Gynae conditions Flashcards
What are uterine polyps ?
benigns growths attached to the inner wall of the uterus that extends in to the uterine cavity
What age are uterine polyps more common?
perimenopause and post-menopause
Risk factors for uterine polyps?
hypertension obesity tamoxifen hrt hx of cervical polyps
symptoms of uterine polyps
irregular bleeding bleeding between periods heavy periods bleeding after menopause can be asymptomatic
treatment of uterine polyps
GA surgery - curettage with or without hysteroscopy
Can uterine polyps be cancerous
Yes some can be precancerous
what are cervical polyps?
benign growth on surface of cervical canal
who are cervical polyps most common in?
post menarche and pre-menopausal women
symptoms of cervical polyps
abnormal bleeding
-heavy
-post menopause bleeding
bleeding after sex
can cervical polyps be asymptomatic
yes
investigations needed for uterine polyps
Vaginal US
Hysteroscopy
investigations needed for cervical polyps
can be seen as red/purple projections from the cervical canal in pelvic examination
treatment for cervical polyps
removed using forceps
are cervical polyps likely to re-grow
no
what is endometritis?
inflammation of the lining of the uterus - usually caused by infection. Can be pregnancy related or non-obstetric
Who is most likely to get endometritis?
post-partum women, 1-3% of births.
10 x more common if have caesarean
what causes endometritis?
Thought to be a lower gential tract infection that has spread up to infect the endometrium.
risk factors for endometritis (post-partum)
c-section prolonged labour, rupture of membranes intrapartum chorioamnionitis obesity DM HX of pelvic infection
Symptoms of endometritis (post-partum)
fever foul, profuse, blood discharge abdo pain abnormal bleeding dyspareunia dysuria
signs of endometritis (post-partum)
tender, bulky uterus on abdo exam
raised temp
tachycardia
investigations for endometritis (post partum)
Blood cultures
Midstream urine
high vaginal swab
treatment of endometritis (post partum)
antibiotics (IV) - go to hospital
What is cervical ectropion?
a condition where the central (endocervical) columnar epilethelium protrudes out through the external os of the cervix and onto the vaginal portion of the cervix and undergoes transformation
What is the transformation seen in cervical ectropion
Columnar epithelium from the endocervix becomes stratified squamous epithelium
symptoms of cervical ectropion
usually asymptomatic
can cause discharge, bleeding
pain before/after sex
investigations for cervical ectropion
cervical smear
treatment of cervical ectropion
usually self-limiting
cauterising is main treatment
what is atrophic vaginitis?
inflammation of the vagina due to the thinning and shrinking the tissues as well
Cause of atrophic vaginitis?
lack of oestrogen after the menopause. oestrogen normally keeps the tissues supple and moist and thickens the lining of the vagina. less oestrogen = thinning of tissues.
symptoms of atrophic vaginitis
bleeding
painful sex
vaginal discharge
how is atrophic vaginitis diagnosed?
clinical diagnosis
treatment for atrophic vaginitis
Cream or pessary containing oestrogen
what are vaginal ulcers?
a discontinuity of the skin or mucous membranes - the membrane is lost and the underlying tissue is exposed
who is most affected by
vaginal ulcers?
Younger women due to STI nature
Causes of vaginal ulcers?
Herpes
Syphilis
Bacterial/fungal infections
symptoms of vaginal ulcers?
Open ulcers or cuts pain +/- burning sensation abnormal discharge itching dry vagina dyspareunia dysuria Bleeding
Treatment of vaginal ulcers
STIs are most common cause so treat them!
what is vaginal cancer?
squamous cell carcinoma involving the posterior wall of the upper third of the vagina
How common is vaginal cancer?
RARE - 1% of gynae cancers
symptoms of vaginal cancer
bleeding
may have Gi/urinary symptoms if invaded rectum/bladder
how is vagina cancer diagnosed?
Colposcopy
biopsy, cervical cytology, endometrial biopsy
Is vaginal cancer treated with chemotherapy?
NO
Treatment of vaginal cancer?
depends on stage.
surgery and radiotherapy are very effective in early stages
what is endometriosis
The presence of tissue resembling endometrial glands and stroma outside the uterine cavity which induces chronic inflammatory reaction
Where does endometriosis commonly occur?
ovary, rectrovaginal pouch, uterosacral ligaments, o the pelvic peritoneum
How does endometriosis cause the pain?
