Gynaecology Flashcards
Define primary amenorrhoea
-Not starting menstruation
-By 13 yrs if no other signs of pubertal development
-By 15 years if signs of puberty
Define hypogonadism and give 2 causes ?
-> Lack of sex hormones
-> Hypogonadotropic hypogonadism : deficiency of LH and FSH
-> Hypergonadotropic hypogonadism : lack of response to LH and FSH by the gonads
What can cause hypogonadotropic hypogonadism ?
-Low GnRH -> low FSH & LH -> low oestrogen
-Hypopituitarism
-Damage to hypothalamus or pituitary
-Chronic conditions : CF, IBD
-Excessive exercise or dieting
-Constitutional delay in growth and development
-Endocrine disorders : growth hormone deficiency, hyopothyroid, cushing’s or hyperprolactinaemia
-Kallman syndrome
What is Kallman syndrome
-Genetic condition causing hypogonadotropic hypogonadism
-Causes a failure to start puberty and is associated with reduced or absent sense of smell
What is hypergonadotropic hypogonadism and what can cause it ?
-The gonads failure to respond to LH and FSH.
-There is no negative feedback from oestrogen, meaning the anterior pituitary continues to produce LH and FSH
-Damage to gonads
-Congenital absence of the ovaries
-Turner’s syndrome
Give 5 causes of primary amenorrhoea
-Hypogonadotropic hypongonadism
-Hypergonadotropic hypogonadism
-Congenital adrenal hyperplasia
-Androgen insensitivity syndrome
-Structural pathology
What is androgen insensitivity syndrome
-Occurs in someone who is genetically male (XY) but the tissue are unresponsive to androgen hormones
-Causes female phenotype : normal female external genitalia and breast tissue. BUT internally there are testes and an absent uterus, upper vagina, fallopian tubes and ovaries.
Give 5 structural pathologies than can cause primary amenorrhoea
-Imperforate hymen
-Transverse vaginal septae
-Vaginal agenesis
-Absent uterus
-Female genital mutilation
Define secondary amenorrhoea
-No menstruation for more than 3 mnths after previous regular menstrual periods
Give 8 causes of secondary amenorrhoea
-Pregnancy
-Menopause & premature ovarian failure
-Hormonal contraception
-Hypothlamic or pituitary pathology
-PCOS
-Asherman’s syndrome
-Thyroid
-Hyperprolactinaemia
Give 4 reasons why the hypothalamus would reduce GnRH production leading to secondary amenorrhoea
-Excessive exercise
-Low body weight and ED
-Chronic disease
-Psychological stress
Give 2 pituitary causes of amenorrhoea
-Pituitary tumours (e.g. prolactinoma)
-Pituitary failure due to trauma, radiotherapy, surgery or sheehan syndrome (postpartum hypopituitarism caused by necrosis of the pituitary gland)
Why does hyperprolactinaemia cause secondary amenorrhoea ?
-High prolactin -> prevents GnRH release from the hypothalamus
-Most common cause = pituitary adenoma. Often galactorrea also present
How is a prolactinoma managed ?
-> CT or MRI
-> Dopamine agonists (e.g. bromocriptine/cabergoline)
What 5 hormone tests are done in secondary amenorrhoea
-HCG -> preganancy
-LH and FSH (high = primary ovarian failure)
-Prolactin -> hyperprolactinaemia (followed by MRI)
-TSH
-Testosterone (raised = PCOS, androgen insensitivity, congenital adrenal hyperplasia)
When and what treatment is given to reduce the risk of osteoporosis in secondary amenorrhoea
-> Vit D and calcium if amenorrhoea lasts >12 mnths
-> HRT or combined oral contraceptive pill due to low oestrogen levels
Go over menorrhagia mindmap
Draw out mindmap
How is menorrhagia managed if no contraception is wanted ?
-> Tranexamic acid (if no associated pain)
-> Mefenamic acid (if associated pain)
How is menorrhagia managed if contraception is wanted ?
-1st : mirena coil
-2nd : combined oral contraceptivepill
-3rd : cyclical oral progestogens
-4th : progesterone only pill or implant
-Finals : endometrial ablation and hysterectomy
What are fibroids and who are they more common in ?
-Oestrogen sensitive tumours of smooth muscle of the uterus (uterine leiomyomas)
-Black women
What are the 4 types of fibroid ?
-Intramural -> within myometrium
-Subserosal -> below outer layer of uterus
-Submucosal -> blow endometrium
-Pedunculated -> on a stalk
If not asymptomatic, how do fibroids present? (6)
- Menorrhagia
- > 7 days menstruation
- Abdo pain, worse on menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel Sx due to pelvic pressure or fullness
- Deep dyspareunia (pain during sex)
What is the initial investigation for fibroids in menorrhagia ?
