
RFs - HPV, lichen sclerosis, lichen planus, smoking…
Vulval carcinoma Px
Pruritis, burning, soreness, bleed, pain, lump
Unifocal lesion on labia majora / clitoris / perineum
Vulval carcinoma Ix
Biopsy
Staging
1 - vulva
2 - vagina (lower 1/3) / urethra / anus
3 - upper 2/3 vagina / bladder / rectal / lymph nodes
4 - distant mets
Vulval carcinoma Mx
Surgical resection +/- lymphadenectomy
Small - wide local excision
Advanced - radical vulvectomy
Ovarian torsion
Ovary twists - compromise blood supply - ischaemia, necrosis
Adnexal torsion - involves fallopian tube
Often mass present
Ovarian torsion Px
Sudden onset colicky abdo / pelvic pain, unilateral
N+V, distress
Fever (minority)
Adnexal tenderness on VE, palpable mass
Ovarian torsion Ix
Bloods - bhCG, abdo bloods
USS - free fluid / whirlpool sign
Ovarian torsion Mx
Laparoscopy - dx and tx
Detorsion +/- oophorectomy
PID
Infection / inflammation of female pelvic organs - uterus, fallopian tubes, ovaries, peritoneum
PID causes
Chlamydia- most common
Gonorrhoea
Mycoplasma genitalium / hominis
PID Px
- Lower abdo / pelvic pain
- Fever
- Deep dyspareunia
- Dysuria
- Abnormal PV bleed
- Dysmenorrhoea
- PV discharge
- Cervical motion tenderness
PID Ix
Pregnancy test - r/o ectopic
High vaginal swab
Chlamydia / gonorrhoea screen
PID Mx
- IM ceftriaxone stat + oral doxycycline 14d + oral metronidazole 14d
OR oral ofloxacin + oral metronidazole
Admit if septic, consider removal of coils
Drain any abscess
PID Cx
Perihepatitis - Fitz-Hugh Curtis syndrome
- inflammation of liver capsule from infection spread, adhesions form - RUQ pain
Infertility
Chronic pelvic pain
Ectopic
Primary amenorrhoea
Failure to establish menstruation
- by 15yo if secondary sexual characteristics
- by 13yo if none
Secondary amenorrhoea
Cessation of menses where previously normal
- 3-6mo if previously normal
- 6-12mo if previous oligomenorrhoea
Oligomenorrhoea
Irregular periods
Primary amenorrhoea causes
Turner’s
testicular feminisation
anatomical abnormality
anorexia
exercise
CAH
imperforate hymen
AIS
Kallman
thyroid
Secondary amenorrhoea causes
Stress
exercise
PCOS
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis
Sheehan’s
Ashermann’s
pregnancy
Oligomenorrhoea causes
PCOS, contraception, perimenopause, thyroid disease, DM, anorexia, exercise, meds
Amenorrhoea Ix
- Pregnancy test
- FBC, U/E, coeliac, TFTs, prolactin, FSH, LH, oestradiol, progesterone, testosterone, 17-hydroxyprogesterone
- Low FSH / LH - hypothalamic problem
- Raised - ovarian problem (eg Turners)
- Karyotype - if ?genetic
- USS - ovaries, pelvic anatomy
- Progesterone challenge test - elicit withdrawal bleed - if bleed, suggests enough oestrogen, but not ovulating (eg PCOS) - no bleed, low oestrogen / outflow obstruction
Amenorrhoea Mx
Tx cause
Contraception to regulate periods
HRT if ovarian insufficiency
Premenstrual syndrome (PMS)
Emotional / physical sx during luteal phase of menstrual cycle
PMS Px
Anxiety, stress, fatigue, mood swings, bloating, breast pain, headaches
PMS Ix
Sx diary - cyclical
PMS Mx
Stop smoking, exercise, sleep well, regular small balanced meals
Paracetamol / ibuprofen
COCP - Yasmin brand
SSRI if severe - continuous / during luteal only
CBT
Premature ovarian insufficiency (POI)
Menopause onset + elevated gonadotrophins <40yo
POI causes
Idiopathic
Bl oophorectomy
Radio / chemo
Infection, eg mumps
Autoimmune
Resistant ovary syndrome - FSH receptor pathology
POI Px
Menopause - hot flushes, night sweats, vaginal dryness, infertility
Secondary amenorrhoea / oligomenorrhoea
POI Ix
Bloods
- Raised FSH, raised LH, low oestradiol
Raised FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart
POI Mx
HRT
Offer cOCP until age of menopause
Bicornuate uterus
2 horns to uterus - heart shaped
Dx on US
Risk of miscarriage, premature birth, malpresentation
Imperforate hymen
Hymen at vaginal entrance formed, not open
Cyclical pelvic pain, no PV bleed
Surgical incision to tx
Transverse vaginal septae
Septum across vagina
- perforate - with hole, difficulty with intercourse
- imperforate - sealed + cyclical pelvic pain without blood
Dx on US / exam
Tx - surgery
Vaginal hypoplasia + agenesis
Hypoplasia - abnormally small vagina
Agenesis - absent vagina
Ovaries usually unaffected
Mx - vaginal dilator / surgery
Asherman’s syndrome
Adhesions in uterus after damage - eg surgery, miscarriage
Asherman’s syndrome Px
- Recent surgery, endometritis etc
- secondary amenorrhoea
- lighter periods
- dysmenorrhoea
- infertility
Asherman’s syndrome Ix
Hysteroscopy - gold std
Hysterosalpingography - contrast injected into uterus, see in XR
Sonohysterography - fill uterus with fluid, scan on USS
MRI
Asherman’s syndrome Mx
Dissect adhesions in hsyteroscopy
FGM
partial / total removal of external genitalia or injury to female genital organs for non-medical reasons
Type 1
Partial / total removal of clitoris +/- prepuce
Type 2
as above + labia minora +/- majora
Type 3
as above + narrowing of vaginal orifice
Type 4
All other harmful procedures - eg scraping, cautery
Mx
- <18yo - report to police
- >18yo - report if F relatives at risk, risk to unborn child
- De-infibulation surgery - for type 3
Infertility
Start Ix after 12mo unprotected sex trying to conceive (6mo if >35)
Causes
problems with sperm, ovulation, tubes, uterus….
