Gynae FC from PPT Flashcards
which cell type produces oestrogen in the menstrual cycle
granulosa cells
which hormone surge acts to cause ovulation
LH
which hormone drops to cause the bleeding in the menstrual cycle and where is it produced
- drop in progesterone levels cause bleeding
- progesterone produced by the corpus luteum - corpus luteum degenerates, it stops producing progesterone, which is when the lining of the womb is shed
which medication can be used to postpone a period - when on holiday
noresthisterone - take 3 a day from 3 days before period is due and stop taking when bleeding acceptable
- or take 2 packets of COCP back to back
what is the definition of primary amenorrhoea
- failure to menstruate by the age of 16
- or failure to menstruate by the age of 14 in someone with no secondary sexual characteristics
what are 5 causes of primary amenorrhoea
- Turner’s syndrome
- GU malformation - imperforate hymen
- hypothalamic failure - exercise, stress, anorexia
- constituional delay
- Kallmann’s syndrome
- sarcoidosis
- hyperprolactinaemia
- gonadal dysgenisi
- Swyer syndrome
- late onset CAH
what is the definition of secondary amenorrhoea
- absence of periods for ≥ 6 months
- in someone who is not pregnant
what are 5 causes of secondary amenorrhoea
- marathon runenrs
- PCOS
- premature ovarian failure
- iatrogenic
- pregnancy
- Sheehan’s syndrome
- Asherman’s syndrome
- hyperthyroidism
what biochemical findings would be present in someone with premature ovarian failure
- hypergonadotrophism
- hypooestrogenism
- raised FSH
how would you investigate primary amenorrhoea
- karyotype
- USS
- full history
- bloods - oestrogen, progesterone, Lh, FSH, testosterone
how would you investigate secondary amenorrhoea
full history - rule out exercise
pregnancy test
TFT
FSH and LH
mid luteal progesterone
prolactin
free androgen
how would you treat primary amenorrhoea
- history incl family histiry
- examination
- treat cause - surgery, oestrogen, pituitary tumour = surgery/chemo
how is secondary amenorrhoea treated
- cyclic progesterone
- bromocriptine - treat hyperprolactinaemia
- GnRH replacement - if cause hypothalamic failure
- thyroid replacement
- treat underlying cause
what is the triad of PCOS
Rotterdam criteria (2/3 must be present)
- 12 cysts on the ovary OR an ovary >10ml
- signs of clinical (excess hair) or biochemcial (blood test) raised testosterone/hyperandrogenism
- oligo or amenorrhoea
how does PCOS normally present
- oligomenorrhoea
- hirsutism
- infertility
- associated with obesity, metabolic syndrome, T2DM, sleep apnoea
what investigations would you expect do for someone with PCOS
serum testosterone/free androgen
thyroid function
prolactin
sex hormone binding globulin
test for diabetes
USS
what are some long term complications of PCOS
gestational diabetes
T2DM
CVD
endometrial cancer
NO increased risk of ovarian or breast cancer
what are some differentials for PCOS
thyroid dysfunction
hyperprolactinaemia
CAH
androgen secreting tumours
Cushing’s syndrome
how is PCOS treated
weight loss
smoking cessation
find and treat - T2DM, HTN, dyslipidaemia and OSA
clomifene - induces ovulation
metformin
ovarian drilling - fertility
COCP w/ w/drawal bleeds
hair removal cream
define menorrhagia
heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle and interferes with QoL
no measurable quantity of blood
what is the name for menorrhagia with no identifiable underlying cause
dysfunctional uterine bleeding
what are some causes of menorrhagia
MC - fibroids
bleeding disorder - present at menarche
hypothyroidism
unknown
polyps
adenomyosis
endometriosis
cancer
what sort of questions do you need to ask in a history for menorrhagia
flooding
clots
interfere with life/work
pain
symptoms of anaemia
if its always been like this
what investigations for menorrhagia
FBC
physical VE
TSH
cervical smear
STI screen
TVUS
endometrial biopsy
hysteroscopy
how do you medically treat menorrhagia
reassure
mirena coil - 1st line
tranexamic acid - antifibrinolytic
NSAIDs - mefanamic acid
surgical options for menorrhagia treatment
endometrial ablation - ONLY IF COMPLETED FAMILY
uterine artery embolisation
hysterectomy - last resort
define dysmenorrhoea
painful periods
+/- N + V
what are some causes of primary and secondary dysmenorrhoea
primary - unknown, no underlying physical cause
