Gynae Problems Flashcards
1
Q
‘prolonged and increased menstrual flow i.e. heavy menstrual bleeding’
is defined as what?
A
Menorrhagia
2
Q
‘regular intermenstrual bleeding’
is defined as what?
A
Metrorrhagia
3
Q
‘menses occurring at <21 day interval’
is defined as what?
A
Polymenorrhea
4
Q
‘increased bleeding and frequent cycle’
is defined as what?
(more bleeding per day of period and more relevantly to the name have cycles more frequently)
A
polymenorrhagia
5
Q
‘prolonged menses and intermenstrual bleeding’ is defined as what?
(period is longer and there’s bleeding inbetween periods)
A
menometrorrhagia
6
Q
‘absence of menstruation >6 months’
is defined as what?
A
amenorrhea
7
Q
‘menses at intervals of >35 days OR presence of fiver or fewer menstrual cycles over a year’
is defined as what?
A
Oligomenorrhea
8
Q
List the ‘local disorders’ that can cause menorrhagia
A
- Fibroids
- Adenomyosis
- Endocervical or endometrial polyp
- Endometrial hyperplasia
- Intrauterine contraceptive device (IUCD)
- Pelvic inflammatory disease (PID)
- Endometriosis
- Malignancy of the uterine or cervix
- Hormone producing ovarian tumours
- Arteriovenous malformation
9
Q
List the ‘systemic disorders’ that can cause menorrhagia
A
- Endocrine:
- Hyperthyroidism
- Hypothyroidism
- Diabetes mellitus
- Adrenal disease
- Prolactin disorders
- Haematological disease
- Von Willebrand’s disease
- Immune thrombocytopenic purpura (ITP)
- Factor II, V, VII and XI deficiency
- Liver disorders
1. Cirrhosis - Renal disease
- Drugs
- anti-coagulants (warfarin, clopidrogel, rivaroxaban)
10
Q
What obstetric causes of menorrhagia should be considered (as well as local and systemic causes)?
A
Pregnancy complications such as:
- miscarriage
- extopic pregnancy
- gestational trophoblastic disease
- or placenta praevia
11
Q
Discuss dysfunctional uterine bleeding
A
Dysfunctional uterine bleeding occurs in the absence of pathology
It is a diagnosis of exclusion made in 50% of women with abnormal uterine bleeding
There are two types: anovulatory and ovulatory
12
Q
Describe anovulatory dysfunctional uterine bleeding
A
- 85% of all DUB
- Occurs at extremes of reproductive life
- Irregular cycle
- More common in obese women
13
Q
Describe ovulatory dysfunctional uterine bleeding
A
- More common in women aged 35-45 years
- Regular heavy periods
- Due to inadequate progesterone production by corpus luteum
14
Q
What investigations should be considered in women presenting with menorrhagia?
A
- Full blood count
- Thyroid function tests
- Coagulation screen
- Renal/Liver function tests
- Transvaginal ultrasound
- endometrial thickness
- presence of fibroids and other pelvic masses
- Endometrial sampling
- pipelle biospies
- hysteroscopic directed endometrial biopsies under GA
- dilatation and curettage (D&C)
- Cervical…
- smear IF due
- if cervix looks abnormal on speculum refer for colposcopy
15
Q
What are the medical options for management of dysfunctional uterine bleeding?
A
- Progestogen-releasing IUCD- Mirena IUS
- COCP
- Anti-fibrinolytics
- NSAIDs
- Oral progestogens
- GnRH analogus/agonists
- Danazol
16
Q
According to NICE, what is the first line treatment for menorrhagia?
A
Mirena IUS
17
Q
Discuss the Mirena as a management option for menorrhagia
A
Mirena IUS
- Compliance concerns
- Avoid drug interactions
- Mean reduction in menstrual blood loss=95% at one year
- Doubles up as contraception
- May cause breakthrough bleeding in the first 3-9 months after insertion
18
Q
Discuss the combined oral contraceptive pills as a management option for dysfunctinal uterine bleeding
A
COCP
- Contraception
- 30% reduction in menstrual blood loss
- Contraindications attached
19
Q
Discuss anti-fibrinolytics as a management option for dysfunctional uterine bleeding
A
Anti-fibrinolytics- tranexamic acid
- taken only during menstruation
- decreased blood loss by 50%
- appropriate when woman is considering conceiving
20
Q
Discuss NSAIDs as a management option for dysfunctional uterine bleeding
Give example
A
NSAIDs- mefenamic acid
- taken during menstruation only
- appropriate when woman is considering conceiving
- apoptotic processes produces prostaglandins (effective when menorrhagia is accompanied by dysmenorrhea)
- contraindicated in Hx of duodenal ulcers or severe asthma
- decreases blood loss by 20-25%
21
Q
What NSAID could be considered as a managment option for dysfunctional uterine bleeding?
