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Obs & Gynae > Gynae problems > Flashcards

Gynae problems Flashcards

1
Q

Which part of the menstrual cycle does PMS occur?

A

Luteal phase (in days prior to onset of menstruation)

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2
Q

During which parts of a woman’s life are PMS not present?

A

Before menarche
During pregnancy
After menopause

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3
Q

What is PMS caused by?

A

Fluctuation in oestrogen and progesterone hormones during menstrual cycle

*?increased sensitivity to progesterone
or
?interaction between sex hormones and serotonin/GABA

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4
Q

How does PMS present?

A

Depends on individual

    Low mood
    Anxiety
    Mood swings
    Irritability
    Bloating
    Fatigue
    Headaches
    Breast pain
    Reduced confidence
    Cognitive impairment 
    Clumsiness
    Reduced libido
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5
Q

Absence of menstruation after:

  • hysterectomy
  • endometrial ablation
  • Mirena coil

Can PMS still occur in these situations?

A

Yes, as ovaries still function and hormonal cycle continues.

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6
Q

Aside from physiological PMS, when else can PMS occur?

A 
COCP
Cyclical HRT (containing progesterone)
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7
Q

When PMS features are severe and have a big impact on the quality of life, what is this called?

A

Premenstrual dysphoric disorder

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8
Q

How is PMS diagnosed conservatively?

A

Using symptom diary spanning TWO menstrual cycles

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9
Q

How is PMS diagnosed confirmed?

A

Administer GnRH analogues to halt menstrual cycle (temporarily induces menopause)

If symptoms resolve, then it is PMS

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10
Q

How is PMS managed conservatively?

A

Lifestyle changes - diet, exercise, alcohol, smoking, stress, sleep

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11
Q

How is PMS managed pharmacologically?

A

COCP (Drospirenone)
SSRI antidepressants
CBT
Oestrogen patches with progesterone cover (from endometrial hyperplasia from oestrogen)
GnRH analogues to induce menopause then HRT after to recover
Danazole/tamoxifen for breast pain
Spironolactone for physical symptoms of PMS such as breast swelling, water retention and bloating

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12
Q

How can PMS be managed surgically as a last resort?

A

Hysterectomy
Bilateral Oophorectomy

Give HRT if woman is under 45 to replace lost hormones from the operation.

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13
Q

In what form can progesterone be given for treating PMS?

A 
Cyclical progestogens (norethisterone)
Mirena coil
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14
Q

Which drug aims to tackle the physical symptoms of PMS (breast swelling, bloating, water retention)?

A

Spironolactone

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15
Q

What drug can be used to treat cyclical breast pain with PMS?

A

Danazole/tamoxifen

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16
Q

What is the risk of using oestrogen only (without progesterone cover) to treat PMS?

A

Oestrogen can induce endometrial hyperplasia.

Progesterone counteracts these effects.

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17
Q

Define dysmenorrhoea

A

Painful menstruation

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18
Q

What is the brief pathophysiology behind dysmenorrhoea?

A

High prostaglandins in endometrium causes contraction and uterine ischaemia

–> leads to pain during menstruation

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19
Q

What is primary dysmenorrhoea?

A

When no organic cause found for dysmenorrhoea.

*coincides with start of menstruation

Very common - particularly in adolescent women

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20
Q

What is the management of primary dysmenorrhoea?

A

Analgesia - NSAIDs

Ovulation suppression (OCP)

Reassurance in young adolescents

Pelvic pathology is more likely if medical treatment fails and should be followed up as such. (secondary dysmenorrhoea)

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21
Q

What is secondary dysmenorrhoea?

A

When pain is due to pelvic pathology.

*Pain often precedes and is relieved by onset of menstruation

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22
Q

How does secondary dysmenorrhoea present?

A

Pain often precedes and is relieved by onset of menstruation

Deep dyspareunia
Menorrhagia
Irregular menstruation

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23
Q

How is secondary dysmenorrhoea investigated?

A

USS pelvis

Laparascopy

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24
Q

What are the most significant causes of secondary dysmenorrhoea?