secondary:
- endometriosis
- adenomyosis
- fibroids
- PID
- cancer
how should dysmenorrhoea be investigated
clinical assessment
USS
endometrial biopsy
laparoscopy
STI screen
how is primary dysmenorrhoea treated
NSAIDS - mefanemic acid given during menstruation
paracetamol
COCP
smooth muscle anti-spasmodics - hyoscine butylbromide
how is secondary dusmenorrhoea treated
NSAIDS - mefanemic acid
paracetamol
treat underlying cause - fibroids
mirena
what is the main diagnosis to rule out when someone presents with post coital bleeding and what are some other causes
cervical cancer **
other:
polyps, cervical trauma, cervicitis, vaginitis, chlamydia
what is the main diagnosis to rule out when someone presents with post-menopausal bleeding and what are some other causes
endometrial cancer until proven otherwise***
other:
vaginitis, foreign bodies, carcinoma of cervix or vulva, polyps, oestrogen w/drawal
clarify it isn’t rectal bleeding
what is the average age of onset of menopause
51
how is menopause diagnosed
retrospective diagnosis
after 12 months of amenorrhoea
what are the symptoms of the peri-menopause
irregular periods
vasomotor symptoms - hot flushes, night sweats, impact on sleep and mood
mood swings
decreased sexual desire
joint aches and muscle pains
vaginal dryness
headache and dry skin
loss of energy
before what age is menopause deemed premature
before the age of 40
what are the long term complications of the menopause
osteoporosis (oestrogen inhibits oesteoclasts, so when it drops they become hyperactive)
CVD
dementia
how is the menopause managed
lifestyle - reduce risk factors - smoking, heart disease, alcohol, diabetes
hormonal treatments - HRT, vaginal oestrogen
non-hormonal - clonidine, alpha receptor agonist
CBT
what are the benefits and risks of HRT
benefits:
- relief of symptoms
- bone mineral density protected
- possibly prevent long term morbidity
risks:
- breast ca
- VTE
- CVD
- stroke
how is the risk of endometrial cancer from HRT reduced
progesterone alongside oestrogen replacement
- stops oestrogen causing excessive proliferation of the endometrium by allowing shedding
- not necessary if - they have had hysterectomy or have mirena
which route of HRT hives the highest increased risk of DVT and how is it reduced
oral HRT
- reduced by giving transdermal patch instead
- transdermal always offered in people with BMI >30
how is the risk of CVD managed in someone with HRT
aim to manage and optimise RF before comencing on HRT - HTN, diabetes, cholesterol etc
- if someone has prev had a stroke or MI = NOT HAVE HRT AT ALL
what are the different preparation of HRT available
pessary
cream applied with applicator for local vaginal symptoms - bleeding, pain, UTI
patch
oral tablet
what are some indications for a transdermal HRT patch
patient choice
gastric upset - malabsorption like Crohn’s
increased risk of VTE
what are some common side effects of transdermal HRT patch
skin irritation
what is the difference between the hormone levels in HRT and OCP
COCP give supraphysiological dose of oestrogen
HRT only gives a physiological dose of oestrogen - body used to this
what is the definition of premature ovarian failure
when periods stop <40 years of age
what are the causes of premature ovarian failure
idiopathic
iatrogenic - chemo, radio, surgery
how does premature ovarian failure present
infertility
amenorrhoea
what are the diagnostic criteria for premature ovarian failure
age <40
FSH > 25 in 2 samples > 4 weeks apart
plus 4 months of amenorrhoea
how is premature ovarian failure treated
oestrogen replacement - HRT, COCP, encourage until 50
androgen replacement - testosterone gel
fertility - donor egg
define miscarriage
the loss of pregnancy before 24 weeks gestation
(after 24 = still birth)
what proportions of pregnancies miscarry
15-20%
usually in first trimester
what parental ages pose the highest risk of miscarriage
maternal age >35
paternal age >40
what are 5 risk factors that increase risk of miscarriage
- increased maternal age
- smoking in pregnancy
- alcohol and drugs
- high caffeine intake
- obesity
- infections and food poisoning
- medicines like ibuprofen
- health conditions - thyroid, severe HTN
- cervical incompetency
what factors are not associated with miscarriage but some people believe them to be
heavy lifting
