Gynae Flashcards
Define primary amenorrhoea
failure to start menses by 16
by 14 if no signs of puberty
Define secondary amenorrhoea
previous menses, then no menstruation for >6m
NOT pregnant
causes of primary amenorrhoea
constitutional delay GU malformation hypothalamic failure (anorexia, Kallman's) gonadal failure (Turners)
causes of secondary amenorrhoea
premature ovarian failure HPO axis failure hyperprolactinaemia ovarian (PCOS, tumours, menopause) iatrogenic (depot, implant) obstruction
features of Kallman’s
delayed puberty, anosmia, primary amenorrhoea
hypogonadotrophic hypogonadism in men
mx of Kallman’s
hormone replacement
GnRH for fertility
ix in amenorrhoea
if secondary?
FSH/LH, hCG, prolactin, karyotype, TFT, USS
if secondary –> check day 21 progesterone, serum free androgens
in amenorrhoea, when are FSH/LH raised?
when are they low?
Raised - ovarian failure (premature menopause)
Low - hypothalamic (constitutional delay, weight loss, anorexia, hypothalamic/pituitary tumour)
what causes raised prolactin?
which drug lowers it?
stress, hypothyroid, prolcatinomas, drugs
bromocriptine (dopamine agonist)
what increases testosterone/
androgen secreting tumour
CAH
Cushings
slightly raised in PCOS
what is ashermans?
adhesions in endometrium eg post surgery
what is sheehans?
necrosis of pituitary gland after PPH
define premature ovarian failure?
cessation of menses for 1 year before the age of 40
can be preceded by irregular cycles
pres of premature ovarian failure
cessation of menses for 1y <40
hot flushes, night sweats, vaginal dryness/atrophy, sleep disturbanc
RFs for POF?
FH
chemo/radio
autoimmune disease
endometriosis?
presence of endometrial tissue outside of the uterus
pres of endometriosis?
cyclical pain
deep dyspareunia
menorrhagia
ix in endometriosis?
r/o other causes abdo/pelvic exam triple swabs TVUS abdo USS **LAPAROSCOPY = gold standard**
mx of endometriosis
NSAIDs (ibuprofen, pcm, mefenamic acid)
Suppress menstruation (COCP, IUS, implant)
Specialised (GnRH analogues)
+/- surgery (improves fertility)
mechanism of GnRH analogues?
LH agonist - initially stimulates pituitary glad to secrete gonadotrophins then rapidly inhibits due to down regulation
what is adenomyosis
invasion of myometrium by endometrial tissue
endometriosis into myometrium
define menorrhagia?
excessive, regular menstrual loss (>80ml and/or >7d)
what if no underlying cause of menorrhagia?
DUB
causes of menorrhagia
fibroids, endometriosis, polyps, malignancy
coag disorder, hypothyroid, DM
anticoag treatment, chemo
DUB
what are fibroids?
benign tumour –> leiomyoma
ix of fibroids?
bulky non tender uterus
mx of fibroids?
goserelin (GnRH agonist)
<3cm - IUS, transexamic acid, NSAID, COCP
> 3cm - trans-cervical resection of fibroids, myomectomy
pres of fibroids?
menorrhagia, peliv pain, dysmenorrhoea, LUTS, bowel
+/- infertility
red flag sx in menorrhagia?
PCB/IMB
dyspareunia
dysmenorrhoea
discharge
ovarian cysts usually rupture mid cycle.. pres?
ix?
mx?
acute abdo pain, PV bleed, N+V
r/o ectopic!!! hCG
FBC swaps.
USS +/- laparoscopy
analgesia
if unstable –> surgery
pres of ovarian torsion?
acute abdo pain (u/l) radiating to back/thigh/pelvis
N+V
ix in ovarian torsion?
always r/o ectopic!!
USS
mx of ovarian torsion
laparoscopy
analgesi
Ovarian Ca
most common?
epithelial
RFs for ovarian ca?
unopposed oestrogen exposure
BRCA
HNPCC
pres of ovarian ca
vague + non-specific –> usually presents late
abdo bloating, early satiety, anorexia, urinary sx, PV bleeding
ix in ovarian ca
RMI = [Ca125 x USS x menopausal status]
CT
mx of ovarian ca
MDT
chemo
oophorecetomy
endometrial ca type?
adenocarcinoma
RFs for endometrial ca
unopposed oestrogen
pres of endometrial ca
PMB
watery discharge
ix of endometrial ca
US
hysteroscopy + biopsy
CXR + MRI
mx of endometrial ca
TAH+BSO
+/- radio
cervical ca type
SCC
cervical ca RFs
HPV 16, 18
early intercourse
STIs
smoking
pres of cervical ca
vaginal discharge
PCB
dyspareunia
ix in cervical ca
Smear screening from 25-50 every 3y, 50-65 every 5
what smear results = refer to colposcopy
borderinle dyskariosis AND HPV +ve
moderate dyskariosis
severe dyskariosis
mx of cervical ca
dysplasia –> LLETZ
surgery + chemo
if >1b –> chemoradio
define subertility?
