Gynae p3 Flashcards
Def Amenorrhoea
Absence of menstruation
What is primary amenorrhoea
When menstuation hasn’t started by age 16
What is secondary amenorrhoea
Previous normal menstruation ceases for 3 months or more
Oligomenorrhoea
Menstruation occurs ev 35 dyas –> 6 m
Physiological causes of amenorrhoea (3)
Pregnancy
After menopause
During lactation
Primary pathological causes of amenorrhoea
Congenital abnormalities
Or acquired disorders
Secondary pathological causes of Amenorrhoea (3)
Premature menopause
PCOS
Hyperprolactinaemia
Drugs causing amenorrhoea (3)
Progestogens
GnRH analogues
Antipsychotics
hypothalamic causes of ameorrhoea
Hypothalamic hypogonadism (anorexia/XS exercise) Tumours
Tx of hypothalamic causes of amenorrhoea
Supportive
replace O if req - COCP/HRT
Pituitary causes of amenorrhoea
Hyperprolactinemia - hyperplasia
Mx pit causes of amenorrhoea (2)
Cabergoline
Surgery
outflow tract issues - causes of amenorrhoea - congenital (2)
Imperforate hymen
Transverse vaginal septum
Outflow tract issues - causes of amenorrhoea - acquired (2)
Cervical stenosis
Ashermans
Tx outflow tract issues –> amenorrhoea
Surg
Def menopause
Permanent cessation of menstruation from loss of ovarian follicular activity
Median age menopause
51
When is natural menopause recognised
After >12 months consecutively of amenorrhoea
What is perimenopause
Time beginning w/ 1sat features of approaching menopause + ends 12m after LMP
Def premature menopause
Menopause occuring before the age of 40
Vasomotor Sx menopause
night sweats
sleep disturbance
hot flushes
Tx vasomotor Sx menopause
Clonidine
Psychological Sx menopause (3)
Memory problems
Loss of mental sharpness
Easier to lose temper
Urogenital Sx menopause (43)
Vaginal atrophy/urinary problems
Loss of oestrogen receptors on urethra/bladder –> destrusor instability + incontinence
Atrophy –> itching, burning, dryness
Other Sx of menopause
OP
Sexual problems
Ix menopause (2)
FSH levels
AMH - antimullerian hormone = low levels in ov failure
What are the 3 main types of HRT ?
Combined - O+P
Oestrogen only
Who can have oestrogen only HRT
Women who have had hysterectomy
What is Tibolone
Testosterone derivative for F who desire amenorrhoea = Tx vasomotor, psycho + libido problems
What are SERM’s
Selective oestrogen receptor modulators - clomiphene, raloxifene
Mode of action SERMs
Make ovaries ovulate
Dont fit on brain/breast/EM receptors :)
Negative of SERMS
expensive
+ves of Oral HRT (2)
Cheap
Effective
-ves of oral HRT (4)
Partial metabolism in gut
Can cause indigestion problems
Peaks + troughs in plasma levels
Incr risk VTE
+ves of transdermal HRT patch (2)
Avoids liver
Continuous absorption
-ves transdermal HRT patch (2)
Expensive
skin reactions
+ves of TO gel HRT
Continuous absorption
-ves of TO gel HRT (4)
O prep only
Messy
Incr risk CA
Expensive
+ves of implant HRT
Only have to replace every 6 months
-ves of implant HRT (3)
Cant be removed
Still req P
Problems w/ oestrogen sensitivity
+ves of vaginal cream HRT (2)
Specific local effectr
Great for urogenital Sx
-ves vaginal cream HRT (2)
O only
LT EM stim b/c systemic absorption
What is cyclical/sequential HRT
Take O every day + P only last 14 days menstrual cycle
Will still have period
Who is cyclical/sequential hRT for
F on HRT who have menopausal Sx but still have periods
What is continuous combined HRT
O+P everyday without a break
Or O everyday
Who has continuous combined HRT
Menopausal F who have been >2 yinto the mennopause
Use of mirena in HRT
for O only as an adjunct
Have to change every 4 years not 5
Things to know when coming off HRT
Staggered approach b/c withdrawal Sx
Aim = to get off HRT at age of menopause
When must youi STOP HRT
If any Sx/signs of breast cancer
Risks HRT (4)
Br cancer
EM cancer
VTE
CVD?
