Gynae Flashcards
A surge in which hormone initiates ovulation? How long after this surge does ovulation take place?
LH
36 hours
What does FSH do?
stimulates development of ovarian follicles and subsequent secretion of oestrogen
what does LH do?
Production of oestrogen
Conversion of graafian follicles into progesterone producing corpus luteum (prog causes endometrium to become more receptive to implantation)
Surge leads to ovulation
High oestrogen and progesterone causes what effect on GnRH and FSH?
Negative feedback so inhibits HPO axis
Role of oestrogen?
Endometrial thickening and thinning of cervical mucus (to allow for easier sperm passage)
two phases of menstrual cycle?
Follicular and luteal phase
Duration of follicular phase?
variable
Duration of luteal phase?
Ovulation occurs on day 14. Corpus luteum lives for 14 days.
What hormone does the corpus luteum secrete? what does it do?
progesterone.
- Stabilises endometrium
(if fert takes place then prog production cont and endometrium stays stabilised)
(if no fert, then CL dies and prog levels drop, result in unstable endometrium and shedding)
Classification of menorrhagia
Primary - idiopathic (dysfunctional uterine bleeding) = majority Secondary - Adenomyosis - Uterine fibroids - Coagulation disorder/anticoag rx - Hypothyroidism - Polyps/hyperplasia - IUD (copper coil)
23 yo female presents with concerns regarding her heavy bleeding? Briefly list the questions you’ll ask
Cycle
- PMP
- regular - duration?
- no. of days bleeding
- no. of days heavy bleeding
- clots/flooding
- no. tampons/sanitary towels (how often change)
Assoc sx
- dysmenorrhoea
- vaginal discharge
- IMB/PCB
- Dyspareunia
- pelvic pain
Medications
PMhx
Impact on QOL
Examination for menorrhagia
- signs of anaemia or hypothyroidism
- abdo exam
- speculum (smear if due)
- Bimanual pelvic examination
Investigations for menorrhagia
Bloods (FBC-anaemia, TFTs, clotting)
If NAD on exam then further investigations not necessary
- TV USS (endometrial thickening, adnexal masses)
- Hysteroscopy (1st line if PMB)
Management of menorrhagia?
- Mefanamic acid (NSAID)
- Tranexamic acid (anti-fibrinolytic)
- COCP
- Mirena (IUS) - large number of women will be amenorrhoeic at 1 yr after insertion
- Endometrial ablation (destroys basal layer via diathermy, laser, transcervical endomet resection)
- Hysterectomy
Causes of amenorrhoea?
Primary (lack of menstruation by the age of 16) - outflow obstruction - ovarian disorders - pit disorders - hypothalamic disorders Secondary (absence of menstruation for 6 months) - cerebral - hypothalamic-pit - thyroid (hyper/hypo) - adrenal - ovary - uterine/vaginal
List some causes of cerebral secondary amenorrhoea?
starvation excessive exercise anorexia stress anti-dopaminergic drugs neoplasm
What pituitary problem can cause secondary or primary amenorrhoea?
prolactinoma - secretes prolactin therefore neg feedback to hypo to reduce GnRH which reduces FSH, LH –> anovulation and amenorrhoea
Adrenal causes of amenorrhoea?
- cushing’s syndrome
- androgen secreting tumour
Ovarian causes of amenorrhoea?
- PCOS
- menopause
- chemo/rad
- resistant ovary syndrome
Uterine/vaginal causes of amenorrhoea?
- pregnancy
- cervical stenosis
- Mirena IUS
- ascherman’s syndrome
Primary outflow causes of amenorrhoea?
- mullerian agenesis
- androgen insesitivity
- imperforate hymen
Ovarian disorders causing primary amenorrhoea?
PCOS Gonadal dysgenesis (turners syn)
Brief hx for amenorrhoea?
- preggo?
- contraception
- galactorrhoea
- androgenic sx (hirsutism, acne, wt gain)
- wt loss
- daily issues (exercise, eating, stress)
- sweats and flushes (menopause)
Pmhx
- chemorad, surgery gynae
Dx
- APs, heroin, methadone, metoclopramide
- Contraceptives (injectable progestogens)
Fhx
- hx of premature menopause or late menarche)
18yo female presents with lower abdo pain with a crampy feeling that occurs on the first day of her period? What term would you use to describe this presentation? What are the causes?
