Gynae Flashcards
HRT types
oesetrogen + progesterone or oestrogen only
oesetrogen + progesterone or oestrogen only
types of HRT
risks of oestrogen only HRT
endometrial hyperplasia –> endometrial cancer
endometrial hyperplasia –> endometrial cancer
risk of oestrogen only HRT
risks of any HRT
increased VTE risk in 1st 6/12, increased breast cancer risk after 5 years of treatment
increased VTE risk in 1st 6/12, increased breast cancer risk after 5 years of treatment
risks of any HRT
premature ovarian failure
cessation of mentruation for 1 year before 40 years old
cessation of mentruation for 1 year before 40 years old
premature ovarian failure
menstrual phase occurs becuase
no ovum has been fertilised, corpus luteum breaks down, therefore cessaton of progesterone production, vasoconstriction of spiral arteries which supply the functional layer of the endometrium, layer necroses + is shed
pulsing of what hormone initiates puberty
GnRH
GnRH pulsation initiates
puberty
ovarian hyperstimulation S
associated with HCG in maturing follicles during IVF, lower abdo discomfort, N, V, abdo distension
associated with HCG in maturing follicles during IVF, lower abdo discomfort, N, V, abdo distension
ovarian hyperstimulation S
1’ amenorrhoea causes
Turner’s S, testicular feminisation, congenital adrenal hyperplasia, congenital malformation of the genital tract
Turner’s S, testicular feminisation, congenital adrenal hyperplasia, congenital malformation of the genital tract are causes of
1’ amenorrhoea
2’ amenorrhoea causes
periods stop for >6/12 hypothalamic amenorrhoea (stress, excessive exercise), PCOS, hyperprolactinaemia, premature ovarian failure, thyrotoxicosis, Sheehan S (hypopituitarism), Asherman S (intrauterine adhesions)
hypothalamic amenorrhoea (stress, excessive exercise), PCOS, hyperprolactinaemia, premature ovarian failure, thyrotoxicosis, Sheehan S (hypopituitarism), Asherman S (intrauterine adhesions) are causes of
2’ amenorrhoea
mittelschmerz is
mid cycle pain, sharp
endometriosis is
growth of ectopic endometrial tissue o/s of the uterine cavity, ?initiate by retrograde menstruation spreading endometrical cells w/i the pelvis
ovarian torsion is
sudden onset, deep colicy pain, V, distress
pelvic pain differentials
endometriosis, PID, migraine, lower back pain, adenomyosis, adhesions, ectopic, ovarian torsion, appendicitis, IBS, cystitis, depression, sleep disorders, abuse (past + present)
amenorrhoea differentials
1’: delayed puberty, PCOS, Turner’s S, imperforated hymen, transverse vaginal septum
2’: pregnancy, menopause, lactation, iatrogenic (progestogens, GNRH analogues, some antipsychotics), premature menopause, PCOS, hyperprolactinaemia (pituitary hyperplasia, benign adenoma), hypothalamic hypogonadism (low BMI, excessive exercise, tumour), thyroid dysfunction
dysmenorrhoea differentials
idiopathic (common), fibroids, adenomyosis, endometriosis, PID, ovarian tumours
menorrhagia differentials
subjective to PTs beliefs, idiopathic, fibroids, polyps, coagulopathy, adenomyosis, malignancy
PCB differentials
cervical ectropion, polyps, CIN, cervicitis, vaginitis
infertility differentials
female factors: ovulation (PCOS, hypothalamic hypogonadism, hyperprolactinaemia, premature ovarian faliure), fallopian tube (PID, endometriosis, previous Sx), cervical, implantation
male factors: sperm numbers, motility, morphology (smoking, EtOH, drugs, chemical exposure, genetics, idiopathic)
both: sexual (ED, dyspareunia)
PMB differentials
endometrial cancer, cervical cancer, premalignant endometrial hyperplasia, sequential HRT, atrophic vaginitis, polyps, cervicitis, ovarian carcinoma
IMB differentials
anovulatory cycles, fibroids, polyps, adenomyosis, ovarian cysts, chronic pelvic infection, STI, miscarriage
oligomenorrhoea
infrequent periods -/- 35/7-6/12 between periods
PMB is
bleeding 1 year post-menopause
menorrhagia history
