Gynae Flashcards
What is menarche?
+ when is normal
Onset of menstruation
Around 13 usually
At what age would you class puberty as being early in females / males?
Females <8
Males <9
At what age would you class puberty as being late in females / males?
Females >13
Males >14
What is the first sign of puberty in females?
Breast budding
What is the first sign of puberty in males?
Testicular enlargement
What stimulates the production of secondary sexual characteristics in females?
FSH + LH –> oestrogen
This is thelarce
What is menorrhagia?
Heavy menstrual bleeding
Over 80ml loss in one cycle
Affecting quality of life - physical, emotional, social
What would be classed as irregular periods?
Period outside of 23-35 day cycle with variability of more than 7 days between shortest and longest cycle
What is primary amenorrhoea?
Never had a period by 16
Or by 14 if no development of secondary sexual characteristics either
What is secondary amenorrhoea?
Previously had periods but no period for 6 months or more
What is oligomenorrhoea?
Infrequent periods - between 35 and 6 months between periods
What is post-menopausal bleeding?
Bleeding more than 1 year after menopause
What is dysmenorrhoea?
Painful periods
What are the causes of menorrhagia?
primary - unknown secondary; - uterine fibroids - polyps Less common: - PID - endometrial / cervical cancers - coagulopathies - very rare
What would you ask for in the history of a patient with menorrhagia (to establish its existence)?
flooding - flooding sanitary towels / having to change tampons excessively / using both
passing clots bigger than a 10p piece
How would you investigate a patient with menorrhagia?
Look for signs of anaemia
Masses - uterine (fibroids), ovarian (cancer)
Tenderness on examination - adnomyosis
Bloods - anaemia, coag screen, TFTs
TVUS (endometrial thickness / fibroids / ovarian mass) - biopsy if indicated
When would you biopsy a patient with menorrhagia who has had a TVUS?
POST MENOPAUSAL
Endometrial thickening of more than 4mm if symptomatic
More than 11mm if asymptomatic
How would you treat a patient presenting with menorrhagia?
First line = IUS
Second line = Tranexamic acid / Mefanamic acid
Third line = progestogens or GnRH agonists
Last resort = surgery
What are the differentials for dysmenorrhoea?
Primary - at the start of menstruation = common Fibroids Adenomyosis Endometriosis PID Ovarian tumours
How would you treat primary dysmenorrhoea?
NSAIDs, COCP
What are the causes of IMB?
Non-malignant:
- Fibroids
- Polyps
- Adenomyosis
- Ovarian cyst
- PID
Malignant - endometrial cancer
How would you investigate a patient with IMB?
Assess blood loss
FBC, coag screen, TFTs
TVUS - endometrial thickness - biopsy if needed
How would you manage a patient with IMB?
IUS or COCP
High dose progesterone to cause amenorrhoea - but withdrawal bleed occurs
HRT in perimenopause
CASE
A patient with pain that starts a few days before menstruation and ends 1-2 days after bleeding starts
+ pain during sex
Endometriosis
What is endometriosis?
Presence / growth of endometrial tissue outside the uterus
Where are the common sites of endometriosis?
Uterosacral ligaments Ovaries Vagina Rectum Bladder
What are the complications of endometriosis?
Chocolate cysts
Fibrosis and adhesions
What are the typical features of endometriosis?
Cyclical pain with menstruation (starts a few days before)
Deep dyspareunia
Subfertility
Acute pain if rupture of chocolate cyst
Can be haematuria or rectal bleeding if tissue on bladder or rectum
How would you investigate a patient with suspected endometriosis?
O/E - tender and thickened adnexa
TVUS to exclude ovarian endometrioma (remove in case ovarian malignancy)
Gold standard = laparoscopy to see the lesions
How would you treat a patient with endometriosis?
NSAID - ibuprofen, naproxen, mefanamic acid
If don’t want to get preggo:
- Tricyclic COCP
- Oral progesterone pill / depot / IUS
NSAID + analgesia
GnRH analogue
Surgical - diathermy, dissection of adhesions, removing endometriomas, hysterectomy
What might you find on examination of a patient with endometriosis?
Tenderness and thickening in the adnexae
Adnexal masses - endometriomas
Retroverted / immobile uterus - adhesions
Rectovaginal nodule on digital exam
What are the risk factors for endometriosis?
Nulliparous
Family history?
What are the complications of endometriosis?
Subfertility
Frozen pelvis
What are fibroids?
Benign growths of the endometrium
What are the risk factors for fibroids?
Afro-Caribbean
Family history
What are the protective factors for fibroids?
COCP
Parity
+ are oestrogen dependent so regress after menopause
What are the possible locations for fibroids?
Subserous polyp Subserous Intracavity polyp Intramural Submucosal Cervical
What are the complications of fibroids in pregnancy?
Can grow (1/3) Premature labour Malpresentation (transverse lie) Obstructed labour PPH Red degeneration Torsion of pedunculated fibroid after birth - pain
What are the complications of fibroids?
Pregnancy stuff Torsion Calcification after menopause Red degeneration Malignancy (0.1%)
What symptoms can fibroids cause?
Menorrhagia
Dysmenorrhoea
Depending on location - urinary frequency, infertility
How would you investigate a patient with suspected fibroids?
Abdo / bimanual exam for masses TVUS MRI Laparoscopy Hysteroscopy or hysterosalpingogram
How would you manage a woman with fibroids?
