Gynaecology Flashcards
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
- Final : endometrial ablation and hysterectomy
Give 6 possible causes of menorrhagia
- Dysfunctional uterine bleeding
- Fibroids
- PID
- Anticoagulation
- Bleeding disorders (e.g. VWD).
- Contraception (especially copper coil).
Define adenomyosis
Endometrial tissue within the myometrium
Who does adenomyosis usually effect?
- Multiparous women in later reproductive years
What are the symptoms of adenomyosis ?
Menorrhagia
Dysmenorrhoea
Dyspareunia
What is felt on examination in adenomyosis ?
Enlarged, tender , boggy uterus
What is the first line investigation for adenomyosis
Transvaginal USS
How is adenomyosis managed
- Hormonal / non hormonal management of menorrhagia
- GnRH agonists
- Uterine artery embolisation
- Hysterectomy = definitive
what is adenomyosis associated with in pregnancy ?(8)
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
Explain puberty in girls
- Occurs between 8-14
- Breast buds, pubic hair and finally menstruation
Define primary ammenorrhoea
Not starting menstruation by :
- 13 years when there is no other evidence of pubertal development
- 15 years of age where there are other signs of puberty, such as breast bud development
- How can causes of primary ammenorrhea be classified
- Hypogonadotropic hypogonadism -> LH and FSH deficiency
- Hypergonadotropic hypogonadism - > lack of response of the ovaries to LH and FSH
- CAH
- Androgen insensitivity syndrome
- Structural pathology
Give 6 causes of hypogonadotropic hypogonadism
- Hypopituitarism
- Damage to hypothalamus / pituitary (radiotherapy, surgery etc)
- Significant chronic conditions (CF/IBD)
- Excessive exercise or anorexia
- Endocrine disorders : GH deficiency, hypothyroid, cushing’s, hyperprolactinaemia
- Kallman syndrome (+ reduced / absent sense of smell)
Give 3 causes of hypergonadotropic hypogonadism
- Turner’s syndrome (XO)
- Congenital absence of the ovaries
- Previous damage to the gonads
Give 3 other causes of primary ammenorrhoea
- Congenital adrenal hyperplasia
- Androgen insensitivity syndrome
- Structural pathology : imperforate hymen, transverse vaginal septae, vaginal agenesis, absent uterus, FGM
what investigations are done to assess primary ammenorrhoea
INITIAL Ix FOR UNDERLYING CONDITIONS
- FBC, U&E’s , coeliac screen
HORMONAL BLOOD TESTS
- FSH and LH
- Thyroid function tests
- IGF-1 for GH deficiency
- Prolactin
- Testosterone : raised in PCOS, CAH and androgen insensitivity syndrome
GENETIC TESTING
- Microarray for turner’s
Define secondary amenorrhoea
No menstruation for >3mnths after previous regular menstrual periods
Give 8 causes of secondary amenorrhoea
- Pregnancy
- Menopause and premature ovarian failure
- Hormonal contraception
- Hypothalamic or pituitary pathology
- PCOS
- Asherman’s syndrome
-Thyroid pathology - Hyperprolactinaemia
Give 4 hypothalamic causes of secondary amenorrhoea
The hypothalamus reduces GnRH in response to stress = hypogonadotropic hypogonadism
- Excessive exercise (e.g. athletes)
- Low body weight and eating disorders
- Chronic disease
- Psychological stress
Give 2 pituitary causes of secondary amenorrhoea
- Pituitary tumours, such as a prolactin-secreting prolactinoma
- Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
Why does hyperprolactinaemia cause secondary amenorrhoea
- Prolactin acts on the hypothalamus to reduce GnRH.
- No GnRH -> reduced LH and FSH -> hypogonadotropic hypogonadism
What is the most common cause of hyperprolactinaemia
Pituitary adenoma secreting prolactin
What can be used for the treatment of hyperprolactinaemia if necessary
- Dopamine agonists : bromocriptine, cabergoline
what investigations are done to assess secondary amenorrhoea (Five)
- Rule out pregnancy with HCG urine
- LH and FSH
- Prolactin
- Thyroid
- Testosterone
What will LH and FSH levels suggest about the cause of secondary amenorrhoea ?
- High FSH = primary ovarian failure
- High LH or LH : FSH = PCOS
what treatment is given if amenorrhoea lasts >12 mnths and why ?
Increased risk of osteoporosis if there are also low oestrogen levels
- Ensure adequate vitamin D and calcium intake
- Hormone replacement therapy or the combined oral contraceptive pill
what kind of genetic condition is androgen insensitivity syndrome and what does it cause
X-linked recessive
- End-organ resistence to testosterone causing genetically male children (46XY) to have a female phenotype
Give 4 features of androgen insensitivity syndrome
- ‘primary amenorrhoea’
- Little or no axillary and pubic hair
- Undescended testes causing groin swellings
- Breast development may occur as a result of the conversion of testosterone to oestradiol
How is androgen insensitivity syndrome diagnosed ?
