Gynaecology Flashcards
oestrogen: production, active form and function
- produced by: theca granulosa cells surrounding follicles in ovaries in response to LH and FSH (stimulate follicles in ovaries)
- 17-beta oestradiol
- promote secondary sexual characteristics - breast tissue development, growth and development of vulva, vagina and uterus at puberty, blood vessel development in uterus and development of endometrium
progesterone: production and function
- produced by corpus luteum after ovulation
- after 10 weeks placenta is main production site in pregnancy
- function - thickens and maintains endometrium, thickens cervical mucus and increases body temperature
age of normal puberty
- 8-14 girls
- 9-15 boys
takes about 4 years start to finish
why do overweight children enter puberty earlier
aromatase is enzyme in adipose tissue that is ppart of oestrogen production - more adipose = mor oestrogen
def: puberty stages in girls in order
- breast buds
- pubic hair
- menstrual periods begin (menarche - usually 2 years from puberty begins)
tanner staging of puberty
- (under 10) no pubic hair, no breast developmet
- (10-11) light and thin PH, breast bds behind areola
- (11-13) coarse and curly PH, breast begins to elevate beyond areola
- 13-14 adult like but not reaching thigh PH, areolar mounds form and project from siurrounding breast
- 14+ hair extending to medial thigh, areolar mounds reduce and adult breasts form
hormone stages in puberty
- GH increases causing growth spurt
- hypothalamus secretes GnRH during sleep initially then throughout day later in pubery, stimukating FSH adn LH from pituitary gland
- FSH plateus 1 year before menarche, LH continues to rise and spikes just before menarche
- oestrogen suppresses GH stopping growth spurt at menarche
arterial blood supply to pelvis
BRANCHES OF INTERNAL ILIAC:
pudendal
obturator
uterine: branches to ovarian and vaginal
venous drainage of pelvis
mirrors arterial supply except:
left ovarian vein drains to left renal vein - right vein and aorta drain striaght to aorta and IVC)
nerve supply pelvic region (suprapubic and inguinal regions)
ilioinguinal and iliohypogastroic L1
nerve supply pelvic region pudendal nerve
S2-4
supplies skin and muscle of perineum and ends at clitorus
3 zones ureteric course
zone 1: between renal pelvis and iliac arteries
zone 2: between ureteral crossover of iliac arteries and uterine artery crossing over ureter (water under the bridge)
zone 3:between uterine artery crossing over ureter and entry into bladder
phases of mentrual cycle
follicular phase and luteal phase
follicular - start of menstruation to moment of ovulation (first 14/28 days)
luteal - moment of ovulation to start of menstruation (final 14 days)
define: follicular phase inc 4 keey stages of development)
- primordial 2. primary 3. secondary 4. antral
* once follicles reach secondary stage, FSH receptors allow further development
* theca granulosa cells around secondary follicles secrete oestradiol which has negative feedback to pituitary gland to reduce LH and FSH production
* rising oestrogen causes cervical mucus to become permeable to sprem around ovulation
* one of follicles develops further and becomes dominant follicle
* LH spikes just before ovulation causing dominant (Graafian) follicle to release ovum 14 days beore end of cycle
define: luteal phase
- after ovulation, follicle that released ovum collapses and becomes corpus luteum secreting high levels progesterone maintaining endometrial lining
- progesterone also causes cervical mucus to become thick and inpennetrable
- small amount oestrogen secreted by corpus luteum
- when fertilisation occurs, syncitiotrophoblast of embryo secretes hCG aintaining corpus luteum
hormonal changes if no fertilisation
- no production of hCG from syncitiotrophoblast causes corpus luteum to degenerate
- fall in oestrogen and progesterone (from no longer being secreted by corpus luteum) causes endometrium to break down
- stromal cells from endometrium release prostoglandins encouraging endometrium to break down and uterus to contract
