gynae Flashcards
menopause symptoms
due to falling oestrogen levels
menstrual irregularity
vasomotor disturbance - sweats, palpitations, flushes
osteoporosis
vaginal dryness from vagina atrophy - causing infection, UTIs, dyspareuria
if dont want HRT, can be given SSRI
HRT
benefits
risks
Benefits
Relief of menopause symptoms
Bone mineral density protection
Possibly prevent long term morbidity
Risks Breast cancer VTE - risk with oral HRT Cardiovascular disease - only when started in women over 60 Stroke
HRT
uterus
no uterus
uterus - combined HRT (oestrogen and progesterone)
no uterus - oestrogen only
Premature Ovarian Insufficiency (POI)
Menopause <40 yrs
Natural or Iatrogenic
Majority of cases – idiopathic
Other Chromosome abnormalities, FSH receptor gene polymorphisms
Diagnosis FSH >25IU/l – 2 samples >4 weeks apart + 4 months of amenorrhoea
endometriosis what is it
endometriotic tissue outside the uterus
cause unknown
hormonally (oestrogen) driven
endometriosis cause theories
retrograde menstruation - leads to adherence, invasion and tissue growth
metaplasia of mesothelial cells
endometriosis presentation
cyclical pain - due to endometrial tissue responding to menstrual cycle
constant pain - due to adhesions from chronic inflammation
dysmenorrhoea
dyspareunia
endometriosis treatment
combined OCP, or progesterones, or mirena
GnRH agonists (goserelin) - down regulate the pituitary gland (less FSH/LH) have menopausal SE so add HRT
hysterectomy - last resort
adenomyosis
what is it
symptoms
treatment
endometrial tissue in myometrium Cyclic pain, Dysmenorrhoea, Dyspareunia Progesterone IUS (mirena), hysterectomy
fibroids
what are they
location
oestrogen dependent benign smooth muscle tumours of the uterus can be: subserosal - visceral peritoneum intramural submucosal - under the endometrium pedunculated
fibroids presentation
many asymptomatic
menorrhagia (+/- anaemia)
fertility problems - submucosal interfere with implantation (infertility / miscarriage)
pain - torsion from pedunculated fibroids
Dysmenorrhea
fibroids management
myomectomy - to preserve fertility
GnRH analogues to reduce size before surgery (goserelin)
will shrink and calcify at menopause, HRT may cause them to grow
Ulipristal acetate
may cause pregnancy problems - malpresentation
hysterectomy - only cure, for those who have completed their family
heavy menstrual bleeding definition
Menstrual blood loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life
Menorrhagia definition
Heavy Menstrual Bleeding that occurs at expected intervals of the menstrual cycle
Heavy Menstrual Bleeding causes
Uterine fibroids (20-30%) Uterine polyps (5-10%) Adenomyosis (5%)
women >45 think endometrial carcinoma
menorrhagia investigations
FBC transvaginal US bimanual vaginal exam and speculum Endometrial biopsy if >45yrs and: IMB Unresponsive to treatment
menorrhagia treatment
mirena Antifibrinolytics (Tranexamic acid) - Inhibits tissue plasminogen activator NSAID - Mefenamic acid endometrial abalation - completed family reassurance
infertility - ovarian reserve testing hormones (3)
FSH, Antral Follicle Count (AFC), Antimullerian Hormone (AMH)
infertility
ovulating hormones
ovarian reserve testing
tubual patency investigations
LH and progesterone
Ovulation / ovarian function Semen Quality Tubal Patency (+ Uterus)
hysterosalpingogram
USS
infertility - semen quality
Count (>15m/ml)
Motility (>40%)
Morphology (>4%)
Total >39m
male infertility treatment
Mild - Intrauterine Insemination (IUI)
Moderate abnormality - IVF
Severe – Intracytoplasmic Sperm Injection (ICSI)
polycystic ovarian syndrome diagnosis
2/3 of:
hyperandrogenism
oligomenorrhoea
polycystic ovaries on US
causes increased insulin and LH levels hyperandrogenism (testosterone)
polycystic ovarian syndrome management
clomifene citrate or tamoxifen - Oestrogen receptor modulators, induces ovulation (increases FSH). risk of ovarian cancer and multiple pregnancies
weight loss/metformin - improves insulin sensitivity
laproscopic ovarian drilling to those non responsive to above
IVF risks
Multiple Pregnancy
Miscarriage
Ectopic
endometrial cancer pathology
andenocarcinomas of columnar endometrial gland cells
endometrial cancer staging
1 - body of uterus only
2 - body and cervix only
3 - advancing beyond the uterus but not the pelvis
4 - outside the pelvis
endometrial cancer treatment
total hysterectomy with bilateral salpingo-oophorectomy
Adjuvant radiotherpay
progesterone therapy
cervical polyps definition and symptoms
benign tumours of endocervical epithelium
may cause increased mucus discharge and postcoital bleeding
cervical cancer risk factors
High risk HPV (16, 18)
Early age intercourse (<16 years)
Multiple sexual partners
STDs
persistent HPV associated with …
cervical intra-epithelial neoplasia which is pre invasive stage for cervical cancer
cervical intra-epithelial neoplasia 1,2 and 3
teatment
CIN 1 - lower basal 1/3 of cervical epithelium
CIN 2 - 2/3
CIN 3 - >2/3
invasive basal cell carcinoma when crosses the basement membrane
treatment - large loop excision of the transformation zone (LLETZ)
cervical cancer staging
1 - confined to the cervix a) microscopic b) macroscopic
2 - a) to upper 2/3 vagina b) if to parametria