menstrual calendar, flooding, clots, IMB, PCB, dysmenorrhoea, bleeding from elsewhere (PR), contraception use
menorrhagia O/E
anaemia, enlarged uterus - fibroids, tenderness - adenomyosis
adenomyosis is
endometruim breaks through the myometrium of uterus leading to cramps, menorrhagia, abdominal pressure and bloating
endometruim breaks through the myometrium of uterus leading to cramps, menorrhagia, abdominal pressure and bloating
adenomyosis
menorrhagia investigations
FBC, clotting, TFT, TVUS, hysteroscopy, biopsy
menorrhagia management
mirena coil (IUS), tranexamic acid (just during menstruation), mefanamic acid (NSAID), COCP, progestogens (high does/IM), GNRH agalogues (reduce size of fibroid), surgery: polyp removal, endometrial ablation, rescection (fibroids), myomectomy (fibroids), hysterectomy, uterine artery embolisation
TVUS uterus wall thickness “too thick”
> 10mm premenopausal, >4mm postmenopausal
IMB investigations
if appropriate: FBC, urine dip, STI screen, TVUS, hysteroscopy, biopsy
IMB management
IUS, COCP, high dose progestogen, HRT, surgery
amenorrhoea management
supportive, COCP, HRT, correcting organic cause
PCB investigations
speculum, smear, colposcopy if necessary
PCB management
polyp: avulsion, ectropion: frozen, LLETZ if appropriate etc
dysmenorrhoea is
painful periods, associated with high prostaglandin levels due to contraction + uterine ischaemia
dysmenorrhoea history
where in cycle?, relieved by menstruation?, dyspareunia, menorrhagia, oligomenorrhoea, PCB, IMB, STI Hx
dysmenorrhoea management
NSAIDs, COCP, reassurance in idiopathic, treat cause in pathology
subfertility definition
failure to conceive after 1y of regular unprotected sex
1’ vs 2’ subfertility/infertility
1’ means that the person has never conceived, 2’ means that the person had previously conceived (even if resulted in miscarriage)
infertililty investigations
serum progesterone (high mid-luteal = ovulation), TVUS, FSH (high in ovarian failure, low in hypothalamic DZ, N in PCOS), prolactin (prolactinoma), TSH, LH (high in PCOS), testosterone, semen analysis (repeat in 3/12), laproscopy + dye test, hysterosalpingogram
luteal phase is
14 days prior to menstruation e.g. days 14-28 of a 28d cycle
mid luteal phase is
day 21 of a 28 day cycle
infertility management
lifestyle changes, treat cause, induction of ovulation, IUI, ICSI as part of IVF cycle, counselling
complications of assisted conception
multiple pregnancies, ovarian hyperstimulation S, intraperitoneal haemorrhage, infection, ectopic, ch/genetic abnormalities
PMB investigations
bimanual, speculum, smear, TVUS, hysteroscopy, biopsies (Pipelle or during hysteroscopy)
gynae history
PC, HPC (menstruation: cycle l, ir/regular, heavy, painful, LMP, IMB, PCB, PMB, urinary: f, nocturia, urgency, accidents, associations, dysuria, haematuria, prolapse: heavy, dragging sensation, palpable mass), ICE, O+GH (smear, pregnancies, mode of delivery), sexual (active, discharge, dysuria, rash, dyspareunia), C, PMH, PSH, DH + A, SH, FH
pre-cancerous state in cervix
CIN cervical intraepithelial neoplasm
CIN cervical intraepithelial neoplasm
precancerous state in cervix
CIN is only diagnosable on
biopsy
explaining colposcopy
day case, Dr/nurse specialist, speculum, special misroscope (doesn’t enter vagina), stain, swab, biopsy (1/52 turnaround), 15-20 mins, can work same day, some bleeding/discharge 3-5/7, bring pad, avoid sex, tampons, pessaries, creams 24h beforehand + until bleeding stops
colposcopy biopsy result may result in
diathermy, laser, excision depending on result
complications of cervix treatment
premature labour - contact GP if get pregnant, ?cervical l scan
premature labour - contact GP if get pregnant, ?cervical l scan
complication of cervical treatment
most common type of primary ovarian cancer
epithelial cell carcinoma
grading of ovarian carcinoma
boarderline - high grade
most common type of primary ovarian cancer in <30 y.o.
