Gynaecology Flashcards
Period Problems
Period Problems
Amenorrhoea
Pathophysiology
Investigation
Management
Pathophysiology
- Primary - no periods by 15 in otherwise normal girls OR by 13 if also missing other sexual characteristics
- Turner’s (45XO), congenital malformation, functional hypothalamic amenoerrhoea, congenital adrenal hyperplasia, imperforate hymen
- Secondary - cessation of menstruation for 3-6/12 w/ prev normal periods OR 6-12/12 in prev oligomenorrhoea
- Functional hypothalamic, PCOS, hyerprolactinaemia, prem ovarian failure, thyrotoxicosis OR hypothyroidism, sheehan’s, asherman’s (intrauterine adhesions)
Investigation
- bHCG to exclude pregnancy
- FBC, U&E, coeliac screen, TFTs
- Gonadotrophics: low = hypothalamic cause. high = ovarian cause.
- Prolactin
- Androgens (raised in PCOS)
- Oestradiol
Management
- Primary: Ix + treat cause. If primary ovarian insufficiency may benefit from hormonal replacement (eg. to prevent osteoporosis)
- Secondary: exclude pregnancy, lactation + menopause (if >40), treat cause
Dysmenorrhoea
- Pathophysiology
- Investigation
- Management
Primary Dysmenorrhoea
- No underlying pelvic pathology
- Presents as suprapubic cramping pain w/ radiation to back or thighs
- Manage w/
1st: NSAIDs e.g. mefanamic acid + ibuprofen
2nd: COCP
3rd: POP, Depot, IUS
If nil improvement in 3-6/12 or doubt re diagnosis refer to gynae
Secondary Dysmenorrhoea
Typically onset many years after menarche + pain starts 3-4 days prior to period
Causes: Endometriosis, Adenomyosis, PID, IUD, fibroids, cervical Ca, ovarian Ca
Red Flags (urgent ref) = ascites and/or abdo/pelvic mass; abnormal cervix on exam, persistent intermenstrual or postcoital bleeding
Refer all to gynae for investigation
Manage cause e.g. removal of IUD etc (see specific conditions cards for more info)
Menorrhagia (heavy periods)
- Pathophysiolgy
- Investigation
- Management
Pathophysiology
- PALM COIEN
Poylps
Adenomyosis
Leiomyoma (fibroids)
Malignancy + hyperplasia
Coagulopathy eg. von willebrand
Ovulatory dysfunction (anovulatory cycles eg. near menopause)
Iatrogenic eg. IUD
Endometrial
Not otherwise specified (eg. dysfunctional uterine bleeding (no underlying pathology, 50% of cases)); hypothyroid, PID
Investigation
- FBC
- Outpatient hysteroscopy if hx suggests submucosal fibroids, polyps or endometrial pathology (eg. intermenstrual bleeding or risk factros)
- Offer TV USS if poss large fibroids (uterus palpable, exam inconclusive eg. obese) or suspecting adenomyosis (bulky tender uterus on exam)
Management
- Refer if: (basically any evidence of underlying pathology)
Urgent: ascites and/or pelvic/abdo mass
2ww: pelvic mass + features of Ca
Routine: complications eg. compressive symptoms from large fibroids, IDA failing to respond to tx, menorrhagia not improving w/ tx
If no contraception required:
- Mefanamic acid 500mg TDA (if co-existent dysmenorrhoea) OR tranexamic acid 1g TDS (start on 1st day of period)
If requires contraception:
- 1st: IUS (mirena)
- 2nd: COCP
- 3rd: long-acting progestogens eg. depo-provera
Norethisterone can be used short-term to rapidly stop heay bleeding
Describe the presentation, investigation and management of:
- Mittelschmerz
- Premenstrual Syndrome
Mittelschmirz
- Presentation: iliac fossa/pelvic pain, mins-hours, can switch sides each month
- Investigations: clinical diagnosis. No abnormal exam findings.
- Management: simple analgesia
Premenstrual Syndrome
- During luteal phase: Emotional: anxiety, stress, faitgue, mood swings; physical sx (bloating, breast pain)
- Mild: lifestyle advice (specific - 2-3hourly meals)
- Mod: COCP
- Severe: SSRI (continuous or just in luteal phase)
Post-coital and intermenstrual bleeding
- Causes
- Investigation
- Management
Causes
- No identificable pathology (50%)
- Cervical ectropion (33%)
- Cervicitis (e.g. Chlamydia)
- Cervical cancer
- Polyps
- Trauma
Investigation
- STI screen (esp chlamydia) + cervical smear
- Cancer ref if: suspicious looking cervix, vulval lesion or vaginal mass
- (N.B. -ve smear shouldn’t stop ref if looks sus as adenocarcinoma doesn’t show up)
- Routine ref:
- Persistent PCB 6/52 + -ve STI screen
- Persistent PCD 12/52 after treating STI
- Abnormal cervix not in keeping w/ malig eg. ectropion or inflammation
Management
- Refer as above + manage dependent on cause
Menopause
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- loss of follicular activity. Diagnosed w/ no period for 12 months.
