Gynae - conditions Flashcards
what is the normal frequency, duration, volume of a menstrual cycle?
frequency - average 28 days
- <24 frequent, >38 infrequent
duration - average 5 days
- >8 prolonged, <4.5 short
volume - average 40ml over course
- >80ml heavy with ferritin and Hb affected, <5ml light
- clots and flooding
what is dysmenorrhoea?
crampy lower abdominal pain, which starts at the onset of menstruation
- primary: no underlying pelvic pathology
- secondary: pain with associated
what causes the pain in the menstrual cycle? *physiology
The endometrial cells are sensitive to this decline in progesterone, and respond withprostaglandinrelease causing,
- Spiral artery vasospasm–leading to ischaemic necrosis and shedding of the superficial layer of the endometrium
-Increased myometrial contractions
what is the pathophysiology of dysmenorrhoea?
excessive release of prostaglandins (PGF2α and PGE2) by endometrial cells
what are some risk factors for dysmenorrhoea?
- Early menarche
- Long menstrual phase
- Heavy periods
- Smoking
- Nuliparity
how might you investigate dysmenorrhoea?
Abdominal and pelvic examinations (including speculum examination of cervix) ->Uterine tendernessmay be present
- rule out underlying pathology
- STD risk then high vaginal swab and endocervical swab for underlying infection
- transvaginal USS if pelvic mass palpated
what are some causes of secondary dysmenorrhoea?
- Endometriosis
- Adenomyosis
- Fibroids
- Pelvic inflammatory disease
- Adhesions
Non-gynaecological differentials includeinflammatory bowel diseaseand irritable bowel syndrome
how is dysmenorrhoea managed?
lifestyle: stop smoking
meds: NSAIDs, hormonal COCP
other: hot water bottles, electrical nerve stimulation
what is the pathophysiology of menorrhagia?
*PALM-COEIN
structural
Polyp
Adenomyosis
Leimyosarcoma
Malignancy
non-structural
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not classified
what are some risk factors of menorrhagia?
- age (menarche, approaching menopause)
- obesity
- previous caesarean as RF for adenomyosis
- lining of uterus grows in to muscle layer
how might menorrhagia present?
- bleeding deemed excessive
- fatigue
- SOB (Anaemia)
what might the examination for menorrhagia show?
examination - general observation, abdominal palpation, speculum and bimanual examination
- Pallor (anaemia)
- Palpable uterus or pelvic mass
- Try to ascertain if the uterus is smooth or irregular (fibroids)
- A tender uterus or cervical excitation point toward adenomyosis/endometriosis
- Inflamed cervix/cervical polyp/cervical tumour
- Vaginal tumour
what are some differentials for menorrhagia?
- pregnancy: miscarriage, ectopic
- endometrial or cervical polyps: no dysmenorrhoea
- fibroids: pressure sx
- adenomyosis: bulky uterus
- malignancy or endometrial hyperplasia
- coagulopathy
- ovarian dysfunction: PCOS, hypothyroidism
- iatrogenic causes: hormones, copper IUD
- endometriosis
how is menorrhagia investigated?
pregnancy test
FBC
TFT
other hormones
coagulation screen + Von Willebrand
imaging USS pelvis
histology - high vaginal endocervical swab
biopsy microbiology
how is menorrhagia managed?
hormonal pharm: levonorgestrel IUS, COCP, depo
non-hormonal: tranexemic acid, mefanamic acid
surgical: endometrial ablation, hysterectomy
what are the mechanism of action of the non hormonal methods of management of menorrhagia?
- tranexamic acid: inhibits activation of plasminogen and stabilises clot preventing breakdown
- mefanamic acid: NSAID which prevents prostaglandin synthesis and causes vasoconstriction and has effect on increasing plt aggregation
what is amenorrhoea?
absence of menstrual periods
- primary: failure to commence menses in girls 16+ with secondary sexual characteristics or in those 14+ without secondary
- secondary: cessation of periods for more than 6m after menarche
what is oligomenorrhoea?
irregular periods with intervals between menstrual cycles more than 35 days or less than 9 periods per year
what are some causes of amenorrhoea?
hypothalamic: reduced GnRH, functional like ED, chronic conditions, Kallmann
pituitary: prolactinomas, cushings, sheehans
ovarian: PCOS, turner, prem ovarian failure
adrenal: hyperplasia
genital: imperforate hymen, ashermann
what are some causes of oligomenorrhoea?
