Gynaecology Flashcards
Primary amenorrhoea definition?
not beginning menstruation before the age of 13 with no secondary sexual characteristics
not beginning menstruation before age of 15 with development of secondary sexual characteristics
Hypogonadotropic hypogonadism vs hypergonadotropic hypogonadism?
Hypo hypo -> lack of LH and FSH leading to lack of oestrogen
Hyper hypo -> lack of response to LH and FSH leading to excess LH and FSH and lack of oestrogen
Causes of hypogonadotropic hypogonadism?
problems with pituitary or hypothalamus
hypopituitarism
damage (radiotherapy, Sx)
significant chronic conditions (CF, IBD) can cause delay
excessive exercise or dieting
constitutional delay
Kallman syndrome
endocrine disorders (Cushing’s, hypothyroid, GH deficiency, hyperprolactinaemia)
Causes of hypergonadotropic hypogonadism?
Turner’s syndrome
congenital absence of ovaries
previous damage to gonads (torsion, cancer, mumps)
What feature is strongly associated with Kallman syndrome?
anosmia
Causes of primary amenorrhoea?
hypogonadotropic hypogonadism
hypergonadotropic hypogonadism
congenital adrenal hyperplasia
androgen insensitivity syndrome
structural pathology
What causes congenital adrenal hyperplasia?
congenital deficiency of 21-hydrozylase enzyme
autosomal recessive pattern
->
underproduction of cortisol and aldosterone
overproduction of androgens
Presentation of congenital adrenal hyperplasia?
tall for their age
facial hair
primary amenorrhoea
deep voice
early puberty
Presentation of androgen insensitivity syndrome?
female phenotype
male genotype
normal female breast tissue and external genitalia
internally -> testes in abdomen or inguinal canal, no upper vagina, no uterus, no fallopian tubes, no ovaries
Examples of structural pathology causing primary amenorrhoea?
imperforate hymen
transverse vaginal septae
vaginal agenesis
absent uterus
FGM
When to investigate primary amenorrhoea?
no signs of puberty at 13
no periods at 15
Investigations for primary amenorrhoea?
Full Hx and Exam
Bloods for underlying medical condition
FSH and LH
TFTs
IGF-1
prolactin
testosterone
genetic testing (microarray)
X-ray of wrist (constitutional delay)
pelvic US
MRI brain
Secondary amenorrhoea definition?
no menstruation for 3 months after previously regular cycles
investigate after 3-6 months or 6-12 months in women with previously irregular cycles
Causes of secondary amenorrhoea?
pregnancy
menopause
premature ovarian failure
contraception
hypothalamic or pituitary pathology
PCOS
uterine (Asherman’s)
thyroid pathology
hyperprolactinaemia
Hypothalamus causes of secondary amenorrhoea?
excessive exercise
low BMI and eating disorders
chronic disease
physiological stress
Pituitary causes of secondary amenorrhoea?
pituitary tumours (prolactinoma, macroadenoma)
pituitary failure (trauma, Sx, radiotherapy, Sheehan’s syndrome)
Treatment for hyperprolactinaemia?
dopamine agonists (e.g., bromocriptine, cabergoline)
Investigations for secondary amenorrhoea?
Hx and exam
Hormonal bloods (LH, FSH, prolactin, bHCG, TFTs, testosterone)
US pelvis, MRI pituitary
Management options for PMS?
lifestyle changes
COCP
SSRIs
CBT
Menorrhagia definition?
based on what the woman herself considers to be excessive bleeding
more than 80mls of blood loss
Causes of menorrhagia?
dysfunctional uterine bleeding (no cause)
extremes of reproductive age
fibroids
endometriosis
adenomyosis
PID
contraceptives (copper coil)
anticoagulants
bleeding disorders (von Willebrand)
endocrine disorders
CT disorders
endometrial hyperplasia or ca
PCOS
Investigations for menorrhagia?