A 
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumours

Treat according to pathology

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25
Q

What are NON-MALIGNANT causes of intermenstrual bleeding?

A 
Fibroids
Uterine/cervical polyps
Adenomyosis
Ovarian cysts
Chronic pelvic infection
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26
Q

What are MALIGNANT causes of intermenstrual bleeding?

A 
Ovarian ca
Cervical ca
Endometrial ca (most)
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27
Q

What may a speculum examination on a women with intermenstrual bleeding reveal?

A

Cervical polyp

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28
Q

What investigations are carried out on a woman with intermenstrual bleeding?

A

Check blood loss: Hb

Exclude malignancy: cervical smear, USS uterus cavity +/- endometrial biopsy

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29
Q

What criteria are acceptable to perform an endometrial biopsy on a woman with abnormal bleeding?

A 
Endometrium thickened on USS
Polyp suspected
Woman is >40 years of age
IMB is significant
Risk factors for endometrial cancer
If endometrial ablation surgery or IUS gonna be used
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30
Q

What are pharmacological managements of intermenstrual bleeding?

A

IUS or COCP used first line. Induces regular and lighter menstruation. (Use less in older women due to complications)

High dose progestogens given cyclically to mimic normal menstruation

HRT can also regulate erratic uterine bleeding during perimnopause

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31
Q

What are surgical managment options for intermenstrual bleeding?

A

Cervical polyp can be avulsed + sent for histology

Resection of fibroid

Hysterectomy in last resort

Uterine artery embolisation to treat abnormal bleeding due to fibroids. Suitable if woman wants to retain uterus.

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32
Q

How much blood do women lose blood during menstruation on average?

What is deemed excessive?

What is the medical term for this?

A

40ml

> 80ml

Menorrhagia (heavy menstrual bleeding)

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33
Q

What are symptoms of menorrhagia?

A

Changing pads every 1-2 hours
Bleeding lasting more than 7 days
Passing large clots

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34
Q

What are possible differential causes of heavy menstrual bleeding? List at least 4.

A 
Dysfunctional uterine bleeding (DUB)
Extremes of reproductive age
Fibroids
Endometriosis and Adenomyosis
PID
Contraceptives - e.g. copper coil
Anticoagulant medications
Bleeding disorders (VWD)
Endocrine disorders (diabetes/hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome (PCOS)
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35
Q

What are key things to ask about in any presentation with gynaecological problem?

A

Age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening history
Migraines with or without aura (for the pill)
Past medical history and past drug history
Smoking and alcohol history
Family history

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36
Q

What examination and investigations can be carried out for menorrhagia?

A

Pelvic exam with speculum and bimanual - assess for fibroids, ascites and cancers

FBC - check for iron deficiency anaemia

Hysteroscopy (if ?submucosal fibroids,?endometrial pathology, peristent IMB)

Pelvic + transvaginal USS (if large fibroids, adenomyosis, obese, declined hysteroscopy)

Additional tests to consider:

  • Swabs (?infection)
  • Coagulation screen (family hx clotting or heavy periods since menarche)
  • Ferritin if clinical anaemia

TFTs (if features of hypothyroid)

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37
Q

What is the pharmacological management for heavy menstrual bleeding?

A

Exclude causes suggesting underlying pathology

Offer contraception:
1st line - Mirena coil
2nd line - COCP
3rd line - cyclical oral progestogens
(also progesterone only pill or long-acting progesterone - depo or implant)

If contraception declined:
Tranexamic acid - when no associated pain (antifibrinolytic - bleeding)
Mefenamic acid - when associated pain (NSAID - bleeding and pain)

Refer for secondary care if failed

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38
Q

What are the 2 main surgical options for heavy menstrual bleeding in secondary care (i.e. when pharmacological options have failed)?

A

Endometrial ablation

Hysterectomy

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39
Q

What is balloon thermal ablation and what is it used for?

A

Passing special balloon into endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining.

