Gynaecology Flashcards
What are the CFs of PCOS?
- Menstrual irregularity - oligo/amenorrhoea
- Hyperandrogenism - acne, hirsuitism
- Anovulatory infertility - oligo/anovulation
- Increased risk of pregnancy complications eg. spont abortion, gestational diabetes, pre term labour
- Insulin resistance - obesity and T2DM, acanthosis nigricans
What is the theorised pathogenesis behind PCOS?
- Genetic link
- Increased LH and increased LH receptors = increased LH:FSH = excess androgen production
- Insulin resistance = hyperinsulinaemia to compensate for resistance, stimulates theca cells = increased androgen secretion
What are the stages of the menstrual cycle?
- Follicular phase
- Ovulation
- Luteal phase
- Secretory phase
Describe the pre ovulatory phase of the menstrual cycle
- Pulsatile GnRH causes FSH and LH release frm the ant pit
- Follicle grows due to FSH release
- LH releases androgen which is converted to oestrogen by aromatase = increased O
Describe how ovulation occurs
High levels of oestrogen act as positive feedback on FSH and LH - surge of LH causes ovulation, happens at Day 14.
What is the uterus doing around the time of ovulation?
From day 11-15 the uterus is preparing for implantation and fertilisation of the egg:
- Spiral arteries grow
- Endometrium thickens
- Cervical mucus thins to allow sperm to pass
What happens in the luteal phase?
Corpus luteum continues producing oestrogen but lutenised granulosa cells produce lots and lots of progesterone so it is the dominant hormone.
Progesterone and inhibin -ve feedback LH and FSH causing reduced oestrogen - this signifies ovulation has taken place.
What do high levels of progesterone do to the uterus?
Prepares the uterus to thick its cervical mucus = once oocyte fertilised don’t want to let any more sperm through and coil its spiral arteries = once oocyte is fertilised will implant.
What happens in the secretory phase/menstruation?
Corpus luteum changes to the corpus albican which is basically dead - no oestrogen or progesterone produced. Spiral arteries collapse and the lining sheds = menstruation.
What bloods are involved in ix PCOS?
- Total testosterone
- LH (often elevated)/FSH (elevated in premature ovarian failure, differential for PCOS)
- Prolactin - hyperprolactinaemia can cause oligomenorrhoea
- Thyroid profile - often causes irreg periods
- Free androgen index - if raised is diagnostic of PCOS
What is the Rotterdam criteria?
- Transvaginal USS reveals 12 or more cysts on one ovary or increased ovarian volume
- Oligo/anovulation
- Clinical or biochemical signs of hyperandrogenism
How do you treat menstrual irreg in PCOS? Why does it need treating?
Causes endometrial hyperplasia = possible increased risk endometrial cancer. Therapies prevent endometrial thickening.
- Cyclical progestogen
- COCP
- Levonorgestrel IUS = Mirena
What is PCOS?
Polycystic ovary syndrome: menstrual dysfunction and hyperandrogenism
What is the treatment of fertility in PCOS?
Induce normal ovulatory cycles:
- Letrozole - aromatase inhib
- Clomiphene - SERM, selective oestrogen receptor modulator
How do you treat the metabolic complications of PCOS?
- Weight loss can reduce metabolic risks and hyperandrogenism as well as restore ovulatory cycles
- Quit smoking
- Screen for diabetes, dyslipidaemia and HTN
- Metformin - used to be used but not routinely anymore
What are fibroids?
Uterine leiomyomas - benign monoclonal tumours of the smooth muscle cells of the uterine myometrium.
What is the classification of fibroids?
- Intramural - most
- Submucosal - growing into the uterine cavity, may protrude through the cervical os
- Subserosal - growing outwards from the uterus
What are the RF and protective factors of fibroids?
RF - obesity, early menarche, FH, HTN, alcohol consumption, poor diet
Protective - exercise, increased parity, cigarettes
What is the presentation of fibroids?
