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3rd yr clinical > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What are the potential causes of primary amenorrhoea

A

Hypogonadotrophic hypogonadism- Deficiency of LH and FSH (gonadotrophins) dysfunction of pituitary or hypothalamus, chronic conditions, excessive exercise/dieting

Hypergonadotrophic hypogonadism- high LHS and FSH but low sex hormones0 damage to gonads- mumps, congenital absence of ovaries or turner’s syndrome

Congential adrenal hyperplasia - underproduces cortisol, aldosterone and overproduces androgens- tall for age, facial hair, no periods

Androgen insensitivity syndrome- tissues can’t respond to androgens = female phenotype with external genetalia- but testes are in abdomen and no uterus

Structural pathology

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2
Q

What is the management of primary amenorrhoea

A

Replacement hormones - if pregnancy not wanted- combined pill
Observation
Reduce stress, CBT, healthy weight gain

In hypogonadotrophic hypogonaidsm (hypopituitarism or Kallman)- pulsatile GnRH can induce ovulation and menstruation

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3
Q

What are some causes of secondary amenorrhoea

A

Pregnancy, menopause, premature ovarian failure, hormonal contracpetion, pituitary/ hypothalamus pathology, PCOS, Asherman’s syndrome. thyroid issues

Hyperprolactinaemia- high levels prolactin stop release of GnRH in hypothalamus so no LH and FSH- will have galactorrhoea - usually pituitary adenoma - treat with dopamine agonists- bromocriptine/ cabergoline

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4
Q

What must be done in women with PCOS

A

Induce a withdrawl bleed every 3-4 months to reduce risk of endometrial hyperplasia and cancer- regular use of combined OCP or medroxyprogesterone for 14 days

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5
Q

What is the treatment for secondary amenorrhoea

A

Hormone replacement therapy or OCP

Vit D and calcium supplementation - osteoporosis

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6
Q

What pill should be used to help with PMS

A

Drospirenone first line (Yasmin)

Advise on lifestyle changes, SSRIs and CBT

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7
Q

What is the management for menorrhagia

A

No contraception
Tranexamic acid - if no pain
Mefenamic acid- associated pain (NSAID)

Contraception
1. Mirena coil
2. COCP
3.Cyclical oral progesterones/ POP- norithisterone 5mg 3x daily from day 5-26 cycle (increased VTE risk)

Final managements
Endometrial ablation/ hysterectomy

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8
Q

What is the investigation and management of uterine fibroids

A

Hysteroscopy for heavy mentrual bleeding- submucosal fibroids

Pelvic USS for larger fibroids

Management
<3cm- Mirena coil, symptom managament (NSAIDs, tranexamic acid), COCP, POP

> 3cm- Referl to gynae, symptom management, mirena coil, COCP, POP, uterine artery embolisation, myomectomy, hysterectomy, endometrial ablation

GnRH agonists can reduce the size of fibroids before surgery

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9
Q

What is red degeneration of a fibroid

A

Ischaemic, infarction and necrosis of a fibroid due to disrupted blood supply

Larger fibroids>5cm - second and 3rd trim of preg
Severe abdo pain, low grade fever, tachy, vomiting

Supportive management

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10
Q

What is the main presentation of endometriosis

A

Pelvic pain - cyclical pain
Adhesions then can cause chronic non cyclical pain
Deep psypareunia
Dysmenoorhoea
Infertility
Cyclical bleeding from other sites - bowel/ urinary

Endometrial tissue seen on speculum
Fixed cervix on bimanual exam
Tender in vagina, cervix, adenexa

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11
Q

How is endometriosis diagnosed

A

Laparoscopic surgery is the cold standard with biopsu
Pelvic USS can reveal if large

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12
Q

How is endometriosis managed

A

Stop ovulation and reduce endometrial thickening
COCP, POP, Mirena coil, implant, depot infection

Induce a menopause like statpe- GnRH agonists- Goserelin, leuprorelin

Laparoscopic surgery- excise and ablate - help improve fertiligy

Hysterectomy and bilateral salpingo-opherectomy

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13
Q

What are the features, management and diagnosis of adenomyosis

A

-Endometrial tissue in the myometrium
-Later productive years- or several pregnancies