germ cell tumour
risk factors for ovarian cancer
early menarche, late menopause, nulliparity, FH, benign cysts (can undergo malignant change), HNPCC, BRCA mutation
protective factors for ovarian cancer
pregnancy, lactation, COCP
epithelial cell carcinoma is the most common type of
ovarian cancer
germ cell tumour is the most common type of
ovarian cancer in >30 y.o.
early menarche, late menopause, nulliparity, FH, benign cysts (can undergo malignant change), HNPCC, BRCA mutation are risk factors for
ovarian cancer
pregnancy, lactation, COCP are protective factors for
ovarian cancer
ovariam cancer symptoms
persistent bloating, early satiety, LOA, pelvic/abdo pain, weight loss, fatigue, change in bowel habits, urinary f, urgency
persistent bloating, early satiety, LOA, pelvic/abdo pain, weight loss, fatigue, change in bowel habits, urinary f, urgency
ovarian ca
ovarian ca investigations
abdo examination, bimanual, CA125 (>50 y.o.), AFP + hCG (<40 y.o. - germ cell markers), TAUS
risk calculation in ovarian ca
RMI - risk of malignancy index
RMI
US score x menopausal state x CA125
US score features
multilobular cysts, solid areas, mets, ascites, bx lesions
RMI - risk of malignancy index
used in ovarian ca to decide whether to refer to specialist MDT
US score x menopausal state x CA125
RMI
multilobular cysts, solid areas, mets, ascites, bx lesions
features on TAUS that contribute 1 point to US score for RMI
ovarian ca management
Sx (TAH + BSO + partial omentectomy + LN biopsy/removal), potential for fertility-sparing Sx in boarderline DZ, chemo (carboplatin/cisplatin for high grade), follow up CA125, palliative care
ovarian ca staging
1 - ovaries only, 2 - pelvis only, 3 - abdo + pelvis, 4 - distant spread, inc liver
PMB must rule out
endometrial ca
endometrial ca risk factors
age (60 y.o.), nulliparity, unopposed oestrogen therapy (6x increase), early menarche, late menopause, obesity, DM, tamoxifen, PCOS, ovarian granulosa cell tumour (oestrogen secreting)
age, nulliparity, unopposed oestrogen therapy, early menarche, late menopause, obesity, DM, tamoxifen, PCOS are risk factors for
endometrial ca
after the menopause submucosal fibroids usually
calcify
calcification of which fibroids usually occurs after the menopause
submucosal
endometrial ca investigations
TVUS, measure thickness, hysteroscopy, biopsy, Pipelle biopsy, MRI, CXR
management of endometrial ca
TAH + BSO, post-op external beam radiotherapy in high risk DZ
vaginal atrophy presentation
dyspareunia, dryness, PCB
endometrial hyperplasia
abnormal proliferation of endometrium, presents with IMB, PMB, menorrhagia, irregular bleeding
rish factors for endometrial hyperplasia
obesity
abnormal proliferation of endometrium, presents with IMB, PMB, menorrhagia, irregular bleeding
endometrial hyperplasia
fibroids symptoms
asymptomatic, menorrhagia, infertility, abdo mass, pain (if torsion), dysuria, hydronephrosis, constipation, sciatica, bloating, dysmenorrhoea, urinary retention
asymptomatic, menorrhagia, infertility, abdo mass, pain, dysuria, hydronephrosis, constipation, sciatica, bloating symptoms of
fibroids
fibroids management
IUS, tranexamic acid, COCP, NSAIDs, progesteroenes, Sx (myomectomy, hysteroscopic endometrial ablation, hysterectomy)
fibroids associations
most common near the menopause, rare before puberty + after menopause, more common in Afro-Carribeans, FH
most common near the menopause, rare before puberty + after menopause, more common in Afro-Carribeans, FH
fibroids
fibroids investigations
TVUS, MRI, laparoscopy (differentiate from an ovarian mass/adenomyosis)
benign conditions that can raise CA125
endometriosis, menstruation, benign ovarian cysts
premature ovarian failure
menopausal symptoms <40 y.o.