- Asymptomatic
- Excessive or prolonged heavy periods - Fe def anaemia
- Intermenstrual bleeding
- Compressive sx - pelvic pain, constipation, urinary sx
- Recurrent miscarriage or infertility
What do you find o/e of PCOS?
- Palpable abdo mass arising from pelvis
- Enlarged, irreg, firm, non tender uterus palpable on bimanual pelvic exam
- Signs of anaemia due to menorrhagia
What are the ix into fibroids?
- Pregnancy test
- FBC
- Transvaginal US or pelvic US
- MRI - only if US is not definitive
- Endo metrial sampling for histology
- Hysteroscopy w biopsy
What is the management of fibroids?
- NSAIDs - reduce menstrual blood loss when cause is unknown but less evidence in fibroids
- Tranexamic acid
- COCP or Levonorgestrel IUS
- Mifepristone = progesterone receptor inhib
- Ulipristal acetate
- Surgery
When is surgery indicated in fibroids? What surgery is done?
- Excessively enlarged uterine size
- Pressure sx
- Med management not controlling sx
- Reduced fertility
Surgery - myomectomy, hysteroscopic endometrial ablation, total hysterectomy
What is endometriosis?
Extrauterine implantation and growth of endometrial tissue. Deposits more freq on pelvic structures, most commonly the ovaries. Commonly causes pain but also may lead to reduced fertility and adhesion formation.
Define adenomyosis and endometrioma
Adenomyosis - deposits of endometrial tissue in myometrium of uterus
Endometrioma - cystic structures developing on ovaries = chocolate cysts
What are the RF of endometriosis?
- Early menarche
- Late menopause
- Nulliparity
- Delayed childbearing
- Short menstrual cycle
- FH
What are the CF of endometriosis?
- Chronic pelvic pain
- Dysmenorrhoea
- Irreg periods
- Dyspareunia
- Dyschezia - cyclical (pain pooing)
- Bloating, nausea - cyclical
- LUTS - cyclical
- Infertility/sub fertility
- Fixed retroverted uterus
What are the ix into endometriosis?
- Laparoscopy - gold standard
- USS - initial, excludes other causes
- MRI - used in suspected deep endometriosis, esp bowel bladder or ureter
What is the conservative management of endometriosis?
- Pain management - simple analgesics, hormonal therapies reduced pain sometimes - COCP, POP, implant and mirena
- GNRH analogues - reduce O and induce annovulation = hopefully prevent periods and the associated pelvic pain
- Psychological treatment - depression and anxiety commonly in endometriosis pt
What is the surgical management of pt w endometriosis?
- Excision or ablation of endometriomas
- 3 months of GnRH agonists pre operative in bowel bladder ureter endometriosis
- Hysterectomy
What is the management of infertility in pt w endometriosis?
- Excision or ablation of endometriosis and adhesiolysis
- Ovarian cystectomy
What is pre menstrual dysphoric disorder?
PMS = normal psychological and physical sx experienced by woman premenstrually, PMDD is severe PMS and is abnormal.
What are the symptoms of PMDD?
- Symptoms at worst in the 6 days leading up to period (luteal phase)
- Symptoms cause difficulties coping with workplace or domestic demands, causing problems w relationships
- Emotional sx - irritability, labile affect, low mood, anxiety, lassitude, suicidal feelings
- Physical sx - breast tenderness, bloating, clumsiness, fluid retention
How do you manage PMDD?
- Ask pt to keep sx diary for 2 complete cycles
- Reassurance and explanation help woman often
- CBT
- SSRIs eg. Fluoextine
- Transdermal oestrogen, given with progestogen if has a uterus
- IUS Mirena coil
What is menorrhagia and how is it defined?
Excessive abnormal uterine bleeding over several consecutive cycles interfering physical, emotional, social QOL.
