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Y4 Obs & Gyn > Gynae - conditions > Flashcards

Gynae - conditions Flashcards

1
Q

what is the normal frequency, duration, volume of a menstrual cycle?

A

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

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2
Q

what is dysmenorrhoea?

A

crampy lower abdominal pain, which starts at the onset of menstruation

  • primary: no underlying pelvic pathology
  • secondary: pain with associated
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3
Q

what causes the pain in the menstrual cycle? *physiology

A

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
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4
Q

what is the pathophysiology of dysmenorrhoea?

A

excessive release of prostaglandins (PGF2α and PGE2) by endometrial cells

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5
Q

what are some risk factors for dysmenorrhoea?

A
  • Early menarche
  • Long menstrual phase
  • Heavy periods
  • Smoking
  • Nuliparity
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6
Q

how might you investigate dysmenorrhoea?

A

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
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7
Q

what are some causes of secondary dysmenorrhoea?

A
  • Endometriosis
  • Adenomyosis
  • Fibroids
  • Pelvic inflammatory disease
  • Adhesions

Non-gynaecological differentials includeinflammatory bowel diseaseand irritable bowel syndrome

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8
Q

how is dysmenorrhoea managed?

A

lifestyle: stop smoking
meds: NSAIDs, hormonal COCP
other: hot water bottles, electrical nerve stimulation

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9
Q

what is the pathophysiology of menorrhagia?
*PALM-COEIN

A

structural

Polyp
Adenomyosis
Leimyosarcoma
Malignancy

non-structural

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not classified

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10
Q

what are some risk factors of menorrhagia?

A
  • age (menarche, approaching menopause)
  • obesity
  • previous caesarean as RF for adenomyosis
    • lining of uterus grows in to muscle layer
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11
Q

how might menorrhagia present?

A
  • bleeding deemed excessive
  • fatigue
  • SOB (Anaemia)
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12
Q

what might the examination for menorrhagia show?

A

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
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13
Q

what are some differentials for menorrhagia?

A
  • 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
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14
Q

how is menorrhagia investigated?

A

pregnancy test
FBC
TFT
other hormones
coagulation screen + Von Willebrand
imaging USS pelvis
histology - high vaginal endocervical swab
biopsy microbiology

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15
Q

how is menorrhagia managed?

A

hormonal pharm: levonorgestrel IUS, COCP, depo
non-hormonal: tranexemic acid, mefanamic acid
surgical: endometrial ablation, hysterectomy

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16
Q

what are the mechanism of action of the non hormonal methods of management of menorrhagia?

A
  • 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
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17
Q

what is amenorrhoea?

A

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
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18
Q

what is oligomenorrhoea?

A

irregular periods with intervals between menstrual cycles more than 35 days or less than 9 periods per year

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19
Q

what are some causes of amenorrhoea?

A

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

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20
Q

what are some causes of oligomenorrhoea?

A
  • PCOS
  • Contraceptive/Hormonal treatments
  • Perimenopause
  • Thyroid disease/Diabetes
  • Eating disorders/excessive exercise
  • Medications e.g. anti-psychotics, anti-epileptics
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21
Q

what are some investigations carried out for oligomenorrhoea and amenorrhoea?

A
  • detailed hx
  • pregnancy test
  • bloods: TFT, prolactin, FSH, LH, hormones
  • karyotyping
  • USS
  • progesterone challenge test
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22
Q

how is amenorrhoea managed?

A

*MDT
- COCP, POP, IUS
- HRT
- Sx control acne tx etc
- lifestyle if ED
- treat underlying cause
- clomifene to improve fertility
- surgery

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23
Q

how would you define infertility?

A

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

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24
Q

what are some general causes of infertility?

A
  • Male infertility (30%)
  • Ovulatory disorders (25%)
  • Tubal damage (20%)
  • Uterine or peritoneal disorders (10%)
  • No identifiable cause (25%)
25
Q

what are some causes of female infertility?

A

disorders of ovulation inc. PCOS
tubal causes - PID
uterine + peritoneal causes like endometriosis
idiopathic

26
Q

how is female infertility investigated in primary care?

A

*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
27
Q

when do you refer a woman to secondary care for infertility?

A
  • 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
28
Q

how is female infertility investigated in secondary care?

