Gynae Flashcards
What are the special components of a gynae history?
Menstrual history Contraception Cervical smear Obstetric history Previous gynae history
What are the important things to note for a gynae history?
Age
Parity
Date of LMP
Date of last smear
How do you take a menstrual history?
Menarche / menopause Duration of bleeding Cyclicity - interval from first to first day Any change in amount or duration Pain Date of LMP Contraception use Intermenstrual / Post-coital bleeding
How do you denote cycles?
5/28
Duration of bleeding / days between first day of bleeding
How do you denote an obstetric history?
Parity = number of births (live or still) after 24weeks gestation Gravidity = total number of pregnancies including current one
When is colposcopy done?
Women with smears suggestive of CIN or with an abnormal-looking cervix
What happens at colposcopy?
Done in OP
Microscope allows visualisation of cervical epithelium
Cusco’s speculum allows passage of scope
Any abnormal looking areas are biopsied
If histology shows severe cellular changes, abnormal areas should be removed using laser treatment
What do cervical smears identify?
Cytological cellular dyskaryosis
What do cervical biopsies identify?
Histological cellular dysplasia
CIN I, II, III or invasive disease
When is TVUS done?
Early pregnancy
Empty bladder
What USS is used in PMB and why?
Transabdominal
Measure endometrial thickness
>5cm in post menopausal women then proceed to biopsy
What is the purpose of an early pregnancy USS?
Check fetal heartbeart (present by 6weeks’ amenorrhoea)
Number of fetuses
CRL to calculate gestation
What is HSG and what is it used for?
Hysterosalpingography
To assess uterine cavity and patency of tubes
Catheter into cervix, radiocontrast medium injected into uterine cavity and X-rays taken
What is the gold-standard investigation for abnormal uterine bleeding?
Hysteroscopy + pipellle Biopsy
What are the complications (+ rates) of laparoscopy?
Bowel injury 0.6 per 100
Bladder injury 0.3
Ureteric injury 0.3
Vascular injury 0.1
What are the different types of hysterectomy and how do you decide which is done?
Vaginal
Abdominal
Laparoscopic
Depends on uterine findings
What is a subtotal hysterectomy?
Cervix left behind
When is total abdominal hysterectomy used?
Large uterus
Multiple large fibroids
Adenomyosis
Endometriosis
What are the complications of hysterectomy?
Short-term: fever, haemorrhage Ureteric damage 1 in 200 Bladder 1 in 100 Bowel 1 in 200 Long-term: pain, regret, pelvic floor laxity, prolapse, premature ovarian failure, bladder and bowel dysfunction
What is cystometry?
Measures bladder pressure during filling and voiding
Detects detrusor instability
What are the components of a gynae examination?
General
Abdo
Pelvic: speculum then bimanual
How do you determine / compare uterine size?
Level at which fund us can be palpated
12 weeks = symphysis pubis
20 weeks = umbilicus
36 weeks = xiphisternum
What do you look for on external inspection of the vulva?
Abnormal discharge Anatomy Inflammation Ulceration Swellings Atrophic changes Scars Prolapse (with and without patient bearing down)
How do you examine for prolapse?
With and without patient bearing down
Cough: may show SUI
Sims speculum with patient in left lateral position
What do you use Cusco speculum to examine for?
Visualise cervix
Look at anterior and posterior vaginal walls
Describe what you are examining for on bimanual palpation
Vaginal walls for scarring, cysts and tumours
Vaginal fornices for scarring, thickening and swelling
Cervix: size, shape, position, angle, mobility. Cervical motion tenderness
Uterus: ante- or retroverted
Adnexa: put fingers in one of lateral fornices. Ovaries and F.tubes not normally palpable
Define infertility
Inability of a couple to conceive after 1-2 yrs of unprotected intercourse
Or 6 months if over 35yo
What is infecundity?
The inability of a couple to produce a live birth
Why does fertility decline with age?
Women born with discrete supply of oocytes, the number of which declines with age
Only 500 mature oocytes are released during reproductive life
Decline in fertility directly related to declining oocytes popn and the egg’s inherent quality
What are the most common causes of infertility?
Ovulation defects
Male factor
Tubal disease
Unexplained
What male factors may contribute to infertility?
Sperm count and function
Ejaculate characteristics and immunology
Anatomic anomalies
What are the causes of ovulatory dysfunction?
Chronic systemic illness Eating disorders PCOS Hyperprolactinaemia Hypo or hyperthyroidism Cannabis used NSAIDs
What tubal factors can cause infertility?