Dysmenorrhoea = painful menstruation - Primary = no obvious organic cause - Secondary = underlying condition. >teen year. change in usual pain. \+ Endometriosis \+ PID \+ IUS \+ sub mucous fibroids \+ asherman's syndrome \+ psychosexual problems \+ cervical stenosis
Clinical features + Assoc symptoms of dysmenorrhoea?
2 days of pain during bleeding then gradually easing
- lower abdo, pelvic pain
- cramps
- backache
- N,V,D
- Dyspareunia > 2dary
- abnormal bleeding > 2dary
- vaginal discharge > 2dary
Rx for primary dysmenorrhoea?
Mefanamic acid 500mg TDS (take when start bleeding) NSAID
OCP –> stops ovulation so is effective in 90%
Types of uterine fibroids?
Subserosal,
Submucosal
Intramural
Pedunculated
What is urinary incontinence?
Involuntary loss of urine
Definition of stress urinary incontinence?
Involuntary loss of urine on effort or exertion or on coughing/sneezing.
Due to urethral sphincter weakness
Definition of urge urinary incontinence?
Involuntary loss of urine preceded by a strong desire to void
Difference between mixed, overflow and continuous urinary incontinence?
Mixed = aspects of both urge and stress incontinence
Overflow = Occurs when the bladder becomes large and flaccid and has little or no detrusor tone or function. Due to injury from surgery or postpartum
Continuous = cont loss of urine. assoc with fistulae or congenital abnormality. (ectopic ureter)
Differentials for urinary incontinence?/Inc frequency?
DM UTI Stress incontinence Urge incontinence Overflow incontinence Continuous incontinence Mixed incontinence
Ix for a women who presents urinary incontinence?
Urinalysis +/- MSU (exclude infection)
Freq/volume chart
Urodynamic study
What is the most common cause urinary incontinence? Commonest cause in elderly women?
Most common = stress incontinence
Elderly women = over activity syndrome (DOA) +/- urge incontinence
Risk factors for stress incontinence?
- Vaginal deliveries
- Age
- Prolapse
- previous surgery
Mx of stress incontinence?
Conservatively
Non surgical
- Physiotherapy for pelvic floor exercises for at least 3 months. 3 sets of 10 reps of max contractions for 10 secs
- Reduce BMI, stop smoking, reduce caffeine
- Vaginal cones (help with pelvic floor training)
- electrical stimulation
- Duolextine (SNRI) = enhances urethral sphincter activity
Surgical
- Tension free vaginal tape (helps support urethra)
- Injections of bulking agents into the urethral walls
- Colposuspension
Hx for incontinence?
- Urinary sx (incontinence, frequency, voiding, UTIs)
- Gynae hx (smears, cycle, surgery, prolapse)
- Obs (parity, MOD, wt of children)
- PMHx (constipation, chronic cough, cardiac, DM, psychiatric)
- Dhx (beta blockers, anticholinergics, diuretics)
- Fhx
- Shx (impact on QOL)
How does detrusor overactivity syndrome usually present?
Irritative sx
- freq
- urgency
- urge incontinence
- dysuria
- nocturia
- Triggered by cold, opening front door, hearing water
Mx of DOA?
Conservative
Non surgical
- Bladder RETRAINING - min of 6 wks (extend intervals between voiding)
- Adv 1-1.5l liquids a day
- stop caffeine, tea
- Stop smoking
- Drugs (anticholinergics such as oxybutynin = relaxes detrusor muscle), TCAs, and desmopressin (anti-diuretic)
Surgical
- Intravescial botox = temporary paralysis of detrusor muscle. repeated 6-12 months. 10% SE of retention.
- Sacral implantation/implanted = S3 continuous stimulation
- Detrusor myomectomy or cystoplasty
Cottage cheese discharge with itchy vulvitis?
Candida. Rx with clotrimazole.
Offensive smelling, yellowy frothy discharge? With a strawberry cervix. vulvovaginitis.
Trichomonas vaginalis
How does Bacterial vaginosis present?
offensive smelling, thin, white/greyish, fishy discharge
Most common causes of vaginal discharge?
Physiological
Candida
TV
BV
Less common causes of vaginal discharge?
- gonorrhoea
- chlamydia (less common)
- ectropion
- cervical cancer
- foreign body
In which two conditions is cervical excitation seen in assoc with pelvic pain?
- PID
- ectopic preggo
Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis
UTI
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen
Ectopic
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
PID
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Appendicitis
Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
miscarriage
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Ovarian torsion
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
Endometriosis
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present
IBS
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
ovarian cyst
Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
urogenital prolapse.
Sx of dragging
Key counselling points for women trying to get pregnant?