Transvaginal USS first line for diagnosis

Management
No contraception
Tranexamic acid / mefenamic acid

Contraception
Mirena coil
COCP
OCP

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14
Q

What is the definition of menopause and peri-menopause

A

Menopause- no periods for 12 months

Post menopause- the period from 12 months after final period

Peri-meopause- vasomotor symptoms and irregular periods

Premature menopause- before 40

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15
Q

What are the hormone findings in menopause

A

Lack of ovarian follicular function
-Oestrogen and progesterone are low
-LH and FSH are high- no negative feedback

FSH blood test must be one to diagnose in women over 45

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16
Q

How long do women around perimenopause need contraception for

A

-2 years after last menstrual period for women under 50
-1 yr after LMP for women over 50

Good contraception options
Barrier
Mirena
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 due to reduced bone mineral density)

VTE restrictions with OCP

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17
Q

What are the causes of premature ovarian insufficiency

A

Menopause before 40
Typical menopause symptoms + elevated FSH

Idiopathic
Iatrogenic- chemo, radio or surgery
Autoimmune (coeliac, adrenal insufficiency, type 1 diabetes, thyroid)
Gentic- turner’s syndrome
Infections- Mumps, TB, CMV

two options for treatment
COCP or traditional hormone replacement therapy

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18
Q

How do you pick what HRT regime a woman gets

A

Has a uterus:
Combined- needs endometrial protection with progesterone + oestrogen

Without a uterus
Oestrogen only HRT

Still gas periods
Cyclical HRT with cyclical progesterone and regular breakthrough bleeds

More than 12 months without period and has a uterus
Continuous combined HRT

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19
Q

What is Clonidine used for

A

Lowers BP and reduced HR- helps with vasomotor symptoms and hot flushes

Useful when HRT contraindicated

Can cause- dry mouth, headaches, dizzy, faituge

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20
Q

What risks are associated with HRT

A

-Increased risk of breast cancer- especially combined
-Increased risk endometrial cancer - reduce this by adding a progesterone
-Increased risk of VTE (2-3 times) - use patches not pills to reduce this risk -Increased risk of stroke and CAD with longer term use in older women (only in combined)

Risks aren’t increased in women under 50 or those without a uterus

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21
Q

What are the contraindications for HRT

A

Undiagnosed abnormal bleeding
Endometrial hyperplasia/ cancer
Breast caner
Uncontrolled HTN
VTE
Liver disease
Active angina/ MI
Pregnancy

Check BMI and BP
Ensure cervical/ breast screening up to date

22
Q

How is oestrogen HRT delivered

A

Transdermal patches (most useful and lower risks)

23
Q

How is progesterone HRT delivered

A

Bled within last 12 months-
Cyclical progesterone for 10-14 days per month
Can switch to continuous after 12 months of treatment

No bleeding in 2 yrs if under 50 and 1 yr if over 50
Continuous combined HRT

Cyclical options- tablets or patches with oestrogen and progesterone

Mirena coil- continuous- can give this with oestogen only pills

24
Q

What are the two types of progesterones in HRT

A

C19 progestogens- from testosterone- more male effects- norithesterone, levonorgestrel- helpful with reduced libido

C21- more female as come from progesterone- progesterone- helpful with depression and acne

25
Q

What is tibolone and when is it used

A

Synthetic steroid - helpful in patients with reduced libido

Continuous combined form of HRT
Need to be more than 12 months without a period

Can cause irregular bleeding

Can also use transfermal testosterone for low libido

26
Q

What follow up should be done when giving HRT

A

3 month follow up after starting for side effects to settle etc

Refer to specialist if problematic/ irregular bleeding after 3-6 months

Ensure appropirate contraception

Stop oestrogen contraceptives/ HRT- 4 weeks before major surgery

27
Q

What are some of the side effects of HRT

A

Oestrogenic
-Nausea and bloating
-breast swelling/ tender
-headache
-leg cramps

Progestogenic
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin

28
Q

What criteria is used for a diagnosis of PCOS

A

Rotterdam criteria with 2 of these 3 features

Oligovulation or anvoluation (absence of periods/ irregular)
Hyperandrogenism- hirsutism and acne
Polycystic ovaries on USS

