Gynae Flashcards
Define primary and secondary amenorrhoea
1- Failure to start mensturation by 16 (14 if no signs of puberty)
2- Previous menses, then no menstruation for >6months and NOT pregnant
Causes of primary amenorrhoea
Constitutional delay (familial)
GU malformation
Hypothalamic failure - anorexia, Kallman’s syndrome (low GnRH and lack of sense of smell)
Gonadal failure - Turners syndrome (45x) - neck webbing, short stature, obesity, CV problems ->(ECG/Echo)
Causes of secondary amenorrhoea
Premature ovarian failure
H-P-O axis failure - stress, exercise, weight
Hyperprolactinaemia (suppresses ovulation)
Ovarian - PCOS, tumours, menopause
Iatrogenic - depot, implant, Post COCP
Obstruction
Features of Kallmans
Management
Delayed puberty, lack of sense of smell
Some - cleft lip/palate, absence of 1 kidney, deafness, shortened digits, eye movement problems
Hormone replacement (testosterone in males / FSH/LH) -> puberty
or GnRH -> fertile
Investigations in amenorrhoea ? What changes if its secondary?
FSH/LH, hCG, prolactin, karyotype, TFT, USS
Less likely to do karyotype / USS
Check day 21 progesterone, serum free androgen (PCOS)
With amenorrheoa when are FSH/LH raised? Low?
Raised - ovarian failure (premature menopause)
Low - Hypothalmic (constitutional delay, weight loss, anorexia, exercise, hypothalamic/ pituitary tumour)
What causes increased prolactin? Drug to lower?
Stress, hypothyroid, prolactinomas, drugs
Bromocriptine (D agonist)
What causes an increase in testosterone?
Androgen secreting tumour
Congenital adrenal hyperplasia / cushings
Moderate increase in PCOS
What is ashermans? Sheehan’s?
A- adhesions of the endometrium Eg after surgery
S- necrosis of the pituitary gland after significant PPH
A 37 year old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative.
What is the most likely diagnosis? Definition? Sx? Risk factors?
Premature ovarian failure
Cessation of menses for 1 year before the age of 40
Can be preceded by irregular cycles
Sx - Hot flushes, night sweats, vaginal dryness, vaginal atrophy, sleep disturbance, irritability
Risk - FH, exposure to chemo / radiotherapy, autoimmune disease
14 - no periods, but gets cyclical pain
Looks well O/E
Diagnosis?
Imperforate hymen
Difference between 1 / 2 dysmenorrhoea ? Cause of 1? 2?
1- absence of underlying pelvic pathology - Fall in progesterone ->Prostaglandin release -> myometrium contract -> ischemia and pain
2- Endometriosis, adenomyosis, PID, fibroids, endometrial polyps, malignancy
30 yr old complaining of cyclical abdo pain
What else do you want to know?>
Dysparenuia, PCB, IMB, menorrhagia, bowel / urinary Sx, IBS sx
Cyclical pain
Deep dyspareunia, menorrhagia
No PCB / IMG, not on contraception
No urinary / bowel Sx
Diagnosis? 3 theories of cause?
Endometriosis
Sampson’s - retrograde mensturation
Meyers - metaplasia
Halbans - lymphatic / haematogenous spread
Endometriosis and pain on defecation Where is it? What is seen on ovaries during a scan generally in endometriosis?
Pouch of Douglass
Chocolate cysts - altered blood
Investigations in endometriosis ?
Exclude others
Abdo exam / pelvic exam , triple swabs, TVUS, abdo US
Gold standard for endometriosis diagnosis?
Management ?
Laparoscopy
Suspected - NSAIDs (iboprofen, mefanamic acid), Paracetamol
Medial - Suppress mensturation - COCP, IUS, implant, depot / refer to gynae
Specialised - GnRH analogues
Surgery - Laparoscopic (improves fertility), or radical surgery if severe disease
How do GnRH alalouges work?
LH agonists - initial stimulation of pituitary secretion of gonadotrophins then rapidly inhibitors secretion due to down regulation
Mrs P (60yo) attends her GP practice complaining of cyclical abdominal pain.
No dyspareunia, menorrhagia
No PCB or IMB, not on contraceptive
No urinary/bowel symptoms
Diagnosis? What is it? Investigation?
MX?
Adenomyosis - invasion of myometrium by endometrial tissue
MRI
Same as endometriosis
Define menorrhagia? How often is no cause found and what is this termed? Underlying causes
Excessive, regular Menstural loss (>80ml and/or >7days bleeding)
50% - dysfunctional uterine bleeding
Uterine - Fibroids, endometriosis/adenomyosis, polyps / malignancy, Systemic - coagulation disorders, hypothyroidism, diabetes, liver/kidney disease
Iatrogenic - Anticoagulant treatment / chemo
Most common benign tumour in women? Sx? Risk factors?