bumping tummy
having sex
ait travel
being stressed
what are 5 common causes for one-off miscarriages
- unknown
- chromosomal abnormalities
- abnormal fetal development
- maternal illness
- infection
- trauma
- cervical weakness
- chronic maternal disease (SLE)
what is the definition of recurrent miscarriage
the loss of >3 consecutive pregnancies before 24 weeks with the same biological father
what are 3 causes of recurrent miscarriage
antiphospholipid syndrome
uterine abnormalities
thrombophilia - Factor V leiden, protein C or protein S deficiency
parental chromosomal abnormality - unbalanced Robertsonian translocation
infection - BV associated with 2nd trimester loss
what are the signs and symptoms of a threatened miscarriage
mild:
- mild abdo pain
- mild vaginal bleeding
CERVICAL OS IS CLOSED
what are the signs and symptoms of an inevitable miscarriage
severe abdo pain
vaginal bleeding
CERVICAL OS IS OPEN
can get a finger in the os
what are some other classifications of miscarriage
incomplete miscarriage - most of the products have already been passed but process still happening
missed miscarriage - fetus dies and remain in utero, os is closed, may be completeley asymptomatic - confirmed by USS
pregnancy of uncertain viability - small sac with no visible heart beat - rescan 10-14 days
complete - os closed, empty uterus
how is a miscarriage managed
A-E appraoch to bleeding
epectant management (conservative)
inevitable and incomplete miscarriage - misoprostol or surgical evac
what are the 3 main causes of PV bleeding in early pregnancy
ectopic pregnancy
miscarriage
molar pregnancy
what is the definition of an ectopic pregnancy
implantation of a fertilised ovum outside the uterine cavity
97% occur in fallopian tubes
what are 5 risk factors for ectopic pregnancies
1, damage to tubes - PID or surgery
2. previous ectopic
3. endometriosis
4. copper coil
5. IVF
6. smoking
7. past infection of tubes or appendicitis
what are some features of ectopic pregnancy
EXAM - LMP 8 weeks ago
vaginal bleeding
pain - generalised abdo or confined to an iliac fossa
shoulder tip pain from haemoperitoneum
how would you investigate someone with a suspected ectopic pregnancy
USS - intrauterine, fetal heart beat
serial HCG measurements
pelvic exam - cervical excitation/motion tenderness on speculum
how should an ectopic pregnancy be managed
A-E for bleeding
surgical - salpingectomy (only if one fallopian still viable) if not - salpingotomy
medical - methotrexate if BHCG is low
what are some clinical features of a molar pregnancy
vaginal bleeding
pain
uterus larger than it should be for dates
very very high BHCG
clinical hyperthyroidism
severe morning sickness
how is molar pregnancy managed
removal by suction
what is lichen sclerosus and how is it treated
not an STI
creates patchy white thin skin around vulval area
possibly autoimmune
observe if no response to treatment - can be pre-malignant
topical steroid cream or topical tacrolimus
kids - 50% resolve by menarche
what is the pre-malignant stage of cervical cancer that can be picked up in screening
cervical intra-epithelial neoplasia
pre-invasive
60% regress to normal w/in 2 years
many develop squamous carcinoma of cervix
what should be done in an abnormal smear
refer to colposcopy
if abnormal cytology or HPV +ve
when are women offered cervical screening
sexually active women agedd 25-64
every 3 years from 25-50
every 5 years from 50-64
what proportion of cervical abnormalities are picked up by screening
95%
what are some risk factors for CIN
HPV infection
multiple partners
smoking
immune compromisation
how is CIN managed
HPV vaccine
colposcopy - further asses abnormal smear
large loop excision of transformation zone
what is the cell type usually seen in cervical cancer
squamous cell carcinoma
whats staging tool is used to stage cervical cancer
FIGO stagiing - 1/2/3/4
what is stage 1 cervical cancer
confined to cervix
what is stage 2 cervical cancer
spread into top part of vagina
what is stage 3 cervical cancer
spread into other nearby organs such as the ureter
what is stage 4 cervical cancer
distant mets
what are some risk factors for cervical cancer
HPV infection
early stage intercourse (<16)
STIs
cigarette smoking - HPV persistence
previous CIN/abnormal smear
multiparity
history of other genital tract neoplasia
