Gynaecology Flashcards
Common features of PCOS
Excessive androgens
Hirsutism (excessive hair)
Infrequent periods
Ovarian cysts on imaging
Obesity Acne Subfertility Chronic pelvic pain Depression
Investigations for PCOS
Rotterdam criteria (2/3 present):
Multiple ovaries (12 or more >10cm)
Infrequent or no periods
Clinical or biochemical signs of hyperandrogenism
Bloods - testosterone (raised), LH (raised), FSH (normal), Progesterone (low),
Imaging - US
Also - thyroid (rule out hypothyroidism), prolactin (hyperprolactinaemia)
Management of PCOS
Infrequent periods - Induce bleeding (otherwise unopposed oestrogen will cause endometrial thickening) - using COCP or a progesterone analogue
Weight loss - can induce normal menstrual cycle. Orlistat in severe cases
Infertility - Clomifene and metformin can induce ovulation. Consider laparoscopic ovarian drilling
Hirsutism - Cosmetically, anti-androgen medication
Treat complications - diabetes, psych problems, dyslipidaemia
Causes of menorrhagia
PALM COEIN
Polyp Adenomyosis Leiomyoma (fibroid) Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic - hormones, IUD Not classified yet
Investigations of menorrhagia
Bloods: FBC - anaemia U+E's and LFTs - underlying liver problem? blood loss can affect electrolyte levels Thyroid - underactive? Other hormones - if PCOS suspected Coagulation and test for VWD
Imaging:
Transvaginal US (especially if palpable uterus or pelvic mass)
Cervical smear - if not up to date
High vaginal and enocervical swabs (infection)
Pipelle endometrial biopsy
Management of menorrhagia
Treat cause
Conservative - iron supplements, analgesia
Levongestrol-releasing system (mirena)
Other pharmacological treatment - Tranexamic acid, mefanamic acid (taken during bleeding)
Surgical - Endometrial ablation or hysterectomy
What is a threatened miscarriage? Features
Continuing pregnancy with bleeding
Some bleeding (less than menstruation) Cervical os is closed
What is a delayed or missed miscarriage? Features
Gestation sack contains dead fetus, before 20 weeks
Without symptoms of expulsion
Mothers may have light vaginally bleeding
Pain usually not a feature
Cervical os closed
What is a inevitable miscarriage? Features
Heavy bleeding with clots and pain
Cervical os is open
What is an incomplete miscarriage? Features
Not all products expelled
Pain and bleeding
Cervical os is open
Management of miscarriage
Expectant - wait for miscarriage. Appropriate if not much bleeding. Appropriate for incomplete. Rescan in 2 weeks
Medical - vaginally misoprostal
Surgical - heavy or persistant bleeding. Suction or gen surg
What are predisposing factors for an ectopic pregnancy?
Anything that slows ovum's passage to the uterus. Damage to the tubes - PID, previous surgery Previous ectopic Endometriosis IUCD POP Subfertility IVF Smoking
Where are most ectopic implanted?
Ampulla of the tubes
Management of ectopics
Expectant, medical or surgical
Stable women should be offered expectant or medical - asymptomatic, hCG <3000. Ectopic <3cm, no fetal activity. No haemoperitoneum
Expectant - must have falling hCG
Medical - methotrexate single dose
Surgical - laporoscopy, salpingectomy/otomy
Fibroid presentation
Asymptomatic Menorrhagia - do not usually cause intermenstrual of postmenopausal bleeding Anaemia Fertility problems Pain Mass
Complications of fibroids
Red degeneration - their growth can outstrip blood supply - they are oestrogen sensitive and so grow in pregnancy
Pregnancy - enlargement 2nd trimester
Torsion
Treatment or uterine fibroids
Minimal symptoms = no treatment needed
Levonogestrel-releasing IUS - first line
GnRH analogues - Goserelin
Ullipristal acetate- selective progesterone recepyor modulator
Myomectomy - only treatment to improve fertility
Uterine artery embolization
Hysterectomy
Presentation of endometriosis
Pelvic pain - cyclical due to response from menstrual cycle Dysparanuia Dysuria Pain of defecation Subfertility No symptoms
Investigations for endometriosis
Transvaginal US
Bowel involvement - MRI
Gold standard - laparoscopy with biopsy
Adenomyosis - mri is gold standard
Treatment of endometriosis
Depends on symptoms severity
NSAIDs for symptoms
Empirical - COCP of progestogen if fertility not an issue (if analgesics worked)
IVF
GnRH analogues (if analgesics didn’t work)
Surgery - if medical management failed
Causes of subfertility
Male factor Tubular damage Anovulation- premature ovarian failure, turners, chemotherapy, surgery, PCOS, excessive weight gain or loss Unexplained Fibroids Endometriosis
Investigations and advice for subfertility
Semen analysis
Serum progesterone 7 days prior to expected next period (day 21 in 28 day cycle)
Folic acid
Advise BMI 20-25
Advise regular intercourse
Smoking/drinking
What medication is used in management of ectopic
Methotrexate
Causes of PID
Ascending infection - chlamydia, uterine instrumentation, post-partum
Can descend - appendicitis
Features of PID
Lower abdominal pain associated with vaginal discharge Fever Dyspareunia Intermenstrual or postcoital bleeding Dysmenorrhoea Cervical motion tenderness
Pelvic inflammation secondary to chlamydia (Fitz Hugh Curtis syndrome) - RUQ discomfort
Investigations for PID
Vulvovaginal swabs
FBC
CRP
Blood cultures if sepsis
Management of PID
Outpatient - ceftriaxone 500 mg Station or azithromycin plus doxycycline for 14 days and metronidazole 400 mg for 14 days
Inpatient - ceftriaxone IV plus doxycycline
Contact tracing
Oral ofloxacin and oral metronidazole or
IM ceftriaxone + oral doxycycline + oral metronidazole