A
Mefenamic acid
22
Q
What oral progestogens can be considered as a management option for dysfunctional uterine bleeding?
A
- Norethisterone
- Medroxyprogesterone acetate
23
Q
Discuss GnRH analogues/agonists as management options for dysfunctional uterine bleeding
List some examples
A
GnRH analogues
- act on the pituitary to stop oestrogen production
- results in amenorrhea
- long-term use causes osteoporosis unless combined with HRT and are therefore used in the short-term (<6 months)
- examples include: Goserelin, decapeptyl, Buserelin
24
Q
Discuss Danazol as a management option for dysfunctional uterine bleeding
A
A synthetic mild androgen derivative that acts on the HPO axis and endometrium
Rarely used
25
What are the surgical options for dysfunctional uterine bleeding?
Who can they be offered to?
* Endometrial resectin/ablation
* Hysterectomy
26
Discuss endometrial ablation as a management option for dysfunctional uterine bleeding?
(in comparison to hysterectomy...)
* day case procedure
* shorter operating times
* shorter recovery
* fewer complications
* combined HRT required
* 20-70% of patients will become amenorrhoeic
* 20-30% will have a major reduction in bleeding
27
Discuss hysterectomy as a management option for dysfunctional uterine bleeding
* major operation
* longer operating time
* longer recovery
* more complications
* no cervical smears required (for total hysterectomies)
* oestrogen only HRT (unless cervix is retained)
* a definitive treatment (if total hysterectomy)
* infertility
28
What are the possible causes of intermenstrual bleeding?
1. Cervical ectropion
2. PID and STI
3. Endometrial or cervical polyps
4. Cervical cancer
5. Endometrial cancer
6. Undiagnosed pregnancy/pregnancy complications
7. Hyatidiform molar disease
29
What are the 'hallmark' psychological changes seen in Premenstrual Syndrome?
* depression
* irritability
* emotional lability
30
What are the features of premenstrual syndrome?
* bloating
* cyclical weight gain
* mastalgia
* abdominal cramps
* fatigue
* headache
* depression
* changes in appeitie and increased craving
* irritability
31
What is the investigations/diagnosis of premenstrual syndrome?
Ask the woman to keep a menstrual diary of her symptoms over at least 2 cycles
32
What are some of the treatment options for PMS?
* SSRIs or SNRIs which are taken daily or during the luteal phase of the cycle
* CBT
* Lifesyle advice e.g. stress reduction, alcohol reduction, caffiene reduction, increase in exercise
* COCP, transdermal oestrogen, short-term GnRH
* Last resort: hysterectomy
33
How do GnRH analogues work?
When GnRH is given continuously (instead of in the pulsatile manner that natural endogenous GnRH is released) it desensitises the receptors in the anterior pituitary.
This downregulates the pituitary and decreases FSH and LH and therefore oestrogen and progesterone levels too
34
What are the possible causes of post-coital bleeding?
1. Cervical ectropion
2. Cervical carcinoma
3. Trauma
4. Atrophic vaginitis
5. Cervicitis secondary to STIs
6. Polyps
7. Idiopathic
35
What is a cervical extropion?
Aslo known as a cervical erosion
Where the cervix develops a red, raw appearance that may bleed on contact
36
What is the most common cause of cervical ectropion?
Hormonal changes due to high oestrogenic states in pregnancy or use of hormonal contraceptives, especially the combined pill
37
What is the definition of postmenopausal bleeding?
What are the NICE recommendations regarding PMB?
Bleeding after the menopause (menopause= no periods for 1 year)
NICE Guidelines state that women over the age of 55 with PMB should be investigated within 2 week by ultrasound for endometrial cancer.
38
What are the possible causes of PMB?
1. Atrophic vaginitis
2. Endometrial polyps
3. Endometrial hyperplasia
4. Endometrial carcinoma
5. Cervical carcinoma
6. Ovarian cancer
7. Vaginal cancer
39
What is the most common cause of PMB?
Atrophic vaginitis
40
What is atrophic vaginitis?
A benign condition where the epithelium thins and breaks down in response to low oestrogen levels
41
Approximately what percentage of women with PMB have endometrial cancer?