PID
Previous tubal surgery
Previous ectopic pregnancy
Endometriosis
What things do you examine for in a woman with history of infertility?
BMI Body hair distribution Galactorrhoea Secondary sexual characteristics Pelvis structural abnormalities, fixed or tender uterus
What are the baseline female investigations for infertility?
Follicular phase LH, FSH
Luteal phase progesterone (day 21)
Rubella status
HSG or diagnostic laparoscopy + due to test tubal patency
Describe normal semen analysis
Volume >2ml
Concentration >20
Initial forward motility >50%
Normal morphology >30%
How do you treat anovulation?
Clomiphene
Gonadotrophins / pulsatile LHRH
Dopamine agonists (hyperprolactinaemia)
Weight loss / gain
How does clomiphene work?
Anti-oestrogen
Occupies receptors in hypothalamus to increase GnRH release
Leads to increased release of LH/FSH inducing follicular development and ovulation
How do you manage tubal disease?
Surgery or IVF
How can you manage male factor infertility?
IUI IVF Intracytoplasmic sperm injection (ICSI) Donor insemination Donor sperm
What are the stages of IVF?
- Follicle aspiration
- Fertilisation
- Embryo transfer
What is dyspareunia?
Painful sexual intercourse
What are the differentials of chronic pelvic pain?
Adenomyosis Endometriosis Adhesions Gynae malignancy GI pathology
What are the differentials for acute pelvic pain?
PID Tubo-ovarian abscess Early pregnancy complications Gynae malignancy Ovarian cyst: rupture, haem, torsion Fibroid necrosis Ovulation pain Abscess UTI / renal calculi Appendicitis
What specific questions should you ask in a history of pelvic pain?
Relationship to menstrual cycle Bowel habit N&V Vaginal discharge LMP Dyspareunia Smears STI, sexual history
How does ovarian cyst torsion present?
Acute pain worse on one side, radiates to upper thighs
Associated nausea and vomiting
What is Mittelschmerz?
Acute pain associated with ovulation
What is pelvic pain associated with endometriosis like?
Pain begins up to 2 weeks before period
Usually relieved when bleeding starts
Deep dyspareunia
What are the causes of dyspareunia?
Adhesions / fibrosis Atrophic changes Vulval dystrophy PID Endometriosis Fibroids Ovarian mass
What are fibroids?
Benign tumours of the myometrium
What are the symptoms of fibroids?
Menstrual abnormalities: normally heavy periods. Can also cause IMB or PMB
Abdominopelvic mass
Pain
Subfertility
Pressure symptoms: frequency, nocturia, urgency
What are the potential complications of fibroids?
Degeneration Torsion Malignancy Infertility Obstructed labour Risk of PPH
What is the medical management of fibroids?
GnRH analogues - cause temporary reversible menopause
Reduce fibroids volume by 50%
Used prior to surgery, up to 6 months
What are the surgical options for fibroids?
Transcervical resection of fibroids
Myomectomy
Hysterectomy
Uterine artery embolisation
What are the complications of myomectomy?
Haemorrhage
Hysterectomy
What is endometriosis?
Tissue resembling the endometrium lying outside the endometrial cavity
Responds to cyclical hormonal changes, so bleeds at menstruation
What is adenomyosis?
Presence of endometrial tissue within the myometrium
What are the most common sites for endometriosis?
Ovaries
Pouch of Douglas
Uterosacral ligaments
What are the clinical features of endometriosis?
Secondary dysmenorrhea Heavy periods Dyspareunia Lower abdo pain Infertility
What are the potential differential diagnoses for endometriosis?
PID Pelvic pain syndrome Sub mucous fibroids Ovarian accident Adhesions
How is endometriosis diagnosed?
Diagnostic laparoscopy
Shows powder-burn spots and chocolate cysts
What are the complications of endometriosis?
Often due to fibrosis and scarring
Rupture of an endometrioma and release of irritant material can cause peritonism
What are the aims of treatment in endometriosis?
Alleviate symptoms
Stop progression of disease and development of complications
Improve fertility
What medical therapies are used in endometriosis?
COCP Progestogen Mirena coil GnRH analogues Mefenamic of tranexamic acid
How do hormonal therapies help in endometriosis?
Suppress ovulation
What conservative surgery may be performed in endometriosis?
Division of adhesions with diathermy or laser
Removal of endometriomas
What radical surgery may be used in endometriosis?
Total abdominal hysterectomy + bilateral salpingo-oophorectomy
How do you diagnose PCOS?
2 of 3 of…
- Infrequent or no ovulation
- Clinical or biochem signs of hyperandrogenism: hirsutism, acne, male pattern alopecia, elevated free testosterone
- Polycystic ovaries on USS
What are the other features of PCOS?