Hx and Exam
pelvic exam with speculum and bimanual
FBC (anaemia)
swabs (infection)
coag screen
TFTs
TVUS or PUS
outpatient hysteroscopy (if suspected fibroids, suspected endometrial pathology, persistent IMB)
Management of menorrhagia?
if cause -> treat
tranexamic acid + mefenamic acid
Mirena coil
COCP
cyclical oral progesterone
refer if management unsuccessful or symptoms suggest underlying pathology
Final options for menorrhagia?
endometrial ablation
hysterectomy
What are fibroids?
uterine leiomyomas
benign tumours of the smooth muscle or the uterus
oestrogen-sensitive
Types of fibroids?
intramural
subserosal
submucosal
pedunculated
Presentation of fibroids?
often asymptomatic
menorrhagia
prolonged menstruation
abdo pain
bloating or fullness
urinary or bowel symptoms
deep dyspareunia
reduced fertility
palpable pelvic mass on abdo or bimanual exam
Investigations for fibroids?
hysteroscopy
pelvic US
MRI prior to Sx
Mx of fibroids?
if <3cm:
Mirena coil (no distortion of uterine cavity)
symptomatic management with tranexamic acid and mefenamic acid
COCP
cyclical oral progesterons
GnRH analogues may be used prior to Sx to reduce size of fibroids
Sx options -> endometrial ablation, myomectomy, hysterectomy
If >3cm:
refer to gynae
mx as above + uterine artery embolisation
Complications of fibroids?
menorrhagia
iron deficiency anaemia
reduced fertility
pregnancy complications (miscarriage, premature labour, obstructive delivery)
constipation
urinary outflow obstruction
UTIs
red degeneration of fibroid
torsion of fibroid
malignant change to leiomyosarcoma (rare)
What is red degeneration of fibroids and how does it present?
ischaemia, infarct and necrosis of fibroid due to disrupted blood supply
occurs in larger fibroids during second or third trimester
severe abdo pain, low grade fever, tachycardia, vomiting
supportive management
What is endometriosis?
condition where ectopic endometrial tissue grows outside of the uterus
Presentation of endometriosis?
cyclical abdo or pelvic pain
deep dyspareunia
dysmenorrhoea
infertility
cyclical bleeding from other sites (haematuria, PR bleeding)
urinary and bowel symptoms
Investigations for endometriosis?
pelvic US (often unremarkable)
laparoscopy is gold standard (+/- biopsy)
Mx of endometriosis?
analgesia first-line (NSAIDs and paracetamol)
hormonal (COCP
POP
injection
implant
Mirena coil
GnRH analogues)
hormonal therapy will improves symptoms but not fertility
Sx -> laparoscopic excision or ablation, adhesiolysis, hysterectomy
What is adenomyosis?
condition where endometrial tissue grows inside of the myometrium
Presentation of adenomyosis?
later in reproductive years, usually in multiparous women
dysmenorrhoea
menorrhagia
deep dyspareunia
infertility
pregnancy complications
Investigations for adenomysosis?
TVUS
(MRI and TAUS are alternatives)
(gold standard is histological exam of uterus after hysterectomy -> obviously not always suitable)
Mx of adenomyosis?
non-contraceptive (tranexamic acid, mefenamic acid)
contraceptive (Mirena, COCP, cyclical oral progesterones)
Sx (GnRH analogues, endometrial ablation, uterine artery embolisation, hysterectomy)
Pregnancy complications associated with adenomyosis?
infertility
miscarriage
preterm birth
SGA
PPROM
malpresentation
need for c section
PPH
Rotterdam criteria for PCOS?
2 of the 3 key features:
oligoovulation or anovulation
hyperandrogenism (hirsutism, acne)
polycystic ovaries on US
Presentation of PCOS?
oligomenorrhoea or amenorrhoea
infertility
obesity (70%)
hirsutism
acne
hair loss in male pattern
Complications of PCOS?
insulin resistance and DM
acanthosis nigricans
CVD
hypercholesterolaemia
endometrial hyperplasia and ca
obstructive sleep apnoea
depression and anxiety
sexual problems
Investigations for PCOS?