symptoms: hot flushes, night sweats, infertility, 2’ amenorrhoea, raised FSH, raised, LH
hot flushes, night sweats, infertility, 2’ amenorrhoea, raised FSH, raised, LH
premature ovarian failure
premature ovarian failure causes
idiopathic, chemo, radiation, AI
premenopausal ovarian masses
follicular/lutein cyst, dermoid cyst, endometriomas, benign epithelial tumour
follicular/lutein cyst, dermoid cyst, endometriomas, benign epithelial tumour most common massees in
premenopausal
post menopausal ovarian masses
benign epithelial tumour, ca
benign epithelial tumour, ca most common masses in
postmenopausal
types of cyst
physiological/functional cysts, benign germ cell tumours, benign epithelial tumours
physiological/functional cyst comprise
follicular cysts + corpus luteum cysts
follicular cyst
commonest, due to non-rupture of the dominant follicle/failure of atresia in non-dominant follicle, regress after several menses
corpus luteum cyst
instead of corpus luteum breaking down if no pregnancy it fills with blood/fluid, intraperitoneal bleeding
benign germ cell tumours comprise
dermoid cysts aka mature cystic teratomas
dermoid cysts
lines with epithelial tissue (therefore may contain skin, hair, teeth), > common benign ovarian tumour in >30 y.o., asymptomatic, torsion risk
benign epithelial tumours comprise
serous cystadenoma + mucinous cystadenoma
serous cystadenoma
bears resemblance to serus carcinoma (most common type of ovarian ca)
mucinous cystadenoma
large, may become massive, rupture may cause pseudomyxoma peritonei
pseudomyxoma peritonei
cancerous cells producing abundant mucin or gelatinous ascites
follicular cysts + corpus luteum cysts are
physiological/functional cysts
commonest, due to non-rupture of the dominant follicle/failure of atresia in non-dominant follicle, regress after several menses
follicular cyst
instead of corpus luteum breaking down if no pregnancy it fills with blood/fluid, intraperitoneal bleeding
corpus luteum cyst
dermoid cysts aka mature cystic teratomas are
benign germ cell tumours
lines with epithelial tissue (therefore may contain skin, hair, teeth), > common benign ovarian tumour in >30 y.o., asymptomatic, torsion risk
dermoid cyst
serous cystadenoma + mucinous cystadenoma are
benign epithelial tumours
bears resemblance to serus carcinoma (most common type of ovarian ca)
serous cystadenoma
large, may become massive, rupture may cause pseudomyxoma peritonei
mucinous cystadenoma
cancerous cells producing abundant mucin or gelatinous ascites
pseudomyxoma peritonei
cysts in early pregnancy
usually physiological, resolve from 2nd trimester, reassurance
whirl pool sign on US
ovarian torsion or bowel volvulus
endometrial ca is most commonly what type of ca
adenocarcinoma
endometrial ca risk factors are “broadly speaking” due to
high oestrogen:progesterone ratio
endometrial ca develops when there’s high oestrogen/when oestrogen therapy = unopposed by progesterone
how does obesity increase risk of endometrial ca
peripheral conversion of androgens to oestrogens
peripheral conversion of androgens to oestrogens is the mechanism whereby
obesity contributes to endometrial ca risk
how does PCOS increase risk of endometrial ca
prolonged periods of amenorrhoea
prolonged periods of amenorrhoea is the mechanism whereby
PCOS contributes to endometrial ca risk
protective factors for endometrial ca
COCP, pregancy
endometrial ca presentation
PMB, in premenopausal women: oligomenorrhagia, IMB, recent onset menorrhagia, abnormal smear
stage 1 endometrial ca
confined to uterus
stage 2 endometrial ca