% conceive in 1st year?
% conceive in 2 years?
failure to conceive in 1y of regular unprotected sex
80%
90%
causes of subfertility
unexplained male (30%) ovulatory (35) tubular (20%) uterine disorders (10%)
pres of PCOS?
infertility, obesity, acne, hirstute oligomenorrhoea, alopecia
criteria for PCOS
Rotterdam (2/3)
- polycystic ovaries
- oligo-ovulation
- hyperandrogenism
mx of PCOS?
if planning pregnancy?
if not?
weight control and exercise
planning for preg [clomifene, metformin, ovarian drilling]
not planning for pregnancy [co-cyprinidrol, COCP, metformin]
causes of female infertility
ovarian
tubular
other
PCOS pituitary tumours Sheehans hyperprolactinaemia POF
PID
ashermans
fibroids
endometriosis
chronic disease
thyroid
adrenal
Causes of primary amenorrhoea when secondary sexual characteristics are present?
GU malformation [imperforate hymen, transverse vaginal septum, absent uterus]
androgen insensitivity syndrome
endocrine [thyroid, hyperprolactinaemia, cushings]
Causes of primary amenorrhoea with absent secondary sexual characterisits?
ovarian failure [gonadal dysgenesis (46XO), POF, chemo, pelvic radiation]
hypothalamic dysfunction [chronic illness, eating disorders]
others [tumours, infection, Kallman’s]
5a-reductase deficiency?
people are genetically male (46XY) but cannot convert testosterone -> dihydrotestosterone
genitalia appear ambiguous / female at birth –> can be classified as a ‘primary amenorrhoea’ as thought to be female
pres of androgen secreting tumour?
virilisation
cause of CAH
21-OH deficiency
inefficient cortisol synthesis -> adrenal hyperplasia -> increased ACTH -> increased progesterone + DHEA + testosterone
pres of CAH?
3 severities
salt-wasting crisis in first month of life
virilising CAH - genital ambiguity
late onset -
causes of POF?
idiopathic
chemo
autoimmune
causes of primary spermatic failure
chemo, maldescent, absent testes
klinefelteres
varicoceles
when do you carry out mid-luteal progesterone level?
investigation in infertility
7 days before onset of menses
Eg day 21 of a 28 day cycle
mx for menorrhagia? (1,2,3)
1 - mirena
2 - tranexamic acid, mefanamic acid, NSAIDs, COC
3 - prostaglandins, GnRH
+/- surgical - endometrial ablation, embolisation, hysterectomy
how to improve fertility in endometriosis?
ablation
mx for endometriosis
NSAIDs, COC, progesterones
GnRH
IUS
ablation
mx of fibroids
mirena, tranexamic acid
GnRH -> shrinks prior to surgery
surgery - myomectomy, ablation, hysterectomy, embolisation
3 main types of ovarian cyst
1 - functional [follicular, corpus luteal, theca lutein]
2 - benign epithelial cyst
3 - malignant
comps of ovarian cyst
torsion
rupture
haemorrhage
meigs syndrome triad ?
benign fibroma, ascites, pleural effusion
histological classifications of breast ca
invasive ductal adenocarcinoma - 75% invasive lobar adenocarcinoma - 15% medullary carcinoma - 5% Paget's disease of breast - 1-4% papillary carcinoma - 1%
pres of breast ca
lump skin tethering nipple inversion dilated veins ulceration peau d'orange
how to describe a breast lump
hardness
irregularity
focal nodularity
fixation to skin/muscle
breast cancer receptors?
estrogen receptor
HER2
hormonal therapy drugs?
ER+
HER2+
ER+ -> tamoxifen
HER2+ -> herceptin (trastuzumab)=monoclonal antibody
tamoixfen se
anti-oestrogen in breast
BUT pro-oestrogen on uterus -> increased risk of endometrial ca
ix in breast ca
examination
imaging [young-USS; old-mammogram]
biopsy [FNA / core needle]
mx of breast ca
surgery
+/- radio
+/- chemo
+/- hormonal therapy
ix in CAH
17a- hydroxyprogesterone
what is oligomennorhea
periods occur every 35d to 6m
common sites for endometriosis tissue
uterosacral ligaments
ovaries - chocolate cyst
+/- pouch of douglas, bladder, vagina, lungs
when to use hysteosalpingogram?
tests for tubal infertility
what is PID
infection of upper female genital tract
cause of PID
ascending infection form endocervix eg STI
RFs for PID
age < 25
prev STI
multiple partners
pres of PID
lower abdo pain
deep dyspareunia
vaginal d/c
may be aSx and present with infertility
PID ix
bloods
chlamydia NAAT
USS
mx of PID
abx to cover all potential organisms –> ceftriaxone (gonorrhoea), azithromycin (chlamydia), doxycycline, metronidazole (BV)