29
Q

What other complications are involved in PCOS

A

Insulin resistance and diabetes
Acanthosis nicricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
Acanthosis nigricans

30
Q

How is insulin resistance linked to PCOS

A

-Insulin resistance means more insulin production is needed for response
-more insulin promotes more release of androgens (testosterone) and supresses sex hormone binding globulin- promotes hyperandrogenism in women

31
Q

What will the blood results show in PCOS

A

*Raised LH
*Raised LH to FSH ratio - high LH compared with FSH

Raised testosterone
Raised insulin
Normal/ raised oestrogen

32
Q

What is the gold standard imaging for PCOS

A

Pelvic USS- transvaginal
Follicles will show “string of pearls appearance”

Need either
-12 follicles in one ovary
Ovarian volume >10cm3

33
Q

How is the risk of endometrial cancer reduced in PCOS

A

Mirena coil
Inducing a withdrawl bleed every 3-4 months with
Cyclical progestoegens or the COCP

34
Q

How is infertility managed in PCOS

A

Weight loss
Clomifene
Ovarian drilling
IVF

Metformin and letrozole

35
Q

How is hirsutism managed in PCOS

A

Weight loss
Dianette - co-cyprindiol - anti-adrogenic but high VTE risk
Topical eflornithine - treat facial hirsuitism

Other options
Electrolysis
Laser hair
Spirnolactone
Finasteroide
Flutamide
Cyproterone acetate

36
Q

How is acne managed in PCOS

A

COCP unless VTE risk

Topic retinoid (adapalene)
Topical abx (Clindamycin with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline abx

37
Q

What does the rate of malignancy index take into account

A

menopausal status
USS findings
CA125

If CA125 elevated in post menopausal woman - 2 week wait suspected cacer referral

Simple cyst with normal Ca125 in post menopausal (USS every 4-6 months)

38
Q

What are the features of Meig’s syndrome

A

Ovarian Fibroma
Pleural effusion
Ascites

Occurs in older women
Removal of tumour is curative

39
Q

What are the features of ovarian torsion

A

Occurs with an ovarian mass/ long infundibulpelvic ligament

Sudden onset severe unilateral pelvic pain
N&V
Palpable mass

Pelvic USS for imaging- Whirlpool sign - free fluid in pelvis and oedema in ovary

Management
Laparoscopic surgery - detorsion or oophorectomy

Complications- rupture, peritonitis, adhesions, infection

40
Q

What are the features of Asherman’s syndrome

A

Adhesions in uterus due o D&C or uterine surgery/ severe pelvic infection- can cause physical obstructions/ infertility

Presentation
Secondary amenorrhoea or lighter periods
Dysmenorrhoea
Infertility

Diagnosis
Hysteroscopy- gold standard - can dissect and treat adhesions

Management
Dissecting adhesions- reoccurence is common

41
Q

What are the features of cervical ectropion

A

Columnar epithelium of the endocervix has extended out onto the ectocervix - Prone to trauma

Transformation zone- border of columnar epithelium of endocervix and stratified squamous epithelium of ectocervix

Presentation
Incidental
Vaginal discahrge
Vaginal bleeding
Dyspareunia
Red velvet part of cervix from the OS

Associated with higher levels of oestrogen- younger women and OCP

Management- silver nitrate cauterisation or cold coagulation due colposcopy

42
Q

What are the features of Nabothian cysts

A

Fluid filled cysts on the cervix- harmless - child birth, minor trauma or cervicitis secondary to infection

Incidental finding
Smooth bumps near the OS- white/ yellow

Management
No treatment
If uncertain- colposcopy

43
Q

What are the various types of pelvic organ prolapse

A

Uterine prolapse- uterus descends into vagina

Vault prolpase- after a hysterectomy the top of the descends into the vagina

Rectocele - defect into posterior vaginal wall- rectum prolapses forward into vagina- associated with constipation, urinary retention and lump in vagina- can press back lump when need to poo

