Gynaecological Conditions Flashcards
What is menarche?
The first menstrual cycle
What is menopause?
When menstrual cycle stops permanently
What is menorrhagia?
Heavy periods
What is metrorrhagia?
Vaginal bleeding that occurs outside of a normal menstrual period
What is oligomenorrhoea?
Irregular and infrequent menstrual periods
What is primary amenorrhoea?
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
What is secondary amenorrhoea?
The cessation of previously established menstruation for 3 cycles or for 6 or more months
What are some red flag symptoms for endometrial cancer?
-Blood glucose high with visible haematuria >55yrs
-Hb low with visible haematuria >55yrs
-Post menopausal bleeding
-Thrombocytosis with visible haematuria or vaginal discharge >55yrs
What are some red flag symptoms for vulval cancer?
-Vulval bleeding (unexplained) in women
-Vulval lump or ulceration (unexplained)
What’s some red flag symptoms for cervical cancer?
Appearance of cervix consistent with cervical cancer
What are some red flag symptoms for ovarian cancer?
-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
What are some red flag symptoms for vaginal cancer?
Vaginal mass (unexplained and palpable) in or at the entrance to the vagina
What marker is raised in ovarian cancer?
CA125
What is intermenstrual bleeding?
vaginal bleeding (other than postcoital) at any time during the menstrual cycle other than during normal menstruation
What is postcoital bleeding?
non-menstrual bleeding that occurs immediately after sexual intercourse
What is breakthrough bleeding?
irregular bleeding associated with hormonal contraception
What are some causes of postcoital bleeding?
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.
What are some iatrogenic causes of intermenstrual bleeding?
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.
What are some causes of intermenstrual bleeding?
Pregnancy-related, including ectopic pregnancy and gestational trophoblastic disease.
Oestrogen-secreting ovarian cancers.
What are some physiological causes of intermenstrual bleeding?
Vaginal spotting may occur at around the time of ovulation.
Hormonal fluctuation during the perimenopause (this should be a diagnosis of exclusion)
What are some vaginal causes of intermenstrual bleeding?
Adenosis.
Vaginitis (bleeding uncommon before the menopause).
Tumours
What are some cervical causes of intermenstrual bleeding?
Infection - chlamydia, gonorrhoea.
Cancer (but bleeding is most often postcoital).
Cervical polyps.
Cervical ectropion.
Condylomata acuminata of the cervix
What are some uterine causes of intermenstrual bleeding?
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
What are the causes of breakthrough bleeding?
Unscheduled vaginal bleeding is common when a new contraceptive method is started and often settles without intervention
What must be established in a menstrual history?
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
What must be established in an obstetric history?
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
What must be established in a gynaecological history?
Current use of contraception
Smears - most recent test results, any previous smear abnormalities, colposcopy, treatment for abnormalities, etc.
Previous gynaecological investigations or surgery
What other history must be established when investigating abnormal bleeding?
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)
What examinations can be done when investigating abnormal bleeding?
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)
What’s the appearance of Cervical ectropion (or erosion)?
red ring around the external os due to extension of the endocervical columnar epithelium over the ectocervix
What’s the appearance of a cervical polyp?
mass arising from the endocervix, usually protruding through the external os into the vagina
Occasionally, endometrial polyps can be seen extruding through the cervix
What’s the appearance of cervicitis?
cervix appears red, congested and sometimes oedematous
purulent discharge
What investigations can be done for abnormal bleeding?
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
What’s the management for abnormal bleeding?
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
What are the two types of dysmenorrhea?
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
What are some risk factors for primary dysmenorrhea?
earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea
What are some features of primary dysmenorrhea?
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
What are some features of secondary dysmenorrhea?
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
What are some clinical features that indicate a serious secondary cause of dysmenorrhoea?
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
Whats the management for primary dysmenorrhoea?
NSAIDs or paracetamol for pain relief
Hormonal contraception
Local application of heat
What are some causes of primary amenorrhoea if secondary sexual characteristics are present?
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
What are some causes of primary amenorrhoea if secondary sexual characteristics are NOT present?
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
What are some causes of the failure of the hypothalamic-pituitary axis?
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
What are some causes of secondary amenorrhoea if no sign of androgen excess?
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
What are some signs of androgen excess?
Hirsutism
Acne
Virilisation
What are some causes of secondary amenorrhoea if there’s signs of androgen excess?
PCOS
Cushing’s syndrome
Late-onset congenital adrenal hyperplasia
Adrenal or ovarian carcinoma
What history should be established when investigating amenorrhoea?
Duration of amenorrhoea.
Contraception, recent and current. - need to exclude pregnancy too
Vasomotor symptoms.
Galactorrhoea.
Exercise habits.
Stresses.
Medication history.
Past medical history
What examinations should be done to investigate amenorrhoea?
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
What investigations can be done for amenorrhoea?
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
What’s the management of amenorrhoea?
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
When should perimenopause be suspected?
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
What symptoms are associated with menopause?
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
When should FSH levels be used to diagnose menopause?
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)
