Gynaecology Flashcards
Causes of abnormal uterine bleeding
Fibroids
Endometrial hyperplasia
Endometrial cancer
Adenomyosis
Perimenopause
Polyps
PCOS
Causes of post menopausal bleeding
Endometrial cancer
Endometrial atrophy
Endometrial hyperplasia
Polyps
First line medical management for abnormal uterine bleeding
Mirena coil
How long must pelvic pain last to be classed as chronic pelvic pain?
> 6 months
Causes of acute pelvic pain
Miscarriage
Ectopic pregnancy
Appendicitis
UTI
PID
Torsion/rupture of ovarian cyst
Acute pancreatitis
Cholangitis
Define endometriosis
Presence of endometrial-like tissue outside of the uterus
What age group does endometriosis typically effect?
25-35
What is the definitive way to diagnose endometriosis
Laparoscopic surgery
Medical management of endometriosis
Analgesia
Hormonal treatment - OCP, mirena coil
Surgical management of endometriosis
- Laparoscopic surgery - to excise endometrial tissue and remove adhesions
- Hysterectomy
What is adenomyosis and who does it typically effect?
The presence of endometrial tissue within the myometrium
Older women who have had children
What are fibroids?
Benign smooth muscle tumours of the myometrium
Fibroids effect…
… 30% of women over 30
Symptoms of fibroids
Asymptomatic
Menorrhagia
LUTS
Pelvic pain
Complications of fibroids
- Torsion
- Red degeneration
- Malignant change to leiomyosarcoma
- Pregnancy complications e.g. miscarriage, preterm labour
What criteria is used for making a diagnosis of PCOS?
The Rotterdam Criteria
What 3 key features are included in the Rotterdam Criteria? How many of these do you need for diagnosis?
2/3 features required for diagnosis:
1. Oligoovulation/anovulation
2. Hyperandrogenism
3. Polycystic ovaries on USS
Insulin resistance is a crucial part of PCOS. Give 3 ways increased insulin impacts PCOS
- Insulin promotes the release of androgens -> hyperandrogenism
- Insulin suppresses sex hormone-binding globulin (produced by the liver) which normally binds to androgens and suppresses their function
- High insulin halts the development of follicles in the ovaries -> anovulation
What would hormonal blood test show in PCOS?
- Raised LH
- Raised LH:FSH ratio
- Raised testosterone
- Raised insulin
- Normal/raised oestrogen
What is gold standard for visualising the ovaries?
Transvaginal ultrasound
On TVS what findings indicate PCOS?
- 12 or more developing follies in one ovary
- Ovarian volume >10cm3
- Follicles arranged around the periphery of the ovary giving a ‘string of pearls’ appearance
Why are women with PCOS at increased risk of endometrial cancer?
Normally after ovulation the corpus luteum releases progesterone. Women with PCOS ovulate infrequently/not at all -> insufficient progesterone. This means their endometrium proliferates in the presence of unopposed oestrogen -> endometrial hyperplasia -> rf for endometrial cancer
Give 3 options for restoring ovulation in women with PCOS?
- Weight loss
- Clomifene
- IVF
Give 2 broad causes of incontinence
- Detrusor overactivity
- Sphincter weakness
What features would indicate detrusor overactivity incontinence?
- Urgency
- Frequency
- Nocturia
- ‘Key in the door’
- Incontinence during intercourse
What type of incontinence is seen with sphincter weakness?
Stress incontinence
What innervation, neurotransmitter and receptors are involved with detrusor overactivity?
- Parasympathetic
- ACh
- Muscarinic
Give general management options for incontinence
- Wt loss
- Smoking cessation
- Reduce caffeine
- Leakage barriers
- Vaginal support - pessaries
- Vaginal oestrogen
What speculum should be used for investigating prolapsed?
Sims speculum
Give 2 surgical options for managing prolapse
- Hysterectomy for uterine prolapse
- Colpocleisis for women who do not wish to retain sexual function
Give 3 non-surgical options for managing prolapse
- Pelvic floor training (>16 weeks)
- Topical oestrogen (if prolapse + atrophy)
- Pessaries
Give 4 types of prolapse
- Uterine prolapse
- Vaginal vault prolapse
- Cystocele
- Rectocele
What 2 phases occur in the ovaries during the menstrual cycle?
- Follicular phase
- Luteal phase
What 3 phases occur in the endometrium during the menstrual cycle?
- Menstral phase
- Proliferative phase
- Secretory phase
What is the typical time period from ovulation to menstruation?
14 days
What happens during the follicular phase of the menstrual cycle?
- Initially low progesterone + oestrogen and increasing FSH
- The developing follicle releases oestrogen
- Oestrogen inhibits FSH and increases LH
- LH surge results in ovulation
What happens during the luteal phase of the menstrual cycle?
- Follicle in ovary forms corpus luteum and secrete progesterone
- If the ovum is not fertilised the corpus luteum regresses to form the corpus albicans
- Progesterone decreases which results in mensuration
What endometrial phase does the luteal phase in the ovary trigger?
