gynae Flashcards
Ladies presenting from which countries should you consider FGM?
Somalia, Sudan, Kenya, Eritrea, Ethiopia and the Yemen, Malia, Guinea and Egypt
How is FGM classified?
Type 1 - clitoroidectomy - partial or total removal of clitoris and/or prepuce
Type 2 - partial/total removal of clitoris and labia minor ± excision of labia majora.
Type 3 - infibulation - narrowing of vaginal orifice by creation of a seal through cutting and appositioning of labia minora/majora, ± clitoroidectomy.
Type 4 - any other harmful procedures to female genitalia for non-medical reasons e.g. pricking, piercing, cauterisation, incision and scraping
Acute complications of FGM
haemorrhage, pain, urinary retention, sepsis, HIV, tetanus, death
Long-term sequelae of FGM
Chronic pain, apareunia, dyspareunia, anorgasmia, sexual dysfunction, keloid scar, UTIs, micturition difficulty, sub fertility, psychological/emotional trauma.
Describe the sequence of events in female puberty
Breast bud development -> pubic hair -> axillary hair -> menarche
Briefly describe the hormonal changes through the ovarian cycle
Follicles start developing independently, low steroid/inhibin = little negative feedback on HPG axis -> increasing FSH and LH -> follicle growth + oestrogen production.
Rising oestrogen -> -ve feedback HPG axis -> reduced FSH -> one follicle survives, others polar bodies.
Oestrogen increases sufficient to cause +ve feedback HPG -> LH surge (FSH suppressed by Inhibin) -> ovulation.
Luteineised follicle secretes oestrogen + progesterone, restoring -ve feedback HPG. End of cycle = corpus luteum regresses to reset the cycle (no fertilisation) or is maintained by the syncytiotrophoblast of the embryo which secretes hCG, it is supported by placental hCG which controls HPG axis around 4months.
With respect to the uterine cycle, length of cycle varies due to variation in….?
Follicular phase, luteal phase remains constant hence you measure LH 14 days before end of cycle to catch ovulation.
A 23 year old woman attends her GP, she is soon to go on a beach holiday and has heard of a pill that can delay her menstruation to avoid it coinciding with the holiday. What treatment options are there for delaying menstruation?
take norethisterone 5mg TDS 3 days before expected period. If overweight/smoker/35+/risk of VTE use medroxyprogesterone acetate.
What is oligomenorrhoea and at what age is it more likely?
Infrequent periods - cycles lasting over 35 days and/or fewer than 9 periods per year, extremes of reproductive age
How is amenorrhoea classified?
Primary - failure to commence menses
Secondary - cessation of periods for >6 months after menarche in the absence of pregnancy.
How would you investigate oligomenorrhoea/amenorrhoea?
Pregnancy test!
FSH - raised if POF, low/normal in hypothalamic-pituitary cause
LH - raised in POF/PCOS; low/normal in hypothalamic-pituitary cause
oestradiol - low in hypothalamic and POF
testosterone - raised in PCOS
prolactin - raised in prolactinoma, stress, hypothyroid
TFT if clinically suggestive?
Common causes of oligomenorrhoea
PCOS, hormonal/contraceptive treatments, perimenopause, thyroid dysfunction, diabetes, ED, excessive exercise, medications (anti-psychotics/AEDs)
Common causes of amenorrhoea
Hypothalamic (low GnRH, low FSH/LH) - ED, exercise, severe chronic disease (thyroid, psychiatric disorder, sarcoidosis), Kalllman syndrome.
Pituitary - prolonged use of contraception (esp Depo-Provera can take 18m as pituitary downregulated), prolactinoma, other pituitary tumour (acromegaly, Cushings), Sheehans syndrome.
Ovarian - PCOS (though more commonly oligomenorrhoea), Turners Synd, POF
Consider - adrenal (CAH), genital tract abnormality (Ashermans syndrome, imperforate hymen, septum)
How is premature ovarian failure managed?