what are the harmful forms of HPV most associated with cervical cancer
HPV 16 and 18
which oncoproteins do these HPV subtypes contain and why does this cause cancer
contain E6 and E7 oncoproteins
- E6 - prevents p53 tumour suppressor gene working
-E7 attacks retinoblastoma tumour suppressor gene
leads to overstimulation of growth of the cells of the cervix
what are the symptoms of cervical cancer
often asymptomatic and caught with smear
POST COITAL BLEEDING
PMB
water vaginal discharge
advanced:
- heavy vaginal bleeding
ureteric obstruction
weight loss
bowel disturbance
vesico-vaginal fistula
pain
how do you investigate someone with suspected cervical cancer
history - last smear and result
physical exam - VE and speculum
punch biopsy for histology
CT abdo and pelvis - stage
MRI pelvis - identify and stage lymph nodes
how is cervical cancer treated
LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE
- knife cone biopsy +/- pelvic lymph nodes
- simple hysterectomy
- cervicetomy/tracelestomy
- radiacl hysterectomy and pelvic lymph nodes
- chemo/rafio if too large for surgery (impacts fertility)
which histological cell types is usually seen in endometrial cancer
adenocarcinoma
what are the different stages of endometrial cancer
staged with FIGO
stage 1 - confined to endometrium and uterus
stage 2 - grown into cervix
stage 3 - into ovaries, vagina and surroudning lymph nodes
stage 4 - distant spread
who is more at risk of endometrial cancer
post-menopausal women
what causes endometrial cancer
unopposed oestrogen
- obesity
- early menarche
- late menarche
- mulliparity
- PCOS
- lynch syndrome
- HRT
what are some risk factors for endometrial cancer
obesity - adipose tissue released oestrogen
post-menopause - loss of progesterone to unopposed oestrogebn
what are some protective factors against endometrial cancer
parity - high progesterone and low oestrogen
combined COCP
how does endometrial cancer present
post-menopausal bleeding
pre-menopausal - heavy/irregular periods, PV discharge, pyrometra
what investigations should be done for someone presenting with suspected endometrial cancer
transvaginal USS
endometrial biopsy
hysterectomy
MRI
how is endometrial cancer treated
surgery - total abdo hysterectomy +/- lymph nodes
radiotherapy - adjuvant
progesterone therapy
good prognosis - 5 year survival for stage 1 = 80%
what histological cell type would be seen in vulval cancer and what causes it
squamous cell
younger women - HPV
older women - lichen slerosus
how does vulval cancer present
vulval itching
vulval soreness
persistent lump
bleeding
pain on passing urine
past history of VIN or lichen slerosus
what cell type is mainly seen in ovarian cancer
epithelial cell tumours
other:
granulosa, cell (teratomas) or secondary - upper GI cancers
what are some causes of ovarian cancer
gene mutation - BRCA 1 and 2, HNPCC (lynch)
ovulation - more you do = higher risk (early menarche, late menopause, nullparity, never taken pill)
what are the main risk factors for ovarian cancer
nulliparity
early menarche and/or late menopause
family history - genes
what are some protective factors against ovarian cancer
pregnancy
breastfeeding
COCP
tubal ligation (prevents ovulation)
how does ovarian cancer present
bloating/IBS like symptoms
abdo pain/discomfort
change in bowel habit
urinary frequency - bladder pressure
bowel obstruction
asymptomatic until late
how do you investigate ovarian cancer
Ca125 levels
transabdo USS
whether they are pre or post menopause
combine USS, menopause status and Ca125 levels to determine malignancy index
what are the USS findings suggestive of ovarian malignancy
- bilateral
- multiocular
- ascites
- solid areas
- mets
one point scored for each
what score on the risk of malignancy index warrants a referral to gynae
250 or above
how is ovarian cancer treated
surgery
chemo
biologics
holistically
define endometriosis
presence of endometrial tissue outside the uterus
what ares some sites that endometriosis can occur and what symptoms can this cause
pouch of douglas - rectal bleeding during period
lungs or pharynx - coughing up blood during period
nose - nosebleeds during period
umbilicus
points of previous scarring - gets big and painful when on period (appendix scar)
endometrioma - bleeding into ovaries
?lacrimal glands, bloody tears?
