With contraception - 1st line is Mirena coil - 2nd is antifibrinolytics eg tranexamic acid taken when bleeding, or antiprostaglandins eg mefenamic acid taken when bleeding especially if also dysmenorrhea or COCP - 3rd line is progesterones IM or norethisterone

Gynae Flashcards by Rebekah M

Primary amenorrhoea

Failure to start menstruating

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Secondary amenorrhoea

Periods stop for over 6 months other than pregnancy

Hypothalamic pituitary ovarian axis disorders common

Ovarian and endometrial causes rare

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Oligomenorrhoea

Infrequent periods

Common cause is PCOS or extremes of reproductive life

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Menorrhagia

Excessive blood loss

Over 80mL/cycle

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Dysmenorrhea

Painful periods

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PCOS Management

Weight loss and exercise
Metformin if BMI over 25 and trying to conceive
COCO

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Causes of menorrhagia

Girls - Pregnancy and dysfunctional uterine bleeding

Women - IUD, fibroids, endometriosis, adenomyosis, pelvic infection, polyps, hypothyroidism

Peri-menopausal - consider endometrial carcinoma

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Treating menorrhagia

With contraception

1st line is Mirena coil
2nd is antifibrinolytics eg tranexamic acid taken when bleeding, or antiprostaglandins eg mefenamic acid taken when bleeding especially if also dysmenorrhea or COCP
3rd line is progesterones IM or norethisterone

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When should women be prescribed cyclical combined HRT

If LMP was less than one year ago

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When should women be prescribed continuous combined HRT

If they have…
Taken cyclical combined for at least one year
Or
It has been 1 year since LMP
Or
It has been at least 2 years since LMP if they had premature menopause (before age 40)

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If the woman still has her uterus what should HRT consist of?

Progesterone and Oestrogen

Progesterone can reduce risk of endometrial cancer that exists with use of unopposed oestrogen

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Diagnosis of fibroids?

Bulky uterus
Menorrhagia

Ix = trans vaginal USS

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First line Tx of fibroids

Levonorgestrel releasing IUS

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Gold standard investigation for patients with suspected endometriosis

Laparoscopy

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First line endometriosis treatment if patient does NOT wish to conceive

COCP

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Criteria for diagnosing bacterial vaginosis

3 of the following

Thin, white homogenous discharge
Clue cells in microscopy
Vaginal pH over 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)

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Treatment for bacterial vaginosis

Oral metronidazole

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Treatment for Trichomonas vaginalis

Oral metronidazole

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Symptoms of suspected ovarian cancer

Persistently any of these symptoms... 
Abdominal distension/bloating
Early satiety or loss of appetite
Pelvic or abdominal pain
Increased urinary urgency or frequency

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Meigs Syndrome

Benign ovarian tumour
Ascites
Pleural effusion

Cervical screening

Borderline or mild dyskaryisis

Original sample tested for HPV

if negative goes back to routine three yearly recall
if positive patient referred for colposcopy

Cervical screening

Moderate dyskaryosis

Consistent with CIN II

Refer for urgent colposcopy

Within 2 weeks

Cervical screening

Severe dyskaryosis

Consistent with CIN III

Refer for urgent colposcopy

Within 2 weeks

High risk subtypes of HPV such as 16, 18 & 33

Cervical screening

Suspected invasive cancer

Refer for urgent colposcopy

Within 2 weeks

Cervical screening Inadequate smear

Repeat If inadequate 3 times then assessment by colposcopy

Premature ovarian failure definition

The onset of menopausal symptoms and elevated gonadotropin levels before the age of 40

Causes of premature ovarian failure

Idiopathic - most commonly Chemotherapy Autoimmune Radiation Occurs in 1 in 100 women

Post menopausal bleeding is...

Endometrial cancer until proven otherwise

Risk factors for endometrial cancer

``` Obesity Nulliparity Early menarche and late menopause Unopposed oestrogen Diabetes mellitus Tamoxifen PCOS ```

First line investigation for endometrial cancer

Trans vaginal USS - normal endometrial thickness of under 4mm has a high negative predictive value Then hysteroscopy with endometrial biopsy

Staging of ovarian cancer 1

Tumour confined to ovary

Staging of ovarian cancer 2

Tumour outside ovary but within pelvis

Staging of ovarian cancer 3

Tumour outside pelvis but within abdomen

Staging of ovarian cancer 4

Distant metastasis

Threatened miscarriage

Painless vaginal bleeding before 24 weeks Usually at 6-9 weeks Bleeding often less than menstruation Cervical os closed

Missed(delayed) miscarriage

Gestational sac with dead foetus before 20weeks without symptoms of expulsion Light vaginal bleeding/discharge and symptoms of pregnancy which disappear. Usually no pain Cervical os is closed

Inevitable miscarriage

Heavy bleeding with clots and pain Cervical os is open

Incomplete miscarriage

Not all products of conception expelled Pain and vaginal bleeding Cervical os is open

Ovarian Cysts Physiological Follicular

Commonest type of ovarian cyst Due to non rupture of the dominant follicle or failure of atresia in a non dominant follicle Commonly regressed after several menstrual cycles

Ovarian Cysts Physiological Corpus luteum cyst

During menstrual cycle of pregnancy doesn't occur corpus luteum should break down and disappear.. if this doesn't occur the corpus luteum may fill with blood or fluid and form a cyst More likely to present with intraperitoneal bleeding than follicular cysts

Ovarian Cysts Benign germ cell tumours Dermoid cysts

Also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth Most common ovarian tumour in women under 30 Median age diagnosis is 30 Bilateral in 10-20% Usually asymptomatic. Torsion more likely than with other ovarian tumours

Ovarian Cysts Benign epithelial tumours (Arise from the ovarian surface epithelium) Serous cystadenoma

Most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) Bilateral in 20%

Ovarian Cysts Benign epithelial tumours (Arise from the ovarian surface epithelium) Mucinous cystadenoma

Second most common benign epithelial tumour Typically large and may become massive If ruptures may cause pseudomyxoma peritonei

First line treatment for symptomatic relief of endometriosis

NSAIDs and/or paracetamol If analgesia helps then hormonal treatment such as COCP or progesterones should be tried

Clinical features of endometriosis

``` Chronic pelvic pain Dysmenorrhea - pain often starts days before bleeding Deep dyspareunia Subfertility Non gynae - urinary symptoms ``` On examination - reduced organ mobility, tender modularity in the posterior vaginal fornix and visible vaginal endometrotic lesions may be seen

Urinary incontinence First line urge incontinence

Bladder retraining

Urinary incontinence First line stress incontinence

Pelvic floor muscle training

Need for contraception after the menopause

12 months after the last period in women over 50 24 months after the last period in women under 50

Expectant management of an ectopic can only be performed for...

1. An unruptured embryo 2. <30mm in size 3. Have no heartbeat 4. Be asymptomatic 5. Have a BhCG level of under 200lU/L and declining