- Buccal smear or chromosomal analysis to reveal 46XY genotype
How is androgen insensitivity syndrome managed
- Counselling - raise the child as female
- Bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
- Oestrogen therapy
What is atrophic vaginitis and how is it managed ?
- Vaginal dryness, dyspareunia and occasional spotting in post menopausal women
- Tx : vaginal lubricants and moisturisers. Topical oestrogen can help if needed.
what is Asherman’s syndrome and what is it most often caused by ?
- Adhesions within the uterus
- Dilatation and curettage procedure in the treatment of RPOC
How does Asherman’s present ?
Usually following dilatation and curettage, uterine surgery or endometritis with :
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea (painful periods)
- Can also present with infertility
What is the gold standard for diagnosing intrauterine adhesions ?
- Hysteroscopy
What is primary dysmenorrhoea and how is it managed ?
- Painful period with no underlying pathology
- NSAIDS like mefenamic acid/ ibuprofen
- Second line : COCP
Give 5 causes of secondary dysmenorrhoea
- Endometriosis
- Adenomyosis
- PID
- Copper coil
- Fibroids
Define endometriosis
- Growth of ectopic endometrial tissue outside of the uterine cavity.
- Lump of endometrial tissue outside the uterus = endometrioma
- Endometriomas in the ovaries = ‘chocolate cysts’
How does endometriosis present ?
- Cyclical abdo or pelvic pain
- Deep dyspareunia
- Dysmenorrhoea
-Infertility - Cyclical bleeding from other sites, e.g. haematuria
what is seen on examination in endometriosis ?
- Speculum : visible endometrial tissue in the vagina (esp posterior fornix).
- Bimanual : fixed cervix
What is the gold standard Ix for diagnosing endometriosis ?
- Laparoscopy
How does the american society of reproductive medicine stage endometriosis ?
- Stage 1: Small superficial lesions
- Stage 2: Mild, but deeper lesions than stage 1
- Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
- Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
what is the 1st line management of endometriosis ?
Simple analgesia : paracetamol, NSAIDs
If analgesia is ineffective, how is endometriosis managed >
Hormonal management with the COCP, progesterone only pill, injection, implant, coil
If analgesia / hormonal contraception doesn’t help the Sx of endometriosis, what Tx options can be offered in secondary care ?
- GnRH : idnuce ‘pseudomenopause’
- Laparoscopic surgery to excise / ablate the endometrial tissue.
- Hysterectomy
What are fibroids ?
Benign tumours of the smooth muscle of the uterus
Explain the different types of fibroid
- Intramural : within the
- Subserosal : just below the outer layer of the uterus.
- Submucosal : just below the lining of the uterus
- Pedunculated : on a stalk.
If not asymptomatic, how do uterine fibroids present ?
- Menorrhagia : IDA
- Prolonged menstruation
- Abdo pain
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia
- Reduced fertility
Diagnosis of fibroids
Transvaginal USS
Management of menorrhagia secondary to fibroids
- IUS : cannot be used if distortion of uterin cavity
- NSAIDs e.g. mefenamic acid
- Tranexamic acid
- COCP
- Oral progestogen
- Injectable progestogen
Medical treatment options to shrink fibroids before surgery
- GnRH agonists (Triptorelin)
3 surgical options for shrinking / removing fibroids
- Myomectomy
- Hysteroscopic endometrial ablation
- Hysterectomy
What is red degeneration of fibroids ?
- As they are sensitive to oestrogen, they grow in pregnancy
- This can obstruct blood flow
- Pregnant women, presenting with low grade fever, pain, vomiting.
what are the symptoms of PMS ?
- Emotional symptoms : anxiety, stress, fatigue and mood swings
- Physical symptoms : bloating, breast pain
What is the step-wise management of PMS ?
- Mild : lifestyle advice
- Moderate symptoms
: COCP
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg) - Severe : SSRI (Fluoxetine)
What is the criteria used for diagnosing PCOS. ?
- Rotterdam criteria
What is the rotterdam criteria
- Requires 2! of 3 features :
- Oligoovulation/anovulation = irregular or absent periods
- Hyperandrogenism = hirsutism and acne
- Polycystic ovaries on USS
what is defined as polycystic ovaries on USS ?
≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³
what is crucial complication of PCOS ?
Insulin resistance and in turn DM
what might be seen on examination in a woman with insulin resistance as a result of PCOS ?
- Acanthosis nigricans
: thickened, rough skin, typically found in the axilla and on the elbows.
what baseline blood tests are done in PCOS to help diagnose and rule out other pathology
- Testosterone
- Sex hormone-binding globulin (low in PCOS)
- LH
- FSH
- Prolactin (may be mildly elevated in PCOS)
- TSH
what do hormonal blood tests typically show in PCOS ?