what are the 3 theories of how endometriosis develops
- sampson’s - retrograde menstruation
- meyer’s - metaplasia of mesothelial cells
- Halban’s - via the blood or lymphatic system
what are the symptoms of endometriosis
PAIN
SUB-FERTILITY
heavy bleeding
bleeding from other places during pregnancy
what are the features of the pain in endometriosis
worse 2-3 days before period
gets better after period
cyclical pain
deep dyspareunia
dysuria
pain on defecation - pouch of Douglas involvement
improves when pregnant - low oestrogen
why does endometriosis cause sub-fertility
areas of endometriosis release cytokines and harmful chemicals which can damage areas of reproductive tract
damage can cause - reduced fallopian tube motility, scarring, bleeding, toxicity to oocyte, adhesions and ovarian dysfunction
what is the main differential for endometriosis
adenomyosis - areas of endometrial tissue are localised to myometrium
what is the gold standard diagnosis for endometriosis
laparoscopy
what are the 2 generic approaches to treatment for endometriosis
- abolish cyclicity
- invoke glandular atrophy
- in addition - pain releif - mefenamic acid, paracetamol
what are some treatment options for endometriosis that work by abolishing cyclicity
COCP - triphasing - young women who don’t want pregnancy
GnRH agonists - induced menopause, reversible, need HRT also
what are some endometriosis treatments which work by invoking glandular atrophy
use of progesterone
- POP - stops bleeding, can = PMS Sx
- Depot provera
- mirena
*don’t want pregnancy
how can endometriosis be treated in ladies who wish to get pregnant
ablation - burning away of endometriotic tissue
excision - cutting away of endometriotic tissue
what are some surgical options for endometriosis in a woman who has completed their family
oophorectomy - no ovaries => no oestrogen => no cycle => no endometriosis
hysterectomy
low dose HRT after to help menopause symptoms
what is adenomyosis and who is it most commonly seen in
excess endometrial tissue in the myometrium
older women who have had lots of children
what causes adenomyosis
unknown
how does adenomyosis present
cyclic pain - worse when period starts
can last for 2 weeks after period stops (longer pain with endometriosis)
dysmenorrhoea
dyspareunia
what is the gold standard diagnosis for adenomyosis
MRI scan
how is adenomyosis treated
often hysterectomy - completed family
what are fibroids
benign smooth muscle tumours of the uterus - uterine leiomyomas
very common (20% of reproductive age)
what causes fibroids
unknown
oestrogen dependent - shrink after menopause
associated with mutation in gene for fumarate hydratase
what are the risk factors for fibroids
increasing age (until menopause)
afro-carribean
family history
early puberty
obesity
how do fibroids present
menorrhagia
dysmenorrhoea
fertility problems
miscarriage
pain
mass
pressure symptoms - frequency, varicose veins
bloating/constipation - IBS Sx
may be incidentally found and asx
how are fibroids investigated
abdominal examination
bimanual pelvic examination
TVUS
Trans abdo USS
hysteroscopy
what would be felt on pelvic exam in someone with fibroids
bulky, NON-tender uterus
how are fibroids managed
<3cm - IUS, tranexamic acid, NSAIDs (mefenamic acid) or COCP
> 3cm - trans-cervical resection of fibroids, myomectomy, hysterectomy, uterine artery embolisation
what are endometrial polyps
benign growths of the endometrium
some can be cancerous or pre-cancerous
what are some risk factors for endometrial polyps
benign peri or post menopausal
HTN
obesity
taking tamoxifen (breast cancer chemo)
how do polyps present
irregular menstrual bleeding
menorrhagia
inter-menstrual bleeding
post-menopausal bleeding
infertility in younger Pts - compete with fetus for space
what is the main differential for polyps
fibroids
how are polyps investigated
USS - trans vaginal and abdo
hysteroscopy
endometrial biopsy
how are polyps treated
can be left alone - monitor and biopsy if malignancy concern
GnRH analogues (oestrogen sensitive)
polypectomy - hysteroscopically
hysterectomy
what are the main types of benign ovarian tumours
- functional cysts
- mucinous cystadenomas