Evidence of insulin resistance:
Obesity
Acanthosis nigricans: dry rough skin with grey-brown pigmentation
What are the diagnostic investigations used in PCOS?
Total testosterone
Sex-hormone binding globulin
Calculate free androgen index
What other causes of oligo/amenorrhoea should be ruled out when considering PCOS?
Premature ovarian failure
Hypothyroidism
Hyperprolactinaemia
What are the 5 key hormones in the menstrual cycle?
GnRH
FSH and LH
Oestrogen
Progesterone
What happens in the follicular phase of the menstrual cycle?
FSH and LH levels rise causing a follicle to mature
Granulosa cells in the follicle secrete oestrogen
Oestrogen levels rise
Negative feedback so FSH falls
What happens at ovulation?
Oestrogen causes LH surge (anterior pituitary)
LH surge promotes
Maturation of oocyte, rupture of follicle and ovulation
What is the luteal phase?
Follicle becomes the corpus luteum
CL secretes progesterone
Negative feedback suppresses FSH and prevents recruitment of another follicle
What happens to the corpus luteum?
If pregnancy occurs, hCG maintains progesterone synthesis
No pregnancy then corpus luteum involutes and progesterone levels decline
What triggers menstruation?
Progesterone levels falling
What are the different phases of the endometrium?
Proliferative phase
Secretory phase
Progesterone falls
What is the proliferative phase of the endometrium?
Corresponds to follicular phase
Driven by oestrogen
Increased thickness of endometrium and proliferation of glands
What happens in the secretory phase of the endometrium?
Progesterone effect
Glands become tortuous and secretory
Define amenorrhoea
Temporary or permanent absence of menstruation
Define primary amenorrhoea
No periods by age 14 in the absence of secondary sexual characteristics
Or age 16 regardless of normal development
Define secondary amenorrhoea
Absence of periods for 6 months in a woman who has previously been menstruating
Define oligomenorrhoea
Interval >35 days between periods
What are the hypothalamic causes of amenorrhoea?
Weight loss
Intensive exercise
What are the reproductive organ causes of amenorrhoea?
Imperforate hymen
Cervical stenosis
PCOS
Turner’s syndrome
What are the pituitary causes of amenorrhoea?
Hyperprolactinaemia
Hypopituitarism
Sheehan’s syndrome
What are the systemic causes of amenorrhoea?
Chronic illness
Weight loss
Thyroid disease
Cushing’s
What is dysmenorrhea?
Pain during menstruation
What is primary dysmenorrhea?
No pelvic pathology
Crampy, radiates to lower back or thighs
Cause is myometrium hyperactivity and increased uterine production of prostaglandin
What is secondary dysmenorrhea?
Pelvic pathology
Associated dyspareunia
What are the causes of secondary dysmenorrhea?
Endometriosis
Adenomyosis
PID
Obstruction to menstrual flow
What is the average blood loss during menstruation?
35 ml per cycle
What is defined as excessive menstrual blood loss and why?
> 80ml
Leads to anaemia as unable to compensate between cycles
Define menorrhagia
Excessive menstrual blood loss that interferes with a woman’s physical, social and material quality of life
How do you assess menorrhagia?
Subjective
Pictorial blood loss assessment charts
Objective assessment
What are the common gynae causes of menorrhagia?
Fibroids Polyps Endometriosis PID Endometrial cancer Cervical cancer
What are the systemic causes of menorrhagia?
Hypothyroidism Von Willebrand's disease ITP Factor II, V, VII, XI deficiency Liver or renal disease
What clinical examinations should you do in a history of menorrhagia?
General: anaemia, thyroid, clotting
Speculum: discharge, cervical pathology
Bimanual: enlarged uterus (fibroids), pelvic tenderness (endometriosis/PID), adnexal masses
What are the classes of medical therapy that may be used to treat menorrhagia?
Tranexamic acid (antifibrinolytic) Mefenamic acid (prostaglandin inhibitor) Hormonal therapy
How does the mirena coil treat menorrhagia?
Intrauterine progestogen
Prevents endometrial proliferation
Decreases MBL by 90%
What are the side effects of the mirena coil?
Breast tenderness
Acne
Headache
How does the COCP help in menorrhagia?
Acts on HPovarian axis to suppress ovulation
Decreases MBL by 45%
What other hormone treatments may be used to treat menorrhagia?
Cyclical progesterone
GnRH analogue
How do GnRH analogues reduce menstrual blood loss?