Cyclic HRT - oestrogen (+ progesterone if she has a uterus)
DEXA scan - vitamin D and calcium
Define premature ovarian failure
Onset of menopausal symptoms and elevated gonadotrophins (LH and FSH) before the age of 40. Usually idiopathic but can occur secondary to chemo, radiation, autoimmune.
Define polycystic ovary syndrome
Endocrine disorder affecting 5-10% pre-menopausal women, characterised by oligo/a-menorrhoea, excess androgen production and presence of multiple immature follicles ‘cysts’ within the ovary as seen on imaging.
What is the underlying aetiology in PCOS?
increased frequency of GnRH pulse -> increased LH levels which promotes androgen production and insulin resistance which suppresses hepatic SHBG production causing increased free androgens.
Increased androgens prevent LH surge sufficient to cause ovulation so follicles within the ovary remain arrested early in development hence seen as ‘cysts’ on imaging.
Clinical features of PCOS
Oligo/a-menorrhoea, obesity, subfertility, acne, hirsutism, chronic pelvic pain, depression, acanthosis nigricans, male-pattern hair loss, hypertension
A 23 year old female visits her GP complaining of infrequent periods - her cycle usually lasts 37-39 days and in the last year she has had 8 periods. You also note she is rather hirsute and her BMI at last checking was 31.
What is your differential ddx?
PCOS - oligomenorrhoea, hirsute, obese
hypothyroidism - obesity, insulin resistance, oligomenorrhoea
Cushings - obesity, acne, htn, insulin resistance
hyperprolactinaemia - oligo/amenorrhoea, acne, hirsute.
How is PCOS diagnosed?
By fulfilling 2 out of 3 of the Rotterdam criteria:
oligo/a-menorrhoea
clinical/biochemical sx hyperandrogenism
polycystic ovaries seen on US (>12follicles in one ovary, or ovary vol >10cm3).
What investigations would you perform in someone with clinical picture suggestive of PCOS and when?
Bloods - (FSH and LH best taken day 1-3):
- FSH - normal/low
- LH - raised (classically LH:FSH 3:1)
- Progesterone - low (corrected for time in cycle)
- Testosterone - high
- SHBG - low
may be worth testing for diabetes simultaneously
(if ?diagnosis - TSH, prolactin)
US ovary - 12+ cysts in one/ovarian vol >10cm3
What are the general themes of managing PCOS?
Rx underlying diabetes/htn. If overweight advise diet and exercise to lose weight will help all facets of mx! oligo/a-menorrhoea infertility obesity hirsutism
A 35 year old female attends GP clinic as following subfertility investigations she was found to have PCOS. How would you counsel her on improving fertility with PCOS?
If overweight lifestyle changes - achieving BMI <30 can be enough to trigger ovulation on its own.
Drug rx - Clomifene citrate and/or metformin
- clomifene stimulates ovulation, can only be given for 6months due to risk of ovarian hyper stimulation/ca, also risk of multiple pregnancy
- not responding = ?ovarian drilling
A 17 year old girl is newly diagnosed with PCOS and attends your clinic to discuss management. The main symptom of her PCOS is oligomenorrhoea. However, she says she is quite happy to have periods less frequently anyway so does not see the need for treatment. What would you advise?
She is unlikely to be ovulating in her current state, anovulation means progesterone production is suppressed, leaving oestrogen unopposed. Unopposed oestrogen promotes endometrial hyperplasia, which increases risk of endometrial cancer. For that reason it is advisable to have 3+ periods per year. So would advise use of COCP, levonorgestrel-IUS, cyclical progesterone such as medroxyprogesterone. OCs also have the benefit of treating hirsutism and acne.
A 21 year old comes to your clinic distressed as she is growing more dark hair on her face. You believe this to be hirsutism associated with her previously diagnosed PCOS. How would you manage this?