- seroud cystadenomas
- dermoid cyst ‘mature cystic teratoma’
features of functional cysts, mucinous cystademonas, serous cystadenomas, dermoid cysts
- FC - enlarged persisten follicle, resolves after 2/3 cycles, may cause pain or peritonitis if bleed, COCP inhibits
- mucinous cystademonas - massive, unilateral, solid, common, 15% malignant, mucus ascites if rupture
- serous cystadenomas - MC epithelial tumour, bilateraly, 25% malignant
- dermoid cyst - contain skin/hair/teeth, MC cysts in <30 y/o, torsion most likely
how do benign ovarian tumours present
ASx - incidental findings
chronic pain - dull ache, dyspareunia, cyclical pain, pressure effects
acute pain - unilateral - if bleeding, torsion, or rupture
irregular vaginal bleeding
hormonal effects
abdo swelling or mass - ascites may = malignancy or rupture mucinous cystadenoma
how should benign ovarian tumours be investigated
FBC
Ca125 (if >40)
> 40 other tumour markers - AFP, CEA, HCG
TVUD, TAUS
consider MRI, mass >7
MRI and CT for staging malignancy
how should benign ovarian tumours be treated
A-E
pre-menopausal - preserve fertility and exclude malignancy. no malignancy = leave, if cyst >5cm or Sx - laparscopic ovarian cystectomy
post-menopausal - calculate risk of malignancy index, leave alone if <5cm, watch and wait, remove if >5cm or Sx - bilateral oophorectomy
what are some risk factors for ovarian torsion
pregnancy
malformations
tumours
previous surgery
how does ovarian torsion prevent
acute unilateral abdo pain (often during exercise)
radiates - back, thigh, pelvis
N + V
fever = necrotic
how do you investigate ovarian torison
rule out ectopic - pregnancy test
USS with colour doppler = GS
how is ovarian torsion managed
laparoscopy
plus analgesia and fluid resus
how does a ruptured ovarian cyst present
acute abdo pain (often during exercise)
PV bleed
N+V
circulatory collapse +/- weakness, syncope
fever/sepsis
how should a ruptured ovarian cyst be investigated
rule out ectopic - urinary HCG
USS
laparoscopy - GS
how should someone with a ruptured ovarian cyst be managed
A-E
stable - analgesia and supportive (fluid, painkiller)
unstable/bleeding - surgery - laparotomy may be needed
what is pelvic inflammatory disease
a chronic infection of the upper genital tract
what causes PID
STI - 25% chlamydia and gonorrhoea
uterine instrumentation - hysteroscopy, insertion of IUCD, TOP
post-partum (retained tissue)
descend from other organs - appendicitis
what are the risk factors for PID
age <25
history of STI
new and multiple sexual partners
what are some protective factors against PID
barrier contraception
Mirena
COCP
what are the symptoms of PID
lower abdo pain
may be unilateral or bi
may be constant or intermittent - but normally chronic
deep dyspareunia
vaginal discharge
IMB
PCB
dysmenorrhoea
fever
how would you investigate someone with suspected PID
history
exam - VE and speculum
Full STI screen - high and low vaginal swabs, endocervical swabs, urine sample
TVUS if abscess suspected
FBC, CRP, culture - acutely unwell
what are some signs you’d see on examination in someone with PID
cervical excitation (motion tenderness) on VE
vaginal discharge
adnexal tenderness
what are some complications of PID
tubo-ovarian abscess
Fitz-Hugh Curtis syndrome - liver capsule inflammation
recurrent PID
ectopic pregnancy
subfertility from tubal blockage
how is PID managed
contact tracing
ABx - ceftriaxone, dosycycline, metronidazole, azithromycin
very unwell - admit for ABx
what ASx screening is offered in GUM clinics
female - self take vulvo-vaginal swab (gonorrhoea and chlamydia) NAAT, bloods for HIV and STIs
hetero male - first void urine, bloods
MSM - first void urine (chlamydia and gonorrhoea), pharyngeal swab, rectal swabs, bloods - STI, HIV, Hep B
what tests are available at GUM for people with symptoms
vulvovaginal swab
high vaginal swab
urethral swabs for men
first void urine for men
dipstick urinalysis (pus cells)
bloods
rectal and pharyngeal swabs and cultures for MSM
what are some symptoms that female with STI problems will present with
vaginal discharge
vulval discomfort/soreness, itching and pain
superficial dyspareunia