- average age: 51
- Symptoms normally last 2-5 years
Presentation
- Hot flushes –> exercise, weight loss, reduce stress
- Sleep disturbance -> avoid late night exercise, good sleep hygeine
- Mood - sleep, exervise, relaxation
- Cognitive symptoms - exercise, sleep hygeine
- Urogenital sx
Investigation
- Reduced: oestrogen/progesterone + androgens
- Raised: FSH + LH
Management
Contraception - continue 12/12 after last period in women >50 OR 24/12 in women <50
*Lifestyle advice *(as above)
Non-HRT
- Vasomotor sx - fluoxetine, citalopram, venlafaxine
- Vaginal dryness - lubricant/moisturiser
- Psych sx - self-help, CBT, antidepressants
- Urogenital - vaginal oestrogen (can use alongside HRT)
HRT
- With uterus: Oestrogen and Progesterone
- Without uterus: oestrogen
- Routes: patch (transdermal), IUS, oral
Stopping Treatment
- Vasomotor sx - 2=5yrs HRT w/ regular attempts to discontinue
- Vaginal oestrogen may be needed longterm
HRT
Indications
Types
Contraindications
Side effects
Indications
- Vasomotor menopausal symptoms - flushing, insomnia, headache
- Premature menopause - give to reduce osteoporosis risk (until age 50)
Types
- With uterus: Oestrogen + Progesterone (combined)
- Without uterus: Oestrogen only
- Other: Tibolone (synthetic compound w/ oestrogenic, progestogenic + androgenic activity)
Rout: oral or transdermal (transdermal better as reduces risk of VTE)
Contraindications
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
Side-Effects
- Common: nausea, breast tenderness, fluid retention, weight gain
- Complications:
- Increased risk of breast cancer (reduces back to normal level 5 years after stopping HRT. Worse w/ combined)
- Increased risk endometrial cancer (worse w/ unopposed oestrogen)
- Increased VTE risk (worse w/ combined. BUT transdermal doesn’t have same effect)
- Increased risk of stroke
- Increased risk of IHD (if taken more than 10 years after menopause)
Post-Menopausal Bleeding
- Causes
- Investigation
- Management
Causes
- Post-menopausal bleeding is >6/12 after last period
- Causes: atrophic vaginitis or endometrial atrophy (most common), endometrial hyperplasia, endometrial cancer
Investigation
- TV USS:
If endometrium <4mm + no other risk factors (eg. DM, tamoxifen, obesity, fam/personal hx of non-polyposis colonic ca) –> primary care mx + look for other cause
If endometrium >4mm or other risk factors –> 2ww for hysteroscopy + endometrial biopsy (cancer vs hyperplasia)
Early Pregnancy Complications
Early Pregnancy Complications
Hyperemesis Gravidarum
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Onset <20/52 (most common 8-12)
- Thought to be due to raised B-HCG levels: multiple pregnancies, trophoblastic disease, hyperthyroid, nulliparity, obesity
Presentation
- Following triad needs to be present for diagnosis:
-5% pre-pregnancy weight loss
- Dehydration
- Electrolyte Imbalance
- Complications: can –>
- wernicke’s due to low B1 (thiamine)
- Mallory-Weiss tear
- Central pontine myelinolysis
- Acute tubular necorsis
- Foetal: Small for gestational age, pre-term birth
- Can use PUQE score to classify severity
Investigation
- Weight
- Ketonuria
- MSU (UTI is differential)
- Blood: FBC, U&E, glucose, LFTs, amylase, TFTs, ABG
- USS - confirm viability, gestation + exclude multiple preg/trophoblastic disease
Management
1st: Antihistamines (PO cyclizine or promethiazine)
2nd: Ondansetron or metoclopramide
(metoclop -> extrapyrimidal SE (so only short course). Ondansetron -> cleft lip/palate in 1st trimester)
Consider admission for IV hydration
Ectopic Pregnancy
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- RF: PID, surgery, prev ectopic, endomatriosis, IUD, POP, IVF (3% of preg)
Presentation
6-8/52 amenorrhoea then:
- Lower abdo pain
- PV bleeding
- Shoulder tip pain or pain of defaecation/urination (peritoneal bleeding)
- Dizziness, fainting, syncope
Examination
- Abdo tender, cervical excitation, adnexal mass (do NOT examine for this as risk of rupturing)
Investigation
TV USS
+ve pregnancy test
Management
Expectant
Size <35mm, unruptured, no foetal heartbeat, asymptomatic,bHCG <1000
Monitor over 48h. If BHCG rises or symptoms start –> intervention
Medical Management
- Size <35mm, unruptured, no foetal heartbeat, no significant pain, HCG <15000
- Methotrexate + f/u
Surgical Management
- Size >35mm, ruptured, visible heartbear, pain, bHCG >5000
- Salpingectomy (if no risk factors for infertility) or salpingotomy (if RFs e.g. contralateral tube damage- 1 in5 end up needed methorex or salpingectomy as well)
Miscarriage
Causes
Classification/Presentation
Investigation
Management
Recurrent Miscarriage Management
Causes
Recurrent miscarriage can be due to:
- Antiphospholipid syndrome
- Endocrine: poorly controlled DM or thyroid. PCOS
- Uterine abnormality
- Parental chromosomal abnormality
- Smoking
Classification/Presentation
Threatened - painless PV bleed <24/52. Closed cervical os.