- negative feedback from oestrogen and progesterone stops to hypothalamus and LH and FSH begin to rise again
def: PMS
pre-menstrual syndrome
* psychological, emotional and physical symptoms occuring during luteal phase of menstrual cycle
* symtpoms resolve once menstruation begins
* not occuring pre-menarche, during pregnancy or after menopause
pathophysiology: PMS
fluctuation in oestrogen and prgesteone levels
exact mechanism unknown but ?increased sensitivity to progesterone or interaction between sex hormones and serotonin and GABA
presentation: PMS
- low mood
- anxiety
- moodswings
- irritability
- bloating
- fatigue
- headaches
- breast pain
- reduced confidence
- cognitive impairment
- clumsiness
- reduced libido
PMS symptoms can occur after hysterectomy, mirena coil, endometrial ablation
def: progesterone-induced premenstrual disorder
PMS symtpoms while on progesterone therapy = COCP and HRT
diagnosis: PMS
symtpom diary spanning 2 menstrual cycles demonstrating cyclical symtoms occuring just before menstruation and resolveing on onset of menstruation
definitive diagnosis with GnRH analogues to halt menstrual cycle and see if symptoms resolve
rx: PMS
- general healthy lifestyle changes (diet, excercise, smoking, alcohol, stress and sleep
- COCP
- SSRI antidepressants
- CBT
COCP recommended in: PMS
containing drospirenone - antimineralocorticoid effects similar to spironalactone
use continuously and not cyclical
def: primary amenorrhoea
not starting menstruation by 13 with no evidence of puberty or by 15 with other signs of puberty
causes: primary ammenorrhoea
- hypogonadotrophic hypogonadism
- hypergonadotrophic hypogonadism
- congenital adrenal hyperplasia
- androgen insensitivity syndrome
- structural pathology (imperforate hymen)
def: hypogonadotrophic hypogonadism
- not enough gonadotrophins to stimulate ovaries to produce oestrogen
- hypothalamic (not enough GnRH) or pituitary problem (not enough FSH or LH)
causes: hypogonadotrophic hypogonadism
- hypopituitarism
- significant chronic conditions
- excessive excercise/dieting
- constitutional delay
- endocrine disorders
- Kallmann’s syndrome
def: hypergonadotrophic hypogonadism
problem with ovaries themselves - pituitary gland goes into overdrive to try and combat this so increased amounts of FSH and LH
causes: hypergonadotrophic hypogonadism
- previous damage to gonads (torsion, cancer or infections)
- congenital absence of ovaries
- Turner’s syndrome
rx: primary ammenhorroea
- investigate for underlying cause: bloods, hormone profile, imagine
- treat underlying cause: constitutional - reassure, low body weight - advise weight gain
- replace hormones where needed (hypo hypo - pulsatile GnRH or COCP)
rx: hypogonadotrophic hypogonadism
- pulsatile GnRH
- COCP
def: secondary ammenorrhoea
no menstruation for 3+ months after previous regular menstrual periods
causes: secondary ammenorrhoea
- ovarian pathology - pregnancy, menopause and premature ovarian failure, hormonal contraception and PCOS
- pituitary pathology - tumours, hyperprolactinaemia, trauma/srugery/sheehan syndrome (damage to pituitary following large blood loss during childbirth)
- hypothalamic pathology - excessive exercise, low body weight and eatind disorders, crhonic disease and psychological stress
- uterine causes - Asherman’s syndrome (intrauterine adhesions)
- thyroid pathology - hyperthyroidism
ovarian causes: secondary amennorhoea
- pregnancy
- PCOS
- menopause/pof
- hormonal contraception
pituitary causes: secondary amennorhoea
- tumours
- trauma/surgery/sheehan syndrome
- hyperprolactinaemia
hypothalamic causes: secondary amennorhoea
- excessive exercise
- eating disorders
- low body weight
- chronic disease
- psychological stress
uterine causes: secondary amennorhoea
asherman’s syndrome
thyroid causes: secondary amennorhoea
hyperthyroidism
rx: secondary amenorrhoea
- treat underlying cause
- replace hormones
- if 12 months amenorrhoeic - bone protection
- PCOS - COCP for 3 motnhs and 1 week break for withdrawal bleed