Fibroids
Menorrhagia, pelvic pain, secondary dysmenorrhea, urinary tract problems (frequency, urgency, incontinence, hydronephrosis), bowel problems (bloating / constipation)
Age, early puberty, obesity, black ethnicity, FHx
Investigation of fibroids ? Mx?
Bulky non tender uterus
Goserelin (GnRH agonist) -> suppresses oestrogen
<3cm - IUS, Tranexamic acid, NSAID, COCP
>3cm- trans cervical resection of fibroids (TCRF), myomectomy, hysterectomy, Uterine fibroid embolisation (UFE)
What sx of menorrhagia suggest underlying pathology (Eg PID, endometriosis, endometrial Ca)?
Investigations ?
Persistent post coital /intermenstural bleeding, dysparenuria, dysmenorrhea, pelvis pain, Urinary/bowel Sx, vaginal discharge
Detailed hx Abdo / biannual examination Speculum exam of cervix Blood test - iron deficiency Other appropriate dependent on Sx - Eg ultrasound....
What are fibroids also called?
Leiomyomas - Smooth muscle and fibroblasts
Bar fibroids, Eg of other benign ovarian tumours and a bit about them
Functional Cysts
Enlarged persistent follicle or corpus luteum. Normal < 5cm, resolve after 2/3 cycles. Can cause pain and peritonitis sx if they bleed. COCP inhibits.
Mucinous Cystadenomas
Massive. Unilateral, Appear solid, common in 30-40 yr old, 15% malignant
Serous Cystadenomas
Most common epithelial tumour, commonly bilateral, 30-50yr old, 25% malignant
Dermoid cyst
‘mature cystic teratoma’, contain skin/hair/teeth most common cyst in < 30s. Bilateral 20/30%. Torsion most likely in dermoid cyst.
Ovarian cysts usually rupture mid cycle
Presentation? Investigations? Mx?
Acute abdo pain, PV bleed, nausea & vomiting, circulatory collapse ± weakness / syncope
Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
Laparoscopy is diagnostic but usually get USS first
Stable -> analgesia
Bleeding / unstable -> surgery
Ovarian torsion occurs unilaterally in combination with a pathologically enlarged ovary
RF? Presentation? Ix?Mx?
Rf - pregnancy, malformations, tumours, previous surgery
P- Acute abdo pain (often unilateral) radiates to back, thigh, pelvis
N&V
Fever - indicates necrotic ovary
Ix: Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
USS with colour Doppler analysis is diagnostic
Management:
Laparoscopy
+ Analgesia; NSAIDs, opiates
Ovarian Ca Most common histological RF Presentation Common differential Ix Mx Staging What would you think if a young (<30yr)
; Epithelial Serous adenocarcinoma (50%)
increased risk with increased number of ovulations – early menarche and late menopause, null parity. BRCA1 (40% lifetime risk) BRCA2 (25% lifetime risk) and HNPCC. (Protective: COCP + having children, anovulation, pregn, lactation, POP/Mirena
Presentation: (typically vague and non specific – therefore most present late e.g with ascites)
Persistent abdo bloating
Early satiety, anorexia
Urinary urgency / frequency
PV bleed
Lower abdo pain/ back pain or dyspareunia
Common differential? IBS but any over 50 presenting with new IBS type symptoms must have Ca125 done
Ca125, US scan (take these combined with menopausal status to calculate risk score)
CT scan
If younger = afp and hcg – germ cell tumours
Management: refer to MDT if U x M x CA125. Refer to Gyn Onco if 250 or more
Platinum based chemo, oophorectomy, bevacizumab
CT scan and laparoscopy for staging
Staging 1 = limited to ovaries, 2 = limited to pelvis, 3 = limited to abdomen, 4 = distant mets outside abdomen
80% of cases in over 50s -> think germ cell line if under 30y/o
Endometrial ca Most common histological type? Risk factors? Presentation? Investigations? Management? Factors associated with a poor prognosis?
Most cmn gynae Ca: 90% adenoCa, 10% adenosquamous
Risk factors: Oestrogen dependent ca |(causes excess proliferation of endometrial cells)so at increased risk when endometrium is exposed to unopposed oestrogen e.g. Oestrogen only HRT, Tamoxifen, PCOS, obesity, diabetes, HTN, oestrogen secreting tumours, nulliparity, late menopause,
Presentation:
Post menopausal bleeding (have to exclude endometrial cancer)
Watery discharge
Investigations:
US
Hysteroscopy with endometrial biopsy is definitive diagnostic ix
(CXR and MRI for spread)
Management:
Limited to uterus or cervix (stages 1 and 2) = total hysterectomy and bilateral salpingo-oophrectomy
Stage 3 - post op radiotherapy
Unsuitable for surgery -> radiotherapy and progestogens e.g. medroxyprogesterone
Poor progn if: older age, advanced clinical stage, deep myometrial invasion in Stage 1 or 2, high grade, adenosquamous histology
What is strange about tamoxifen and receptors
Antagonist in breast but agonist in uterus
Cervical Ca Most common histological type? Risk factors? Preventative measure? Presentation? Screening? When do you refer for colposcopy? Treatment?
