Gynaecological Conditions

Question 1

What is menarche?

Answer 1

The first menstrual cycle

Question 2

What is menopause?

Answer 2

When menstrual cycle stops permanently

Question 3

What is menorrhagia?

Answer 3

Heavy periods

Question 4

What is metrorrhagia?

Answer 4

Vaginal bleeding that occurs outside of a normal menstrual period

Question 5

What is oligomenorrhoea?

Answer 5

Irregular and infrequent menstrual periods

Question 6

What is primary amenorrhoea?

Answer 6

The failure to establish menstruation by the expected age
15-16 in girls with secondary sexual characteristics
13-14 in girls with no secondary sexual characteristics

Question 7

What is secondary amenorrhoea?

Answer 7

The cessation of previously established menstruation for 3 cycles or for 6 or more months

Question 8

What are some red flag symptoms for endometrial cancer?

Answer 8

-Blood glucose high with visible haematuria >55yrs
-Hb low with visible haematuria >55yrs
-Post menopausal bleeding
-Thrombocytosis with visible haematuria or vaginal discharge >55yrs

Question 9

What are some red flag symptoms for vulval cancer?

Answer 9

-Vulval bleeding (unexplained) in women
-Vulval lump or ulceration (unexplained)

Question 10

What’s some red flag symptoms for cervical cancer?

Answer 10

Appearance of cervix consistent with cervical cancer

Question 11

What are some red flag symptoms for ovarian cancer?

Answer 11

-Appetite loss or early satiety (persistent or frequent – particularly more than 12 times per month)
-Abdominal distension (persistent or frequent – particularly more than 12 times per month)
-Ascites and/or a pelvic or abdominal mass
-Abdominal or pelvic pain (persistent or frequent – particularly more than 12 times per month)
-Irritable bowel syndrome symptoms within the last 12 months in women age 50 years and over
-Change in bowel habit (unexplained)
-Fatigue
-unexplained weight loss

Question 12

What are some red flag symptoms for vaginal cancer?

Answer 12

Vaginal mass (unexplained and palpable) in or at the entrance to the vagina

Question 13

What marker is raised in ovarian cancer?

Answer 13

CA125

Question 14

What is intermenstrual bleeding?

Answer 14

vaginal bleeding (other than postcoital) at any time during the menstrual cycle other than during normal menstruation

Question 15

What is postcoital bleeding?

Answer 15

non-menstrual bleeding that occurs immediately after sexual intercourse

Question 16

What is breakthrough bleeding?

Answer 16

irregular bleeding associated with hormonal contraception

Question 17

What are some causes of postcoital bleeding?

Answer 17

Infection.

Cervical ectropion - especially in those women taking the combined oral contraceptive (COC) pill.

Cervical or endometrial polyps.

Vaginal cancer.

Cervical cancer - usually apparent on speculum examination.

Trauma or sexual abuse.

Vaginal atrophic change.

Question 18

What are some iatrogenic causes of intermenstrual bleeding?

Answer 18

Tamoxifen.

Following smear or treatment to the cervix.

Missed oral contraceptive pills.

Drugs altering clotting parameters - eg, anticoagulants, selective serotonin reuptake inhibitors (SSRIs), corticosteroids.

Alternative remedies when taken with hormonal contraceptives - eg, ginseng, ginkgo, soy supplements, and St John’s wort.

Question 19

What are some causes of intermenstrual bleeding?

Answer 19

Pregnancy-related, including ectopic pregnancy and gestational trophoblastic disease.

Oestrogen-secreting ovarian cancers.

Question 20

What are some physiological causes of intermenstrual bleeding?

Answer 20

Vaginal spotting may occur at around the time of ovulation.

Hormonal fluctuation during the perimenopause (this should be a diagnosis of exclusion)

Question 21

What are some vaginal causes of intermenstrual bleeding?

Answer 21

Adenosis.

Vaginitis (bleeding uncommon before the menopause).

Tumours

Question 22

What are some cervical causes of intermenstrual bleeding?

Answer 22

Infection - chlamydia, gonorrhoea.

Cancer (but bleeding is most often postcoital).

Cervical polyps.

Cervical ectropion.

Condylomata acuminata of the cervix

Question 23

What are some uterine causes of intermenstrual bleeding?

Answer 23

Fibroids (occur in over 25% of women of reproductive age).

Endometrial polyps.

Cancer (endometrial adenocarcinoma, adenosarcoma and leiomyosarcoma).

