Gynaecological Problems Flashcards
What is the average menstrual cycle length?
28 days (but normal if between 21-35 days)
How long does the luteal phase usually last?
14 days
What is the normal cycle length range for the follicular stage?
10 to 16 days
What does gonadotropin-releasing hormone (GnRH) control?
pituitary hormone secretion
What are the 3 events/phases that occur in the menstrual cycle called?
follicular phase, ovulation and luteal phase
Which two types of cells within the follicle are responsible for oestrogen and progesterone synthesis? and what do these cells respond to?
theca cells (respond to LH) granulosa cells (respond to FSH)
What are the 3 most important hormones that are needed to generate a normal menstrual cycle?
FSH, LH and oestrogen
As the follicles grow, there is a ____ feedback by both oestrogen and _____ on the pituitary to decrease ____ secretion.
negative
inhibin
FSH
Which follicle is most likely to survive as FSH levels drop during the negative feedback loop?
the follicle with the most efficient aromatase activity and highest concentration of FSH-induced LH receptors.
This follicle will become the dominant follicle and continue its development towards ovulation.
What does activin do?
Works to increase FSH binding in the follicles
How do the ovaries prepare for ovulation?
FSH induces LH receptors on the granulosa cells to compensate for lower FSH levels.
Production of oestrogen increases until it exerts a positive feedback loop which causes the LH surge.
What principle is used in ovulation predictor tests?
LH surge is the best predictor of imminent ovulation
How long after the LH surge does ovulation happen?
12 hours
What happens to the remaining granulosa and theca cells after release of the oocyte?
they form the corpus luteum
which hormone does the corpus luteum secrete?
progesterone
what do high levels of progesterone do?
suppress FSH and LH secretion
What happens to the corpus luteum in the absence of beta human chorionic gonadotrophin?
it will undergo luteolysis and regress. this results in a decrease in progesterone secretion which results in the endometrium shedding and menstruation happening.
What test is used to check for ovulation?
mid-luteal progesterone level - this test is done 7 days before expected menses
What does menorrhagia mean?
prolonged or increased (>80ml per period) menstrual flow
which does metrorrhagia mean?
regular intermenstrual bleeding
what does polymenorrhea mean?
menses occurring at <21 day intervals
what does polymenorrhagia mean?
increased bleeding and frequent cycle
what does menometrorrhagia mean?
prolonged menses and intermenstrual bleeding
what does amenorrhea mean?
absence of menstruation >6months
what does oligomenorrhea mean?
menses at intervals of >35 days or presence of five or less menstrual cycles a year.
what are some causes of menorrhagia/heavy menstrual bleeding?
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, systemic causes
What is dysfunctional uterine bleeding?
menorrhagia in the absence of pathology
what are some investigations which can be performed in the presence of menorrhagia?
FBC, TFT, coagulation screen, renal/liver tests, transvaginal US, endometrial sampling, cervical smear
What are the management options for dysfunctional uterine bleeding?
- progesterone releasing IUCD (Mirena IUS)
- COCP
- antifibrinolytics (tranexamic acid)
- NSAIDs (e.g. mefenamic acid)
- oral progestogens
- GnRH analogue/agonists
- Danazol
if all else fails then consider surgery (endometrial resection/ablation) or hysterectomy
What are some causes of intermenstrual bleeding?
cervical ectropion, PID and STD, polyps, cancer, pregnancy, hyatidiform molar disease
what is premenstrual syndrome?
occurrence of cyclical somatic, psychological and emotional symptoms that occur in the luteal phase of the menstrual cycle and resolve by the time menstruation ceases
What are the clinical features of premenstrual syndrome?
bloating cyclical weight gain mastalgia (breast pain) abdominal cramps fatigue headache depression changes in appetite and increased cravings irritability
What are the treatment options for PMS?
- severe symptoms may be treated with SSRIs
- CBT
- lifestyle changes
- COCP, transdermal oestrogen, short-term GnRH Analogues
- last resort = surgery
What are some causes of post-coital bleeding?
cervical ectropion cervical carcinoma trauma atrophic vaginitis cervicitis secondary to STD polyps idiopathic
What are the causes of post-menopausal bleeding?
atrophic vaginitis, endometrial polyps endometrial hyperplasia endometrial carcinoma cervical carcinoma ovarian cancer vaginal cancer
What is the first-line investigation for post-menopausal bleeding?
transvaginal ultrasound
What are the treatment options for atrophic vaginitis?
topical oestrogen and vaginal lubricants. can also consider HRT
How is endometrial hyperplasia treated?
dilatation and curettage, progesterone treatment (mirena IUS first line)
What is the most common cause of menstrual irregularities?
polycystic ovarian syndrome (PCOS)
What are the 3 key features of PCOS we use to diagnose?
- clinical/biochemical evidence of hyperandrogenism
- polycystic ovaries on USS
- oligo/amenorrhea
What are the clinical features of PCOS?
obesity/overweight hypertension acanthosis nigricans acne hirsutism alopecia insulin resistance irregular periods
What are the hormonal changes seen in PCOS?
increased LH:FSH ratio
LH levels high and FSH levels low or normal
What are the treatment options for PCOS patients who are infertile?
lifestyle advice clomifene metformin ovarian drilling gonodotrophin injections
What is the medical term for painful periods?
dysmenorrhea
What are some causes of dysmenorrhea?
primary dysmenorrhea (no underlying cause, just physiological) endometriosis adenomyosis PID intrauterine devices fibroids
Which condition would be indicated if a patient had a ‘bulky uterus’?
adenomyosis
What investigations could be used for dysmenorrhea?