-Hysteroscopy
-Pelvic USS may be needed in larger fibroids
How are fibroids of <3cm managed ?
Medical : same as menorrhagia
Surgical : endometrial ablation, resection of fibroids, hysterectomy
How are fibroids >3cm managed ?
-Medical : same as menorrhagia
-Surgical : uterine artery embolisation, myomectomy, hysterectomy
Explain the surgical options used in larger fibroids
-Uterine artery embolistion : catheter passed through femoral artery to uterine artery to cut of O2 supply to fibroid and shrink it
-Myomectomy : surgical removal
-Hysterectomy : removing uterus and fibroids
Give 3 severe complications of fibroids?
-Red degeneration of fibroid
-Torsion of fibroid
-Malignant change to leiomyosarcoma (very rare)
What is red degeneration of fibroids
-Ischaemia, infarction and necrosis of the fibroid occurring most commonly in the 2nd or 3rd trimester of pregnancy
-Presents with severe abdo pain, low grade fever, tachycardia and vomiting
-Manage : supportive
Define endometriosis
-Ectopic endometrial tissue outside of the uterus
-Endometrioma : lump of endometrial tissue
-‘Chocolate cyst’ : endometrioma in the ovaries
If not asymptomatic, how does endometriosis present? (5)
-Cyclical abdominal or pelvic pain
-Deep dyspareunia
-Dysmenorrhoea
-Infertility
-Cyclical bleeding from other sites (e.g. haematuria, blood in stool)
What is the gold standard investigation for endometriosis?
-Laparoscopic surgery w biopsy of lesions
-Pelvic USS is often unremarkable
what are the management options of endometriosis ?
- 1st line : analgesia (NSAIDS, ibuprofen)
- 2nd : hormonal treatment (COCP, progestogens)
- 3rd : GnRH analogues
What surgical options can help with fertility / symptom management of endometriosis
-Laparoscopic surgery to excise or ablate endometrial tissue and remove adhensions
-Hysterectomy and bilateral salpingo-opherectomy (ovary removal induces menopause and so stops ectopic endometrial tissue responding to the menstrual cycle)
Define adenomyosis
Endometrial tissue inside the myometrium (muscle layer of the uterus)
How does adenomyosis present ?
-Dysmenorrhoea
-Menorrhagia
-Dyspareunia
Can present with infertility or pregnancy related complications
What isn the 1st line investigation for adenomyosis ?
-Transvaginal USS of pelvis
How is andenomyosis managed?
Same as menorrhagia and dependent on want for contraception
Perimenopause
Menopause
Postmenopause
-Perimenopause : time leading up to the last period and the 12 mnths afterwards. Vasomotor and irregular periods
-Menopause : point at which menstruation stops
-Postmenopause : period from 12 mnths after the final menstrual period onwards
Explain the physiology behind why menopause occurs and the hormone levels
-> Decline in the development of ovarian follicles
-> Reduced oestrogen production
-> Increasing FSH and LH levels due to lack of negative feedback from oestrogen
-> Anovulation resulting in irregular periods
-> Without oestrogen endometrium does not develop leading to ammenorrhoea
-> Low oestrogen causes perimenopausal symptoms
What 4 conditions does a lack of oestrogen increase the risk of ?
-Cardiovascular disease and stroke
-Osteoporosis
-Pelvic organ prolapse
-Urinary incontinence
What is premature ovarian insuffiency and what does it cause?
-> Early onset menopause (<40 yrs) : irregular periods, secondary amenorrhea and Sx of low oestrogen levels (hot flushes, night sweats, vaginal dryness)
-> Hypergonadotropic hypogonadism
-> Raised LH and FSH, low oestradiol
- > Dx : raised FSH and menopausal sx
Give 5 causes of premature ovarian insufficiency
-> Idiopathic
-> Iatrogenic (chemo,radiotherapy)
-> Autoimmune (coeliac etc)
-> Genetic (+ Fx)
-> Infections (mumps, TB, cytomegalocirus)
What is required for a diagnosis of primary ovarian insufficiency ?
-> Woman, <40 yrs with typical menopausal symptoms plus elevated FSH (>25 IU/l on 2 consecutive samples separated by >4 wks)
How is primary ovarian insuffiency managed?
-HRT : traditional or combined oral contraceptive pill
What are the associations with HRT?
-Lower BP compared to combined pill
-Risk of VTE, reduced by using patches rather than oral
What can be used to alleviate symptoms in perimenopausal and postmenopausal women ?