Cystocele- Defect in anterior vaginal wall- bladder prolapses back into vagina - cystourethrocele- when the urethra and baldder prolapse

44
Q

What is the examination and management of a pelvic organ prolapse

A

Sims speculum- U shaped held on the opposite wall to whats being inspected

Management
Conservative- mild symptoms and do not tolerate pessaries/ surgery
Physio (pelvic floor), weight loss, lifestyle changes, treat stress incontinence, vaginal oestrogen

Pessaries
Ring- sit around cervix and hold uterus up
Need changes and cleaned every 4 months
Oestrogen cream with them

Surgery
Avoid mesh repairs

45
Q

What are the different types of urinary incontinence

A

Urge- overactivity of the detrusor muscle- feeling sudden urge to go, accidents

Stress- weak pelvic floor and sphincter muscles- urine leaks when laughing/ coughing etc

Mixed- combination of urge and stress

Overflow - chronic urinary retention due to an obstruction to outflow - can be due o anticholinergic meds, fibroids, pelvic tumours, neuro conditions (MS, diabetic neuropathy) - rare in women more in men

46
Q

What are the risk factors for urinary incontinence and how is it investigated

A

Risk factors
-Older age, post menopausal, high BMI, previous vaginal delivery, pelvic organ prolapse, pelvic floor surgery, neuro issues, cognitive impairment

Investigation
Examine pelvic tone - bimanual exam ask woman to squeeze tight against fingers- score 0-5

-Bladder diary
-Urine dip
-Post void residual bladder volume bladder scan
-Urodynamic testing - pressures in bladder vs rectum (stop all anticholinergics 5 days before this)

47
Q

How is urinary incontinence managed

A

Stress incontinence
-Avoid caffeinie, diuretics, overfilling bladder
-Weight loss
-Supervised pelvic floor exercises for 3 months before surgery
-Surgery- tension free vaginal tape/ sling procedures to add suport to the urethra
-Duloxetine- SNRI when surgery not possible

Urge incontinence
-6 weeks of bladder retraining
-Anticholinergic medication- oxybutynin, tolterodine, solifenacin- can lead to cognitive decline
-Mirabegrn- less anticholinergic burder but contraindicated in uncontrolled HTN - BP needs monitored on it - can cause hypertensive crisis- stoke/ TIA

-Botox injections into bladder wall
-Percutaenous sacral nerve stimulation
-Augmentation cystoplasty (enlarge bladder)
-Urinary diversion with urostomy

48
Q

What are the features of atrophic vaginitis

A

Dryness and atrophy of vaginal wall due to lack of oestrogen
Menopausal women

Presentation
Ichy, dryness, dyspareunia, bleeding, recurrent UTI, stress incontinence, pelvic organ prolpase

Pale mucosa, thin skin, reduced skin folds, erythema, dryness, sparse pubic hair

Management
Vaginal lubricant
Topical oestrogen
-Estriol cream
-Estriol pessaries
-Estradiol tablets
-Estradiol ring (replace every 3 months)

Contraincations- angina, breast cancer, VVTE

49
Q

What are the features of a Bartholins cyst

A

-Blocked bartholins glands - if infected can be an abscess

Management
Warm compress, analgesia

Bartholin’s abscess- needs antibiotics - swab to culture- E.Coli most common antibiotic but send for chlamydia and gonorrhoea

Surgical interventions for abscess
-Word catheter - local - pus drained
-Maesupialisation- GA - abscess drained

50
Q

What are the features of lichen sclerosus

A

Chronic inflammatory skin condition- white shiny pactches

Associated with other autoimmune conditions

Presentation
Aged 45-60- vulval itching and skin changes
Pain worse at night, skin tightness, painful sex, erosions, fissures

Signs and symptoms made worse due to friction

Management
Potent topical steroids - clobestasol propionate 0.05% (dermovate) - once a day for 4 weeks then gradually reduced

Emollients

Complications
Risk of developing squamous cell carcinoma of the vulva

51
Q
A

3rd yr clinical (22 decks)

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