High vaginal and endocervical swabs
pelvic USS
diagnostic laparoscopy
What are management options for dysmenorrhea?
NSAIDs
COCP
levonogestrel intrauterine system
GnRH analogues
What is primary amenorrhea?
failure of menstruation by 16 years of age
what are some causes of primary amenorrhea?
genital tract abnormalities mullerian agenesis premature ovarian failure genetic causes hypothalamic disorders iatrogenic autoimmune endocrine pituitary disorders
what are some causes of secondary amenorrhea?
hypothalamic disorders autoimmune pituitary iatrogenic endocrine abnormalities ashermann's syndrome physiological causes
What investigations should be performed if patient presents with amenorrhea?
general examination,
visual field tests, examination of external genitalia
urine or serum bHCG
What is the climateric period?
the period around the beginning of the menopause (also called perimenopause)
At what age is menopause considered premature?
under 45 years
What are the physical effects of menopause?
vasomotor symptoms joint pains dry and itchy skin hair changes vaginal dryness recurrent UTI urogenital prolapse osteoporosis cardiovascular disease dementia
what are the psychological effects of menopause?
labile mood, anxiety, tearfulness, loss of concentration, poor memory, loss of libido
what is the main management option for menopause?
HRT
Side effects of HRT?
breast enlargement leg cramps dyspepsia fluid retention nausea headaches fluid retention breast tenderness acne mood swings depression irritability constipation increased appetite
What risks are associated with HRT?
breast cancer
venous thromboembolism
endometrial cancer
What are absolute contraindications of HRT?
suspected pregnancy breast cancer endometrial cancer active liver disease uncontrolled hypertension known VTE known thrombophilia otosclerosis
What are some causes of vulval pruritus?
skin conditions (eczema, psoriasis etc) lichen sclerosus lichen planus infection extramammary paget's disease of the vulva
How does lichen sclerosis present?
- pruritus
- skin irritation on the vulva
- hypopigmentation
- atrophy of the skin
- hair loss in affected area
- affected area bleeding
- pinpoint vessels visible
- white polygonal papules that coalesce to form plaques
what are some complications of lichen sclerosis?
atrophy and fusion of the labia
stenosis of the introitus
difficulty defecation
development of vulvar intraepithelial neoplasia (VIN)
What are the treatment options of lichen sclerosis?
topical high-dose steroids and emollients
what does normal vaginal discharge look like?
clear and appears white/pale yellow and typically odourless
which microorganism is part of the normal vaginal flora?
lactobacilli
what are some causes of abnormal discharge?
bacterial vaginosis
vulvovaginal candidiasis
STD
trichomoniasis
what are the risk factors associated with pelvic infection?
- age <25years
- multiple sex partners
- unprotected sex
- recent insertion of IUD
- recent change in sexual partner
How might a pelvic infection due to PID present?
- irregular menstrual bleeding
- abnormal vaginal discharge
- chronic pelvic pain
- infertility
what signs on examination may you find with pelvic infection?
cervical motion tenderness
adnexal tenderness
How are pelvic infections treated?
- if acutely unwell then sepsis 6
- partner notification
- oral ofloxacin + oral metronidazole + IM ceftriaxone + doxycycline
what is the most common type of ovarian cyst?
functional ovarian cysts (follicular, corpus luteal and theca luteal cysts)
what are bartholin cysts/abscesses?
when the bartholin glands become infected and enlarged (located at the 5 and 7 o’clock position next ti vagina entrance)
How are bartholin cysts treated?
antibiotics
surgical procedure called marsupialization
what should be your first step if a female patient of reproductive age presents with acute abdominal pain?
pregnancy test
what are the signs and symptoms of uterine fibroids?
- asymptomatic
- menorrhagia and dysmenorrhea
- lower abdominal pain during menstruation
- subfertility
- pressure symptoms
how are uterine fibroids diagnosed?
transvaginal ultrasound
How are uterine fibroids managed?
- mirena IUS
- myomectomy
- hysterectomy
- short-term GnRH analogues
- uterine artery embolisation
what are the signs and symptoms of endometriosis?
- dysmenorrhea
- deep dyspareunia
- subfertility
- dysuria
- urgency
- dyschezia
How is endometriosis diagnosed?
- via laproscopy
- on pelvic exam - tender nodularity on posterior fornix
how is endometriosis managed?
- symptomatic relief (NSAIDs)
- COCP or progestogens
- surgery
What are the signs and symptoms of ovarian torsion?
- sudden onset of deep colicky pain
- vomiting and distress
- adnexal tenderness/ acute abdomen
how is ovarian torsion diagnosed?
USS will show classical whirlpool sign
how is ovarian torsion managed?
laparoscopy to untwist ovary and remove cyst. if ovary necrotic then removed.
what are the signs and symptoms of PID?
vaginal discharge
bilateral lower abdominal pain
what investigations are used to diagnose PID?
FBC
high vaginal or endocervical swabs
How is PID managed?
antibiotics
what are the signs and symptoms of mittelsczmerz?
mid cycle pain
often (every cycle)