SCC, 90% squamous cell Ca, 10% adenoCa from columnar epithelium
Rf - HPV 16, 18, (31,33, 45) early age intercourse, multiple partners, STIS,multiparity, smoking, COCP, immuno-suppressed pts, previous CIN, other genital tract neoplasia
Prevention - Gardasil HPV vaccine to 12/13 yr old girls
Presentation:
Vaginal discharge (offensive)
PV bleed – postcoital/micturating/defecating PCB/IMB/PMB, dyspareunia
Late sx – painless haematuria, chronic urinary freq, altered bowel habit, leg oedema, pelvic pain.
Smear - Targets transformation zone (squamous-columnar jct) and HPV testing from age 25 – 50 every 3 years, age 50 – 65 every 5 years or yearly if at high risk e.g. HIV
Refer to colposcopy IF:
Borderline dyskaryosis AND HPV +ve
OR Moderate or severe dyskaryosis
Treatment
Dysplasia -> laser therapy/ cryotherapy -> LLETZ/ cone biopsy
Stage 1B+ (ca at opening of womb) -> surgery with chemo therapy
Stage 2B+ (vagina)-> ?chemoradiation
3 (surrounding structures)
4(spread outside vagina and womb)
[chemo and radio in any stage above 1b]
What is subfertility? % of couples who conceive in 1yr? 2yr? Usual causes?
Failure to conceive in 1 year or regular unprotected sex
80%, 90%
Unexplained 25% Male factors 30% Ovulatory disorders 25% Tubal damage 20% Uterine disorders 10%
40% - factors in both partners
A 27 y/o lady attends your practice complaining of inability to get pregnant despite regular unprotected intercourse for the past year…
…You can’t help but notice she is obese, has acne, and an unusual amount of hair on her upper lip and chin
Diagnosis?
Other sx they may get?
PCOS
Oligomenorrhoea, alopecia (male pattern), sleep apnea, psych problems
Assuming other causes have been excluded what is the diagnosis to criteria for PCOS ?
Rotterdam criteria
Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
Oligo-ovulation or anovulation.
Clinical and/or biochemical signs of hyperandrogenism.
Two of the three following criteria are diagnostic of the condition, assuming other causes have been excluded (Rotterdam criteria):
PCOS - DD? Ix? Mx if wish to conceive? If don’t wish to conceive?
Thyroid disorder (particularlyhypothyroidism).
Hyperprolactinaemia.
Cushing’s syndrome.
Acromegaly.
Side-effects of medication (medication causing hirsutism, weight gain or oligomenorrhoea as side-effects, for example).
Late-onsetcongenital adrenal hyperplasia (CAH). – 21 hydroxylase deficiency
Androgen-secreting ovarian or adrenal tumours.
Investigations
Total testosterone: Normal to slightly raised in PCOS.
Free testosterone levels may be raised but if total testosterone is >5 nmol/L, exclude androgen-secreting tumours and CAH.
Sex hormone-binding globulin. Normal or low in PCOS.
LH may be elevated
Ultrasound scan
Other blood tests, where indicated from the clinical picture, to exclude other potential causes - eg, TFT (thyroid dysfunction), 17-hydroxyprogesterone levels (CAH), prolactin (hyperprolactinaemia), DHEA-S and free androgen index (androgen-secreting tumours), and 24-hour urinary cortisol (Cushing’s syndrome).
Fasting glucose and oral glucose tolerance tests are useful in assessing insulin resistance/diabetes. Women who are overweight or have other risk factors for diabetes should have an oral glucose tolerance test on diagnosis of PCOS.[6]
Fasting lipid levels should be checked.
Weight control and exercise
No pregnancy planning - co-cyprindrol, COCP, metformin
Planning - clomifene, metformin, laparoscopic ovarian drilling
Causes of female infertility
Ovarian - PCOS, pituitary tumours, Sheehan’s, hyperprolactinaemia, premature ovarian failure, turners syndrome
Tubes / uterus / cervix - PID, sterilisation, ashermans, fibroids, endometriosis, uterine malformation , surgery
Thyroid
Adrenal - cushings, CAH
Chronic disease
Causes of primary ammenhorea when secondary sexual characteristics are present
Usually GU malformation - Imperforate hymen, Transverse vaginal septum , Absent uterus
Androgen insensitivity syndrome
Endocrine - thyroid, hyperprolactinaemia, cushings, PCOS (rare primary)
Primary amenorrhea with absent secondary sexual characteristic?
Ovarian failure - gonadal dysgenesis (turners 46XO), prematurity ovarian failure, chemo, pelvic irradiation
Hypothalamic dysfunction - decrease GnRH -> decreased LH/FSH
-Chronic system illness, eating disorders, weight loss, exercise, stress, depression
Tumours, head injury, infection, tumours, kallman’s syndrome