causes: menorrhagia
fibroids
endometriosis
adenomyosis
PID
copper coil
extremes of reproductive age
anticoagulants
bleeding disorders
endocrine disorders - DM and hypothyroid
connectivetissue disorders
endometrial hyperpasia/cancer*
dysfunctional uterine bleeding (diagnosis of exclusion - no other identifiable cause)
hx: menorrhagia
- age of menarche
- cycle length
- IMB and PCB
- contraceptive hx
- sexual hx
- ?pregnancy
- plans for pregnancy
- cervical screening hx
- migraines (with ot without aura)
- pmhx and dhx
- smoking and alcohol
- fhx
ix: menorrhagia
- speculum and bimanual
- FBC
- TFss
- coagulation screen if ?bleeding disorfer
- ferritin is clinically anaemic
hormonal rx: menorrhagia
mirena coil
COCP
cyclical oral progesterones
POP/implant/depot
non hormal rx: menorrhagia
- TXA - not pain relief but reduces bleeding
- mefanamic acid - pain relief and reduces bleeding
secondary rx: menorrhagia if initial rx not worked
- endometrial ablation
- hysterectomy
def: fibroids
- benign tumours or uterine smooth muscle
- oestrogen sensitive - grow during pregnancy and smaller after menopause
- submucosal most common type
symptoms: fibroids
- asymptomatic
- heavy menstrual bleeding
- bloating/feeling of fullness
- urinary/bowel symptoms
- deep dyspareunia
types of fibroid
- intramural - within myometrium (these change shape and distort uterus with growth)
- subserosal - below outer layer of uterus (can fill abdominal cavity, growing outwards and becoming very large)
- submucosal - just below lining of uterus (endometrium)
- pedunculated - on a stalk
ix: <3cm fibroids
- OP hysteroscopy
rx: <3cm fibroid
- manage HMB - mirena coil if <3cm and no uterine distorion, NSAIDs and tranexamic acid, COCP
surgery: - resection during hysteroscopy
- endometrial ablation
- hysterectomy
ix: >3cm fibroid
- pelvis USS
rx: >3cm fibroid
- manage HMB
surgery - uterine artery embolisation
- myomectomy (improves fertility)
- hysterectomy
importnat rx: endometriosis and mirena coil
only if <3cm and no uterine distorion
rx: large fibroids pre-surgery
GnRH agonists - goserelin reduce size pre-surgery
def: red degeneration of fibroid
- fibroid rapidly increases in size in pregnancy
- outgrows blood supply - becomes infarcted and necrosed
- causes severe abdo pain
- supportive management
def: endometriosis
ectopic endometrial tissue outside of uterus
def: endometrioma
lump of endometrial tissue outside of uterus
keyword: endometriosis
chocolate cyst
symptoms: endometriosis
cyclical pelvic pain
becomes chronic and non-cyclical as adhesions form
deep dyspareunia
blood in urine/stools during menstruation
subfertility
diagnosis: endometriosis
laproscopic surgery
may be picked up on USS
rx: decreased fertility in endometriosis
SURGERY:
* clear adhesions
* removes endometriomas
* normalise pelvic anatomical structure
ix: endometriosis
- history
- speculum - deposits in vagina
- bimanual - fixed uterus/cervix, tenderness on deep palpation and adnexal tenderness
- pelvis USS often normal
- LAPROSCOPIC SURGERY IS GOLD STANDARD
staging: endometriosis
stage 1 - small/superficial
stage 2 - deeper or pouch of douglas
stage 3 - deep, pouch of douglas and ovaries
stage 4 - deep and large, extensive adhesions
rx: endometriosis
HORMONAL OR SURGICAL
* analgesia
* hormonal medication (stop ovulation and decrease endometrial thickening) COCP
* progesterone (inc mirena or depot)
* induce medical menopause - GnRH goserelin
* laproscopic surgery
* TAH and BSO
def: myometriosis
enometrial tissue in myometrium
deiagnosis: myometriosis
TVUSS
def: menopause
retrospective diagnosis of no periods for 12 months usually around age 51
enopause is point at which menstruation stops
def: postmenopause
describes period from 12 months after final menstrual period onwards
def: perimenopause
time around menopause where vasomotor synptoms and irregualr periods occur
inclused time leading up to last period and 12 months afterrwards
def: premature menopause
due to premature ovarian insufficiency
menopause before 40
physiology: menopause