The menstrual phase
What happens during the menstrual phase of the menstrual cycle?
Falling progesterone results in shedding of the endometrium
What happens during the proliferative phase of the menstrual cycle? What ovarian phase does it coincide with?
- Increasing oestrogen causes endometrial growth and early development of spiral arterioles and glands
- Follicular phase in the ovaries
What happens during the secretory phase of the menstrual cycle? What ovarian phase does it coincide with?
- Increasing progesterone (from the corpus luteum) prepares the endometrium for implantation (development of spiral arterioles and endometrial production of glycogen)
- Early luteal phase in the ovaries
What is the 1st and 2nd line management of stress incontinence?
- Pelvic floor exercises/physio
- Duloxetine
What is the 1st and 2nd line management of urge incontinence?
- Bladder training
- Oxybutinin
What are side effects of oxybutinin?
Anticholinergic side effects - can’t see, can’t pee, can’t spit, can’t shit
- Dry eyes
- Dry mouth
- Urinary retention
- Constipation
What is hypogonadism?
Lack of sex hormones - oestrogen and testosterone
What are 2 reasons for hypogonadism?
- Hypogonadotropic hypogonadism
- Hypergonadotropic hypogonadism
What is hypogonadotropic hypogonadism?
A deficiency of LH and FSH
Give 5 causes of hypogonadotropic hypogonadism
- Hypopituitarism
- Damage to hypthal/pit. by radiotherapy or surgery for cancer
- Excessive exercise/dieting
- Kallman syndrome
- Endocrine disorders - hyperprolactinaemia, Cushing’s, hypothyroidism
What is Kallman Syndrome? What’s an additional feature of it?
- Genetic condition causing hypogonadotropic hypogonadism
- Anosmia (reduced/absent sense of smell)
What is hypergonadotropic hypogonadism?
Where the gonads fail to respond to stimulation from the gonadotropins (LH/FSH)
Why do you get high LH/FSH in hypergonadotropic hypogonadism?
Without negative feedback from the sex hormones the anterior pituitary produces increasing amounts of LH and FSH. This leads to high LH/FSH and low sex hormones
What are 3 causes of hypergonadotropic hypogonadism?
- Previous damage to gonads - torsion, cancer, infections (mumps)
- Congenital absence of ovaries
- Turners syndrome
What type of amenorrhoea does congenital adrenal hyperplasia cause?
Primary amenorrhoea
Why can androgen insensitivity syndrome present with primary amenorrhoea?
Although girls have female external genitalia, internally there are testes. They have absent uterus, upper vagina, fallopian tubes and ovaries.
What is the most common structural cause of primary amenorrhoea? What are the symptoms?
- Imperforate hymen
- Cyclical pain as menses builds up but is unable to escape
What are the levels of 1) LH/FSH and 2) sex hormones, in hypogonadotropic hypogonadism?
1) Low LH/FSH
2) Low sex hormones
What are the levels of 1) LH/FSH and 2) sex hormones, in hypergonadotropic hypogonadism?
1) High LH/FSH
2) Low sex hormones
Treatment of hypogonadotropic hypogonadism where pregnancy is wanted?
Pulsatile GnRH to induce ovulation and mensuration
Treatment of hypogonadotropic hypogonadism where pregnancy is not wanted?
COCP to replace sex hormones
What is secondary amenorrhoea?
No mensuration for more than 3 months
What type of hypogonadism do you get in secondary amenorrhoea? Why?
- Hypogonadotropic hypogonadism
- The hypothalamus reduces production of GnRH in response to sig. physiological/psychological stress to prevent pregnancy in situations in which the body may not be fit
Give 5 causes of secondary amenorrhoea. Which is the most common cause?
- Pregnancy (most common)
- Menopause/primary ovarian insufficiency
- Hyperprolactinaemia
- Ovarian causes - PCOS
- Thyroid pathology
What happens in hyperprolactinaemia?
High prolactin levels act on the hypothalamus to prevent release of GnRH –> no LH/FSH
What’s the most common cause of hyperprolactinaemia?
Pituitary adenoma secreting prolactin
What’s the treatment of hyperprolactinaemia?
Dopamine agonists (bromocriptine/cabergoline) to reduce prolactin production
Why is it important to have a withdrawal bleed in PCOS? What can be used to stimulate this?
- To prevent the risk of endometrial hyperplasia and endometrial cancer
- Medroxyprogesterone for 14 days/regular use of the COCP
When is first line for symptom control of menorrhagia if painless?
Tranexamic acid
What type of drugs are tranexamic acid and mefenamic acid?
- Tranexamic - antifibrinolytic
- Mefenamic - NSAID
What can be given when menorrhagia is associated with pain?
Mefenamic acid
What can be given for hirsutism in PCOS? Which is contra-indicated in pregnancy?
Anti-androgen
- Cocyprindol
- Spirolactone
- Finasteride (c.i. in preg)
What are functional cysts? Give 2 examples
- Cysts related to fluctuating hormones of the menstrual cycle
- Follicular cysts
- Corpus luteum cysts
What are corpus luteum cysts?