Adenomyosis (usually only symptomatic in later reproductive years).

Endometritis

Question 24

What are the causes of breakthrough bleeding?

Answer 24

Unscheduled vaginal bleeding is common when a new contraceptive method is started and often settles without intervention

Question 25

What must be established in a menstrual history?

Answer 25

Last menstrual period - ask whether the last period was a 'normal' period. Regularity and cycle length. Duration of abnormal bleeding - discuss prolonged versus recent change. Presence of menorrhagia. Timing of bleeding in the menstrual cycle. Associated symptoms - eg, abdominal pain, fever, vaginal discharge, dyspareunia. Factors that aggravate bleeding - eg, exercise, intercourse

Question 26

What must be established in an obstetric history?

Answer 26

Previous pregnancies and deliveries, including time since last delivery/miscarriage/termination. Current breastfeeding. Risk of current pregnancy - increased, for example, with unprotected intercourse, forgotten pills or gastroenteritis. Risk factors for ectopic pregnancy - for example, a history of pelvic inflammatory disease or endometriosis, IVF treatment, use of an intrauterine contraceptive device (IUCD) or the POP

Question 27

What must be established in a gynaecological history?

Answer 27

Current use of contraception Smears - most recent test results, any previous smear abnormalities, colposcopy, treatment for abnormalities, etc. Previous gynaecological investigations or surgery

Question 28

What other history must be established when investigating abnormal bleeding?

Answer 28

Sexual history - risk factors for sexually transmitted infection (STI) in those aged <25 years, or at any age with a new partner or more than one partner in the preceding year; past history of and treatment for STIs. Medical history - eg, bleeding disorders, diabetes. Current medication (including unprescribed)

Question 29

What examinations can be done when investigating abnormal bleeding?

Answer 29

Establish (by history and examination) that the bleeding is from the vagina, not the rectum or in the urine BMI - RF for endometrial cancer Abdo exam - palpate for masses Lower genital tract examination (speculum and bimanual)

Question 30

What’s the appearance of Cervical ectropion (or erosion)?

Answer 30

red ring around the external os due to extension of the endocervical columnar epithelium over the ectocervix

Question 31

What’s the appearance of a cervical polyp?

Answer 31

mass arising from the endocervix, usually protruding through the external os into the vagina Occasionally, endometrial polyps can be seen extruding through the cervix

Question 32

What’s the appearance of cervicitis?

Answer 32

cervix appears red, congested and sometimes oedematous purulent discharge

Question 33

What investigations can be done for abnormal bleeding?

Answer 33

Pregnancy test Infection screen Blood tests- FBC, clotting, TFTs, FSH/LH level Transvaginal ultrasound- look for structural abnormality Endometrial biopsy if indicated NICE guidelines on heavy menstrual bleeding recommend hysteroscopy with endometrial biopsy

Question 34

What’s the management for abnormal bleeding?

Answer 34

2 week wait referral for suspected cancer Abx and contact tracing if infection Contraception- For persistent bleeding beyond the first three months' use, or where there is a change in bleeding pattern, or where a woman has not participated in a National Cervical Screening Programme, a speculum examination should be performed

Question 35

What are the two types of dysmenorrhea?

Answer 35

Primary - absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain Secondary - caused by an underlying pelvic pathology (such as endometriosis, fibroids, or pelvic inflammatory disease [PID]) or by intrauterine device (IUD) insertion

Question 36

What are some risk factors for primary dysmenorrhea?

Answer 36

earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea

Question 37

What are some features of primary dysmenorrhea?

Answer 37

usually starts 6–12 months after the menarche once cycles are regular The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses pain is usually lower abdominal but may radiate to the back and inner thigh Pelvic examination is normal

Question 38

What are some features of secondary dysmenorrhea?

Answer 38

often starts after several years of painless periods pain is not consistently related to menstruation and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation Other gynaecological symptoms (such as dyspareunia) are often present Pelvic examination may be abnormal, but normal findings do not exclude secondary dysmenorrhoea

Question 39

What are some clinical features that indicate a serious secondary cause of dysmenorrhoea?

Answer 39

Positive pregnancy test with vaginal bleeding. Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids). Abnormal cervix on examination. Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge

Question 40

Whats the management for primary dysmenorrhoea?

Answer 40

NSAIDs or paracetamol for pain relief Hormonal contraception Local application of heat

Question 41

What are some causes of primary amenorrhoea if secondary sexual characteristics are present?