If asymptomatic - just annual check up to see size and growth
If menorrhagia + less than 3cm with no distortion of the uterine cavity:
- 1st line IUS
- 2nd line tranexamic acid (anti-fibrinolytic)
- 3rd line norethisterone from day 5-26
Surgical - resection, ablation, myomectomy, uterine artery ablation
What are the differentials for cervical excitation?
PID
Ectopic pregnancy
CASE
Obese lady who has always had irregular periods, bad acne, issues with facial hair and is now trying to get pregnant with difficulty.
Differential?
PCOS
Polycystic ovary syndrome
What are the pathophysiological features of PCOS?
Disordered LH production
Peripheral insulin resistance (so raised insulin levels)
Increased androgens
What are the clinical features of PCOS?
Oligo/amenorrhoea
Obesity
Acne
Hirsutism
What would you see on examination of a patient with PCOS?
High BMI Hirsutism Acne Alopecia Acanthosis nigrans
How would you investigate a patient with suspected PCOS?
Day 2-5 LH and FSH for ovulation
TFTs - exclude hyper/hypothyroidism
Prolactin - exclude hyperprolactinaemia
Testosterone
If hyperandrogenism - DHEAS (dihydroepiandosterone sulfate), SHBG (sex hormone binding globulin)
Exclude other causes of primary oligo/amenorrhoea
Pelvic USS
How would you make a diagnosis of PCOS?
Rotterdam criteria
2 of:
- Oligo/anovulation
- Hyperandrogenism - hirsutism, acne, alopecia, or biochemical
- Polycystic ovaries on USS - >12 antral follicles on one ovary, 2-8mm in size, in enlarged ovary >10mm
How would you treat a patient with PCOS (not wanting to get pregnant)?
Weight loss + exercise
COCP
Antiandrogens
How would you treat a patient with PCOS (wanting to get pregnant)?
Metformin
Clomiphene
How would you treat a patient with severe PCOS not responding to treatment?
Laparoscopic ovarian drilling
CASE
A 29 year old presents having collapsed at home following severe abdominal pain and bleeding.
Diagnosis?
Ectopic pregnancy until proven otherwise
What is ectopic pregnancy?
Implantation of the embryo outside the uterine cavity
What are the risk factors for ectopic pregnancy?
PID Previous pelvic / tubal surgery Assisted conception Previous ectopic Smoking
+ rule out in a woman with an IUD - prevents intrauterine pregnancies but not tubal ones
What are the clinical features of ectopic pregnancy?
Abnormal vaginal bleeding - dark
Abdominal pain ± collapse
Amenorrhoea of 4-10 weeks
Shoulder tip pain
What would you see on examination of a woman with ectopic pregnancy?
Tachycardia (blood loss) Abdominal / rebound tenderness Cervical excitation Adnexal tenderness Closed os
How wold you investigate a woman with a suspected ectopic pregnancy?
Pregnancy test - urine bhCG
TVUS
Serum hCG >1000IU/ml (declining / slow rising levels)
Diagnostic laparoscopy
What would you see on a TVUS in an ectopic pregnancy?
Empty uterus
Free fluid
Mass - tubal / elsewhere
From beta hCG levels, how would you distinguish between a viable uterine pregnancy and an ectopic pregnancy?
Raising = viable uterine
Declining / slow rising = ectopic or non-viable intrauterine
What is incontinence?
Involuntary leakage of urine
What can cause incontinence?
Stress incontinence Detrusor overactivity Fistula Neurological Overflow Functional Mixed Incontinence
What are the symptoms associated with detrusor overactivity?
Urge incontinence
Frequency Nocturia Nocturnal enuresis ‘Key in the door’ ‘Handwash’ Intercourse
What are the symptoms associated with stress incontinence?
Involuntary leakage with increased intra-abdominal pressure Cough Laugh Lifting Exercise Movement
How would you investigate a patient with urinary incontinence?
Bladder diary - frequency volume chart
Urinalysis
Residual urine measurement
Questionnaire - ePAQ
+ assess pelvic floor muscles, prolapse
+ residual urine volume (post-void volume) - cystometry
+ urodynamic testing after conservative management
How would you manage stress incontinence?
Conservative = Kegel exercises
SNRI - duloxetine - enhances the urethral sphincter
Surgery = sling / suspension
How would you manage overactive bladder (detrusor overactivity)?
Bladder drills Anticholinergic drugs - oxybutynin Botox Augmentation Bypass
What lifestyle measures would you give to someone with urinary incontinence?
Avoid caffeine Modify fluid intake Weight loss Avoid straining Stop smoking
What medication would you use to treat detrusor overactivity?
+ side effects
Anti-cholinergic eg Oxybutynin, Tolterodine
SE = dry mouth, constipation, drowsiness, blurred vision
What are the options for incontinence before surgery?
Lifestyle Containment options: - Catheters - Leakage barriers - pads and pants - Vaginal support devices - Skin care - Odour control
What are the symptoms of utero-vaginal prolapse?
Feeling like something is coming down / dragging sensation
Lump
Discomfort
Pelvic floor + sexual symptoms
How would you investigate a patient with suspected prolapse?
Sims speculum examination
What are the treatment options for uterovaginal prolapse?
Lifestyle - lose weight etc
Conservative = pessaries
Surgical (eg hysteroplexy, sacroplexy, anterior or posterior wall repair)
Oestrogen replacement - adds turgor to the vagina
What are the types of prolapse?
Frontal = urethrocoele or cystocoele Apical = uterine prolapse Back = enterocoele (small bowel) or rectocoele (rectum)