3 - a) extended to lower 1/3 of vagina b) or pelvic wall
4 - a) spread to bladder or rectum b) distant organs
cervical cancer symptoms
vaginal bleeding (post-coital) watery discharge ureteric obstruction
vulval cancer symptoms
Vulval itching Vulval soreness Persistent ‘lump’ Bleeding Pain on passing urine
vulval cancer staging
I <2cm (79% 5 yr survival)
II >2cm (59% 5 yr survival)
III Adjacent organs / Unilateral Nodes (43% 5 yr survival)
IV Bilateral nodes / Distant mets
lichen sclerosis presentation
can predispose to …
autoimmune
elastic tissue turns to collagen
intensely itchy
can be a predisposing cause of vulval cancer
lichen sclerosis management
clobetasol propionate cream
vulval cancer pathology
squamous cell carcinoma
ovarian cancer presentation
asymptomatic / vague Bloating / ‘IBS’ like symptoms Abdominal pain/discomfort Change in bowel habit Urinary frequency Bowel obstruction
ovarian cancer aetiology
epithelial cell (carcinoma) e.g. Serous cystadenocarcinomas Endometrioid carcinoma
ovarian cancer
risk factors
protective factors
nulliparity early menarche / late menopause ovarian cysts BRCA 1 / 2 mutations HNPCC (lynch syndrome)
pregnancy
COCP
ovarian cancer
investigations
tumour marker
FBC,UE,LFT transvaginal US CXR CT abdo/pelvis CA125
suspected ovarian cancer risk of malignancy
RMI formula
risk of malignancy index RMI = US x M x CA125
US score - 1 less than one abnormal feature of cyst on USS, 3 more than one abnormal feature of cyst on USS
M - menopause status 1 pre 3 post
250+ = refer
ovarian torsion presentation
venous return is occluded
severe lower abdominal pain and vomitting
pain improves after 24 hours as ovary starts to die
whirl pool sign on TV US
pelvic inflammatory disease symptoms
lower abdominal pain - uni or bilateral / constant or intermittent
dyspareunia
vaginal discharge
pelvic inflammatory disease
management
investigations
ceftriaxone and metronidazole and doxycycline
Inflammatory markers are raised
USS excludes abscess and ovarian cyst
ashermans syndrome what is it
cause
complications
scar tissue in the womb
often a result if miscarriage
can cause infertility, amenorrhoea
prolactinoma presentation
menstrual disturbance
amenorrhoea / oligomenorrhoea
raised prolactin causes hypogonadism, infertility
menopause investigations
anti-Müllerian hormone
FSH
FIGO staging of ovarian cancer
1 - limited to one or both ovaries
2- limited to pelvis
3 - limited to abdomen
4 - distant metastases outside abdominal cavity
Amenorrhoea – Investigations
Pregnancy test if appropriate FSH/LH levels Prolactin levels Total testosterone and sex-hormone binding globulin levels karyotyping - possible turners syndrome
Primary amenorrhoea
Secondary amenorrhoea
Oligomenorrheoa
definitions
Primary amenorrhoea: periods have not started by age of 16
Secondary amenorrhoea: periods stop for 6 months or more
Oligomenorrheoa: Infrequent periods (more than every 35 days for 6 months)
Irregular Menstruation and Intermenstrual Bleeding investigations
Assess effect of blood loss- FBC TFT/clotting if clinically indicated FSH/LH levels if menopause suspected Cervical smear if required US of uterine cavity Women > 35 Younger if medical treatment failed
fibroids investigations
Abdominal/bimanual pelvic examination
US (transvaginal and transabdominal)
Hysteroscopy/hysterosalpingogram
FBC
cervical / intrauterine polyps
presentation
Diagnosis
Management
asymptomatic
Menorrhagia
IMB
US
Hysteroscopy
Resection with cutting diathermy or avulsion
endometrial cancer risk factors
Exogenous oestrogen - Unopposed oestrogen therapy
Endogenous oestrogen excess - PCOS with prolonged amenorrhea, Late menopause
T2DM
HNPCC / lynch syndrome
endometrial cancer symptoms and signs
Postmenopausal bleeding (most common)
Premenopausal patients - Irregular/IMB, Occasionally recent onset menorrhagia
Atrophic vaginitis may coexist
endometrial cancer investigations
tranvaginal US
endometrial biopsy
MRI abdo/pelvis
CXR
cervical Intraepithelial Neoplasia
Screening guidlines
investigations
All females from age 25 or first intercourse, whichever comes last
Repeat every 3 years until 49
From age 50-64
Every 5 years
From age 65
Only those not screened since 50 or have had abnormal tests
cervical smear
colposcopy
cervical cancer pathology
squamous cell carcinoma (70%)
polycystic ovarian syndrome presentation
Stereotypical patient
Obese, acne, excess body hair
Oligo- or amenorrhoea
Miscarriage
endometriosis investigations
laparoscopy and biopsy - Only way to be certain
transvaginal USS to visualise chocolate cysts
MRI if adenomyosis is suspected
prolapse management
Pessary
surgery
common causes of pelvic pain
- Pelvic inflammatory disease occuring after the insertion of IUCD (common complication of this) but PID is usually more bilateral than unilateral
- Uterine perforation
- Acute PID – due to STI infection
- Ectopic pregnancy
secondary amenorrhoea causes
hypothalamic-pituitary-ovarian causes - stress, exercise, weight loss
hyperprolactinaemia
ovarian causes - polycystic ovarian syndrome
uterine causes - pregnancy
cervical cancer treatment
radical hysterectomy
+/- chemoradiotherapy
may be able to do local excision (fertility sparing)
ovarian cyst features
multilocular cyst
solid areas
metastases
ascities