2nd generation, non-hysteroscopic endometrial ablation technique

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40
Q

What are the 4 types of fibroids?

A

Intramural
Subserosal
Submucosal
Pedunculated

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41
Q

What are fibroids?

A

Benign tumours of the smooth muscle of uterus.

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42
Q

Which hormone induces growth of fibroids?

A

Oestrogen

43
Q

How do fibroids present?

A

Asymptomatic usually.

HMB is the most frequent symptoms
Prolonged menstruation, lasting more than 7 days
Abdo pain, worse during menstruation
Bloating/feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility

Abdo + bimanual examination may reveal palpable pelvic mass or an enlarged firm non-tender uterus.

44
Q

Abdominal and bimanual examination of fibroids may reveal what?

A

Palpable pelvic mass
or
Enlarged firm non-tender uterus

45
Q

What investigations can be done for fibroids?

A

Hysteroscopy (submucosal fibroids with HMB)

Pelvic USS (larger fibroids)

MRI scanning (consider before surgery - size, shape and blood supply of fibroids)

46
Q

What are the management options for fibroids less than 3cm?

A

Same as with HMB

  • Mirena coil (1st line)
  • Symptomatic management (NSAIDs + tranexamic acid)
  • COCP
  • Cyclical oral progestogens

Surgical options:

  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy
47
Q

What are the management options for fibroids more than 3cm?

A

Referral to gynaecology

  • Symptomatic management (NSAIDS + tranexamic acid)
  • Mirena coil
  • COCP
  • Cyclical oral progestrogens

Surgical options:

  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy

GnRH agonists (goserelin, leuprorelin) can be used to reduce the size of fibroids before surgery.

48
Q

Which artery is used to gain access in uterine artery embolisation?

A

Femoral artery

49
Q

What are complications of fibroids?

A
  • HMB (often with iron deficiency anaemia)
  • Reduced fertility
  • Pregnancy complications - miscarriages, premature labour and obstructive delivery
  • Constipation
  • Urinary outflow obstruction and UTI
  • Red generation of fibroid
  • Torsion of fibroid (usually affects pedunculated fibroids)
  • Malignant change to leiomyosarco (very rare <1%)
50
Q

What is red degeneration of fibroids?

A

Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply.

*Usually occurs in larger fibroids (5cm+) during 2nd and 3rd trimester

51
Q

In which part of pregnancy does red degeneration of fibroids usually occur?

A

2nd or 3rd trimester

52
Q

Why does red degeneration usually occur during pregnancy?

A

Fibroid enlarges during pregnancy, outgrowing its blood supply and becomes ischaemic.

Also due to kinking in blood vessels as uterus changes shape and expands during pregnancy.

53
Q

How does red degeneration of fibroids usually present?

A 
Red degeneration presents :
Severe abdominal pain
Low-grade fever
Tachycardia
Often vomiting.
54
Q

What is the management for red degeneration of fibroids?

A

Supportive management only

Rest
Fluids
Analgaesia

55
Q

Pregnant women with history of fibroids presents with severe abdo pain and a low-grade fever.

What is the likely diagnosis?

A

Red degeneration of fibroids

56
Q

The vast majority of ovarian cysts in premenopausal women are ______.

A

Benign

57
Q

Cysts in postmenopausal women are more concerning for ________ and need further investigation.

A

Malignancy

58
Q

Patients with multiple ovarian cysts have a “____________” appearance to the ovaries.

A

“String of pearls”

59
Q

What is the triad necessary to diagnose PCOS over simply having multiple ovarian cysts?

A

Anovulation
Hyperandrogenism
Polycystic ovaries on USS

60
Q

What are the two types of functional cysts?

*Functional cysts are related to fluctuating hormones of the menstrual cycle. Very common in premenopausal women.

A

Follicular cysts (most common)

Corpus luteum cysts

61
Q

___________ cysts can cause pelvic discomfort, pain or delayed menstruation.

Often seen in early pregnancy.

A

Corpus luteum cysts

62
Q

What are 5 types of non-functional cysts?