uterus + cervix
stage 3 endometrial ca
invaded through uterus
stage 4 endometrial ca
distant spread
Nexplanon/Implanon
forms of implant
forms of implant
Nexplanon/Implanon
implant mechanism of action
slow release progesterone, prevents ovulation, thickens cervical mucus
pros of the implant
highly effective, long lasting (3 yrs), no oestrogen (no VTE, migraine risk)
cons of the implant
professional needs to insert/remove, 7/7 until it’s effective, irregular/heavy periods, headache, N, breast pain
long term complications of PCOS
subfertility, DM, stroke, TIA, CAD, OSA, endometrial ca
subfertility, DM, stroke, TIA, CAD, OSA, endometrial ca are long term complications of
PCOS
features of PCOS
subfertility/infertility, oligomenorrhoea/amenorrhoea, hirsuitism, acne, obesity, acanthosis nigricans
PCOS investigations
US, FSH, LH, prolactin, TSH, testosterone, OGTT
PCOS results
raised LH:FSH, prolactin N/mildly raised, testosterone N/mildly raised
cervical ectropion symptoms
PCB, vaginal discharge
cervical ectropion causes
elevated oestrogen: COCP, ovulatory phase, pregnancy
cervical ectropion management
ablation for troublesome symptoms
fibroids aka
leiomyomata
leiomyomata aka
fibroids
fibroids are
benign tumours of the myometrium
benign tumours of the myometrium
fibroids
fibroids are rare in
parous women, COCP use, injectable progestogens
parous women, COCP use, injectable progestogens rarely get
fibroids
types of fibroid
intramural, subserosal (+ subserosal polyps), submucosal (occasionally for intracavity), cervical
growth of fibroids is probably dependent on
oestrogen + probably progesterone
fibroid complicaitons
torsion of pedunculated fibroid, red degeneration, enlargement in mid-pregnancy, calcification(postmenopausal + asymptomatic), leiomyosarcoma
red degeneration of a fibroid
normally due to inadequate blood supply, pain, uterine tenderness, haemorrhage, necrosis
pregnancy complications of fibroids
premature labour, malpresentation, transverse lie, obstructed labour, PPH, red degeneration, postpartum torsion of pedunculated fibroids
myomectomy + fertility
will preserve fertility, may require c/s at delivery (risk of uterine rupture), risk of adhesions
medication used to reduce size of fibroid whilst awaiting Sx
GNRH analogue
medical Rx for fibroids parameters (i.e. IUS, transaxamic acid, COCP)
fibroid <3cm, not distorting the uterine cavity
fibroid <3cm, not distorting the uterine cavity is the criteria for
medical fibroid management e.g. IUS, transaxamic acid, COCP
degeneration of fibroid during pregnancy presentation
low grade fever, pain, V
degeneration of fibroid during pregnancy management
rest, analgesia
endocervix is lined by
columnar, glandular epithelium
ectocervix is lined with
squamous epithelium
CIN is the
presence of atypical cells w/i the squamous epithelium, dyskaryotic cells with enlarged nuclei + f mitoses
CIN I
mild dysplasia, abnormal cells found in the lower 1/3 of epithelium
CIN II
moderate dysplasia, cells found in lower 2/3 of epithelium
CIN III
severe dysplasia, atypical cells found throughout the epithelium
CIN III aka
carcinoma in situ
cervical ca risk factors
HPV infection, promiscuity, early first intercourse, smoking, COCP, immunocompromise
cervical ca screening programme
25-49 3 yearly, 50-64 5 yearly, >65 for those not screened since 50/abnormal smears
dysplasia vs dyskaryosis
dyskaryosis = smear test result, loosely linked to severity of CIN, dysplasia = from biopsy
mild/borderline smear result
HPV test, if +ve to colposcopy, if -ve return to routine screening