Answer 41

Constitutional delay Genitourinary malformation - imperforate hymen, transverse vaginal septum or absence or uterus or vagina Testicular feminisation - XY, ambiguous genitalia, no internal female organs Hyperprolactinaemia - e.g. hypothyroidism, medication, pituitary tumour Pregnancy

Question 42

What are some causes of primary amenorrhoea if secondary sexual characteristics are NOT present?

Answer 42

Ovarian failure - due to chemo, irradiation or chromosomal gonadal abnormality e.g. turners Hypothalamic failure - chronic illness, excessive exercise, stress, significantly underweight Congenital adrenal hyperplasia (CAH) Ambiguous genitalia - androgen secretion tumours, 5 alpha - reductase deficiency

Question 43

What are some causes of the failure of the hypothalamic-pituitary axis?

Answer 43

Tumours, irradiation, infection or head injury involving the hypothalamus or pituitary Kallmann's syndrome: characterised by failure of secretion of gonadotropin-releasing hormone (GnRH), tumours of the hypothalamus or pituitary gland along with other causes of hypopituitarism and hydrocephalus Other syndromes including empty sella syndrome, Prader-Willi syndrome and Laurence-Moon syndrome

Question 44

What are some causes of secondary amenorrhoea if no sign of androgen excess?

Answer 44

Pregnancy, lactation and the menopause Premature ovarian failure Depot and implant contraception Cervical stenosis and intrauterine adhesions Hypothalamic dysfunction Loss of weight Pituitary disease and hyperprolactinaemia Thyroid disease Iatrogenic - hysterectomy etc Post-pill amenorrhoea- occurs when stopping oral contraceptives does not lead to a resumption of a normal menstrual cycle

Question 45

What are some signs of androgen excess?

Answer 45

Hirsutism Acne Virilisation

Question 46

What are some causes of secondary amenorrhoea if there’s signs of androgen excess?

Answer 46

PCOS Cushing’s syndrome Late-onset congenital adrenal hyperplasia Adrenal or ovarian carcinoma

Question 47

What history should be established when investigating amenorrhoea?

Answer 47

Duration of amenorrhoea. Contraception, recent and current. - need to exclude pregnancy too Vasomotor symptoms. Galactorrhoea. Exercise habits. Stresses. Medication history. Past medical history

Question 48

What examinations should be done to investigate amenorrhoea?

Answer 48

BMI examined for signs of excessive androgens (hirsutism, acne, temporal balding), thyroid disease and Cushing's syndrome Evaluation of the development of secondary sexual characteristics is required for primary amenorrhoea A vaginal, external genital and pelvic examination may be appropriate

Question 49

What investigations can be done for amenorrhoea?

Answer 49

Pregnancy test - urinary or serum hCG FSH and LH - raised in ovarian failure, high levels w/ short stature suggests turner’s, low levels suggest constitutional delay or hypothalamic cause e.g. weight loss Prolactin - pituitary causes Total testosterone and sex hormone-binding globulin - raised suggests androgen secreting tumour, or late onset CAH, raised in PCOS TFTs - low both suggests pituitary failure Pelvic ultrasound - check anatomy and investigate PCOS In some cases: karyotyping, mri or ct, hysteroscopy

Question 50

What’s the management of amenorrhoea?

Answer 50

HRT for premature ovarian failure Constitutional late puberty requires reassurance and waiting. Structural abnormalities may be amenable to surgery Prolactin corrected if possible Management of patients with Turner syndrome includes growth hormone for short stature and also identifying and monitoring any associated cardiac, renal and thyroid abnormalities. Give contraception testicular feminisation any residual gonadal tissue is removed to avoid the risk of malignancy Bone protection

Question 51

When should perimenopause be suspected?

Answer 51

There is an initial change to the menstrual pattern — the menstrual cycle length may shorten to 2–3 weeks or lengthen to many months. The amount of menstrual blood loss may change, and commonly increases slightly

Question 52

What symptoms are associated with menopause?

Answer 52

Hot flushes/ night sweats Cognitive impairment and mood disorders Urogenital symptoms - vulvovaginal irritation, burning, itching, dryness, dysuria, frequency, urgency Altered sexual function - reduced libido Sleep disturbances Joint and muscle pains, headaches, and fatigue

Question 53

When should FSH levels be used to diagnose menopause?

Answer 53

Aged over 45 years with atypical symptoms. Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle. Younger than 40 years with a suspected diagnosis of premature ovarian insufficiency Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate (DMPA)