-HRT
Explain the 3 steps in choosing HRT
- Do they have local or systemic Sx?
-Local : topical treatments
-Systemic : go to step 2 - Does the woman have a uterus
-No : continuous oestorgen only HRT
-Yes : Combined, go to step 3 - Have they had a period in the last 12 mnths ?
-Yes : give cyclical combined HRT
-No : continuous combined HRT
Why is combined HRT given to postmenopausal women with a uterus ?
-> Progesterone prevents endometrial hyperplasia and endometrial cancer secondary to ‘unopposed’ oestrogen.
Give 5 non-hormonal treatments for menopausal symptoms
-Lifestyle changes
-CBT
-Clonidine
-SSRI
-Venlafaxine
-Gabapetin
Give 4 indications for HRT use
-.Replacing hormones in premature ovarian insufficiency
-Reducing vasomotor symptoms
-Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
-Reducing risk of osteoporosis in women under 60
Go over menopause and HRT mindmap
Draw mindmap
What criteria is used for a diagnosis of PCOS?
ROTTERDAM : at least 2/3 needed ->
-Oligoovulation and anovulation presenting with irregular or absent menstrual periods
-Hyperandrogenism : characterised by hirsutism and acne
-Polycystic ovaries on USS
What do the hormal blood tests typically show in PCOS?
-Raised LH
-Raised LH to FSH ratio
-Raised testosterone
-Raised insulin
-Normal or raised oestrogen levels
Low sex hormone binding globulin
What imaging is used in PCOS
-Pelvic USS
-Transvaginal USS is gold standard for visualising ovaries
How may the follicles be arranged on a transvaginal USS in PCOS?
-> ‘String of pearls’ appearance
-> The diagnostic criteria is either :
- 12 or more developing follicles on one ovary
- Ovarian volume of more than 10cm3
What is a common associated condition with PCOS?
-Insulin resistance and DM
What are the key aspects of PCOS management ?
-> weight loss : fertility, and hirsutism management
-> Mirena coil : endometrial cancer risk
-> COCP : manages endometrial cancer risk due to ‘unopposed oestrogen’, acne and hirsutism
What are the 2 kinds of functional ovarian cyst and who are they common in ?
-Follicular -> most common ovarian cyst
-Corpus luteum
What is the most common benign ovarian tumour in women under 30
-Dermoid cyst / teratoma
-Lined with epithelial tissue and so many contain skin, hair and teeth
What is the tumour marker for epithelial cell ovarian cancer ?
-CA125
What is the risk of malignancy index and what does it take into account?
-Estimates the risk of an ovarian mass being malignant
-Menopausal status, USS findings and CA125 levels
How is a simple ovarian cyst in a premenopausal woman managed ?
- <5cm, usually resolves within 3 cycles. No follow up scan
- 5cm to 7cm : routine gynae referral and yearly USS monitoring
->7cm : MRI or surgical evaluation
How are ovarian cysts in postmenopausal women managed ?
-> Check CA125 level
-> IF raised, two week wait gynae referral
Triad of ovarian fibroma, pleural effusion and ascites.
Meig’s syndrome
If not asymptotic. what are the symptoms of an ovarian cyst ?
-Pelvic pain
-Bloating
-Abdo fullness
-Palpable mass
-If the is ovarian torsion, haemorrhage or rupture of the cyst = acute pelvic pain
-Sudden onset severe unilateral pelvic pain
-N&V
-Localised tenderness and possible palpable mass
-Ovarian torsion
Ovarian torsion : Ix of choice, findings and management
-Pelvis USS : ‘whirlpool sign’, free fluid in pelvis and oedema of ovary
-Laparoscopic surgery to un-twist ovary and fix in place (detorsion) or remove affected ovary (oophorectomy)
Common result of pregancy-related endometrial dilatation and curettage
-Asherman’s syndrome
-Can also be caused by uterine surgery or pelvic infection
What is asherman’s syndrome ?
-Adhesions form within the uterus following damage to the uterus
How can asherman’s present ?
-> Usually following recent dilation and curettage, uterine surgery or endometritis with :
-Secondary amenorrhoea
-Significantly lighter periods
-Dysmenorrhoea
-May also present with infertility
What is the gold standard investigation for asherman’s?
-Hysteroscopy : also done for dissection and treatment
What is atrophic vaginitis and why does it occur
-> Dryness and atrophy of the vaginal mucosa
-> Occurs at menopause due to a lack of oestrogen causing the mucosa to become thinner, less elastric and dry
How does atrophic vaginitis present ?
-> Itching, dryness, dyspareunia and bleeding
-> Older women with recurrent UTI, stress incontience or pelvic organ prolapse
How is atropic vaginitis managed ?