- folic acid
- BMI 20-25
- regular intercourse, every 2/3 days
- Smoking and drinking adv
pt presents with an 18 month hx of struggling to get pregnant - what are the cause of sub fertility/infertility? What is the first line ix?
Causes
- male 30%
- ovulation 20%
- tubal damage 15%
- unexplained
- other
Males: semen analysis
Females: 21 day progesterone levels (see if they are ovulating) 7 days prior to next period
What level of Serum progestogen indicates ovulation?
> 30mmol/l
what colour is a PV bleed likely to be in an ectopic preggo?
Dark brown
NICE recommendations for examining a suspected ectopic?
abdominal tenderness cervical excitation (also known as cervical motion tenderness) adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
What is Mittelschmerz?
Mid cycle pain - on ovulation, lower abdo and pelvic pain.
What muscles comprise levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
Aetiology of prolapse?
- pregnancy with VD (pelvic floor damage and denervation)
- congenital (CT disorders like ehlers danlos)
- predisposing factors (constipation, chronic cough, heavy lifting)
- Age (dec in CT structure)
- iatrogenic (hysterectomy, continence procedures)
o prolapse of the upper posterior wall of the vagina and small loops of bowel
enterocele
prolapse of the lower posterior wall of the vagina involving the anterior wall of the rectum
rectocele
cystocele?
prolapse of upper anterior wall of vagina = bladder
urethrocele
prolapse of lower anterior wall of vagina just involving the urethra
Uterine prolapse?
Prolapse of uterus, cervix and upper vagina
Sx of urogenital prolapse?
- discomfort, dragging, heaviness within pelvis
- feel like a lump is coming down
- dyspareunia
- difficulty inserting tampons
Urethrocele
- freq
- urgency
- urinary retention
- incomplete bladder emptying
Rectocele
- constipation
- difficulty defecation
What position is a women best in for examination for suspected prolapse?
Left lateral using a Sims speculum
Examination of a suspected prolapse would include?
Sims speculum
Bimanual examination - exclusion of pelvic massess
What ix would you do for a suspected prolapse?
- USS to exclude other pelvic masses
- Urodynamics
Treatment of urogenital prolapse?
Conservative - Physiotherapy (pelvic floor exercises) - pessary (ring most common) - reduce wt (BMI < 30) Surgical - anterior repair for cysto-urethroceles - posterior repair for recto and enteroceles. - vaginal hysterectomy - use of vaginal mesh
Clinical features of uterine leiomyomas?
Largely asymptomatic
- dysmenorrhoea
- menorrhagia
- pressure sx (urinary freq)
- pelvic pain
- dyspareunia
- abdo pain/swelling
Mx of uterine fibroids?
If asymptotic then monitor control menorrhagia and dysmenorrhoea - TXA, mefanamic acid, OCP or IUS Shrink fibroid (GnRh analogous or uterine artery embolisation) Surgery (myomectomy or hysterectomy)
Risk factors for uterine fibroids?
- Women of reproductive age (high oestrogen)
- afrocarribean
- obesity
- thx of fibroids
What is the most common type of ovarian cyst?
Follicular (non-rupture of dominant follicile or failure of atresia of non-dominant follicle)
What is the most common type of benign ovarian tumour < 30yo?
Dermoid cyst (mature cystic teratoma)
- hair, teeth, skin
Bilateral in 20%
usually asymp
What is the most common type of benign epithelial ovarian tumour?
serous cyst adenoma.
What benign tumour is most like the most common type of ovarian cancer?
serous cyst adenoma –> serous carcinoma
What benign tumour can grow to massive proportions?
mucinous cyst adenoma
Rupture of a mucinous cyst adenoma could lead to what?
pseudomyxoma peritonei
Which physiological cyst is most likely to present with intraperitoneal rupture?
Corpus luteal
What tumour markers will you look at in a postmenopausal women with a suspected cyst?
CA125 CA 19.9 LDH AFP serum beta hCG
Clinical features of ovarian cysts?
Asymp
Chronic pain (dull ache, pressure sx,)
Acute (bleeding, rupture, torsion)
Abnormal uterine bleeding
Ix for ovarian cysts?
Preggo test Abdo exam (masses, ascites, tenderness, peritonism) Bimanual (adnexa) Bloods (FBC and tumour markers) TA/TV USS tumour markers.
simple ovarian cyst in a 26 yo female. <5cm in size. Rx?
Watch and wait. should resolve in 3 menstrual cycles.
what is the tumour marker for pancreatic cancer?
CA19.9
tumour marker for ovarian cancer?