A

*tubal patency testing
- hysterosalpingography - screens for tubal occlusion
- if known comorbidities Diagnostic laparoscopy and dye

29
Q

how is female infertility managed?

A
  • lifestyle for weight, stress
  • medical: clomifene, gonadotropins, dopamine agonists
  • surgical: tubal microsurgery, laparoscopies
30
Q

what are some causes of male infertility?

A
  • primary spermatogenic failure
  • genetics with kleinfelters, androgen insensitivity
  • obstructive azoospermia with b/L seminal duct obstruction
  • varicocele
  • hypogonadism
  • chemo etc
31
Q

how is Male infertility investigated in primary care?

A
  • 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
32
Q

when would you refer male infertility to secondary care?

A

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

33
Q

how is male infertility investigated in secondary care?

A
  • Genetic testing
  • Sperm culture
  • Endocrine tests e.g. FSH and testosterone
  • Imaging of the urogenital tract
  • Testicular biopsy
34
Q

how is male infertile managed?

A

lifestyle: weight, stress, smoking and alcohol

medical: gonadotropins if hypogonadism

surgical: obstructive causes

35
Q

how is infertility in general managed?

A
  • clomifene
  • tubal microsurgery
  • IVF
  • counselling before, during and after fertility testing
36
Q

what advice might you give to a couple trying to conceive?

A
  • 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
37
Q

what is dyspareunia ?

A

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
38
Q

what might be the pathophysiology of female dyspareunia?

A
  • lack of lubrication in post-menopausal
  • oral contraception with oestrogen, progestin
  • endometriosis
  • alterations to vaginal anatomy
  • skin diseases
39
Q

what might be male specific pathophysiology of dyspareunia?

A

Peyronie disease
- scar tissue on tunica albuginea
- pathological curvature of penis

40
Q

what are common causes for dyspareunia for male and females?

A

genitourinary infections (e.g.,urethra,prostate,seminal vesicles, orbladder)

sexually transmitted infections(e.g.,gonorrhoea,chlamydia)

psychological factors

41
Q

how might dyspareunia present?

A
  • 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
42
Q

how might you examine dyspareunia?

A
  • 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
43
Q

how might you investigate dyspareunia?

A
  • vaginal pH, microscopy
  • testing for STD
  • transvaginal USS - evaluate endometriosis
  • tissue biopsy if malignancy suspected
44
Q

how might you manage dyspareunia?

A
  • treat causes
  • water-based lubricants
  • oestrogen creams, tablets, rings for menopause
  • oral contraceptives
  • surgical or anatomical changes
  • abx for infection
  • sexual therapy and CBT
45
Q

what surgeries are done for incontinence?

A
  • The tension free vaginal tape (TVT) sling involves placing a tape of mesh underneath the urethra
  • burch colposuspension
  • laparoscopic colposuspension
46
Q

what anatomical features are important in the pelvic floor?

A
  • 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
47
Q

what risk factors are considered in those with prolapse?

A
  • 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
48
Q

what are some types of prolapses?

A

dislocation of urethra
cystocele or cystourethrocele
rectocele
uterine prolapse
enterocoele
perineal body prolapse

49
Q

what is a cystocoele?

A

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

50
Q

what is a rectocele?

A

prolapse of the posterior vaginal wall due to weakness or divarication of the levatores ani, the rectum bulges into the vagina

51
Q

what is a uterine prolapse?

A

*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
52
Q

what is an enterocoele?

A

pouch of Douglas hernia prolapse of the upper part of the posterior vaginal wall
*Contains the peritoneum and usually a loop of bowel

53
Q

what is a perineal body prolapse?

A

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

54
Q

what is dislocation of urethra?

A

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

55
Q

how might a prolapse present?

A
  • sensation of pressure, heaviness, ‘bearing-down’
  • urinary symptoms: incontinence, frequency, urgency
56
Q

how is prolapse managed?

A
  • physio: effective in young women
  • pessary tx: temporary
  • surgery
  • cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • uterine prolapse: hysterectomy, sacrohysteropexy
  • rectocele: posterior colporrhaphy
57
Q

what are the indications for a pessary tx?

A
  • 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
58
Q

what are some disadvantages for pessary?

A
  • 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
59
Q

when might surgery be offered in prolapse?

A

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

Y4 Obs & Gyn (16 decks)

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