Gynaecological Conditions Flashcards

Question

What must be established in a menstrual history?

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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)

Answer 5

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)

Answer 6

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

Answer 7

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

Answer 8

cervix appears red, congested and sometimes oedematous purulent discharge

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

Hirsutism Acne Virilisation

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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)