Gynaecological problems 1

Question 1

What occurs on day 1-4 of the menstrual cycle?

Answer 1

menstruation

endometrium is shed 
myometrial contraction (poss pain due to vasopressin receptors)

Question 2

What occurs on day 5-13 of the menstrual cycle?

Answer 2

GnRH (hypothalamus) stimulate LH+FSH
Follicular growth
Follicles produce oestradiol + inhibin
FSH secretion suppressed so only one follicle/oocyte matures
Oestradiol rises
LH rises - ovulation follows 36 hours after
Endometrium reforms, thickens when stromal cells proliferate + glands elongate

Question 3

What happens on day 14-28 of the menstrual cycle?

Answer 3

Follicle become corpus luteum
Oestradiol and Progesterone = secondary changes in endometrium
Corpus luteum fails if eggs not fertilised
Progesterone and oestradiol
Endometrium breaks down

Question 4

How are menstrual disorders managed?

Answer 4

FBC
Pelvic US
Sometimes endometrial biopsy and hysterectomy if intermenstrual bleeding/thickened/irregular endometrium/ ages >40

Question 5

What is the medical treatment for menstrual disorders?

Answer 5

reduce volume (IUS/tranexamic acid/mefanamic acid/combined contraceptive)

Question 6

What is the surgical treatment for menstrual disorders?

Answer 6

hysteroscopic surgery
hysterectomy
myomectomy/embolization if fibroids

Question 7

What is menarche?

Answer 7

onset of menstruation

last stage of puberty in females
on average 13 years
may be irregular at first

Question 8

What is precocious puberty?

Answer 8

if menstruation occurs before 10/other secondary sexual characteristics before 8

Question 9

What are the causes of precocious puberty?

Answer 9

increased GnRH due to meningitis
encephalitis
CNS tumours
hydrocephaly and hyperthyroidism/ increased oestrogen secretion due to tumours

Question 10

What is menopause?

Answer 10

permanent cessation of menstruation resulting from loss of ovarian follicular activity
median age 51 years

Question 11

What is defined as premature menopause?

Answer 11

menopause occurring before the age of 40

Question 12

What are the causes of premature menopause?

Answer 12

usually no cause
surgical menopause - if bilateral oophorectomy 
infections 
autoimmune disorders 
chemotherapy 
ovarian dysgenesis 
metabolic diseases

Question 13

How is premature menopause managed?

Answer 13

HRT until at least 50

Oocyte donation for fertility

Question 14

What are the symptoms of menopause?

Answer 14

vasomotor symptoms - hot flushes and night sweats
Urogenital problems - vaginal atrophy causing dyspareunia, cessation of sexual activity, itching, burning and dryness
urinary symptoms - frequency, urgency, nocturia, incontinence
sexual problems
osteoporosis

Question 15

What are the RFs for osteoporosis after menopause?

Answer 15

parental history of fracture 
early menopause 
chronic use of corticosteroids 
prolonged immunisation 
prior fracture 
diseases - RA, NM disease

Question 16

Why is osteoporosis common after menopause?

Answer 16

compromised bone strength predisposes to increased risk of fracture

Question 17

What are the different types of HRT that can be given?

Answer 17

Oestrogen
Progesterone
Tibolone
Androgens

Question 18

How can oestrogen be given as part of HRT?

Answer 18

orally
transdermally
subcutaneously
topically

Question 19

How can progesterone be given as part of HRT?

Answer 19

cyclically or continuously with oestrogen

orally, patch, IUS

Question 20

How is tibolone given as part of HRT?

Answer 20

synthetic steroid compound
used in post menopausal women who desire amenorrhoea and treats
conserves bone mass and reduces risk of vertebral fracture

Question 21

What androgens can be used in post menopausal women?

Answer 21

testosterone administered either as a patch or submit implant
used to improve libido but not successful in all women

Question 22

What are the benefits of HRT?

Answer 22

treat hot flushes within 4 weeks 
vaginal dryness, soreness, pain, urinary frequency and urgency respond well to oestrogen 
sexuality may be improved
osteoporosis - reduced fracture risk 
reduces risk of colorectal cancer

Question 23

What are the risks of HRT?

Answer 23

Breast cancer - increased risk if combined
Endometrial cancer - increased risk if oestrogen only
VTE - increased risk
Gall bladder - increased risk

Question 24

What are the causes of post menopausal bleeding?

Answer 24

endometrial carcinoma 
endometrial hyperplasia 
cervical carcinoma 
atrophic vaginitis 
cervicitis 
ovarian carcinoma 
cervical polyps

Question 25

What are the basic investigations for post menopausal bleeding?

Answer 25

bimanual and speculum examination
cervical smear
transvaginal (TVS) sonography
if thickened/multiple bleeds then endometrial biopsy and hysterectomy

Question 26

What is the initial management for postmenopausal bleeding?

Answer 26

dependent on cause
removal of cervical polyps
endometrial atrophy - treat with oestrogen cream/pessaries
endometrial hyperplasia - IUS/hysterectomy
HRT - stop after treatment

Question 27

Describe normal vaginal discharge?

Answer 27

physiological discharge common and non offensive

increased at ovulation, pregnancy and when taking OCP
cervical everyone and ectropion may cause discharge

Question 28

What are the pathological causes of vaginal discharge?

Answer 28

• bacterial vaginosis - treat with abx
• candidiasis - treat with imidazole
• chlamydial infection
• gonorrhoea
• trichomonas vaginalis - treat with abx
• atrophic vaginitis - due to oestrogen deficiency so common before menarche, after menopause and during lactation
• foreign body - retained tampons and swabs after childbirth (offensive discharge)
• malignancy - cervical carcinoma (bloody and offensive discharge - biopsy)