Suppresses pituitary release of FSH and LH
What is a subtotal hysterectomy?
Cervix left behind
What are the complications of a hysterectomy?
Short-term: fever, haemorrhage
Damage to bowel, urinary tract
Long-term: pain, regret, pelvic floor laxity
What are fibroids?
Benign tumour of the myometrium (leiomyoma)
Hormonally-dependent
Why do you get heavy bleeding with fibroids?
Enlarged uterine cavity to increase surface area of endometrium from which menstruation occurs
What is a myomectomy?
Removal of fibroids
What is the most common cause of menorrhagia?
DUB
What are the cervical causes of intermenstrual or post coital bleeding?
Ectopy
Polyps
Malignancy
Cervicitis
What are the intrauterine causes of intermenstrual or postcoital bleeding?
Polyps Fibroids Endometrial hyperplasia Endometrial malignancy Endometritis
Define postmenopausal bleeding
Vaginal bleeding occurring more than 12 months after the menopause
What needs to be excluded in a woman with PMB?
Endometrial, ovarian or cervical cancer
What proportion of those presenting with PMB are found to have a malignancy?
9%
What is the most common cause of PMB?
Atrophic changes to the genital tract, due to oestrogen deficiency
What are the clinical features of atrophic changes to the female genital tract?
Small amounts of bleeding
Local symptoms of vaginal dryness, soreness
Superficial dyspareunia
What examination should you do in a woman presenting with PMB?
Abdo: ascites or masses
Vulva, vagina and cervix
What investigations are done in a woman with PMB?
USS of pelvis: ?endometrial thickness
Hysteroscopy
Endometrial biopsy
How do you treat atrophic vaginitis?
Oestrogen replacement to prevent recurrence of PMB and other symptoms of oestrogen-deficiency eg dyspareunia
Topical oestrogen
Systemic HRT given in combination with progesterone in women with a uterus
What is the average age of menopause?
51
What leads to cessation of menstruation at menopause?
Depletion of oocytes and their increased resistance to FSH and LH
What is there increased risk of during the peri-menopausal stage and why?
Endometrial hyperplasia
Oestrogen secretion continues without the progesterone opposition required to protect the endometrium
What should you ask about in a woman presenting with ?menopause?
Vasomotor symptoms and mood changes LMP Pattern of menses in the past few years Cervical smear Family history
What are the symptoms of menopause?
Hot flushes and night sweats
Mood disturbance
Atrophy of vaginal tissue: dyspareunia and bleeding
Atrophy of urethra: dysuria, frequency, incontinence
What are the long-term consequences of menopause?
Osteoporosis
Cardiovascular disease risk increases markedly compared with pre-menopause
What investigations should be done in ?menopause?
Serum FSH levels confirm diagnosis
Others should be tailored to symptoms
What treatments are available for menopause?
Lifestyle factors: exercise, smoking cessation
HRT
Bisphosphonates
What are the components of HRT and why?
Oestrogen and progesterone
Progesterone protects the endometrium
What are the side effects of HRT?
Nausea Fluid retention Hirsutism Leg cramps Breast discomfort
What are the contraindications to HRT?
Endometrial carcinoma Breast carcinoma Undiagnosed vaginal bleeding Undiagnosed breast lumps Severe liver disease Pregnancy History of VTE
What are the risks of HRT?
Increased risk of breast cancer
Increased CVS and stroke risk in older patients
What is the contraceptive advice for women around the menopause?
Continue contraception for 1 year after LMP if they are over 50, or for 2 years if under 50
How is osteoporosis managed?
Cons: smoking cessation, weight-bearing exercises
Calcium and vit D
HRT if under 50
Bisphosphonates
What is premature ovarian failure?
Premature menopause
Under 40 with secondary amenorrhoea and high FSH on 2 occasions
What are the causes of premature ovarian failure?
Chemotherapy
Radiotherapy
Viral infections eg mumps
How is premature menopause managed?
HRT
Dietary advice to avoid osteoporosis
Counselling about IVF
What muscles are involved in maintaining continence?
Detrusor
External urethral sphincter
Internal urethral sphincter
Pelvic floor
Define urinary frequency
More than 8 voids per day
Define nocturia
More than 2 voids per night
How do you measure severity of incontinence?
Amount of leakage
Pads - size and number
Lifestyle modifications
What examination should you do in a history of incontinence?
Obesity Scars Abdo or pelvic masses Visible incontinence Prolapse Pelvic floor tone CNS - neuro disorders?
What is cystometry?
Functional test of bladder function
Type of urodynamic study
Assesses capacity, flow rate and voiding function
What is the main cause of incontinence?