- Occur when the corpus luteum fails to break down and instead fills with fluid
- Can cause pelvic discomfort, pain, delayed menstration
- Often seen in early pregnancy
What are follicular cysts?
- Represent the developing follicle
- When they fail to rupture and release the egg the cyst can remain
- Most common ovarian cyst
- Harmless and tend to disappear after a few menstrual cycles
What cysts are associated with endometriosis? Give both names for them
- Endometrioma
- Chocolate cysts
What is the management of simple cysts in premenopausal women…
1. <5cm
2. 5-7cm
3. >7cm
- No further Rx, will resolve within 3 cycles
- Routine referral to gynae + yearly USS
- MRI/surgical evaluation as can be hard to characterise with ultrasound
What is meigs syndrome?
A triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleural effusion
- Ascites
- Typically occurs in older women
- Removal of the tumour results in complete regulation of symptoms
What are LH, FSH, oestrogen and progesterone levels in menopause?
- Oestrogen and progesterone are low
- LH and FSH are high as no negative feedback from oestrogen
What is the medical management of fibroids <3cm? What is this the same management as?
- Mirena coil (1st line)
- Symptomatic management (NSAIDS/tranexamic acid)
- COCP/POP
- Same management as heavy menstrual bleeding
What is the management of fibroids >3cm
- Referral to gynae
- May manage in the same way as smaller fibroids
- Surgical options - uterine artery embolisation, myomectomy, hysterectomy
What medications are used to reduce the size of fibroids before surgery? How do they work?
- GnRH agonists e.g. goserelin or leuprorelin
- Shrink the fibroid by inducing a menopause like state, this reduces the amount of oestrogen maintain the fibroid
What aspect of the Rotterdam criteria for PCOS does hirsutism fall under?
Clinical and/or biochemical signs of hyperandrogenism
When should you remove the coli in PID?
If no response to abx after 72 hours
What features indicate ovarian torsion?
- Vomiting
- Peritonism
- Fever
What should you always look out for in patients presenting with secondary amenorrhoea?
Signs of menopause!!!! Night sweats, poor concentration, heat intolerance etc
What indicates a pituitary/hypothalamic issue in secondary amenorrhoea?
Low oestrogen AND gonadotropins
- Low oestrogen should trigger pit/hypothalamus to increase gonadotrophin production
What is haematocolpos?
Accumulation of blood in vagina, normally due to imperforate hymen
What is the classical position of the uterus in endometriosis?
Fixed retroverted uterus
What are the 4 types of fibroids?
- Submucosal - below the endometrium
- Intramural - within the myometrium
- Subserosal - below the outer layer of the uterus
- Pedunculated - on a stalk
What is the management of cysts in post-menopausal women?
- CA125 and refer to gynae
- If raised Ca125 2WW
What is lichen sclerosus?
- A chronic inflammatory skin condition that presents with patched of shiny, white skin
- Commonly affects the labia, perineum and perianal skin in women
Typical presentation of lichen scelrosus
- 45-60 year old female
- Presenting with vulval itching and skin changes
- Koebner phenomenon (signs and symptoms are worse with friction)
How are patients with lichen sclerosus managed?
- FU every 3-6 months with derm or gynae
- Regular emollients
- Flares are managed with potent topical steroids e.g. dermovate
- Steriods are initially used once a day for 4 weeks then every other day for 4 weeks then twice a week
What’s a critical complication of lichen sclerosus?
Development of squamous cell carcinoma of the vulva
What are Bartholin’s glands? What happens when they become blocked?
- A pair of glands either side of the vaginal introitus (the vaginal opening)
- The produce mucus to help vaginal lubrication
- When blocked they can swell and become tender causing Bartholin’s cyst
What’s a complication of Bartholin’s cysts? What’s the management of this?
- Bartholin’s abscess
- Swab of pus/fluids for culture
- Antibiotics
- Surgery (may be required) to drain the abscess
What is the management of Bartholin’s cysts?
Usually resolve with good hygiene, analgesia and warm compresses
What are Nabothian cysts? Are they concerning? What causes them?
- Fluid filled cyst on the surface of the cervix
- They are harmless and unrelated to cervical cancer
- Can occur after childbirth, minor trauma or cervicitis following infection
How can Nabothian cysts present?
- Often asymptomatic so may be found incidentally on speculum examination
- If very large (rare) can cause a feeling of fullness
What is the management of Nabothian cysts?
No treatment required, normally resolve spontaneously
What happens in cervical ectropion?
- When the columnar epithelium of the endocervix extend out to ectocervix (normally stratified squamous epithelium)
- Columnar epithelium is more fragile and prone to trauma and bleeding
How does cervical ectropion present?
- Post coital bleeding
- Increased vaginal discharge
- Dyspareunia
What’s the management of symptomatic cervical ectropium?
Cauterisation of the ectropium using silver nitrate or cold coagulation during colposcopy
What are risk factors for cervical ectropion?
Cervical ectropium is associated with higher oestrogen levels meaning RF include younger age, COCP and pregnancy