General advice
400mcg folic acid OD, healthy BMI, avoid smoking / drinking, reduce stress, intercourse every 2-3d, avoid timing sex
Infertility Ix
- BMI
- STI screen
- Semen analysis
- Rubella immunity in mum
Female hormone testing
- On d2-5 of cycle - LH (high - PCOS), FSH (high - low no. of follicles)
- Serum progesterone d21 (7d before cycle end) - should rise (ovulation)
- Anti-mullerian hormone (high - good ovarian reserve)
- TFTs
- Prolactin - if galactorrhoea / amenorrhoea
Secondary care
- US pelvis
- hysterosalpingogram
- laparoscopy / dye test
Infertility Mx
Anovulation
- Wt loss
- Clomifene
- Letrozole
- Gonadotrophins
- Ovarian drilling - PCOS
- Metformin - PCOS
Tubal
- Tubal cannulation
- laparoscopy to remove adhesions…
- IVF
Uterine
- Surgery - correct abnormalities
Male factor infertility causes
Pre-testicular
- Pituitary / hypothalamus issues
- Stress
- increased prolactin
- Kallman
- Low LH / FSH
Testicular
- Mumps
- undescended
- trauma
- radio / chemo
- cancer
- Klinefelter
Post-testicular
- Damage
- ejaculatory duct obstruction
- retrograde ejaculation
- scarring
- no vas deferens (CF)
- young’s syndrome
Semen analysis sample
Avoid ejaculation for 3-7d, avoid hot baths, deliver to lab <1hr, keep warm
Rpt in 3mo if abnormal
Look at sperm count etc
Male factor infertility Ix
- Abnormal semen - urology referral
- hormone testing - LH, FSH, testosterone
- genetic testing
- transrectal US / MRI
- vasography - inject contrast into vas deferens, XR
- testicular biopsy
Male factor infertility Mx
- surgical sperm retrieval
- surgical correction of vas deferens
- intrauterine insemination
- intracytoplasmic sperm injection
- donor insemination
Ovarian hyperstimulation syndrome (OHSS)
Seen with gonadotrophin / hCG tx
Multiple luteinised cysts in ovaries -> high oestrogen, progesterone, VEGF -> fluid loss -> oedema, ascites, hypovolaemia, RAAS
Px
Low BP, diarrhoea, N+V, pleural effusion, renal failure, ascites, VTEs
Mx
Oral fluids, UO monitoring, paracentesis, IV human albumin solution, ICU tx
Prevention
monitor serum oestrogen during tx, US monitor follicles, lower hCG / gonadotrophin dose
Menopause
Permanent cessation of menstruation - no periods for 12mo - avg age 51yo
Take contraception for 12mo after LMP if >50yo, 24mo if <50yo
Menopause Px
- menstrual cycle length changes
- PV bleeds
- hot flushes, night sweats
- vaginal dryness + atrophy
- urinary frequency
- anxiety / depression
- brain fog
- reduced libido, fatigue
Sx can last 7yrs
long term - osteoporosis, IHD
Menopause Ix
Clinical dx
Consider serum FSH (raised) if atypical sx >45yo, 40-45yo with sx, or ?POI <40yo
Menopause Mx
- Exercise, wt loss
- HRT
- vasomotor sx - fluoxetine, citalopram, venlafaxine, clonidine
- vaginal lubrication
- vaginal oestrogen for atrophy (atrophic vaginitis - dry, pain, spotting)
- vit D supplements post-menopause
- 2-5yrs tx, gradually reduce HRT when stopping
HRT
- Oral / transdermal patch
- If uterus present - give combined HRT (oestrogen + progesterone) - unopposed oestrogens cause endometrial cancer
- If still having periods - give cyclical HRT
- If no periods for >12mo - give continuous HRT
S/Es
- Nausea, breast tenderness, fluid retention, wt gain
CI’s
- current / past breast CA
- oestrogen-sensitive CA
- endometrial hyperplasia
Risks
- VTE, stroke, coronary heart disease, breast CA, ovarian CA