lack of ovarian follicular function
oestrogen and progesterone levels low
LH and FSH high in response to lack of negative feedback
lackof follicles means lack of oestrogen, lack of negative feedbakc to pituitary
lack of follicular development mens anovulation and irregular menstrual cycles
without oestrogen, endometrium does not develop and therefore amenorrhoea occurs
symptoms: perimenopause
- hot flushes
- mood swings or low mood
- premenstrual syndrome
- irregular periods
- joint pains
- heavier of lighter periods
- vaginal dryness and atrophy
- reduced libido
risks: postmenopausal women
cardiovascular disease and stroke
osteoporosis
pelvic organ prolapse
urinary incontinence
diagnosis: perimenopause and menopause
can be made with symptoms clinically in women over 45
FSH blood test can be used in women <40 with suuspected premature menopause or 40-45 year old women with menopausal symptoms or changes to menstrual cycle
rx: contraception and the menopause
- contraception for 2 years after last menstrual period for women <50
- contracetpion for 1 year after last menstrual period for women >50
tx: contraception guidelines for menopause
- UKMEC1: barrier, mirena or copper coil, POP, progesterone implant, depot IF UNDER 45
- COCP is UKMEC2 in over 40 - norethisterone or levonogestrel if over 40 (decreased VTE risk)
depot injection and menopause
depo-provera side effects are weight gain and osteoporosis (decreased bone mineral density) so unstuiable for over 45 year olds in menopause
rx: perimenopausal symptoms
- likely to resolve over 2-5 years without treatment
- HRT - continuous if LMP 12-18 months ago
- HRT - sequencial if still ongoing periods/period in last 12 months
- clonidine
- tibolone (synthetic steroid hormone acts as combined HRT - only after 12 months amenorrhoea)
- SSRI - fluoxetine/citalopram
- vaginal oestrogen cream/mopisturisors
- testosterone for decreased libido
type of HRT
oestrogen and progesterone if uterus still there
oestrogen only if hysterectomy
contraindications: HRT
- undiagnosed abnormal bleeding
- endometrial hyperplasia/cancer
- breast cancer
- uncontrolled HTN
- VTE
- liver disease
- active angina/MI
best forms of HRT
oestrogen: patch
progesterone: mirena coil
use of cyclical HRT
12 months amenorrhoeic for >50y
24 months amenorrhoeic for <50y
def: premature ovarian insufficiency
menopause before 40
pathophysiology: premature ovarian insufficiency
- hypergonadotrophic hypogonadism - underactivity of gonads
- causes raised LH and FSH
- low oestradiol level
causes: premature ovarian insufficiency
- idiopathic (50%)
- iatrogenic (chemo/radi/oophrectomy)
- autoimmune (coeliac/adrenal insufficiency/ T1DM/thyroid disease)
- genetic (+ve fhx) or turners
- infections (mumps/TB/CMV)
symptoms: premature ovarian insufficiency
- irregular periods
- secondary amenorrhoea
- low oestrogen (hot flushes, night sweats and vaginal dryness)
diagnosis: premature ovarian insufficiency
if under 40:
* typical menopausal symtpoms PLUS elevated FSH blood test - persistently raised in 2 separate samples over 4 weeks apart >25IU/L
risks: premature ovarian insufficiency
CV disease
stroke
osteoporosis
cognitive impairment (dimentia)
parkinsonism
rx: premature ovarian insufficiency
- HRT until age of typical menopause (COCP or traditional HRT - lower blood pressure)
- still require contraception
risks: HRT in premature ovarian insufficiency
increased VTE (use transdermal instead)
not contraception
def: PCOS
polycystic ovarian syndrome
* multiple ovarian cysts, oligomenorrhoea, hyperandrogenism and insulin resistance
Rotterdam criteria: PCOS diagnosis
2 out of 3:
1. oligoovulation or anovulation (presenting with irregular or absent menstural periods)
2. hyperandrogenism (hirtuitism and acne)
3. polycystic ovaries on USS of more thtan 10cm^3
Rotterdam criteria: PCOS diagnosis
2 out of 3:
1. oligoovulation or anovulation (presenting with irregular or absent menstural periods)
2. hyperandrogenism (hirtuitism and acne)
3. polycystic ovaries on USS of more thtan 10cm^3