Advise weightloss if she is overweight
Discuss use of cosmetic rx
Start COCP, if 6/12 no improvement add anti-androgen spironolactone.
List some of the long-term consequences of PCOS
Increased risk of DM2 and gestational diabetes (OGTT pre-conception ideally/before 20 weeks, then again at 24-28wks), cardiovascular disease, endometrial cancer, OSA.
What is menorrhagia?
excessive menstrual bleeding which interferes with a womans quality of life. Refers to bleeding not related to pregnancy, and only that during reproductive years.
used to be >80ml/cycle but hard to measure and irrelevant to QOL impact
List the causes of heavy menstrual bleeding
PALM (structural) COEIN (non-structural) Polyps Adenomyosis Leiomyoma (fibroids) Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
What are the 2 main risk factors for heavy menstrual bleeding?
Extremes of reproductive age (at menarche and approaching menopause) and obesity; risk factors relating to specific cause e.g. Adenomyosis and previous C-section
Main features of HMB
Menstrual bleeding deemed excessive by the woman, fatigue, SOB (if anaemic)
What should you establish in woman p/c HMB HPC
Cycle duration, frequency, date LMP? flooding/clots, how many menstrual products are you using per day? When was last smear? PMH (inc pregnancy)? PSH? DHx (including contraceptions, anything taken to stop bleeding)?
List potential findings seen by clinical examination of a woman with HMB
General - sx anaemia e.g. pallor, SOB, palpitations
bimanual examination - enlarged uterus (irregular - ?fibroids), tender uterus or CMT (adenomyosis/endometriosis)
Speculum - cervical inflammation, polyp or tumour, vaginal tumour.
How would you investigate a woman with HMB?
Urine pregnancy test!
Dictated by ddx
Bloods - FBC (anaemia), TFT (?hypothyroid), other hormones (not routine but could consider if ?PCOS etc), coagulation screen and vWD testing (features hx suggestive)
? infection - cervical smear if not up to date, high vaginal and endocervical swabs
Imaging - TVUS - inconclusive/+ = hysteroscopy and endometrial bx
A 37 year old woman presents to clinic with heavy periods during which she experiences flooding. She reports no pain, no changes in her discharge or itching, her smear is up to date and normal, and her LMP was 2 weeks ago. She is G4P4. O/E bimanual examination is unremarkable but on speculum a fleshy pink protuberance can be seen at the 2 o’clock position.
What is her likely diagnosis? How would you investigate and manage this?
HMB 2ndary to cervical polyp
Ix - pregnancy test to rule out, polypectomy and histological examination, FBC to check for anaemia.
a 43 year old woman presents to clinic with HMB that is reducing her QOL as they are painful and she has experienced floods, passes clots and has to change her sanitary products regularly. She is G2P1, LMP 3 weeks ago (cycle getting longer, now ~33 days; period lasts 5 days), cervical smear is up to date. O/E she has a boggy enlarged uterus which is tender to the touch.
What is the likely diagnosis? How would you investigate and treat this lady?
Adenomyosis - dysmenorrhoea and HMB, O/E tender boggy enlarged uterus, a woman approaching menopause
Ix - FBC (check for subsequent anaemia), TVUS.
Mx - medications to reduce bleeding e.g. tranexamic acid, hormonal contraception (IUS), GnRH agonist to shrink lining, hysterectomy
what is the most common cause of HMB?
abnormal uterine bleeding - idiopathic, with no apparent structural/infective/endocrine/haematological pathology.
How would you manage HMB?
Depends on wishes for fertility
- Medical = LNG-IUS (mirena licensed for 5yrs rx, also acts as contraceptive, thins endometrium and can shrink fibroids), COCP, Progesterone only (oral NET taken day 5-26 is not a contraceptive, depot or implant are long acting contraceptives). If preserving fertility can offer tranexamic/mefanemic acid (mef = NSAID analgesic)
- surgery (neither suitable if planning family) = endometrial ablation (risk ectopics, still use contraception), hysterectomy (only definitive rx)
How would you investigate and manage HMB associated with fibroids?