Missed/Delayed - gestational sac w/ no embryonic/foetal pole >20/52 without symptoms of expulsion. Closed os.
Inevitable miscarriage - heavy bleeding w/ clots/pain. open os.
Incomplete- pain PV bleeding, open os, not all POC expelled
Investigation
- TV USS
**Management **
Expectant
- wait 7-14d for spontaneous completion.
If unsuccessful OR if risk of haemorrhage (coagulopathy or late 1st trimester) OR prev traumatic experience (eg. stillbirth, antepartum haemorrhage) OR evidence infection
Medical Management
- Vaginal misoprostol (bleeding should start within 24h)
Surgical Management
- Vacuum aspiration (suction curretage) OR surgical management in theatre (under GA)
Recurrent miscarriage management
- 3 or more <10/52, or 1 or more w/ normal foetus >10/52 –> refer (USS, genetic test, assessment for antiphospholipid syndrome)
Termination of Pregnancy
- Laws
- Method of termination
Laws (1967 Abortion Act)
- Below 24/52 gestation
- 2 registered medical practitioners must sign a legal document (or 1 in emergency)
(limits do not apply in cases where it is needed to save mother’s life, evidence of extreme foetal abnormality or risk of serious physical/mental injury to mother)
Method of Termination
- <9/52 - mifepristone (antiprogesterone) followed 48h later w/ prostaglandins (misoprostol)
- <13/52 - surgical dilatation + suction
- >15/52 - surgical dilatation + evacuation or uterine contents OR late medical abortion (mini labour)
Infertility
Definition
Causes
Investigation
Management
Definition
- Primary (no prev pregnancy), Secondary (prev pregnancy, miscarriage, abortion or ectopic)
- Investigate if >12m no conception
Causes
- Unknown (30%)
- Male factor (20%)
- Ovulatory dysfunction (20%) - hypogonadotrophic hypogonadoism (eg. kallman’s), normogonadotrophic anovulation (PCOS), hypergonadotrophic hypogonadism (premature ovarian failure)
- Tubal damage (15%)
- Other (15%) eg. endometrial (asherman, adenomyosis etc), cervical hostility, prolactinoma
Investigation
- Male: Semen analysis
- Female: Day 21 progesterone (should be at peak + is a marker of corpus luteum function and therefore ovulation)
<16 - repeat, if still low refer to specialist
16-30 - repeat
>30 = ovulation
- Other: TSH, prolactin, USS, LH/FSH, AMH (ovarian reserve)
Management
- General: smoking/alcohol advice, BMI 20-25, reg intercourse, folic acid
- Female
Ovulatory - clomiphene
Tube dysfunction - IVF
Prolactinoma - dopamine agonists
- Male
Intracytoplasmic sperm injection
prolactinoma - dopamine agonists
Assisted Reproductive Techniques:
- IVF + embryo transfer - given gonadotrophins + GnRH agonists/antagonists to stimulate ovulation –> oocyte harvesting
Gonadotrophin use –> risk of ovarian hyperstimulation syndrome (ovarian enlargment + 3rd space fluid shifts)
-> mild (abdo pain + bloating)
-> mod (n+v, USS evidence ascites)
-> Sev (clinical ascited, oliguria, raised haematocrit, hypoproteinaemia)
-> critical (VTE, ARDS, anuria, tense ascites)
- ISCI (mod-severe male factor inferility)
- Intrauterine insemination (relies on patent tubes)