10%
42
What is the first line investigation for a women presenting with PMB bleeding?
What is the exception?
Transvaginal ultrasound
Women on tamoxifen (breast cancer Tx) will have a thickened, irregular and cystic endometrium :. direct visualisation of the cavity by hysterscopy and an endometrial biopsy is indicated in this case
43
What is the management for atrophic vaginitis?
topical oestrogen and vaginal lubricants can be used for symptomatic relief
consider use of HRT
44
What is the mangement of endometrial hyperplasia?
* dilatation and curettage,
* progestogen treatment
1. Mirena IUS is first line
2. and oral progestogens can be used e.g. norethisterone
45
What criteria is used to diagnose PCOS?
Rotterdam Criteria
46
What are the possible features of PCOS?
* Obesity/overweight
* HTN
* Acanthosis nigricans (thickening and pigmentation of the skin of the neck, axillae and intertriginous areas)
* Acne
* Hirsutism- due to increased testosterone
* Alopecia
* There is a link to insulin resistance, diabetes, lipid abnormalities therefore an increased cardiovascular risk
* Irregular periods (most common cause of anovulatory infertility)
47
How is PCOS diagnosed?
The Rotterdam criteria
Requires 2/3 :
1. Clinical or biochemical evidence of hyperandrogenism
* hirsutism, acne, high free testosterone, low sex hormone binding globulin, high free androgen index respectively)
2. Polycystic ovaries on ultrasound scan- defined as an increase in ovarian volume \>10cm3 OR at least 12 follicles in one ovary measuring 2-9mm in diameter
3. Oligomenorrhoea OR amenorrhoea
48
How common are polycystic ovaries?
Polycystic ovaries, by themselves, are common.
PCOS is different.
49
What major health risk is associated with PCOS?
Endometrial hyperplasia and carcinoma due to oligo/amenorrhoea in the presence of pre-menopausal levels of oestrogen
i.e. unopposed oestrogen
50
What LH/FSH levels might you expect in PCOS?
LH levels are very high
FSH levels are low or normal
results in an increased LH:FSH ratio
51
Discuss the management of PCOS
Largely depends on what the patient presents with and what is their main concern
* Protect endometrium by beginning treatment with hormonal contraception
* Optimise BMI
52
What are the first-line management options for PCOS patients with infertility?
* Moderate weight loss of 5-10% can have major improvements in obese patients and is indicated before ovulation treatment over BMI 30
* Clomifene
* a selective oestrogen receptor modulator which blocks oestrogen negative feedback effect on hypothalamus resulting in more pulsatile GnRH secreation and therefore FSH and LH)
* side effects: hot flushes and sweating, increased risk of multiple pregnancy and ovarian cancer (with long term use)
53
What are the side effects of Clomifene?
* hot flushes and sweating
* increased risk of multiple pregnancy
* ovarian cancer (with long term use)
54
What is the second line management for PCOS patients experiencing infertility?
First line= Clomifene
Second line= Adding Metformin which is an insulin-sensitiser, improves glucose tolerance, increases androgen levels and improves ovulation rate
55
What is the third line management for PCOS patients experiencing infertility?
Third line= Ovarian drilling
Involves diathermy to destroy ovarian stroma which reduces androgen-secreting tissue leading a restoration of the normal LH:FSH ratio and a fall in androgens
56
What can be used as an alternative to Clomifene?
Gonadotrophin injections may be used if Clomifene has no effect
57
What is the last resort Tx option for PCOS patients experiencing infertility?
IVF
58
What are the two options for management of acne in PCOS patients?
* Co-cyrprindol (Dianette)
* COCP
59
What is co-cyrindol (Dianette)?
Co-cyrprindol (Dianette) is a combination of cyproterone acetate and ethinylestradiol and is effective to manage acne and hirsutism
Cyproterone acetate is an anti-androgen which blocks the action of androgens on the pilosebaceous glands, leading to a reduction in sebum production reducing acne and hirsutism
(doubt you actually need to know this)
60
How is amenorrhea managemed in PCOS patients?
COCP
Alternatively, cyclical medroxyprogesterone or insertion of a Mirena IUS can be helpful in managing the increased risk of endometrial hyperplasia and cancer in these patients
61
What is dysmenorrhoea and how is classified?
Dysmenorrhoea is characterised by excessive pain during the menstrual period
It is traditionally divided into primary and secondary dysmenorrhoea
As always a good history and thorough examination is needed to inform clincal decision making
62
What is primary dysmenorrhoea?