Ix - TVUS
Mx - 1st line LNG-IUS (alt COCP, tranexamic acid). GnRh agonists can be used for short term rx to reduce size. Surgery - endometrial ablation, hysterectomy, myomectomy and uterine artery embolisation.
A 34 year old woman comes to discuss her treatment options for HMB due to uterine fibroids. A large fibroid was discovered on TVUS after investigations into subfertility. She is very concerned that there will be nothing she can do as she still wishes to add to her family. What treatment would be suitable for her?
Only effective treatment for large fibroids causing subfertility is myomectomy.
LNG-IUS and tranexamic acid etc would help HMB but not fertility, medical rx also less likely to work in large fibroids.
GnRH agonists may reduce size of fibroids but if planning to get pregnant soon would not be suitable as will suppress fertility.
Hysterectomy and endometrial ablation are not suitable for women who wish to get pregnant in future
Fibroids are more likely to cause subfertility if submucosal or >6cm intramural.
What is a uterine fibroid? How are they classified?
Leiomyoma, benign smooth muscle tumour. Most common benign tumour in women.
Subserosal - protrudes into and distorts the outside surface of the uterus, can be pedunculate.
Submucosal - develops immediately underneath endometrium protruding into cavity.
Intramural - most common, confined to myometrium
Risk factors for developing fibroids
Obesity, age, early menarche, family hx (1st degree relative), African-American
How do uterine fibroids usually present?
Usually asymptomatic, incidental finding.
Can present with HMB, pressure sx (e.g. urinary frequency or retention) ± abdominal distension, subfertility. Rarely acute pelvic pain - may occur in Pregnancy with red degeneration of fibroid.
What medications can be used to shrink uterine fibroids pre-operatively?
GnRH analogue - Zolidex - use for 6months max risk osteoporosis, induces temporary menopausal state, reduces fibroid size and lowers risk complications
Selective progesterone receptor modulators - Ulipristal - reduces size of fibroid and menorrhagia, can be used pre-op or as an alternative to surgery.
A 19 year old woman asks to be fitted with a levonorgestrel IUS as she has heard it stops periods. Is this correct? what is its effect on periods?
Levonorgestrel IUS reduces bleeding, with 30% women amenorrhoeic after 12 months of use. However a side effect to note is that it can make your bleeding irregular for the first 4-6/12 of use.
Define the menopause
The end of female reproductive life, a physiological process which begins as peri menopause around the age of 45 and progresses until final menarche and end of fertility (UK average 51). It is diagnosed after 12 months of amenorrhoea
Describe the characteristic hormone changes seen in menopause
Decreasing oestrogen -> anovulatory cycles and raised FSH and LH (esp FSH)
List symptoms of the menopause and peri-menopause.
Vasomotor - hot flushes (peripheral vasodilation and transient rise in temperature, usually start on face and spread to neck and chest), night sweats.
Urogenital - vaginal atrophy and dryness -> dyspareunia, urinary incontinence and UTIs (urethra and bladder share embryological origin with vagina and uterus so also atrophy)
Irregular PV bleeds - menstrual cycles change length, and oestrogen breakthrough bleeding as a result of anovulatory cycles (IMB).
Difficulty sleeping, loss of libido, problems with mood/concentration/memory, headaches.
Why does the risk of osteoporosis increase post-menopause?
Oestrogen supports bone density and mass, as it reduces osteoclast activity. Reduced oestrogen -> unsuppressed osteoclast activity.
How should contraception be managed in women who are menopausal/perimenopausal?
Still continue with contraception until 12 months of amenorrhoea if >50, 24 months of amenorrhoea if <50.