The deposits of tissue is oestrogen-dependent and responds to hormonal changes in the menstural cycle
How common is endometriosis?
Common - most commonly diagnosed in women aged 30-40, prevalence: 10% of all women
Does endometriosis affect fertilty?
Yes it can but not necessarily so. As the extent of endometriosis becomes greater the scar tissue increases which can decrease natural fertility
risk factors for endometriosis
early menarche/late menopause
short menstrual cycles/long duration of menstrual flow
genetic - first degree relatives
obstruction to vaginal outflow
what are protective factors for endometriosis
Multiparity and use of oral contraceptives
symptoms of endometriosis
can be asymptomatic dysmenorrhoea dyspareunia cyclical or chronic pelvic pain subfertility heavy + frequent periods
What are the symptoms of extra-pelvic endometriosis?
pain or bleeding at the time of mensturation at the site of the pathology: eg haematuria, haemothorax
What condition can endometriosis present similar to?
Irritable bowel syndrome
What is the gold standard investigation for endometriosis?
Laparoscopy with histological confirmation
What investigations are currently carried out for endometriosis?
trans-vaginal USS
Treatment for endometriosis
don’t treat if asymptomatic
give analgesia/NSAIDS 1st line
Combined pill can help
Surgery
what is the menopause?
the cessation of the menses for >12 months due to los of ovarian activity
causes of menopause
natural physiology of age leading to reduced oestrogen levels
symptoms of the menopause
menstural irregularity followed by cessation
vasomotor disturbance: sweats, palpitations, hot flushes
vaginal dryness
dyspareunia (painful+difficult)
signs of menopause
anovulatory cycles
reducing oestrogen levels
rising FSH levels
investigations for menopause
may not be necessary unless worried
what level does FSH need to be at for menopause to be diagnosed?
> 30 IU/L
What has HRT been associated with?
breast cancers, endometrial cancer
what other hormone is HRT given with
Progesterone, as unopposed oestrogen can be carcinogenic and cause endometrial hyperplasia.
what non-medical treatment can be offered to women after the menopause?
counselling for pyschosocial and physical symptoms
what is Pelvic inflammatory disease (PID)
infection of the upper female genital tract, including the uterus, fallopian tubes, and ovaries
What is the most common factor of PID
sexual factors
What is the causative organism of chlamydia?
Chlamydia trachomatis
What is the causative organism of gonorrhoea?
neisseria gonorrhoeae
What are the risk factors for PID?
The risk factors for STIs
Termination of pregnancy
intrauterine contraceptive device inserted in the previous 20 days
What are the symptoms of PID?
Bilateral lower abdo pain
Deep dyspareunia
abnormal vaginal bleeding
purulent vaginal or cervical discharge
what are the signs of PID?
lower abdo tenderness cervical discharge cervical motion tenderness fever >38 (can be apyrexial) urinary symptoms
Define adnexa?
The appendages of the uterus, namely the ovaries, fallopian tubes and ligaments that hold the uterus in place
What are the risk factors for STIs?
Young, new sexual partner, multiple sexual partners, lack of barrier contraception, lower socio-economic group
Investigations for PID
Pregnancy test
Cervical swabs for STIs - positive result supports diagnosis, negative result does not exclude PID
Endocervical swabs
USS
General treatment for PID
analgesia
referral to GUM for contact tracing
treat all partners for chlamydia
empirical treatment for chlamydial infection + gonorrhoea if unwilling to get screened
complications of PID
ectopic pregnancy
infertility
pelvic pain
treatment for mild-mod disease
ceftriaxone 500mg as a single IM dose + doxycycline 100mg PO BD, metronidazole 400mg BD for 14 days
what investigation is necessary if patients fail to respond to antibiotic therapy
Laparoscopy to confirm diagnosis or to make an alternative diagnosis
what complications is PID associated with in pregnancy
preterm delivery
foetal morbidity
how can PID be prevented
barrier contraception
regular chlamydia/STI testing
what is premenstrual syndrome (PMS)?
name given to physical, psychological and behavioural symptoms that occur in the 2 weeks before a woman’s monthly period.
