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
What is overactive bladder / urge incontinence
Due to detrusor overactivity
What is stress incontinence
Leaking small amounts when coughing or laughing
What is overflow incontinence
Due to bladder outlet obstruction (prostate enlargement)
Invesrigations of urinary incontinence
Bladder diaries
Vaginally exam - rule out prolapse
Urine dipstick and culture
Urodynamic studies
Management or urge incontinence
Bladder retraining for minimum of 6 weeks
Anti-muscarinics - oxybutynin, tolterodine
Management of stress incontinence
Pelvic floor muscle training - 8 contractions x 3 daily for minimum 6 months
Surgical procedures
Duloxetine
What is high in a molar pregnancy
Ridiculously high bHCG
Causes of primary amenorrhoea
Gonadal dysgenesis (turners syndrome)
Congential malformations of genital tract
Functional hypothalamic amenorrhoea (secondary to anorexia)
Congenital adrenal hyperplasia
Causes of secondary amenorrhoea
Hypothalamic amenorrhoea (secondary to stress, exercise) PCOS Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis Sheehan's syndrome
Investigations in amenorrhoea
Exclude pregnancy FBC U&Es, coeliac screen, TFTs Gonadotrophins - low levels = hypothalamic cause, raised = ovarian problem (ovarian failure) raised in turners Prolactin Androgen - raised in PCOS Oestradiol
Most common presenting complaint in endometrial cancer
Postmenopausal bleeding
Management of endometrial hyperplasia
Progesterones
Mirena coil
Levonorgestrel
Risk factors for endometrial cancer
Unopposed oestrogen
Obesity Diabetes Increased age Late menopause Oestrogen HRT No or few pregnancies PROS Tamoxifen Lynch syndrome
Presentation of endometrial cancer
Postmenopausal bleeding Postcoital bleeding Intermenstrual bleeding Heavy period Abnormal vaginal discharge Haematuria Anaemia Raised platelets
Management of endometrial cancer
Refer - urgent
Surgery - radical hysterectomy with bilateral salpingo-oophorectomy
Also consider radio / chemotherapy
Progesterone therapy
Investigations for endometrial cancer
Transvaginal US (5mm cut off) Pipelle biopsy Hysteroscopy with endometrial biopsy
Risk factors for ovarian cancer
Age (peaks at 60) BRCA1 and BRCA2 Increased ovulation Obesity Smoking Late menopause No pregnancy
Pregnancy decreases the risk of what cancer?
Endometrial
Ovarian
Presentation of ovarian cancer
Non-specific symptoms IBS Abdominal bloating Loss of appetite Pelvic pain Urinary symptoms Weight loss Ascites Abdo or pelvic mass
Investigations of ovarian cancer
Urgent referral CA125 Pelvic US CT - establish diagnosis and stage Histology - CT guided biopsy Ascitic tap Diagnostic laparotomy
Presentation of ovarian torsion
Sudden onset one sided pelvic pain Gets worse Associated nausea and vomiting Tenderness Mass
Investigagions of ovarian torsion
Emergency admission
Pelvic US
Laparoscopic surgery
Causes of premature ovarian failure
Idiopathic - most common, may be FHx Bilateral oophorectomy Radiotherapy Chemotherapy Infection - mumps / TB Autoimmjne disorders - coeliac, adrenal insufficiency, T1DM, thyroid
Presentation of premature ovarian failure
Irregular menstrual periods
Lack of menstrual periods (secondary amenorrhoea)
Symptoms of low oestrogen levels - hot flushes, night sweats, vaginally dryness
Diagnosis of premature ovarian failure
Less than 40, menopausal symptoms, elevated FSH
Risks of premature ovarian failure
Related to lack of oestrogen CVD stroke Osteoporosis Cognitive impairment Dementia Parkinsonism
Management of premature ovarian failure
HRT until normal age of menopause
When are you called for cervical screening?
25-49 - every 3 years
50-65 - every 5 years
How is cervical screening performed?
Screened for HPV
Then looked at for cytology (cellular changes)
If cytology abnormal - colposcopy
First line management of urge incontinence
Bladder retraining
First line management of stress incontinence
Pelvic floor muscle training
What is a severe complication of infertility treatment
Ovarian hyperstimulation syndrome
Someone undergoing a hysterectomy for fibroids might take what short term medication?
GnRH agonists - goserelin
Uterine fibroid <3cm and not distorting the uterine cavity can be managed how?
IUS (medical management
Pelvic pain, dysmenorrhoea, dyspareunia and subfertility should point to what diagnosis?
Endometriosis
Most common benign ovarian tumour in women <25 years old
Dermoid cyst
Most common ovarian pathology found in meigs syndrome
Fibroma
Most common cause of ovarian enlargement in reproductive age
Follicular cyst
Symptoms of ruptured ovarian cyst
Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
Raised FSH/LH in primary amenorrhea, consider what?
Gonadal dysgenesis (turners syndrome)
Lynch syndrome is risk factor for what?
Endometrial cancer
Gold standard invesrigation for endometriosis
Laparoscopy