HPV test, if +ve to colposcopy, if -ve return to routine screening
mild/boarderline smear result
moderate smear
colposcopy
severe smear
urgent colposcopy
colposcopy for
moderate smear/HPV +ve in mild/borderline
urgent colposcopy
severe smear
CIN I/II management
LLETZ/diathermy loop excision
LLETZ complications
bleeding, infection, preterm delivery
stage 1 cervical carcinoma
confined to cervix
stage 2 cervical carcinoma
invasion to vagina
stage 3 cervical carcinoma
invasion to lower vagina, pelvic wall, ureteric obstruciton
stage 4 cervical carcinoma
further spread
stage 1 cervical carcinoma management
cone biopsy/simple hysterectomy
stage 2 cervical cancer management
laparoscopic LN resection, radical trachelectomy, removal of cervix (+/- uterus) + upper part of vagina, chemo-radiotherapy
stage 3 + 4 cervical carcinoma management
chemoradiotherapy
COCP pros
effective (99%), doesn’t interfere with sex, reversible, periods regular, lighter, less painful, relieves PMT, reduces ovarian, endometrial + CRC risk, ?protective against PID, ?reduces ovarian cysts, benign breast DZ, acne vulgaris
COCP cons
forget to take it, no STI protection, increased VTE risk, increased breast + cervical ca risk, increased stroke + IHD risk, SE: headache, N, breast tenderness, tiredness, change in libido, breakthrough bleeding, skin changes, mood changes, rise in BP
VIN
vulval intraepithelial neoplasm, presence of atypical cells in the vulval epithelium. Usual type vs differentiate type
usual type VIN presentation
35-55 y.o. females, multifocal, red/white/pigmented, plaques/patches/papules, erosions/nodules/warty/hyperkeratotic, pruitis, pain
usual type VIN associated with
HPV, CIN, cigarette smoking, chronic immunosuppression, SCC
differentiated type VIN presentation
rarer, older women, unifocal, ulcer/plaque, pruitis, pain
differentiated type VIN is associated with
lichen sclerosis, linked to keratising SCC, high risk of progression to ca
VIN management
Sx excision, topical emollients/steroids for symptom relief
carcinoma of the vulva type
SCC = majority, melanoma, basal cell carcinoma, adenocarcinoma, sarcoma
vulval ca associations
lichen sclerosis, immunosuppression, smoking, Paget’s DZ of the vulva
vulva ca Hx
pruitis, bleeding, discharge, mass
vulval ca O/E
ulcer/mass on labia majora/clitoris, inguinal lymphadenopathy
stage 1 vulva ca
confined to vulval perineum
stage 2 vulva ca
spread to urethra/vagina/anus
stage 3 vulva ca
+ve LN
stage 4 vulva ca
further invasion/mets
vulval ca investigations
biopsy, Sx assessment: CXR, ECG, FBC, U+E, x-match
management of vulval ca
stage 1 DZ = resection, >stage 1 = wide local excision, groin lymphadenectomy
complications of vulva ca Sx
would breakdown, infection, leg lymphoedema, lymphocyst formation, sexual/body image problems
35-55 y.o. females, multifocal, red/white/pigmented, plaques/patches/papules, erosions/nodules/warty/hyperkeratotic, pruitis, pain
usual type VIN presentation
differentiated VIN presentation
rarer, older women, unifocal, ulcer/plaque, pruitis, pain
lichen sclerosis, immunosuppression, smoking, Paget’s DZ of the vulva are associated with
vulval ca
would breakdown, infection, leg lymphoedema, lymphocyst formation, sexual/body image problems are complications of
vulval ca Sx
median age of menopause
51
perimenopause
vasomotor symptoms, menstrual irregularity
surgical menopause
after bx removal of ovaries
causes of premature menopause
infection, AI DZ, chemo, ovarian dysgenesis, metabolic DZ
management of premature menopause
HRT is recommended until 50 y.o.
