Gynaecology Flashcards
3 causes of primary amenorrhoea
- Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
- Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
- Imperforate hymen or other structural pathology
Causes of secondary amenorrhea
Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hyper or hypothyroid)
Excessive prolactin, from a prolactinoma
Cushing’s syndrome
causes of irregular menstruation
an ovulation/ irregular ovulation - bc hormone levels disrupted or ovarian pathology
Extremes of reproductive age (early periods or perimenopause)
PCOS
Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
Intermenstrual bleeding causes
Red flag - cancer
Hormonal contraception Cervical ectropion, polyps or cancer STI Endometrial polyps or cancer Vaginal pathology, including cancers Pregnancy Ovulation can cause spotting in some women Medications, such as SSRIs and anticoagulants
causes of dysmenorrhoea
Primary dysmenorrhoea (no underlying pathology) Endometriosis or adenomyosis Fibroids Pelvic inflammatory disease Copper coil Cervical or ovarian cancer
cause of menorrhagia
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cance
Polycystic ovarian syndrome
Postcoital bleeding causes
red flag - cancer (not v common)
Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
Pelvic pain differentials
UTI Dysmenorrhoea IBS Ovarian cysts Endometriosis PID Ectopic pregnancy Appendicitis Mittelschmerz (cyclical pain during ovulation) Pelvic adhesions Ovarian torsion IBD
causes of pruritus vulvae
Irritants such as soaps, detergents and barrier contraception Atrophic vaginitis Infections such as candidiasis (thrush) and pubic lice Skin conditions such as eczema Vulval malignancy Pregnancy-related vaginal discharge Urinary or faecal incontinence Stress
what hormones are low in Hypogonadotropic Hypogonadism
low LH and FSH
–> low oestrogen, ovaries not stimulated
A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland.
causes of Hypogonadotropic Hypogonadism
A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland.
- Hypopituitarism
- Damage to the hypothalamus or pituitary, (radiotherapy or surgery for cancer)
- Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or IBD)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome
causes of Hypergonadotropic Hypogonadism
gonads don’t respond to LH and FSH so no oestrogen, but no -FB so inc LH and FSH production
result of abnormal functioning of the gonads
- Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
- Congenital absence of the ovaries
- Turner’s syndrome (XO)
what is Kallman syndrome associated with
genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty.
It is associated with anosmia
what investigation can you do for constitutional delay
X-ray wrist
How does hyperprolactinaemia cause secondary amenorrhoea?
high prolactin acts on hypothalamus –> prevent release of GnRH
–>. no LH or FSH
mc cause = pituitary adenoma secreting prolactin
–> tx with dopamine agonists (bromocriptine, cabergoline)
what does high FSH suggest?
primary ovarian failure
what does high LH or LH:FSH suggest?
PCOS
what 3 conditions can raised testosterone indicate?
PCOS
androgen insensitivity
congenital darnel hyperplasia
why do women with PCOS require a withdrawal bleed every 3-4 months?
to dec risk of endometrial hyperplasia and endometrial cancer
–> Medroxyprogesterone for 14 days, or regular use of COCP
When can you get PMS?
Symptoms are not present before menarche, during pregnancy or after menopause.
The symptoms of PMS resolve once menstruation begins
Symptoms can occur in the absence of menstruation after
- a hysterectomy,
- endometrial ablation
- on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues.
They can also occur in response to the COCP or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.
what do you call PMS when has significant effect on QOL?
premenstrual dysphoric disorder
Management of PMS
Lifestyle
COCP
SSRIs
CBT
COCP - containing drospirenone (i.e. Yasmin) –> antimineralocortioid effects, use continuously
transdermal oestrogen patches (with progesterone (pill or Mirena)
GnRH (induce menopause, osteoporosis risk)/ HRT
hysterectomy + bilateral oophorectomy
danazole and tamoxifen - cyclical breast pain
spironolactone - for breast swelling, water retention and bloating.
why would you arrange an outpatient hysteroscopy for heavy menstrual bleeding?
- Suspected submucosal fibroids
- Suspected endometrial pathology, such as endometrial hyperplasia or cancer
- Persistent intermenstrual bleeding
why would you arrange a pelvic and transvaginal US for heavy menstrual bleeding?
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
2 options of surgical management for menorrhagia
endometrial ablation = balloon thermal ablation
hysterectomy.
What fibroids can distort the shape of the uterus?
(probs all idk)
intramural - grow and change shape
subserosal - can grow v large, fill Abdo cavity
how do you investigate for submucosal and larger fibroids?
hysteroscopy - submucosal fibroids presenting with heavy menstrual bleeding.
pelvic US - larger fibroids.
MRI scan - plan surgery
what size cut off for fibroid to refer to gynae?
if >3cm –> gynae
medical (4) and surgical management (3) of large fibroids >3cm with menorrhagia
refer gynae
- Symptomatic management with NSAIDs and tranexamic acid
- Mirena coil - depending on the size and shape of the fibroids and uterus (not if distorted)
- COCP
- Cyclical oral progestogens
Surgical options for larger fibroids are:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
medical (4) and surgical management (3) of small fibroids <3cm with menorrhagia
Mirena coil (1st line) - fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
Surgical options for managing smaller fibroids with heavy menstrual bleeding are:
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
what meds can be given to shrink fibroids before surgery?
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)
–> induce menopause, dec oestrogen
what treatment can potentially improve fertility with fibroids?
myomectomy
via laparoscopic or laparotomy (open)
what is red degeneration of fibroids?
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. - more likely to occur in larger fibroids (> 5 cm) during the 2nd +3rd Tri
fibroid rapidly grows or kinking of blood vessels as uterus changes shape
signs of red degeneration of fibroids
severe abdominal pain, low-grade fever, tachycardia and often vomiting.
Management is supportive, with rest, fluids and analgesia.
name for endometriosis in ovaries and myometrium
ovaries = chocolate cysts myo = adenomyosis
how can the pain from endometriosis change over time?
at start, cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis
can develop adhesions from localised bleeding and inflammation –> chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with nausea.
symptoms tend to resolve after menopause (like adenomyosis and fibroids)
what would you see on pelvic exam for endometriosis ?
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa
what’s gold standard way to diagnose endometriosis
laparoscopic surgery
–> definitive diagnosis with biopsy
Who is adenomyosis more common in?
It is more common in later reproductive years and those that have had several pregnancies (multiparous).
what pregnancy complications is adenomyosis associated with?
Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage
hormone levels in menopause and phsyiology
dec developmental of ovarian follicles –>dec oestrogen
oes has -FB on pit gland, no -FB so inc levels of LH and FSH
no follicular development –> anovulation
no oestrogen –> no endometrial developmental –> no menstruation
no oes –> perimenopausal symptoms
when and what blood test would you do to help diagnose menopause?
FSH
W <40 with ?premature menopause
W 40-45 with menopausal symptoms or change in menstrual cycle