A

Serous cystadenoma

Mucinous cystadenoma

Endometrioma

Dermoid cysts/Germ cell tumours (teratomas)

Sex cord-stromal tumours

63
Q

Serous cystadenoma are what?

A

Benign tumours of epithelial cells

Non-functional cyst

64
Q

Mucinous cystadenoma are what?

A

Benign tumour of epithelial cells.

*can become huge, taking lots of space in the pelvis

65
Q

Endometrioma are what?

A

Lumps of endometrial tissue in ovary - occur in patients with endometriosis.

*cause pain and disrupt ovulation

66
Q

Dermoid cysts/germ cell tumours are what?

A

Benign ovarian tumours

Teratomas

*associated with ovarian torsion

67
Q

Sex-cord stromal tumours are what?

A

Rare benign OR maligant stroma/sex cord tumours

*Several types - Sertoli-Leydig cell tumours and granulosa cell tumours

68
Q

What features suggest malignancy in ovarian cysts?

A
  • Abdo bloating
  • Reduced appetite
  • Early satiety
  • Weight loss
  • Urinary symptoms
  • Pain
  • Ascites
  • Lymphadenopathy
69
Q

What are risk factors for ovarian malignancy?

A
  • Age
  • Post-menopause
  • Increased number of ovulations
  • HRT
  • Smoking
  • Breastfeeding (protective)
  • Family history and BRCA1/BRCA2 genes
70
Q

More number of times woman ovulates during life _____ risk of ovarian cancer.

A

Increases risk of ovarian cancer

71
Q

Factors that reduce the number of ovulations are:

A

Later onset of periods (menarches)

Early menopause

Any pregnancies

Use of COCP

72
Q

What blood tests are done for women with ovarian cysts?

A

Less than 5cm on USS? No blood test needed

CA125 is the tumour marker for determining malignancy potential of ovarian cyst.

LDH
AFP
HCG

73
Q

Women under 40 yo with complex ovarian mass require tumour marker blood tests for a possible __________ tumour

A

Germ cell tumour

74
Q

CA125 is a tumour marker for epithelial cell ovarian cancer - not very specific and many non-malignant causes of raised CA-125 such as:

(List 6)

A 
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
75
Q

Risk of malignancy index estimates risk of ovarian mass being malignant. Takes into account 3 things:

A

Menopausal status
USS findings
CA125 level

76
Q

How is possible ovarian cancer referred?

A

2 week wait referral to gynae oncology specialist

77
Q

How are possible dermoid cysts referred?

A

Referred to gynae for further investigation and consideration of surgery.

78
Q

Simple ovarian cysts in premenopausal women are managed based on their size how?

  1. <5cm
  2. 5cm - 7cm
  3. 7cm+
A
  1. <5cm - Resolve within 3 cycles. Do not require a followup scan.
  2. 5cm - 7cm - Require routine referral to gynae and yearly USS monitoring.
  3. 7cm+ - MRI scan/surgical evaluation as difficult to characterise with USS
79
Q

Persistent or enlarging cysts may require surgical intervention. List 2 types of surgery.

A

Ovarian cystectomy (removal of cyst)

Oophorectomy (removal of affected ovary)

80
Q

What are complications of ovarian cysts?

*Patients present with acute onset pain

A

Ovarian torsion

Haemorrhage into cyst

Rupture, with bleeding into peritoneum

81
Q

What is the triad of Meig’s syndrome?

A

Ovarian fibroma (type of benign ovarian tumour)

Pleural effusion

Ascites

82
Q

Which population does Meig’s syndrome usually occur in?

A

Older women

83
Q

How is Meig’s syndrome managed?

A

Removal of tumour

*results in complete resolution of pleural effusion and ascites! :)

84
Q

What is PID?

A

Pelvic inflammatory disease - inflammation/infection of pelvis organs caused by infection spreading up through the cervix.

85
Q

What are 3 causes of pelvic inflammatory disease?