- Increased freq of bleeding
- Blood loss leaving 80ml
- Bleeding for more than 5 days
- Consistently having blood soaked pads/tampons
- Blood loss interfering w daily activities
What are ovarian and uterine causes of menorrhagia?
- Leiomyomas/fibroids - pelvic pain/pressure sx
- Endometriosis - dyspareunia
- Pelvic inflam disease
- Polyps and endometrial hyperplasia - post coital bleeding, inter menstrual bleeding
- PCOS - hirsuitism, acne
What are some systemic disorders that may cause menorrhagia?
- Coagulation disorders - bruises
- Hypothyroidism
- Liver/renal disease
What are some other causes of menorrhagia?
- Anticoagulants
- IUD contraceptive
- Dysfunctional uterine bleeding - no cause
What are the ix into menorrhagia?
- Pregnancy test
- FBC, exclude Fe def anaemia
- Pelvic USS - assess for structural causes
- If suspect gynaecological malignancy need to be referred for specialist assessment
What are the options in primary care for management of menorrhagia?
- IUS Mirena coil - for those not trying to conceive, thins the endometrium lining
- Tranexamic acid - inibits plasminogen activation, prevents fibrinolysis
- Oral norethisterone - stops menstrual bleeding, used when other options unsuitable
- Long acting progestogen eg. IM medroxyprogesterone acetate every 12 weeks for prevention
What are the options in secondary care for the management of menorrhagia?
- GnRH analogues induce hypogonadal state - false menopause, no ovulation
- Surgical - endometrial ablation, hysterectomy
What is amenorrhoea?
Primary - not started period by the time they are 15 w normal secondary sexual characteristics or 13 w/o secondary sexual characteristics
Secondary - cessation of menstruation for 3-6 months
What are the causes of primary amenorrhoea w normal sexual characateristics?
- Imperforate hymen
- Transverse septum
- Absent vagina or uterus
- Hypothyroidism, hyperthyroidism, hyperprolactinoma, Cushing’s
What are the causes of primary amenorrhoea w/o normal sexual characteristics?
- Primary ovarian insufficiency - Turner’s syndrome
- Hypothalamic pit dysfunc eg. stress, weight loss, excessive exercise
What are some causes of secondary amenorrhoea?
- Menopause, lactation, pregnancy
- Stress, weight loss, excessive exercise - hypothalamic dysfunction
- POI - chemo, RT, autoimmune disease
- PCOS
- Cushing’s
- Late onset adrenal hyperplasia
What are the ix into amenorrhoea?
- Need examination - excessive androgens, thyroid disease, Cushing’s, vaginal exam, secondary sexual characteristics
- Pregnancy test
- USS
- Bloods - prolactin, TFTs, LH, FSH, total testosterone
What is the treatment amenorrhoea?
- If concerned about fertility - fertility clinic - GnRH therapy
- Increase weight, reduce stress and exercise, need eating disorder team
- HRT if premature ovarian failure <40 years until avg age of menopause - 50 years old
- Constitutional late puberty requires reassurance and waiting
- Structural abnormalities may be amenable to surgery
- Bone protection, reduced oestrogen = RF for osteoporosis, need assessment and adequate treatment
- Dopamine agonists for hyperprolactinaemia
- Treat thyroid dysfunction
What are the CFs of Turner syndrome?
- Growth failure and short stature
- Gonadal dysgenesis - ovaries don’t develop properly and can cause premature ovarian failure
- Ovarian failure = no O+P to develop secondary sexual characteristics
- Learning disabilities
- Short webbed neck, low hairline, low set ears, nails turned upwards, wide spaced nipples - shield chest, swollen hands and feet
- Congenital heart defects - bicuspid aortic valve
- Horse shoe kidneys/absent kidneys
- Hypothyroidism
What is the pathophysiology of Turner syndrome?
Partial or complete loss of the second sex chromosome. On karyotypye tests patients have X karyotype not XX which is normal in females.