chronic pelvic pain
vulval lumps and ulcers
IMP
PCB
what are some symptoms of STIs that males may present with
pain/burning during micturition
pain/discomfort in the urethra
urerthral discharge
genital ulcers, sores or blisters
syphillis - primary shankra
genital lumps
rash on penis/genital area
testicular pain/swelling - orchiditis
what is the importance of contact tracing
prevent re-infection of index patient
identify and treat asymptomatic infected individuals as a public health measure - prevent disease from spreading further
what is the definition of incontinence
involuntary leakage of urine at a time which is not socially acceptable
what proprotion of women experience urinary incontinece
20% of adult women
what are the different subtypes of incontinence
overactive bladder (detrusor overactivity) - involuntary bladder contractions
stress incontinence - sphincter weakness
neurlogical - nerve damage/MS
overflow incontinence - retention/prostate enlargement
functional
mixed incontinence
what are some risk factors for urinary incontinence
age
increasing parity
obesity
smoking
previous surgery
what are some causes of urinary incontinence
nerve damage from previous surgery
childbirth
diabetes - neuropathy of bladder control, polyuria, polydipsia, renal impairment, nephropathy
recurrent UTI - frequency
what is the clincial presentation of an overactive bladder
urgency
urge incontinence
frequency
nocturia
nocturnal enuresis
‘key in door’ and ‘hand wash’
intercourse
how does stress incontinence present
involuntary leakage when:
cough
laugh
lifting
exercise
movement
what is the first line investigation for incontinence
HISTORY
bladder diary (Freq volume chart) - when, how much and fluid intake
what other investigations can you do for incontinence
MSU
residual urine measuements - in/out catheter
ePAQ questionnaire
urodynamics
cystogram
what conservative/lifestyle measures can help someone with incontinence
weigth loss
smoking cessation
reduced caffeine intake
avoidance of straining and constipation
what is the first line treatment for overactive bladder
bladder training
can also use pads to absorb any leaked urine
what is the first line treatment for stress incontinence
pelvic floor exercises
what medications can be used in overactive bladder
anticholinergics:
- oxybutin
- solifenacin
- parasympathetic - pissing - decreasing need to urinate
mirabegron
- beta-3-adrenergic receptor agonist (sympathetic storage)
- relaxes detrusor and increases bladder capacity
botox injection - paralyses detrusor to stop it from being overactive
what are the side effects of anti-cholinergics
dry mouth
blurred vision
drowsiness
constipation
tachycardia
what are some surgical options for managing overactive bladder
augmentation cystoplasty
indwelling catheters
bypass (urostomy)
what are the treatment options for stress incontinence
60% cured by PT and conservative measures - pelvic floor exercise, pads, pessaries, skin care, odor control
surgery - sling, suspension - supports urethra to increase urethral resistance
what are the different types of prolapse can occur
cystocele - anterior of vagina and bladder = frequency and dysuria
rectocele - lower posterior vagina and rectum = finger in vagina to aid defecation
enterocele - upper posterior wall of vagina and intestine
uterine prolapse - protrusion of uterus down vagina
vault prolapse - total hysterectomy
what is the pathological reason behind prolapse and what are the risk factors
cause - weakness of ligaments and pelvic floor
risk factors - age, obesity, childbirth, previous surgery
what are the symptoms of prolapse
something coming down - dragging
pain
lump
discomfort
incontinence
sexual dysfunction
unable to go toilet
how should a prolapse be investigated
speculum
how is a prolapse managed
conservative - reassure, pelvic floor exercise
pessary - ring, shelf, gelhorn
surgery if all else fails
what is the definition of subfertility
failure to conceive after 1 year of regular unprotected sex (2-3 times a week)
what are the causes of infertility
unexplained - 25%
male factors - 30%
ovulatory disorders - 25%
tubal damage - 20%
uterine disorders - 10%
in 40% factors due to both partners