- PCOS
- Contraceptive/Hormonal treatments
- Perimenopause
- Thyroid disease/Diabetes
- Eating disorders/excessive exercise
- Medications e.g. anti-psychotics, anti-epileptics
what are some investigations carried out for oligomenorrhoea and amenorrhoea?
- detailed hx
- pregnancy test
- bloods: TFT, prolactin, FSH, LH, hormones
- karyotyping
- USS
- progesterone challenge test
how is amenorrhoea managed?
*MDT
- COCP, POP, IUS
- HRT
- Sx control acne tx etc
- lifestyle if ED
- treat underlying cause
- clomifene to improve fertility
- surgery
how would you define infertility?
a disease of the reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sex (without contraception) between a man and a woman
what are some general causes of infertility?
- Male infertility (30%)
- Ovulatory disorders (25%)
- Tubal damage (20%)
- Uterine or peritoneal disorders (10%)
- No identifiable cause (25%)
what are some causes of female infertility?
disorders of ovulation inc. PCOS
tubal causes - PID
uterine + peritoneal causes like endometriosis
idiopathic
how is female infertility investigated in primary care?
*should be commenced after 1 year in couples who have not concieved, despite regular unprotected sexual intercourse (every 2-3 days)
- mid-luteal phase progesterone to assess ovulation
- chlamydia screening
- testing for susceptibility to rubella
- hormone levels
when do you refer a woman to secondary care for infertility?
- less than 36 the history, examination and investigations are normal in both partners and the couple have not conceived after 1 year
- earlier if previous surgery, PID, STI hx,, abnormal pelvic exam, cancer tx etc
how is female infertility investigated in secondary care?
*tubal patency testing
- hysterosalpingography - screens for tubal occlusion
- if known comorbidities Diagnostic laparoscopy and dye
how is female infertility managed?
- lifestyle for weight, stress
- medical: clomifene, gonadotropins, dopamine agonists
- surgical: tubal microsurgery, laparoscopies
what are some causes of male infertility?
- primary spermatogenic failure
- genetics with kleinfelters, androgen insensitivity
- obstructive azoospermia with b/L seminal duct obstruction
- varicocele
- hypogonadism
- chemo etc
how is Male infertility investigated in primary care?
- semen analysis first line
- if first analysis abnormal → repeat offered ideally 3m after initial test allowing for spermatazoa cycle to be completed
- Repeat testing may be required sooner than 3 months if a severe
- chlamydia screen
when would you refer male infertility to secondary care?
referral to secondary following 2 abnormal semen analysis
earlier if,
- Previous genital pathology
- Previous urogenital surgery
- Previous STI
- Varicocele
- Significant systemic illness
- Abnormal genital examination
- Known reason for infertility e.g. previous cancer treatment
how is male infertility investigated in secondary care?
- Genetic testing
- Sperm culture
- Endocrine tests e.g. FSH and testosterone
- Imaging of the urogenital tract
- Testicular biopsy
how is male infertile managed?
lifestyle: weight, stress, smoking and alcohol
medical: gonadotropins if hypogonadism
surgical: obstructive causes
how is infertility in general managed?
- clomifene
- tubal microsurgery
- IVF
- counselling before, during and after fertility testing
what advice might you give to a couple trying to conceive?
- Regular (every 2-3 days) sexual intercourse throughout the woman’s cycle
- Preparation for pregnancy e.g. taking preconceptual folic acid (400mcg daily)
- Smoking cessation advice to both men and women that smoke
- Avoidance of drinking alcohol excessively
- Women should aim for a BMI of 19-25 kg/m2
what is dyspareunia ?
recurrent or persistent pain within the genital or pelvic region associated with sexual intercourse
- experience pain just before, during, or after sexual intercourse, or other sexual activities
what might be the pathophysiology of female dyspareunia?
- lack of lubrication in post-menopausal
- oral contraception with oestrogen, progestin
- endometriosis
- alterations to vaginal anatomy
- skin diseases
what might be male specific pathophysiology of dyspareunia?