C/I HRT *7)
EM cancer Breast cancer Undiagnosed vaginal bleeding Undiagnosed breast lump Suspected pregnancy Liver disease w/ imp LFT Prev VTE assoc w/ COCP, preg, O replacement
Non-hormonal alts to HRT (2)
Clonidine - esp good for hot flushes/ night sweats
SSRIs/SSNI’s
WHat is a Bartholin’s abscess
Abscess of gland towards post fourchette
Pathophysiology Bartholin’s abscess
Openings at vaginal orifiece secrete mucus to lubricate vaginal
Builf up of f mucus –> blocked gland –> if un Tx –> cyst –> abscess
Infective organisms Bartholin’s (3)
E coli
MRSA
STIS
RF Bartholins ((3)
Prev Bartholins
Sexally active
Hx of vulval surgery
PS Bartholins cyst
Small = asymp
Vulvar pain
Superficial dyspareunia
PS Bartholins abcsess (2)
Acute onset pain
difficulty passing urine
DDx Bartholins (3)
Bartholins gland carcinoma
Bartholins benign tumour
Lipoma/leiomyoma
Ix Bartholins
often clinical
Swab
>40 - biopsy to excl carcinoma
Mx Bartholins
Word catheter Or marsupialisation (vertical incision)
Physiological causes of vaginal discharge (4)
Vestibular gland secretions
vaginal transudate
cervical mucus
Residual menstrual fluid
Hx q vaginal discharge
Timing of onset Colour Odor Blood Irritation Assoc Sx Prev pessary ring Prev hysterectomy Prev obstructed labour DM? Methods of contraception Recent ABx
STIs causing discharge (3)
Chlamydia
TV
N gonorrhoea
non-Sexually transmitted Infections causing discharge (2)
BV
Candida
Inflammator causes of discharge (3)
Allergy to soaps
Atrophic changes
Post op granulation tissues
Malignancy causes of discharge (3)
Vulval carcinoma
Cervical carcinoma
Uterine carcinoma
FB causes of discharge (2)
Retained condom/tampon
Ring pessary
Candidia discharge
Thick itchy white cottage cheese
BV discharge
Grey, fish smelling
O/E - Ix discharge
Abdo palp
Speculum
Bimanual palp
Which discharge causes do you need to swab for?
candida
TV
Chlamydia
Gonorrhoea
Which sicharge cause do you need to MSU for
Infective causes
Other Ix discharge
Cervical cytology
EM sampling/hysteroscopy
Pelvic USS
Laparoscopy
Def pruritis vulvae
Itching or irritation of the vulva
What 4 groups of conditions cause pruritis vulvae?
Vulval dystrophy
Neoplastic
Derm
Infection
O/E pruritis vulvae
Derm? Signs chronic renal and liver disease Examine vulva, urethral meatus, perinanal region VE/Speculum Coloscopy
Features on examination suggestive of vulval infection (3)
Generalised vulvitis
Vaginal discharge
Genital warts/herpes
Features o/e suggestive of vulval dystrophies (4)
Labial fusions
Adhesions
Stenosis of introitus
Leucoplakia
Ix pruritis vulvae
LFT/RFT/GTT/urinalysis
Bacterial swabs
STI screen
Histological (punch biopsies)
Causes of endometritis (4)
Instrumentation of uterus
Complication of pregnancy
Infection - STIs
E.coli/BV/Staph
PS endometritis (3)
Persistent/heavy vaginal bleeding
tender uterus
open cervical os
Ix endometritis
Swabs
FBC
Mx endometritis
BS ABx
US?
RF PID (4)
Young F
Poverty
Sexually active
Nulliparous
Protective factors PID (2)
Mirena
OCP
PS PID
Mostly asymp
PS later w/ subfertility/menstrual problems
Deep dyspaerunia + abnorm bleeding
Bilateral lower abdo pain
O/E PID
Severe incr HR, fever, lower abdo guarding
Cervical excitation + tender adnexae
DDx PID (3)
Appendicitis
Ovarian cyst
Ectopic
Ix PID
Endocervical swabs
Bloods - cultures, FBC, WCC, CRP
Pelvic USS - excl abscess/cysts
Laparoscopy + fimbria biopsy = gold standard
Mx PID
Analgesia
IV ABx
Review in 24 hr - if no improvement –> laparoscopy
Compications PID
Abscess
Subfertility
Ectopic pregnancy
Cause of chronic PID
Persisting infection due to poor Tx PID
Sx chronic PID (6)
Chronic pelvic pain Dysmenorrhoea Deep dyspareunia Heavy irreg menstruation Chronic discharge Subfertility
O/E - chronic PID
Abdo + adenxal tenderness
Fixed retroverted uterus
Ix chronic PID
TV USS
Laparoscopy
Mx chronic PID
Analgesia
ABx
Adhesiolysis
Salpingectomy