what are some risk factors for subfertiity
increasing age
extremes of weight
what are some ovarian factors in females that cause sub-fertility
PCOS
pituitary tumours
Sheehan’s syndrome
hyperprolactinaemia
premature ovarian failure
Turner’s syndrome
hypothyroidism
previous chemo or radio
what are some tubal/uterine causes of subfertility in women
PID
sterilisation
Asherman’s syndrome (adhesions)
fibroids
polyps
endometriosis
uterine malformations
how should sub-fertility be investigated
see both partners
ovulatory tests - mid luteal progesterone levels
ovarian reserve testing
semen analysis - count, motility, morphology
other for women: prolactin, thyroid, free androgen, USS of uterus and tubes, karyotype
what are some causes of male infertility
use of anabolic steroids
high prolactin
CF
history of undescenced testes
childhood measles
working with a lot of heat - chefs
how should male infertility be investigated
semen analysis - sperm coutn, motility, morphology
imaging - vasogram, USS, urology
CF screen
karyotype
how should sub-fertility be managed
keep trying for a year
inform effect of age
intercourse 2-3x a week, folic acid, smear, rubella, stop smoking, BMI normal, no alcohol or drugs
what are the criteria for an early referral to specialist sub-fertility centres
female:
age >35
menstrual disorder
previous abdo/pelvic surgery
PID
male:
previous genital patho or urogenital surgery
previous STI
systemic illness
what are some lifestyle measures to optimise male fertility
avoid extreme heat near genitals
looser pants
stop smoking
moderate alcohol
avoid harmful chemical in occupation
diet/supplements - folic acid
weigth optimisation
what are some treatments for male infertility
mild - intrauterin insemination
moderate - IVF
severe - ICSI (intracytoplasmic sperm injection)
azoospermia - surgical sperm recover or donor
hormonal - bromocriptine
ensure no anabolic steroids
infertility treatment for women
induce ovulation
treat tubal disease
IVF
endometriosis - surgical ablation/excision
what are some methods of assissted conception
ovulation induction
stimulated intrauterine insemination
IVF
ICSI
donor insemination
donor egg
donor embryo
host surrogacy
what are some risks/complications of IVF
multiple pregnancy
miscarriage
ectopic
ovarian hyper stimulation syndrome
bleeding and infection at egg collection
what are some patient factors which affect the success of IVF
age
cause of infertility
previous pregnancies - increase
duration of infertility
number of previous attempts
medical conditions
environmental factors
what is the definition of FGM
all procedures involving partial or total removal of female external genitalia or injury to female organs for non-medical reasons
involves damaging or removing normal, healthy female genital tissue and hence interferes with function
what are the 4 different types of FGM
clitoridectomy
excision (clitoris, labia minora +/- majora)
infibulation - narrowing orifice with stitches
all other harmful procedures to female genitalia
what are some ‘reasons’ given for FGM in certain cultures
brings status and respect
preserves virginity
part of being a woman
rite of passage
upholding family honour
cleanses and purifies a girl
fulfils a religious need
makes girl acceptable for marriage
sense of belonging to community
what are some dangers of FGM
blood borne virus - non sterile equipment
haemorrhage
infection and sepsis
how many women in UK (age 15-49) have been subject to FGM
103,000
what are legal standings on FGM in UK
illegal to do any sort of FGM in UK
illegal to assist in carrying out ( including booking flights, taking them or knowing etc)
if a child is seen with it must report to police
what are some gynae complications of FGM
sexual dysfunction with anorgasmia
chronic pain
keloid scar formation
dysmenorrhoea
haematocolpos - period blood backs up
urinary outflow obstruction
recurrent UTI
difficulty conceiving - sex can be hard
PTSD
what are the responsibilities of doctors with regards to FGM
report all cases of FGM in medical notes (if adult)
call police if child
ensure families know FGM is illegal so they don’t keep doing it to children