List contraindications for HRT
Current/past breast cancer
Oestrogen-sensitive cancer
Undiagnosed PV bleed
Untreated endometrial hyperplasia
Previous idiopathic/current VTE unless already on anti-coagulant
untreated htn
active/recent thromboembolic disease e.g. MI
A 54 year old lady visits the GP to discuss starting HRT as she is troubled by intense hot-flushes and night sweats. Gynae hx - LMP 14/12 ago, G3P3, smear up to date, no sig PMH/DHx/PSH.
What HRT regimen would you recommend
Continuous Combined
Assume this lady has a uterus (no significant PSH indicates no hysterectomy) - so oestrogen and progesterone regimen needed.
>50 and amenorrhoeic for >12months so continuous combined HRT. Can discuss with her the route/formulation she prefers.
A 49 year old lady visits the GP to discuss starting HRT. Her LMP was 18 months ago, she has no sig PMH/PSH/DHx.
What HRT would you advise?
Continuous combined + contraception
No sig PSH/PMH - assume she has a uterus so combined regimen
>12 months amenorrhoea = continuous combined regimen.
Under 50 and <24m amenorrhoea = advise on need for continued contraception use - could use a LNG-IUS for both contraception and HRT, otherwise use non-hormonal contraception.
A 51 year old lady visits the GP to discuss starting HRT. Her LMP was 10 months ago, she has no sig PMH/PSH/DHx
What HRT would you advise?
Combined Cyclical (aka sequential) + contraception
Assumed no hysterectomy = need combined regimen
Perimenopausal lady - <12months amenorrhoea so need daily oestrogen with cyclical progestogens to allow for withdrawal bleeds that are regular and minimise risk enndometrial ca.
Cyclical progestogens include norethisterone or utrogestan
Contraceptives - use progesterone-only implant/injection/pill or non-hormonal contraception.
A 55 year old lady visits the GP to discuss starting HRT. Her LMP was 23 months ago. PSH - total abdo hysterectomy 1yr ago.
What HRT would you advise?
oestrogen only HRT, usually taken continuously
What are the benefits of HRT?
Reduce vasomotor symptoms of menopause (hot flush night sweats), mood swings, vaginal dryness and loss of libido.
Reduce risk osteoporosis
What are the side effects of HRT? How would you counsel a patient on them?
Advise that they are usually worst in first month or two,, settle by 3 months, and that there are many alternative routes or types of each hormone to try.
Oestrogen - nausea, bloating, breast tenderness, fluid retention, headaches, leg cramps, dyspepsia
Progestogen - acne, depression, mood swings, PV bleeding, also migraine/headache/breat tenderness/fluid retention.
A 56 year old patient c/o hot flushes which are severe and interfering with her work. She is reluctant to try HRT due to the side effect profile, and her being relatively well otherwise. What could you offer instead?
fluoxetin/citalopram/venlafaxine for vasomotor sx
How does premature ovarian failure differ to premature menopause?
POF tends to be seen in women <40, premature menopause <45
POF - still might have periods though they are irregular, may still be ovulating and it is still possible to fall pregnant though less likely than in someone without POF. Premature menopause is amenorrhoea for 12 months and anovulation, they are no longer fertile.
A 19 year old woman attends the EPAU having recently taken a home pregnancy test which was positive. She does not wish to continue the pregnancy (7+3/40) and attends for a TOP. Which method of TOP is she likely to have?
Medical TOP usually offered if between 6 and 9 weeks.
What does a medical TOP involve?
PO mifepristone (an anti-progestogen), 48h later given sublingual/buccal/PV misoprostol (prostaglandin)
What forms of surgical TOP are available and for which gestation is each more commonly used?
Surgical dilatation and suction of uterine contents - up to 14wks gestation
Surgical dilatation and evacuation of uterine contents - after 14 weeks gestation
What complications of TOP should you advise a patient of?
failure of TOP retained products of conception infection bleeding cervical trauma uterine perforation/rupture
Describe some of the after care a TOP patient should receive
After abortion may have abdominal cramps and some PV bleeding which should self-resolve in 1-2 weeks
Fertility returns immediately so should discuss contraception
Pregnancy test in 3wks still positive = return ?RPOC
Anti-D should be admitted to a Rh- woman having a surgical TOP >12/40.