CA125
Tumour marker for bowel cancer?
CEA
Meigs syndrome is what and is associated with what?
Benign ovarian fibroma.
Assoc with ascites and pleural effusions
Name a 5 alpha reductase inhibitor? Use?
Finasteride (stops conversion of testosterone to Dihydrotestosterone)
BPH
Excessive hair growth
what is the rotterdam criteria?
Diagnosis of PCOS (2 out of 3 variables)
- Oligo/amenorrhoea (>42 days cycle)
- clinical or biochemical signs of hyperadrogenism (hirsutism, acne, alopecia)
- USS of ovaries > 12 antral follicles in one ovary
- ovarian volume > 10ml
what bloods are likely to show raised markers in PCOS?
raised LH. normal FSH.
raised testosterone
What is the most common endocrine disorder in women?
PCOS
Mx of PCOS?
Lifestyle
- reduce wt (exercise and diet)
Sx of hyperandrogensism
- use of anti-androgens to reduce acne and hirsutism (eflornithin facial cream, finasteride), COCP
Subfertility (wt loss, clomiphene citrate for induction, ovarian diathermy, IVF)
Insulin sensitisers (metformin)
Long periods of secondary amenorrhoea left untreated can inc risk of what?
endometrial hyperplasia and subsequent endometrial carcinoma
Complication of ovulation induction of someone with PCOS?
OHSS
- Shift of fluid from intravascular space to extravascular space
- IV depletion leads to coagulopathy and harm-concentration.
- EV spaces such as peritoneal and pleural spaces fill with fluid
What factor is central to the pathology being OHSS?
VEGF
Most common cancer in women under the age of 35?
Cervical cancer
Cervical smears occur how often?
25-50 = 3 yrly 50-65 = 5 yrly
Smear of a 45 yo female shows moderate grade dyskaryosis. appropriate next step?
refer to colposcopy within 4 wks.
smear of a 26yo shows borderline squamous cell changes? what happens next?
HR HPV tested
- if positive = referred for colposcopy
- if negative = routine recall
High grade dyskaryosis. What happens next and what FU is needed?
refer all to colposcopy within 4 wks.
LLETZ
repeat cytology at 6 months for 1 yr then
annually until next routine smear.
Clinical features of cervical cancer?
PCR, IMB, PMB,
persistent, offense, blood stained discharge
pain in late disease
Speculum, bimanual and PR
Rx for BV?>
oral metronidazole
Rx for TV?
oral metronidazole
What ix will be done if cervical cancer is confirmed on biopsy?
MRI pelvis (size, volume, local invasion and lymph node spread)
CT abdo, chest for mets
Spread of cervical cancer?
Local (vagina, bladder, bowel, parametrium)
Lymph (parametrise, iliac, obturator, para-aortic and pre-sacral)
Blood (liver and lungs)
what staging system used in cervical cancer? numbers?
FIGO. 5 stages
cervical cancer: on the pelvic wall and lower third of vagina - FIGO staging?
Stage 3
cervical cancer: confined to cervix - FIGO staging?
Stage 1
cervical cancer: disease beyond cervix but not to lower third of vagina or pelvic wall - FIGO staging?
Stage 2
cervical cancer: disease invades bladder, rectum or mets?
Stage 4
When would you use a radical trachelecotmy?
Stage I cervical cancer without LN spread
What is a Wertheims procedure?
RADICAL total hysterectomy with BL salpingo-oophorectomy with parametrium
Stage 4 Cervical cancer - what rx?
chemorad with palliation
What are the protective factors in endometrial cancer?
Parity (high progesterone levels)
Smoking
COCP (50% dec in risk over 4 yrs of use - due to progesterone)
What are three oestrogen?
E1 - oestrone = main one during menopause
E2 - oestradiol = main one during reproductive years
E3 - oestriol = main one during pregnancy
What is the main circulating oestrogen in pregnancy?
E3 = oestriol
What is the main circulating oestrogen in menopause?
E1 = Oestrone
What is the main circulating oestrogen during reproductive years?
E2 = Oestradiol
FIGO staging of endometrial cancer?
Stage 1 = confined to body of uterus
Stage 2 = extends into cervix
Stage 3 = extends outside of uterus (peritoneal cavity and lymph)
Stage 4 = bowel, bladder, distant organ involvement
Endometrial cancer is because of what major process?
Excess unopposed oestrogen. no protective effects of progesterone
Clinical features of endometrial cancer?
PMB!!!
<40yo then irregular, heavy, menses, or discharge