Urodynamic stress incontinence
What are the causes of stress incontinence?
Incomplete urethral sphincter (childbirth, menopause, prolapse, chronic cough)
Positional displacement
Intrinsic weakness
Why is stress incontinence associated with prolapse?
If the proximal urethra is below the pelvic floor
Means the raised intra-abdo pressure is no longer transmitted to the proximal urethra
Positive pressure gradient is lost
What factors are associated with stress incontinence?
Increasing age / parity Obesity Genital prolapse Postmenopausal Constipation Smoking / chronic cough
How do you examine for stress incontinence?
Ask patient to cough while standing with a moderately full bladder
Examine vaginal walls with sims speculum in left lateral position
What is detrusor overactivity?
Urethra functions normally
But if uninhibited detrusor activity increases bladder pressure above normal max urethral closure pressure, urinary leakage occurs
What is detrusor overactivity associated with?
Increasing age
History of nocturnal enuresis
Exacerbated by diuretics
What is the conservative management of incontinence?
Weight loss
Reduce caffeine intake
Smoking cessation
Treat constipation or chronic cough
What is the management of stress incontinence?
Cons: pelvic floor exercises
Medical: Duloxetine, oestrogen replacement
Surgery: TVT or colposuspension
How does Duloxetine work in stress incontinence?
Increases tone of urethral sphincter
What types of surgery are used for stress incontinence?
Tension free vaginal tape (TVT)
Colposuspension - paravaginal fascia attached to Cooper’s ligament to hold it in place
What are the complications of surgery for stress incontinence?
Voiding difficulty
Detrusor instability
Enterocoele formation
How is detrusor overactivity managed?
Behaviour: bladder retraining
Antimuscarinics eg oxybutynin or tolterodine
How do antimuscarinics work in incontinence?
Delay initial desire to void
Decrease frequency and strength of detrusor contractions
What drug regimes may be used for incontinence?
Oxybutynin 2.5 mg BD
Tolterodine 2 mg BD
What are the side effects of antimuscarinics?
Dry mouth Reduced visual accommodation Constipation Glaucoma Confusion
What is CISC?
Clean intermittent self-catheterisation
When is CISC indicated?
Voiding dysfunction after suspension operation
Postpartum / post op retention
What are the problems with in dwelling catheters?
Urethral erosion Stone formation Blockage Chronic bacteriuria Risk of pyelonephritis
Define prolapse
Protrusion of an organ or structure beyond its normal anatomical site
What is the most common type of prolapse?
Cystourethrocoele
- bladder and urethra prolapse
What is the 2nd most common type of prolapse?
Uterine descent
How is uterine descent graded?
According to position of cervix on vaginal examination
1st degree - within vagina
2nd - to introitus
3rd - outside introitus (procidentia)
Name the pelvic floor muscles
Levator ani - pubococcygeus and iliococcygeus
Internal obturator and piriform
Superficial and deep perineal muscles
What are the pelvic ligaments?
Transverse cervical or cardinal
Uterosacral
Round ligaments
What are the risk factors for prolapse?
Obstetric factors
Postmenopausal atrophy
Chronically raised intra-abdo pressure (tumour, cough, constipation)
Iatrogenic: hysterectomy, colposuspension
What are the symptoms of prolapse?
Local discomfort / feeling something coming down Worse with standing, straining Interference with sexual function Urinary symptoms: frequency, SUI Bowel symptoms: incomplete emptying
How can you prevent prolapse?
Minimise damage to supporting structures during labour - avoid prolonged 1st and 2nd stages and do postnatal pelvic floor exercises
How is prolapse managed conservatively?
Weight loss
Smoking cessation
Treat constipation
Pelvic floor exercises
How do vaginal pessaries work?
Sits behind pubic bone and in the posterior fornix of the vagina
Encloses cervix
What are the indications for use of vaginal pessaries?
Patient hasn’t completed her family
Conservative management preferred
Medically unfit for surgery
What are the complications of vaginal pessaries?
Vaginal discharge or bleeding
Granulation tissue incarcerating pessary
Discomfort if too large
What is an important factor when considering prolapse surgery?
Are they sexually active: vagina may be shortened and narrowed by surgery leading to dyspareunia
What types of surgery are available for prolapse?
Anterior colporrhapy (anterior repair)
Posterior repair
Vaginal hysterectomy
Manchester repair (Fothergill procedure)
What are the complications of prolapse surgery?
Recurrent prolapse Haemorrhage and vault haematoma Vault infection DVT New incontinence Ureteric or bladder injury