In primary dysmenorrhoea there is no underlying pelvic pathology
It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarache
Excessive endometrial prostaglanding production is thought to be partially responsible
63
What are the features of primary dysmenorrhoea?
* pain typically starts just before or within a few hours of the period starting
* suprapubic cramping pains which may radiate to the back or down the thigh
64
What is the secondary dysmenorrhoea?
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology.
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
65
What are the possible causes of secondary dysmenorrhoea?
* Endometriosis
* Adenomyosis
* Pelvic inflammatory disease
* Intrauterine devices (this refers to the copper coil- Mirena is used as Tx for dysmenorrhoea)
* Fibroids
66
What is the endometriosis?
Presence of endometrial tissue dispersed in the peritoneum or pelvic cavity
67
What is adenomyosis?
Presence of endometrium between the muscle layers of the uterus, uterus will often appear large and globular
68
Where are fibroids found?
Can be in different locations within the uterus
69
What examination findings would you expect in endometriosis?
Uterosacral nodularity and/or tenderness
Fixed retroverted uterus
70
What are the clinical features of endometriosis?
Heavy periods
Dyspareunia
71
What are the clinical features of adenomyosis?
Associated with prolonged, heavy periods
72
What are the examination findings of adenomyosis?
Bulky uterus
73
What are the clinical features of fibroids?
Menstrual pain
Pressure effects on the adjacent organs or fibroid degeneration during pregnancy
74
What are the examination findings of fibroids?
Pelvic mass
75
What are the features of chronic PID?
History of STI
Pain not limited to menstruation
76
What are the examination findings of chronic PID?
Mucopurulent discharge
Cervicitis
Findings suggesting Fitz-Curtis-Hugh syndrome on laparoscopy (see photo)
77
A women presents with...
pain shortly preceeding and accompanying menstruation
start shortly after her first period
O/e and Ix: normal
Diagnosis?
Primary dysmenorrhoea
78
A woman presents with...
heavy periods
dyspareunia
Oe: uterosacral nodularity and/or tenderness and a fixed retroverted uterus
Diagnosis?
Endometriosis
79
A woman presents with...
prolonged, heavy periods
O/e: bulky uterus
80
A woman presents with
menstrual pain and pressure effects on bladder
O/e: pelvic mass
Diagnosis?
Fibroids
81
A woman presents with...
abdominal pain and a history of STI
O/e: mucopurulent discharge, cervicitis, and findings suggestive of Fitz-Curtis-Hugh syndrome on laparoscopy
Diagnosis?
Chronic PID
82
What investigations are used for dysmenorrhoea presentation?
* High vaginal and endocervical swabs- to exclude pelvic infection (Chlamydia or Gonorrhoea)
* Pelvic ultrasound scan- to detect endometriomas, adenomyosis or fibroids
* Diagnostic laparoscopy- often used when the other investigations are normal but symptoms persist, or when the history is suggestive or endometriosis
83
What are the management options for dysmenorrhoea?
* NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women- they work by inhibiting prostaglandin production
* COCP= 2nd line
* Levongestrel Intrauterine system (LNG-IUS or EllaOne) when dysmenorrhoea occurs with menorrhagia
* GnRH analogues are the best to manage symptoms, especially due to fibroids when awaiting hysterectomy
84
What are the classifications of miscarriage?
* threatened
* inevitable
* incomplete
* complete
* missed
85
How would you expect a threatened miscarriage to present?
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6-9 weeks
bleeding often less than menstruation
cervical os is closed
86
How would you expect a missed miscarriage to present?
mother may have light vaginal bleeding/discharge and the symptoms of pregnancy which disappear
pain is not usually a feature
cervical os is closed
87
What is a missed miscarriage?
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
88
How would you expect someone with an inevitable miscarriage to present?
heavy bleeding with clots and pain
cervical os is open
89
How would you expect an incomplete miscarriage to present?
What is it?
not all products of conception of have been expelled
pain and vaginal bleeding
cervical os is open
90
Expectant management is rarely a management option for (tubal) ectopic pregnancies and there is very strict criteria for choosing it.
What is the NICE criteria for expectant management?
Offer expectant management to women who are:
1. clinically stable and **pain free** AND
2. have a tubal ectopic pregnancy measuring **less than 35mm** with **n****o visible heartbeat** on transvaginal ultrasound scan AND
3. have serum **hCG levels of 1000 IU/L** or less AND
4. are **able to return** for follow up