cause of PMS
fluctuating hormones during the menstrual cycle
risk factors for PMS
lack of exercise
being overweight
stress
poor diet
physical symptoms of PMS
bloating
breast pain
insomnia
psychological symptoms of PNS
mood swings
feeling irritable/depressed
loos of interest in sex
poor concentration
signs
acne flare ups
headache
joint/muscle pain
investigations for PMS
not required
might be useful to keep a symptom diary
treatment for mild/mod PNS
lifestyle changes improve diet exercise learn stress relief techniques regular sleep NSAIDs if in pain
Treatment for severe PNS
psychological therapy
hormone meds eg the pill
antidepressants - SSRIs
diuretics if bloating is bad
what needs to be present in order for PMS to be diagnosed?
there needs to be symptom free intervals between a girls periods
what is polycystic ovarian syndrome (PCOS)?
complex endocrine disorder which includes hirsutism and acne
what are the symptoms of PCOS caused by
excessive androgens
complications of PCOS
infertility due to anovulation
impaired glucose tolerance and DM type 2
how many of the 3 criteria need to be filled to make a diagnosis of PCOS
2
what are the 3 criteria for the diagnosis of PCOS
- infrequent/no ovulation
- clinical/biochemical signs of hyperandrogenism or elevated levels of free testosterone
- polycystic ovaries on USS
if polycystic ovaries are found does this establish the diagnosis?
no -not one their own
which 3 hormones should be tested to help with the diagnosis of PCOS?
Total testosterone
sex hormone-binding globulin
free androgen index
what will the findings of the hormone tests for PCOS be?
total testosterone: normal/mod high
sex hormone-binding globulin: normal to low
Free androgen index: normal or elevated
Do polycystic ovaries have to be found to make a diagnosis of PCOS
No
what should be measured to rule out other causes of oligomenorrhoea and hyperprolactinaemia?
- LH and FSH
- Prolactin - maybe mildly elevated
- TSH
treatment for PCOS
lifestyle advice - weight loss
screening for DM
treatment to prevent endometrial hypoplasia
what do women with PCOS and infertility require
assessment for possible causes
weight loss advice if neccessary
may need referral to secondary care for fertility treatment
what test should women who are pregnant with PCOS be offered?
GTT before 20 weeks
spontaneous miscarriage
loss of pregnancy before 24 weeks of gestation. Ectopic pregnancy is not included.
causes of spontaneous miscarriage
often no known cause abnormal foetal development genetically balanced parental translocation incompetent cervix infections placental failure
risk factors for spontaneous miscarriage
age (most frequent in women >30 yrs, even more common >35ys) increased no of births smoking >14 per day doubles risk excess alcohol uncontrolled DM
presentation of spontaneous misscarriage
vaginal bleeding + pain that is worse than period pain is most common
what % of women with threatened miscarriage will miscarry?
approx 50% - increases if they have increasing bleeding
what should you look for in first trimester bleeding?
- is the patient shocked through blood loss?
- products of conception in the cervical canal?
- is the cervical os open?
- is the size of the uterus appropriate for dates?
what is the most important diagnosis to exclude in spontaneous misscarriage
ectopic pregnancy
investigations needed for spontaneous miscarriage
USS - transvaginal, 98% of miscarriages can be diagnosed this way
what is serum hCG
a hormone produced by the placenta after implantation - used in pregnancy tests. used to exclude ectopic in women with a complete miscarriage
treatment of spontaneous miscarriage
can treat conservatively - wait to see if resolve naturally for 7-14 days
what are the indications for surgical management of spontaneous miscarriage?
persistent excessive bleeding, haemodynamically unstable.
infected retained tissue
what is the surgical procedure for removal after miscarriage
manual vacuum aspiration
what is a threatened miscarriage?
mild symptoms of bleeding. usually little/no pain. cervical os is closed
what is an inevitable miscarriage
cervical os is open - usually presents with heavy bleeding, clots and pain.
pregnancy will not continue and go to incomplete/complete miscarriage
what is incomplete miscarriage
when the products of conception are partially expelled. these are often unrecognised missed misscarriages
what is a missed miscarriage?
the foetus is dead but retained.
uterus small for dates
how do missed miscarriages present?
uterus small for gestational date
hx of threatened miscarriage and persistent, dirty brown discharge.
early pregnancy symptoms decreased/gone
what are recurrent miscarriages
three or more in the first trimester
or 3 consecutive
or 1 in second trimester
what is a molar pregnancy?
over growth of the placenta (all or part) in trophobalstic disease