A

STDs:

  • Neisseria genorrhoeae (severe PID)
  • Chlamydia trachomatis
  • Mycoplasma genitalium

Less commonly, non-STDs:

  • Gardnerella vaginalis (associ. with BV)
  • Haemophius influenzae (assoc. with resp infections)
  • E. coli enteric bacteria assoc. with UTIs)
86
Q

What are risk factors for PID?

A

Not using barrier contraception

Multiple sexual partners

Younger age

Existing STDs

Previous PID

Intrauterine device (copper coil etc)

87
Q

How may a woman with PID present?

A 
Pelvic/lower abdomen pain
Abnormal vaginal discharge
Abnormal bleeding (IMB or postcoital)
Dyspareunia
Fever
Dysuria
88
Q

What may an examination on a woman with PID reveal?

A

Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge

Fever or septic signs possible too!

89
Q

What are the investigations for PID?

A

Same as STD testing

NAAT swabs (gonorrhoea/chlamydia)

NAAT swabs for Mycoplasma genitalium

HIV test

Syphilis test

High vaginal swab - BV, candidiasis, trichomoniasis

Microscopy to look for pus cells on vagina or endocervix. Absence = exclude PID

Pregnancy test with women with lower abdo pain - exclude ectopic pregnancy

Inflammatory markers (CRP/ESR) raised in PID and can help support diagnosis

90
Q

How are PID patients managed?

A

GUM referral, contct tracing

Empiric antibiotics while swab results awaited

Abx:

Ceftriaxone and doxycycline (for many bacteria inc gonorrhoea and chlamydia)

Sepsis? -> IV abx and admit.

Pelvic abscess? -> drainage

91
Q

What are complications of PID?

A 
Sepsis
Pelvic abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
92
Q

What is Fitz-Hugh-Curtis syndrome?

How does it present?

How is it found + treated?

A

Complication of PID

Caused by inflammation/infection of liver capsule (Glisson’s capsule) => adhesions between liver and peritoneum.

Bacteria spread from pelvis via peritoneal cavity, lymph or blood

RUQ pain -> referred to right shoulder tip if diaphragm irritated.

Laprascopy to visualise

Treat adhesions by adhesiolysis

93
Q

What is adenomyosis?

A

Endometrial tissue within the myometrium

94
Q

What is endometriosis?

A

Ectopic endometrial tissue outside the uterus (endometrioma)

95
Q

What are “chocolate cysts”?

A

Endometriomas in the ovaries

96
Q

What is a possible cause for endometriosis?

A

Retrograde menstruation

*During menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum

97
Q

What is the main symptom of endometriosis?

A

Pelvic pain - especially during menstruation

98
Q

What are complications of endometriosis?

A

Blood in urine/stools (deposits of endometriosis in bladder or bowel)

Adhesions

Reduced fertility (due to adhesions blocking eggs)

99
Q

How may a woman with endometriosis present?

A 
Cyclical abdo or pelvic pain
Deep dyspareunia
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites (such as haematuria)

Urinary symptoms
Bowel symptoms

100
Q

What may an examination of a women with endometriosis reveal?

A

Endometrial tissue visible in vagina on speculum examination

Fixed cervix on bimanual examination (adhesions)

Tenderness in vagina, cervix and adnexa

101
Q

How is endometriosis investigated?

A

Pelvic USS - large endometriomas and chocolate cysts

Lap surgery - gold standard to diagnose abdo and pelvic endometriosis. Take biopsy for definitive diagnosis.

102
Q

How is endometriosis managed?

Initial

Hormonal

Surgical

A

Analgesia as required

Hormonal management

  • COCP
  • progesterone only pill
  • Depo-Provera injection
  • Nexplanon implant
  • Mirena coil
  • GnRH agonists

Surgical management

  • Lap surgery to excise/ablate endometrial tissue and remove adhesions (adhesiolysis)
  • Hysterectomy
103
Q

How do GnRH agonists work to manage endometriosis and give 2 examples of these drugs?

A

Induce menopause-like state to improve endometriosis symptoms

Goserelin

Leuprorelin

Obs & Gynae (13 decks)

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