Gynaecology Flashcards
What are the potential causes of primary amenorrhoea
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
What is the management of primary amenorrhoea
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
What are some causes of secondary amenorrhoea
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
What must be done in women with PCOS
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
What is the treatment for secondary amenorrhoea
Hormone replacement therapy or OCP
Vit D and calcium supplementation - osteoporosis
What pill should be used to help with PMS
Drospirenone first line (Yasmin)
Advise on lifestyle changes, SSRIs and CBT
What is the management for menorrhagia
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
What is the investigation and management of uterine fibroids
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
What is red degeneration of a fibroid
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
What is the main presentation of endometriosis
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
How is endometriosis diagnosed
Laparoscopic surgery is the cold standard with biopsu
Pelvic USS can reveal if large
How is endometriosis managed
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
What are the features, management and diagnosis of adenomyosis
-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
What is the definition of menopause and peri-menopause
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
What are the hormone findings in menopause
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
How long do women around perimenopause need contraception for
-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
What are the causes of premature ovarian insufficiency
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
How do you pick what HRT regime a woman gets
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
What is Clonidine used for
Lowers BP and reduced HR- helps with vasomotor symptoms and hot flushes
Useful when HRT contraindicated
Can cause- dry mouth, headaches, dizzy, faituge
What risks are associated with HRT
-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
What are the contraindications for HRT
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
How is oestrogen HRT delivered
Transdermal patches (most useful and lower risks)
How is progesterone HRT delivered
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
What are the two types of progesterones in HRT
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
What is tibolone and when is it used
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
What follow up should be done when giving HRT
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
What are some of the side effects of HRT
Oestrogenic
-Nausea and bloating
-breast swelling/ tender
-headache
-leg cramps
Progestogenic
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
What criteria is used for a diagnosis of PCOS
Rotterdam criteria with 2 of these 3 features
Oligovulation or anvoluation (absence of periods/ irregular)
Hyperandrogenism- hirsutism and acne
Polycystic ovaries on USS
What other complications are involved in PCOS
Insulin resistance and diabetes
Acanthosis nicricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
Acanthosis nigricans
How is insulin resistance linked to PCOS
-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
What will the blood results show in PCOS
*Raised LH
*Raised LH to FSH ratio - high LH compared with FSH
Raised testosterone
Raised insulin
Normal/ raised oestrogen
What is the gold standard imaging for PCOS
Pelvic USS- transvaginal
Follicles will show “string of pearls appearance”
Need either
-12 follicles in one ovary
Ovarian volume >10cm3
How is the risk of endometrial cancer reduced in PCOS
Mirena coil
Inducing a withdrawl bleed every 3-4 months with
Cyclical progestoegens or the COCP
How is infertility managed in PCOS
Weight loss
Clomifene
Ovarian drilling
IVF
Metformin and letrozole
How is hirsutism managed in PCOS
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
How is acne managed in PCOS
COCP unless VTE risk
Topic retinoid (adapalene)
Topical abx (Clindamycin with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline abx
What does the rate of malignancy index take into account
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)
What are the features of Meig’s syndrome
Ovarian Fibroma
Pleural effusion
Ascites
Occurs in older women
Removal of tumour is curative
What are the features of ovarian torsion
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
What are the features of Asherman’s syndrome
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
What are the features of cervical ectropion
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
What are the features of Nabothian cysts
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
What are the various types of pelvic organ prolapse
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
What is the examination and management of a pelvic organ prolapse
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
What are the different types of urinary incontinence
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
What are the risk factors for urinary incontinence and how is it investigated
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)
How is urinary incontinence managed
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
What are the features of atrophic vaginitis
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
What are the features of a Bartholins cyst
-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
What are the features of lichen sclerosus
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