Define miscarriage
Expulsion of products of conception before 24 weeks gestation
How does a threatened miscarriage present?
Painless PV bleed, cervical os closed. Typically small amount of blood 6-9 weeks.
How does a missed miscarriage present?
foetus dies but remains in utero. May be asymptomatic or only disappearance of sx of pregnancy, or PV bleed, pain. Cervical os closed. Confirmed by TVUS CRL>7mm without heartbeat.
How is an anembryonic pregnancy diagnosed?
US shows gestational sac >25mm without an embryonic or foetal pole
How does an inevitable miscarriage present?
heavy PV bleeding, clots, pain, cervical os open
How does incomplete miscarriage present?
PV bleeding, pain, not all products of conception have been expelled some still in the canal, cervical os open.
Risk factors for miscarriage
Maternal age (>30-35), previous miscarriage, obesity, smoking, uterine abnormality/surgery, parental chromosomal abnormality, antiphospholipid syndrome, coagulopathies
Differential diagnosis in woman with pain, PV bleed and a positive pregnancy test?
Miscarriage, ectopic pregnancy, cervical/uterine malignancy
How would you manage a woman with suspected miscarriage?
Refer to Early Pregnancy Assessment Unit
TVUS - for definitive dx
Bloods - FBC, blood group and Rhesus status, triple swabs and CRP if pyrexial, b-hCG for serial measurements if ?ectopic
A woman presents to EPAU at 8/40 with heavy PV bleeding and pain, on speculum examination cervical os is open.
What is the diagnosis and how should this be managed?
Inevitable miscarriage
<12 weeks so no need for anti-D
Expectant, medical or manual vacuum aspiration (<12)
A woman presents to EPAU at 13/40 with heavy PV bleeding and pain, on speculum examination cervical os is open and products of conception can be seen in the cervical canal.
What is the diagnosis and how should this be managed?
Incomplete miscarriage
> 12wks so if Rh- administer anti-D
Expectant, medical or surgical mx (prev ERPC)
A woman presents to EPAU at 6/40 having passed a ‘teaspoon-ish’ quantity of blood from her vagina, on speculum examination cervical os is closed. TVUS detects a foetal heartbeat.
What is the diagnosis and how should this be managed?
Threatened miscarriage
<12wks so no need for anti-D
Reassure, redirect back to GP/midwife, safety net sx such as heavier bleeding, clots, pain.
A woman presents to EPAU at 6/40 with painless PV bleeding, on speculum examination cervical os is closed. TVUS = CRL 6mm, no heartbeat.
What is the diagnosis and how should this be managed?
CRL <7mm so cannot accurately comment on heartbeat, re-scan in 1 week.
A woman presents to EPAU at 13/40 with painless PV bleeding, speculum = cervical os is closed. TVUS = CRL 12mm, no heartbeat. What is the diagnosis and how should this be managed?
Missed miscarriage
If Rh- administer anti-D as >12 weeks
Conservative/medical/surgical mx (>12)
What does medical management of miscarriage involve? What follow up would you offer?
vaginal misoprostol (+analgesia, anti-emetics)
stimulate cervical ripening and myometrial contractions
s/e - diarrhoea, vomiting, heavy bleeding and pain, chance it may not work and she requires surgery
pregnancy test in 3 weeks time
What does expectant management of miscarriage involve? What follow up is offered?
Waiting for miscarriage to complete naturally, without medical intervention.
>12weeks = offer anti-D to Rh- women.
follow up = scan in 2 weeks/pregnancy test in 3 weeks
How is a miscarriage managed surgically?
Anti-D to Rhesus- women
<12 weeks - manual vacuum aspiration under LA
>12 weeks - surgical management of miscarriage under GA (prevents ERCP)