What is androgen insensitivity syndrome?
People with this syndrome are genetically male - XY karyotype but their bodies don’t respond to androgens (male hormones) so they have physical traits of a woman.
What are the CFs of androgen insensitivity syndrome?
- Abnormal female internal genitalia - uterine malformations, aplasia/hypoplasia of fallopian tube and uterus
- Or ambiguous genitalia
- Absent axillary hair and pubic hair
- Undescended testes - cryptorchidism
- Delayed puberty
- Infertility
What is the treatment of genetic causes of amenorrhoea?
- Turner syndrome - growth hormone and monitor cardiac, renal or thyroid abnormalities, HRT, oral contraceptives
- Androgen insensitivity - remove residual gonadal tissue to avoid risk of malignancy, psychological support, hernia repair, surgeries to dilate vagina or descend testes if a boy, oestrogen for women once testes removed
What are the causes of dysmenorrhoea?
- Primary dysmenorrhoea = no pelvic pathology, often begins with first menses and there is no cause
Secondary dysmenorrheoa = often pelvic pathology, occurs years after menses:
- Endometriosis
- PID
- Fibroids
- Adhesions
- Developmental abnormalities
- Copper IUD in first few months
What is the management of primary dysmenorrhoea?
- Lifestyle changes - stopping smoking reduces risk of dysmenorrhoea
- Exercise during periods may cause reduction in pain intensity
- Locally applied heat, transcutaneous electrical nerve stim, camomile tea
- NSAIDs eg. ibuprofen, mefanamic acid, naproxen
- Hormonal contraception - COCP, POP, depop injection makes many women amenorrhoeic w/i a year of starting treatment, IUS - if not trying to conceive
- Laparoscopic uterine nerve ablation in severe cases but not v effective
- Hysterectomy can be considered in severe cases - if finished family
What is letrozole and how does it work?
Non steroidal aromatase inhibitor - decreases oestrogen produced by body. Used to prevent growth of breast cancers that are oestrogen receptive and induces ovulation. Decreased O = increased FSH = stimulates follicles and aids ovulation.
What is clomiphene and how does it work?
Is a SERM - blocks oestrogen redceptors, blocking acting of oestrogen. Causes increased FSH and LH - induces ovulation in women who’s infertility is caused by annovulation.
What is mifespristone and how does it work?
Used to end early pregnancy. Is an antiprogestational steroid, blocks progesterone which is the hormone that is increased to indicate that you are pregnant and pregnancy should be continued.
There is also evidence that is has been shown to decrease fibroid size.
What is ulipristal acetate and how does it work?
Selective progesterone receptor modulator. Used for emergency contraception after unprotected intercourse. Is also used to treat fibroids.
MOA - inhibits ovulation by suppressing LH surge and thins the endometrium to inhibit implantation by binding to progesterone receptors.
What is norethisterone?
Is a progestogen - stops the lining of your womb from shedding. Used to delay periods and can be used in menorrhagia.
What are the hormonal changes behind menopause?
- Supply of oocytes falls as a women ages
- Follicular activity falls = reduced oestrogen and inhibin
- Negative feedback lost so LH and FSH increase
What are the CFs of menopause?
- Menstrual irregularity - cycles become longer, shorter or variable
- Vasomotor sx - hot flushes, night sweats
- Urogenital sx - vaginal dryness, dyspareunia, UTIs
- Anxiety/depression
- Difficulty conc
- Sleep disturbance
- Reduced libido
- MSK pains
How is menopause diagnosed?
- Perimenopause based on vasomotor sx and irregular periods
- menopause in women who haven’t had a period for at least 12 months and aren’t using hormonal contraception
- Menopause based on sx in women without a uterus
What are the different types of HRT?
- Women w a uterus - combined oestrogen and progesterone HRT, unopposed oestrogen is a RF for endometrial cancer
- Women w/o uterus - oestrogen only HRT