systemic consequences of monopause
CVS DZ, stroke, vasomotor symptoms, urogenital problems, sexual problems, osteoporosis
vasomotor symptoms associated with the menopause
hot flushes, night sweats (leading to sleep disturbances, tiredness, irritability), present for < 5yrs
urogenital problems caused by the menopause
oestrogen deficiency causes vaginal atrophy (dyspareunia, cessationof sexual activity, reduced libido, pruitis, burning, dryness), uringary symptons: f, urgency, nocturia, incontinence, recurrent infection
osteoporosis definitions
N = T score -/- -1 and +1 osteopenia = T score -/- -2.5 and -1 osteoporosis = T score < -2.5
most common sites for osteoporotic #
wrist/Colles’ #, hip, spine
risk factors for developing osteoporotic #
parental Hx of hip #, early menopause, chronic corticosteroid use, prolonges immobilisation, prior #, low BMI, cigarette smoking, EtOH abuse, low Ca intake, sedentary lifestyle, RA, NMD, chronic liver DZ, malabsorptionS, hyperparathyroidism, hyperthyroidism, hypogonadism
menopause investigations
FSH, anti-Mullerian hormone, TFT, catecholamines, LH, oestradiol, progesterone, bone density
FSH in menopause
gives an indicaion of ovarian reserve, increased = fewer oocytes, used in premature menopause
when should FSH be measured
between days 2-5 of cycle, in amenorrhoeic do 2 samples 2/52 apart
anti-Mullarian hormone
gives direct measurement of ovarian reserve, low = ovarian failure
when should anti-Mullarian hormone be measured
any day
menopause management
HRT (oestrogen alone in women w/o uterus, combined in others)
methods of administration of HRT
PO, transdermally, s/c (implant - oestrogens), topical (vaginally - oestrogens), IUS (progestogens)
pros of HRT
Rx for hot flushes, vaginal dryness, soreness, superficial dyspareunia, urinary f, urgency, reductionin risk of osteoporosis, reduced risk of CRC, reduced risk of CVS DZ, protection against ovarian ca
cons of HRT
breast ca (combined), endometrial ca (oetrogen only), VTE (PO HRT), gall bladder DZ (PO HRT)
duration of HRT
5 years, reassess
alternatives to HRT for menopausal symptoms
hot flushes/night sweats: progestogens, clonidine, SSRI, SNRI, gabapentin
vaginal atrophy: lubricants, moisturisers
osteoporosis: bisphosphonates, strontium ranelate, raloxifene, PTH peptides, denosumab, Ca, vit D
after bx removal of ovaries
surgical menopause
infection, AI DZ, chemo, ovarian dysgenesis, metabolic DZ could be causes of
premature menopause
CVS DZ, stroke, vasomotor symptoms, urogenital problems, sexual problems, osteoporosis are all complications of
the menopause
gives an indicaion of ovarian reserve, increased = fewer oocytes, used in premature menopause
FSH
take sample between days 2-5 of cycle, in amenorrhoeic do 2 samples 2/52 apart
FSH
gives direct measurement of ovarian reserve, low = ovarian failure
anti-Mullarian hormone
contraception in perimenopausal women is recommended for
12/12 after last period, 24/12 in menopausal women <50 y.o.
COCP CI
person Hx/FH VTE, currently pregnant, unexplained vaginal bleeding, severe liver DZ, HbSS, smoking, migraine
endometriosis causes
inflammation which leads to fibrosis and adhesions to form w/i the uterus, chocolate cysts
chocolate cysts
named so becuase accumulated altered blood is dark brown
endometriosis Hx
cyclical chronic pelvic pain, menstrual irregularity, dysmenorrhoea, subfertility, deep dyspareunia, asymptomatic, pain on defaecating during menses, rupture of chocolate cyst leads to acute pain, cyclical bowel/bladder symptoms
endometriosis O/E
VE: tenderness, thickening behind uterus/in adenexa, retroverted innomile uterus (in advnced cases), may be N
endometriosis investigations
laparoscopy +/- biopsy, active lesions = red vesicles/punctate marks, less active lesions = white scars/brown spots
TVUS, MRI
endometriosis DD
adenomyosis, chronic PID, chronic pelvic pain, pelvic mass, IBS
endometriosis Mx
NSAIDs, paracetamol, opiates, IUS, COCP, POP, GNRH analogues, laparascopic diathermy/laser, dissection, hysterectomy + BSO
POP SE
fluid retention, weight gain, erratic bleeding, PMS-like symptoms
GNRH analogues SE
menopausal symtoms, reversible bone demineralisation, (limits therapy to 6/12)
endometritis
infection of the endometrium
endometritis causes
2’ to STI, complication of Sx (c/s, intrauterine termination), IUD, retained products of conception, malignancy (post-menopausal)
endometritis presentation
persistent, heavy bleeding, pain, tender uterus
HRT CI
breast ca, PV bleeding, breastfeeding, DVT/PE