- Raised LH
- Raised LH to FSH ratio
- Raised testosterone
- Raised insulin
- Normal or raised oestrogen levels
what imagin is used in PCOS ?
- Pelvic USS
- Transvaginal USS is gold standard
what is seen on the USS of someone with PCOS
- 12 or more developing follicles in one ovary
- Ovarian volume of more than 10cm3
- ’ String of pearls’ appearance of the ovaries
what is the general management of PCOS ?
- Weight loss
- Low glycaemic index, calorie-controlled diet
- Exercise
- Smoking cessation
what is often given first line for managing hirsutism and acne in PCOS
- Co-cyprindiol (COCP)
- Ant-adrogenic effects
what is a complication of co-cyprindiol
significantly increased risk of VTE
If COCP doesnt work for hirsutism in PCOS what can be given ?
Topical elfornithine
how is infertility managed in PCOS
- Weight loss
SPECIALIST INPUT
- Clomifene
- Laparoscopic ovarian drilling
- IVF : increased risk of ovarian hyperstimulation syndrome
what are women with PCOS at an increased risk of an why ?
- Endometrial cancer
- The are times of unopposed oestrogen due to the irregular or absent periods
what can be given to women with PCOS to reduce the risk of endometrial cancer ?
- Mirena coil
- Inducing a withdrawal bleed at least every 3 – 4 months with either:
- Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
- Combined oral contraceptive pill
How can different types of ovarian cysts be classified ?
- Functional (follicular, corpus luteum)
- Benign germ cell
- Benign epithelial tumours : serous and mucinous cystadenoma
what are follicular cysts
- Commonest type of ovarian cyst in women of reproductive age
- Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- Commonly regress after several menstraul cycles
what is a corpus luteum cyst ?
- Failure of the corpus luteum to break down and fills with fluid.
- More likely to present with intraperitoneal bleeding than follicular cysts
Explain the 2 types of epithelial cyst
- Serous cystadenoma
the most common benign epithelial tumour - Mucinous cystadenoma : can become huge and take up lots of space in the pelvis and abdomen
What is a dermoid cyst / germ cell tumour
- Most common benign overian tumour in women <25
- Teratomas : they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone.
- They are particularly associated with ovarian torsion.
How can ovarian cysts present ?
- Pelvic pain
- Bloating
- Fullness in the abdomen
- Palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
What is the RMI
- Estimates risk of an ovarian mass being malignant
- Takes into account : menopausal status, USS findings and CA125 level
How are simple ovarian cysts in premenopausal women managed ?
- <5cm : will almost always resolve within three cycles. They do not require a follow-up scan.
- 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
- > 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
How are ovarian cysts in postmenopausal women managed ?
- CA125 level check and referral to gynaecology
- Raised CA125 = two week wait
- Simple cysts <5cm with normal CA125 can be monitored with USS every 4-6mnths.
What is Meig’s syndrome ?
Triad of :
- Ovarian fibroma
- Pleural effusion
- Ascites
Give 3 complications of an ovarian cyst
- Torsion
- Rupture, with bleeding into peritoneum
- Haemorrhage into the cyst
How does ovarian torsion present ?
- Sudden onset severe unilateral pelvic pain
- N&V
What Ix are used in ovarian torsion
- Initial : pelvic USS
- Definitive : laparoscopic surgery
What is seen on pelvic USS in ovarian torsion
- ‘Whirlpool sign’
- Free fluid in pelvis
- Oedema of the ovary
How is ovarian torsion managed ?
- Detorsion
- Oophorectomy
What is defined as premature ovarian insufficiency
- Onset of menopausal symptoms and elevated gonadotropin levels before the age of 40 years.
Give 6 causes of premature ovarian insufficiency
- Idiopathic (most common)
- Bilateral oophorectomy
- radiotherapy
- Chemotherapy
- Autoimmune disorders
- Infection (e.g mumps)
what will hormonal analysis show in premature ovarian insufficiency
- Hypergonadotreopic hypogonadism
- Raised LH and FSH (>30 IU/L)
- Low oestradiol levels (<100pmol/l)
What is required for a diagnosis of premature ovarian insufficiency
- <40yrs, typical menopausal Sx and elevated FSH.
- FSH levels need to be persistently raised (>25IU/l) on two consecutive samples separated by >4 wks.
How is premature ovarian syndrome managed ?
- HRT or COCP should be offered to women until the age of the average menopause (51 years)
what is the average age of menopause
- 51 yrs
How long are menopausal women recommended to use effective contraception for ?
