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
How can menorrhagia be managed?
Exclude underlying pathologies - if known cause then treat this.
Tranexamic acid - when no associated pain (antifibrinolytic)
Mefenamic acid (NSAID)
Mirena coil (first line if want contraception)
COCP
If appropriate refer to secondary care - e.g. for endometrial ablation or hysterectomy.
What are risk factors for developing adenomyosis?
Later reproductive years
Multiparous - after several pregnancies
How does adenomyosis present?
Dysmenorrhoea (painful periods)
Menorrhagia (heavy periods)
Dyspareunia (pain during intercourse)
May also present with infertility or pregnancy complications.
On examination can show enlarged or tender uterus.
How is adenomyosis diagnosed?
Transvaginal ultrasound (or MRI or transabdominal ultrasound)
How is adenomyosis managed?
Same treatment as for menorrhagia:
Tranexamic acid - when no associated pain (antifibrinolytic)
Mefenamic acid (NSAID)
Mirena coil (first line if want contraception)
COCP
Cyclic oral progesterone or progesterone only medications
GnRH analogues
Specialist options - endometrial ablation, uterine artery embolisation, hysterectomy
What are some complications of adenomyosis in pregnancy?
- Infertility
- Miscarriage
- Preterm birth
- Small fetus for gestational age
- Pre term premature rupture of the membrance
- Malpresentation
- Need for C section
- Postpartum haemorrhage
What are some differentials for adenomyosis?
PID Uterine myoma Endometrial carcinoma Endometriosis Endometrial polyps
How do GnRH analogues help adenomyosis and menorrhagia?
Induce a menopause like state.
Act as an antagonist to depress oestrogen and progesterone release.
What are the symptoms of endometriosis?
Pelvic pain (cyclical) Dysmenorrhoea Deep dyspareunia Blood in stools/urine Other cyclical urinary / bowel symptoms may be present
Why does endometriosis cause pelvic pain and dysmenorrhoea?
As the endometriomas respond in the same way to hormones. During menstruation this sheds is lining and causes bleeding. This then leads to irritation and inflammation of surrounding tissues which causes pain
What are complications of endometriosis?
Adhesions which can lead to reduced fertility
What may be present on examination of someone with endometriosis?
Endometrial tissue visible in the vagina on speculum examination (particularly the posterior fornix)
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and around the fallopian tubes/ovaries (adnexa)
Pelvic ultrasound may show endometriomas
What is the gold standard option for diagnosing and treating endometriosis?
Laparoscopic surgery.
How is endometriosis managed?
Analgesia COCP / POP Contraceptive injection / implant Mirena coil (IUS) GnRH agonists Surgery - laparoscopic or hysterectomy
How do the COCP, POP, injection, implant and coil help treat cyclical pain in endometriosis?
Can stop ovulation and reduce endometrial thickening.
What are fibroids?
Non cancerous growths that develop in or around the smooth muscle of the uterus. They are also called uterine leiomyomas. They grow in response to oestrogen.
Who most commonly has fibroids?
Very common in women of later reproductive age.
Black women
High oestrogen levels
What are the different types of fibroids?
Intramural (within the myometrium)
Subserosal (just below the outer layer of the uterus and fill the abdominal cavity)
Submucosal (just below the endometrium)
Pedunculated (on a stalk)
How do fibroids commonly present?
Often asymptomatic. Menorrhagia Prolonged menstruation Abdominal pain Bloating/feeling full Urinary or bowel symptoms due to pelvic pressure Deep dyspareunia Reduced fertility
What investigations are done for diagnosing fibroids?
Abdominal and bimanual examination - may reveals a palpable pelvic mass. Hysteroscopy Pelvic ultrasound MRI scanning Bloods looking for any anaemias
How are fibroids managed?
Symptomatic management - NSAIDs and tranexamic acid
Mirena coil ( if < 3cm with no uterine distortion)
COCP
Cyclic oral progesterones
GnRH agonists (reduce size of fibroids)
Surgery - endometrial ablation, myomectomy, uterine artery embolisation or hysterectomy.
May also need referral to specialists.
Which treatment for fibroids may improve fertility?
Myomectomy - removal of the fibroids via surgery.
What is endometrial ablation?
A procedure where the endometrial lining of the uterus is removed. This involves inserting a special ballon into the cavity and filling it with a high temp fluid that burns the endometrium. It results in infertility.
What are some potential complications of fibroids?
Menorrhagia - often with iron deficiency anaemia Reduced fertility Pregnancy complications Constipation Urinary obstruction and UTIs Reg degeneration of the fibroid Torsion of the dibroid Malignant change to leiomyosarcoma (very rare)
What is red degeneration of fibroids?
