Gynaecology Flashcards
What is primary amenorrhoea?
Not starting menstruation
- by 13 years old if no evidence of pubertal development
- by 15 years old if other signs of puberty
What is the normal age for puberty starting?
Girls age 8-14
Boys age 9-15
What is hypogonadism?
A lack of sex hormones - oestrogen and testosterone which normally rise before and during puberty. A lack of these hormones can delay puberty.
What is hypo vs hypergonadotropic hypogonadism?
Hypo - a deficiency in LH and FSH
Hyper - a lack of response to LH and FSH by the gonads
What can cause a deficiency in LH and FSH?
Hypopituitarism Damage to the hypothalamus or pituitary Excessive exercise or dieting Endocrine disorders (e.g. GH deficiency, Cushings, hypothyroidism or hyperprolactinaemia) Some chronic conditions such as IBD Kallmann syndrome
What is kallmann syndrome?
A genetic condition that causes hypogonadotropic hypogonadism, hence stopping puberty. It is associated with a reduced or absent sense of smell (anosmia)
What can cause a failure of the gonads to respond LH and FSH (hypergonadotropic hypogonadism)?
Previous damage to the gonads - e.g. infections Congenital absence of the ovaries Turners syndrom (XO)
What is turner’s syndrome?
A genetic condition where a female only has one X chromosome. It most commonly affects height and sexual development.
What is congenital adrenal hyperplasia?
A autosomal recessive congenital deficiency that causes underproduction of cortisol and aldosterone as well as overproduction of androgens. This can impact growth and puberty as well as electrolyte and glucose balance.
How may a female with congenital adrenal hyperplasia present?
Tall for their age Facial hair Absent periods (primary amenorrhoea) Deep voice Early puberty
What is androgen insensitivity syndrome?
A condition (where the tissues are unable to respond to androgen hormones (testosterone) meaning male sexual characteristics do not develop even thought they are genetically male (XY). This leads to a female phenotype giving external genitalia and breast tissue even though internally there is testes and absent female reproductive organs
Name some causes of primary amenorrhoea
Hypogonadism (lack of sex hormones) Kallman syndrome Congenital adrenal hyperplasia Androgen insensitivity syndrome Structural pathology
What structural pathologies can cause primary amenorrhoea?
Imperforate hymen Transverse vaginal septae Vaginal agenesis (absence) Absent uterus FGM
How is someone presenting with primary amenorrhoea assessed?
Bloods - FBCs, U+Es, coeliacs, FSH/LH levles, thyroid function tests, ILGF1 , prolactin levels, testosterone levels.
Genetic testing
Imagine - e.g. to assess growth delay or look for specific pathology
In what ways can primary amenorrhoea be treated?
Depends on the cause.
- may need replacement hormones - such as pulsatile GnRH or the COCP
- reassurance and observation if constitutional delay.
- or other specific treatments if necessary
What is secondary amenorrhoea?
No menstruation for > 3 mnths after previous regular periods
OR
No menstruation for > 6 mnths after previous infrequent irregular periods
What can cause secondary amenorrhoea?
Pregnancy Menopause + premature ovarian failure Hormonal contraception Hypothalamic or pituitary pathology Ovarian causes - e.g. PCOS Uterine pathologies - e.g. Asherman's syndrome Thyroid pathology Hyperprolactinaemia Excess exercise Low body weight / eating disorders Stress
What is hyperprolactinaemia, what causes it, and how is it managed?
High prolactin levels act on the hypothalamus to prevent release of GnRH, hence stopping release of LH and FSH. This causes amenorrhoea. It can also cause galactorrhea (breast milk production and secretion).
Most common cause is a prolactin secreting pituitary adenoma.
Can use dopamine agonists to reduce prolactin release (e.g. bromocriptine)
What assessment is done for someone with secondary amenorrhoea?
Pregnancy test!! Hormonal blood tests - LH and FSH levels - Thyroid levels - prolactin levels - testosterone levels Ultrasound of the pelvis (looking for PCOS)
What is the likely cause of secondary amenorrhoea if someone has a high FSH?
Primary ovarian failure ( as low oestrogen levels stimulate more GnRH and therefore FSH + LH)
What is the likely cause of secondary amenorrhoea if someone has a high LH: FSH ratio?
PCOS (unknown exactly why but is thought to be to do the pulsatile release of LH being greater)
Can read - https://med.virginia.edu/research-in-reproduction/patient-information/causes-of-pcos/
What can high testosterone levels in someone with secondary amenorrhoea indicate?
PCOS
Androgen insensitivity syndrome
Congenital adrenal hyperplasia
What is a complication of secondary amenorrhoea?
Osteoporosis (so give Vit D, calcium of hormonal replacement / COCP)
What is premenstrual syndrome (PMS)?
Psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle - particular the few days leading up to menstruation.
How does PMS present?
Varies between everyone but can include
- low mood
- anxiety
- mood swings
- irritability
- bloating
- fatigue
- headaches
- breast pain
- reduced libido
How can PMS be managed?
General healthy lifestyle changes - improving diet, exercise, smoking, stress and sleep. COCP SSRI antidepressants CBT (cognitive behavioural therapy) Specific treatments for certain symptoms
What is menorrhagia?
Heavy menstrual bleeding.
How is menorrhagia diagnosed?
More than 80ml of blood loss - normally based on changing pads every 1-2 hours, bleeding lasting more than 7 days and passing large clots.
What can cause menorrhagia?
Dysfunctional uterine bleeding (unknown cause) Fibroids Endometriosis and adenomyosis PID (pelvic inflammatory disease) PCOS (polycystic ovarian syndrome) Contraceptives - particularly the copper coil (IUD) Anticoagulant medications Bleeding disorders Endocrine disorders Connective tissue disorders Endometrial hyperplasia / cancer
What is adenomyosis?
A condition where there is endometrial tissue inside the myometrium (muscular layer). This causes enlargement of the uterus and can lead to dysmenorrhoea and menorrhagia.
What is endometriosis?
When ectopic endometrial tissue grows in places other than the uterus such as the ovaries and fallopian tubes. This is known as an endometrioma.
What are key things to ask about when taking a history for a gynaecological problem?
Age at menarche Cycle length, regularity and menses length If there is any intermenstrual or post coital bleeding Contraceptive history Sexual history Possibility of pregnancy Plans for future pregnancies Cervical screening history PMH, DH, SH (smoking and alcohol), FH
What investigations can be done for menorrhagia?
Speculum and bimanual examination
FBCs to look for iron deficiency anaemia
Hysteroscopy (if suspected fibroids, cancer etc)
Pelvic and transvaginal ultrasound (is suspected large fibroids or adenomyosis)
More specific tests include:
Swabs for signs of infections
Coagulation screening
Thyroid function tests