presentation: PCOS
- oligomenorrhoea/amenorrhoea
- infertility
- obesity
- hirtuitism
- acnes
- hair loss in male pattern
- insulin resistance and diabetes
ix: PCOS
blood tests:
* testosterone (raised)
* sex hormone-binding globulin (low)
* FSH (raised)
* LH (raised)
* prolactin
* TSH
* raised or normal oestrogen
RAISED LH:FSH RATIO
USS finding: PCOS
string of pearls
* 12 or more cysts on one ovary OR
* ovarian volume >10cm^3
rx: PCOS
reduce risks:
* weight loss
* low glycamic index (calorie controlled diet)
* exercise
* smoking cessation
* antihypertensives
rx: endometrial cancer risk PCOS
mirena coil or COCP (need withdrawal bleed 3-4 times in a year)
rx: PCOS managing infertility
- weight loss
- clomifene
- IVF
rx: managing hirtuitism PCOS
- weight loss
- waxing/shaving/laser
- dianette (COCP) for 3 months
- eflonithine topically
rx: managing acne PCOS
dianette (first line) COCP
def: functional ovarian cyst
- related to fluctuating hormones of menstrual cycle
- common in premenopausal women
- follicular/corpus luteum
presentation: ovarian cyst
- often incidental on USS
- pelvic pain
- bloating
- fullness in abdomen
- palpable pelvic mass
acute pain if torsion, haemorrhage or rupture of cyst
def: serous cystadenoma
benign tumours of epitehlial cells
def: mucinous cystadeoma
benign tumour of epithelial cells but can become huge and filled with pus
def: endometrioma
lumps of endometrial tissue within ovary
def: dermoid cyst/ferm cell tumour
- benign ovarian tumour
- teratomas (coming from germ cells)
- can contain various tissue types (skin, teeth, hair and bone)
- can tort
def: sex cord-stromal tumours
- benign or malignant
- arise from stroma (connective tissue) or sex cords (embryonic structures)
- several types - Sertoli-Leydig and granulosa cell tumours
def: corpus luteum cysts
- when corpus luteum fails to break down and fills with fluid
- seen often in early pregnancy
def: follicular cyst
- type of functional cyst
- when developing follicle fails to rupture and release egg
- most common ovarian cyst
- disappear within a few menstrual cycles
- thin walled, no internal structures
ovarian cysts: hx suggesting malignancy
- abdominal bloating
- reduced appetite
- early satiety
- weight loss
- urinary symptoms
- pain
- ascites
- lymphadenopathy
RFs: ovarian malignancy
- age
- postmenopause
- increased number ovulations
- obesity
- nulliparity
- HRT
- family hx BRAC1 and 2
- smoking
factors reducing risk: ovarian malignancy
anything reducing number of ovulations
* later onset menarche
* early menopause
* any pregnancy
* use of COCP
rx: ovarian cyst
- premenopausal cyst <5cm NO FURTHER INVESTIGATION
- premenopausal cyst 5-7cm ROUTINE GYNAE REFERRAL FOR YEARLY USS
- premenopausal 7+cm ?MRI SAN OR SURGICAL EVALUATION
- women <40y with complex ovarian mass 2 WEEK REFERRAL TO GYNAE and LDH, aFP, hCG
- post menopausal cyst CALCULATE RMI with CA125, 2 WEEK WAIT IF CA 125 RAISED
- postmenopausal simple and <5cm = 6 MONTHLY USS
complications: ovarian cyst
- torsion
- haemorrhage
- rupture
def: Meig’s syndrome
triad of:
1. ovarian fibroma
2. pleural effusion
3. ascites
removing tumour resolves ascites and pleural effusion
def: ovarian torsion
- ovary twists in relation to surrounding connective tissue/fallopian tube/ blood supply (adnexa)
- usually due to ovarian mass >5cm
likelihood: ovarian torsion
- younger girls
- before menarche
- longer infundibulopelvic ligaments
presentation: ovarian torsion
- sudden onset severe unilateral pelvic pain
- pain progressively worsening
- associated with nausea and vomiting
- can twits and untwist intermittently meaning pain comes and goes
- o/e localised tendernessand may be palpable mass
diagnosis: ovarian torsion
- pevic USS WHRILPOOL SIGN - free fluid and oedema of ovary
- doppler may show lack of blood flow
- definitive diagnosis - laparoscopic surgery
rx: ovarian torsion
- EMERGENCY since lack of blood supply leads to ischaemia and necrosis
- laparoscopic surgery to either untwist or remove ovary
def: Asherman’s syndrome