-Vaginal lubricants
-Topical oestrogen
-50 year old woman with vulval itching and skin changes in the vulva
-Labia, perianal and perineal skin changes : ‘Porcelain-white’ colour, shiny, tight, thin, slight raised
-Itching, soreness, erosions
-Koebner phenomenon : signs and synptoms made worse by friction -> tight underwear and scratching
Lichen sclerosus
How is lichen sclerosis managed ?
-Potent topical steroids (clobetasol propionate 0.05%)
What is a critical complication of lichen sclerosis
-Squamous cell carcinoma of the vulva
Define the different pelvic organ prolapses
-Uterine : uterus into vagina
-Vault : vault of the vagina into the vagina
-Rectocele : defect in posterior vaginal wall = rectum into vagina
-Cystocele : defect in anterior vaginal wall = bladder into vagina
What are the 3 management options in a pelvic organ prolapse ?
- Conservative
- Vaginal pessary
- Surgery
what does the upper vagina, cervix, uterus and fallopian tubes develop from ?
-Mullerian ducts
What 2 congenital structural abnormalities can lead to cyclical pelvic symptoms without menstruation ?
-Imperforate hymen
-Transverse vaginal septae (if imperforate)
What is the most common causative organism of pelvic inflammatory disease?
-Chlamydia trachomatis
-Can also be caused niesseria gonorrhoea (severe PID) and mycoplasma genitalium
how does PID present ?
-Lower abdo pain
-Fever
-Deep dyspareunia
-Dysuria and menstrual irregularities
-Vaginal or cervical discharge
-cervical excitation
How is PID managed?
-Depends on guidelines
-Ceftriaxone and doxycline will cover many organisms
Give 4 complications of PID
-Perihepatitis : RUQ pain
-Tubular infertility
-Chronic pelvic pain
-Fitz-Hugh-Curtis syndrome
Give 4 signs of a complete hydatidiform mole, including USS sign
-Vaginal bleeding
-Uterus size greater than expected for gestational age
-Abnormally high serum hCG
-USS : ‘snow storm’ appearance
What is Fitz-Hugh-Curtis syndrome ?
-> Complication of PID : inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and peritoneum
-> RUQ pain referred to the right shoulder pain
what are the conservative management options for pelvic organ prolapse
Physio
Weight loss
explain the grades of uterine prolapse
1 : lowest part is >1cm above introitus
2 : lowest part is within 1cm of introitus
3 : lowest part is >1cm below the introitus, but not fully descended
4 : full descent with eversion of vagina
feeling of ‘something coming down’ in vagina
dragging or heavy sensation in pelvis
urinary sx : incontinence, urgency, frequency
bowel sx : constipation, incontinence, urgency
sexual dysfunction : pain, altered sensation
Prolapse
What are the 2 types of benign epithelial ovarian cysts
-Serous cystadenoma
-Mucinous cystadenoma
what are the initial investigations in incontinence
Bladder diary (3 days)
Vaginal examination
Urine dip and culture (if <65 urinalysis)
Urodynamic studies
What is urge incontinence and how is is managed
-Overactivity of detrusor muscle
1 : Bladder retraining for 6 wks
2 : Antimuscarinis (oxybutin)
3 : Merabegron
4 : invasive surgery
What is stress incontinence and how is it managed ?
-Weakness in pelvic floor and sphincter muscles
1 : Lifestyle advice
2 : Pelvic floor exercises for at 3 mnths
3 : Surgery
4 : Duloxetine if surgery declines
cysts in premenopausal vs postmenopausal women
-Premenopausal : usually benign
-Postmenopausal : more concerning. Measure CA125. If raised, refer
COCP
3 mnth inter-menstrual and occasional post-coital bleeding
26 y/o
Cervical ectropion
what is cervical ectropion
Increased oestrogen (COCP, pregnancy) causes larger area of columnar epithelium being present on the ectocervix
what 2 things cause cervical excitation
ectopic pregnancy
PID
what is cervical ectropion
- There is a larger area of columnar epithelium on the ectocervix
how does cervical ectopion present and what is seen on examination of the cervix
- Post coital bleeding
- Vaginal discharge
- Red and tender cervix
what staging is used tp assess development of secondary sexual characteristics
Tanner
what system is used to classify severity of a prolapse
Baden-walker
what is the inheritance of CAH
- Autosommal recessive
Give 6 possible causes of menorrhagia
- Dysfunctional uterine bleeding
- Fibroids
- PID
- Anticoagulation
- Bleeding disorders (e.g. VWD).
- Contraception (especially copper coil).