- 12 months after the last period in women > 50 years
- 24 months after the last period in women < 50 years
Explain the definitions surrounding menopause
- Menopause : when menstraution stops
- Post menopause : period from 12mths after the final menstrual period
- Permenopause : time around menopause, where a woman is experiencing vasomotor Sx & irregular periods
what symptoms are seen in perimenopausal women ?
- Change in periods : change in length and dysfunctional uterine bleeding
- Vasomotor : hot flushes, night sweats
- Urogenital : vaginal dryness & atrophy, urinary frequency
- Psychological : anxiety and depression, STM impairment
Give 2 long term complications of menopause
Osteoporosis
Increased risk of IHD
How can the management of menopausal Sx be classified ?
- Lifestyle
- HRT
- Non-HRT
What is the lifestyle management of the menopause ?
- Exercise, weight loss, reduce stress
- Good sleep hygiene
Give 4 contraindications to HRT as a management of the menopause
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
What are the non HRT management options of menopause-
- Vasomotor : fluoxetine
- Vaginal dryness : lubricant
- Psychological : CBT / antidepressants
Explain the normal epithelial lining of the cervix
- Endocervix : columnar epithelium
- Ectocervix : stratified squamous
- Transformation zone : border between the two.
What is cervical ectropion
When the columnar epithelium of the endocervix has extended to the ectocervix
If not asymptomatic, how can cervical ectropion present ?
- Postcoital bleeding
- Increased vaginal discharge
- Vaginal bleeding
- Dyspareunia
If problematic bleeding is present, how is cervical ectropion managed ?
Cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
Who is more likely to suffer from cervical ectropion ?
- Younger women, those on the COCP and pregnant women
- This is because it is associated with higher oestrogen levels
What is a nabothian cyst
- Smooth, fluid filled cyst near the os of the cervix.
- Between 2mm and 30 mm in size
- Whitish/yellow appearance
- Can occur after childbirth, minor trauma to the cervix or cervicitis
How is a uterine prolapse graded
- Grade 1: The lowest part is more than 1cm above the introitus
- Grade 2: The lowest part is within 1cm of the introitus (above or below)
- Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
- Grade 4: Full descent with eversion of the vagina
If not managed conservatively or with vaginal pessaries, how are different urogenital prolapses managed ?
- Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- Uterine prolapse: hysterectomy, sacrohysteropexy
- Rectocele: posterior colporrhaphy
How is stress incontinence managed
- Lifestyle
- Pelvic floor for at least 3 mnths
- Surgery
- If surgery not wanted, duloxetine
What is the management of urge incontinence ?
- 1 : Bladder retraining for at least 6 wks.
- 2 : Anticholinergic meds (oxybutin)
- 3 : Mirabegron (beta-3-agonist in frail elderly pts preferred over oxybutin)
- 4 : Invasive procedures
What are the side effects of anticholinergic medications ?
- Dry mouth, dry eyes, urinary retention, constipation and postural hypotension
- Can cause cognitive decline, memory problems and worsening of dementia
How does Mirabegron work and what is it contraindicated in ?
- Beta-3 agonstist stimulating the sympathetic nervous system (can raised BP and increased risk of TIA and stroke)
- CI in uncontrolled hypertension
What are the symptoms of lichen sclerosis ?
- Itching
- Soreness and pain, worse at night
- Skin tightness
- Superficial dyspareunia
Usually affects the labia, perineum and parianal skin in women
What is the appearance of the skin in lichen sclerosis ?
- “Porcelain-white” in colour
- Shiny
- Tight
- Thin
- Slightly raised
- There may be papules or plaques
How is lichen sclerosis managed ?
- Potent topical steroids (clobetasol propionate 0.05% - dermovate)
what does lichen sclerosis increase the risk of ?
Squamous cell carcinoma of the vulva
what are the 4 types of FGM ?
- Type 1: Removal of part or all of the clitoris.
- Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
- Type 3: Narrowing or closing the vaginal orifice (infibulation).
- Type 4: All other unnecessary procedures to the female genitalia.
what do the upper vagina, uterus and fallopian tubes develop from
Mullerian ducts -> paramesonephric ducts
what is defined as a complex cysts ?
Muli-loculated (septated)
How are all complex cysts managed ?
Biopsy
what investigations should all women with suspected PCOS receive
- pelvic ultrasound
- FSH and LH
- Prolactin
- TSH
- Testosterone
- Sex hormone-binding globulin (SHBG)
urinary incontinence with a bladder that is still palpable after urination
Urinary overflow
Action if suspected FGM
Report to the police
Management of acutely unwell patient with suspected ruptured ectopic pregnancy
Resuscitate and arrange for emergency laparotomy
What would urodynamics should in overflow incontinence
A high voiding pressure (>70cm H20) with §a low peak flow rate (<15ml/second)
History of endometriosis + acute abdomen + free fluid in pelvis
Ruptured endometrioma
Only surgical management of a fibroid, to retain fertility
Myomectomy