Peyronie disease
- scar tissue on tunica albuginea
- pathological curvature of penis
what are common causes for dyspareunia for male and females?
genitourinary infections (e.g.,urethra,prostate,seminal vesicles, orbladder)
sexually transmitted infections(e.g.,gonorrhoea,chlamydia)
psychological factors
how might dyspareunia present?
- females - pain at entrance to vagina, in abdomen or near cervix during penetration
- males - erection, irritation of skin on penis with rash formation
- sharp, or dull and throbbing pain
- burning pains, pelvic cramping, or muscle tightness orspasms
how might you examine dyspareunia?
- pelvic exams
- visual: labia for ulcers, fissures, labial hypertrophy, vaginal agenesis and imperforate hymen
- colposcope
- penis for curvature
- male for sphincter tone, prostate, rectal and genital areas with scrotum and testicular abnormalities
how might you investigate dyspareunia?
- vaginal pH, microscopy
- testing for STD
- transvaginal USS - evaluate endometriosis
- tissue biopsy if malignancy suspected
how might you manage dyspareunia?
- treat causes
- water-based lubricants
- oestrogen creams, tablets, rings for menopause
- oral contraceptives
- surgical or anatomical changes
- abx for infection
- sexual therapy and CBT
what surgeries are done for incontinence?
- The tension free vaginal tape (TVT) sling involves placing a tape of mesh underneath the urethra
- burch colposuspension
- laparoscopic colposuspension
what anatomical features are important in the pelvic floor?
- puborectalis for faecal incontinence by creating anorectal angle
- pre-rectal fibres form a U shaped sling around urethra and vagina -> stress incontinence
- uterus is supported by cardinal/transverse ligaments and the uterosacral ligaments
what risk factors are considered in those with prolapse?
- those who have had children
- not apparent until after menopause with atrophy and weakening supports of pelvic organs
- rare in those of African descent
- increasing age
- multiparity, vaginal deliveries
- obesity
- spina bifida
what are some types of prolapses?
dislocation of urethra
cystocele or cystourethrocele
rectocele
uterine prolapse
enterocoele
perineal body prolapse
what is a cystocoele?
hernia of the bladder trigone due to weakness of the vaginal and pubocervical fascia
bladder base descends and a bladder pouch is formed which may contain residual urine increasing the risk of UTIs
what is a rectocele?
prolapse of the posterior vaginal wall due to weakness or divarication of the levatores ani, the rectum bulges into the vagina
what is a uterine prolapse?
*descent of uterus and cervix
- first degree: descent of the uterus, but cervix remains in the upper vagina
- second: uterine descent when the cervix reaches down to the vulva on straining, but does not pass through it
- third: when the cervix and some of or the entire uterus are prolapsed outside the vaginal orifice
what is an enterocoele?
pouch of Douglas hernia prolapse of the upper part of the posterior vaginal wall
*Contains the peritoneum and usually a loop of bowel
what is a perineal body prolapse?
part of the anal canal may bulge into the vagina
It follows inadequately sutured tears after childbirth or by failure of healing in such tears
what is dislocation of urethra?
urethra is displaced downwards and backwards off the pubis; may also become dilated (urethrocoele)
This is caused by damage or weakness of the triangular ligament
how might a prolapse present?
- sensation of pressure, heaviness, ‘bearing-down’
- urinary symptoms: incontinence, frequency, urgency
how is prolapse managed?
- physio: effective in young women
- pessary tx: temporary
- surgery
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
what are the indications for a pessary tx?
- Prolapse during pregnancy
- Prolapse immediately after delivery
- When another pregnancy is desired within a short period of time
- Patients unfit for surgery on medical grounds
- Patients who decline an operation
what are some disadvantages for pessary?
- Ulceration of the vagina or cervix – reduced by changing the pessary every 6 months and regularly using oestrogen creams
- A neglected pessary may become embedded in the vaginal wall
- Carcinoma of the vagina may develop
when might surgery be offered in prolapse?
Should only be performed if there is no evidence of genuine stress incontinence, significant detrusor instability, or any urinary symptoms – if there is detrusor instability may make it worse and cause urinary retention