adhesions often after D and C in pregnancy (retained products) or uterine surgery which form physical obstructions and pistort pelvic organs resulting in infertility, abnormal menstruation and recurrent miscarriages
presentation: Asherman’s syndrome
- secondary amenorrhoea
- lighter periods
- dysmenorrhoea
- (infertility)
diagnosis: Asherman;s syndrome
hysteroscopy GOLD STANDARD and can involve dissection and treatment of adhesions
def: cervical ectropion
- endocervix has extended out to ectocervix and are more fragile and prone to trauma
- more likely to bleed during intercourse
- common in younger women,
presentation: cervial ectropion
- increased vaginal discharge
- vaginal bleeding
- dyspareunia
- PCB
rx: cervical ectropion
symptomatic - no treatment
problematic bleeding - cauterisation using silver nitrate or cold coagulation during colposcopy
def: stress incontinence
urine leakage on increased abdominal pressure (coughing, jumping or sneezing)
def: urge incontinence
overactivity of detrusor muscle (overactive bladder)
sudden need to urinate
ix: incontinence
- bladder diary
- urine dip testing (rule out UTI)
- post-void residual void volume
- urodynamic testing
rx: stress incontinence
weight loss
1. pelvic floor exercises 3+ months
2. surgery - tension free vaginal tape, autologous sling or colposuspension
3. duloxetine (second line if refusing surgery)
rx: urge incontinence
- bladder retraining for 6 weeks
- anticholinergics (oxybutanin, tolterodine caution in elderly
- mirabegron
- invasive procedures (botox, sacral nerve stimulation or augmentation cystoplasty)
def: pelvic organ prolapse
descent of pelvis organs into vagina
types: pelvis organ prolapse
- uterine prolapse
- cystocele (bladder) - anterior vaginal wall
- rectocele (rectum) - posterior vaginal wall
- vault (vaginal vault following hysterectomy)
RFs; pelvic oran prolapse
- multiple vaginal deliveries
- instrumental/prolonged/traumatic deliveries
- advanced age and postmenopause
- obesity
- chronic respiratory disease (coughing)
- chronic constipation (straining)
presentation: pelvic organ prolapse
- “dragging sensations”
- urinary symptoms - incontinence, urgency, frequency, weak stream or retention
- bowel symtpoms - consipation, incontinence and urgency
- sexual dysfunction - pain, altered sensation or reduced enjoyment
grading: pelvic organ prolapse
Pop-Q system
0 = normal
1 = lowest part is more than 1cm from introitus
2 = lowest part within 1cm of introitus (above or below)
3 - lowest part more than 1cm below introitus but not fully descended
4 = full descent with eversion of vagina
rx: pelvic organ prolapse
- conservative
- pessaries
- surgical
conservative rx: pelvic organ prolapse
- physio (pelvic florr exercises)
- weight loss
- lifestyle changes (decreased caffeine or pads)
- treatment of related symptoms (incontinecnce)
- vaginal oestrogen cream
vaginal pessary rx: pelvic organ prolapse
- ring sitting around cervix to hold uterus up
- shelf and gellhorn - flat disc with stem sitting below uterus
- cube
- donut
surgical rx: pelvic organ prolapse
colporrhaphy
(mesh repair unlikely to work long term)
def: Nabothian cyst
- white/amber cysts on surface of cerix often around 1cm
- often found incidentally on speculum exam
- often after childbirth, minor trauma or cervicitis
def: atrophic vaginitis
- atrophy and dryness of vagina
- menopausal women
- caused by lack of oestrogen
presentation: atrophic vaginitis
- itching
- dryness
- dyspareunia
- bleeding
rx: atrophic vaginitis
- vaginal lubricants
- topical oestrogen
- review annually to stop oestrogen
def: lichen sclerosis
- chronic inflammatory autoimmune skin condition
- vulval dystrophy
- white patched on vulva
presentation: lichen sclerosis
- vulval itching/soreness
- skin changes (shiny porcelain white skin on labia)
- superficial dyspareunia
rx: lichen sclerosis
- potent topical steroids (clobetasol propionate 0.05% (dermovate) once daily for 4 weeks and then reduced
- emollient use regularly
complications: lichen sclerosis
5% risk of developing SCC of vulva