Ischaemia, infarction and necrosis of a fibroid due to disrupted blood flow.
When is red degeneration of fibroids most common?
Large fibroids >5cm
2nd and 3rd trimester of pregnancy
What should we look out for in a pregnant lady with a known history of fibroids?
Red degeneration - sever abdominal pain, low grade fever, tachycardia and vomiting
What is the common presentation of red degeneration of fibroids?
History of fibroids 2nd/3rd trimester of pregnancy Severe abdominal pain Low grade fever Tachycardia Vomiting
How is red degeneration of fibroids managed?
Supportive - fluids, rest and analgesia
What are some differentials to fibroids?
Ovarian tumour
PCOS
Pregnancy
Endometriosis
How do GnRH agonists work in females?
GnRH agonists work on the ovaries, causing reduced production of oestrogen and progesterone (as the ovaries do not receive gonadotropin stimulation), resulting in low gonadotropin levels.
This is because for ovulation to occur GnRH must be released in a pulsatile manner (if not receptors desensitise)
https://www.youtube.com/watch?v=wZHjwsq5Css
What can GnRH analogues be used for?
Endometriosis / adenomyosis
Fibroids
Dysfunctional uterine bleeding / menorrhagia
Prostate cancer
https://mft.nhs.uk/app/uploads/sites/4/2019/11/19-71-GnRH-analogue-injections-Nov-19.pdf
How are GnRH analogues administered?
Injections - subcutaneous or intramuscular
What are some side effects of GnRH analogues?
Similar to menopausal symptoms e.g. - mood swings - hot flushes - depression - weight changes - vaginal dryness Also look for effects on blood glucose levels in diabetics
What can cause intermenstrual bleeding?
Can be a red flag for cancers Hormonal contraception Cervical or endometrial polyps Vaginal pathologies Pregnancy Ovulation Medications
What is dysmenorrhoea?
Painful periods
What can cause dysmenorrhoea?
Primary dysmenorrhoea (no underlying cause) Endometriosis / adenomyosis PCOS Fibroids PID Copper coil Cervical or ovarian cancer
What can cause post coital bleeding?
Red flag for cancers (cervical, endometrial, vaginal) Cervical cancer, ectropion or infection Atrophic vaginitis Trauma Polyps
What is cervical ectropion?
When cells that normally line the inside of the cervix grow on the outside.
This appears red on speculum examination and can see the transformation zone (well defined border) - where the endocervix (columnar) meets the exocervix (stratified squamous).
https://www.youtube.com/watch?v=UwM3vAV-FFE
How can cervical ectropion present?
Often asymptomatic
Post coital bleeding
Dysparaeunia (pain during sex)
Increased discharge
How does cervical ectropion look different to cervical cancer / CIN on speculum examination?
Cervical ectropion has a well defined border around the transformation zone.
Cervical cancer is poorly defined with patches of redness. May also be visible texture / lumps.
What predisposes someone to cervical ectropion?
Increased exposure to oestrogen
Younger women
On the COCP
Pregnancy
What can cause changes in vaginal discharge?
BV - bacterial vaginosis Candidiasis STDs - chlamydia, gonorrhoea, trichomonas vaginalis Foreign body Cerivcal ectropion Polyps Malignancy Pregnancy Ovulation Hormonal contraception
What can cause pruritus vulvae (itching or the vulva and vagina)?
Irritants - e.g. soaps, barrier contraception Atrophic vaginitis Infections - candidiasis, pubic lice Skin conditions - eczema Vulval malignancy Pregnancy related discharge Stress Urinary or faecal incontinence
What is Asherman’s syndrome?
A condition where adhesions form within the uterus which may bind the uterine walls together. Normally occurs following damage
What is the common presentation for asherman’s syndrome?
Commonly following recent dilation and curettage (pregnancy related), uterine surgery or endometritis. Secondary amenorrhoea Lighter periods Dysmenorrhoea Infertility
How is asherman’s syndrome managed?
Dissection of the adhesions during hysteroscopy
How does androgen insensitivity syndrome present?
Often inguinal hernias in infancy (containing the testes)
Primary amenorrhoea at puberty
Abnormal external genitals
What are the hormone test results in someone with androgen insensitivity syndrome?
Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)
How is androgen insensitivity syndrome managed?
Variety of options - patients are generally raised as females but will be infertile.
Bilateral orchidectomy removes the testes
Oestrogen therapy
Vaginal dilators or surgery