Hormonal bloods:
raised LH
raised LH:FSH ratio
raised testosterone
raised insulin
normal or raised oestrogen
prolactin may be slightly raised
Pelvic US/TVUS:
12 or more developing follicles in one ovary
ovary volume > 10cm3
‘string of pearls’ appearance
screen for diabetes (OGTT)
Mx of PCOS?
reduce risks for obesity, CVD, hypercholesterolaemia and T2DM:
weight loss, smoking cessation, diet, exercise, antihypertensive and statins when necessary
protect against endometrial hyperplasia/ca:
Mirena coil
COCP
cyclical progesterones
Mx infertility:
weight loss
metformin
clomifene
ovarian drilling
IVF
Presentation of ovarian cysts?
most are asymptomatic -> found incidentally on scans
pelvic pain
bloating
fullness in abdo
palpable pelvic mass
acute pelvic pain -> torsion, rupture or haemorrhage of cyst
Most common type of ovarian cyst?
follicular cyst
Types of ovarian cyst?
follicular cyst
corpus luteum cyst (early pregnancy)
serous cystadenoma
mucinous cystadenoma (can get v big)
endometrioma (chocolate cyst)
dermoid cyst/ GCT (teratoma)
sex cord-stromal tumour
Hx of ovarian cysts?
benign vs malignant!!!
Red flags:
abdo bloating
anorexia
early satiety
weight loss
urinary symptoms
pain
ascites
lymphadenopathy
RFs:
age
post-menopause
incr. no. of ovulations
obesity
HRT
smoking
BRCA1 and BRCA2
Investigations for ovarian cysts?
no investigations needed for premenopausal woman with simple cyst <5cm
pelvic US
TVUS
CA 125
women under 40 with complex ovarian mass -> LDH, AFP, HCG (GCT)
Risk of Malignancy Index for ovarian ca?
menopausal status (1,3)
US findings (1,2,3)
CA 125 level
Mx of simple ovarian cysts?
<5cm -> self-resolve within 3 cycles, no follow up required
5-7cm -> routine referral to gynae and yearly US follow up
>7cm -> consider MRI or Sx
Complications of ovarian cysts?
torsion
haemorrhage
rupture
What is Meig’s syndrome?
a triad of:
pleural effusion
ascites
ovarian fibroma
ascites and pleural effusion resolve on removal of mass
RFs for ovarian torsion?
ovarian mass >5cm
benign tumours more common
pregnancy
before menarche in younger girls with long infundibulopelvic ligaments
Presentation of ovarian torsion?
sudden onset severe unilateral pelvic pain
nausea
vomiting
pain can come and go intermittently
localised tenderness
may be a palpable mass
Investigations for ovarian torsion?
pelvic US (TVUS, TAUS)
‘whirlpool’ sign
free fluid in pelvis
oedema of ovary
lack of blood flow on Doppler
definitive diagnosis made with laparoscopic sx
Mx of ovarian torsion?
surgical emergency
detorsion
oophorectomy
Complications of ovarian torsion?
loss of function in affected ovary
infection
abscess formation
sepsis
rupture
peritonitis
adhesions
What is Asherman’s Syndrome?
adhesions form within the uterus, following damage to the uterus
Causes of Asherman’s syndrome?
D&C
ERPC
myomectomy
endometritis
Presentation of Asherman’s syndrome?
secondary amenorrhoea
significantly lighter periods
dysmenorrhoea
infertility
Diagnosis for Asherman’s syndrome?
hysteroscopy gold standard (can treat)
hysterosalpingography
sonohysterography
MRI
Mx of Asherman’s syndrome?
dissection of adhesions during laparoscopic sx
recurrence common
RFs for cervical ectropion?
higher oestrogen levels:
younger women
COCP
pregnancy
Presentation of cervical ectropion?
asymptomatic (picked up on smears)
increased vaginal discharge
vaginal bleeding
dyspareunia
postcoital bleeding
exam of cervix -> well-demarcated border between red columnar epithelium and pale pink squamous ectocervix (transformation zone)
Mx of cervical ectropion?
asymptomatic -> no treatment needed
not pre-malignant, not a contraindication to the COCP
only treat if problematic bleeding -> cauterisation of ectropion using silver nitrate or cold coagulation during colposcopy
What are Nabothian cysts?
fluid-filled cysts often seen on the surface of the cervix
harmless and unrelated to cervical cancer
What is atrophic vaginitis?
dryness and atrophy of the vagina due to a lack of oestrogen
v common post-menopause
Presentation of atrophic vaginitis?
itching
dryness
dyspareunia
bleeding
recurrent UTIs
stress incontinence
POP
Most common cause of post-menopausal bleeding?
atrophic vaginitis
**BUT PMB is endometrial ca until proven otherwise
Mx of atrophic vaginitis?
vaginal lubricants
topical oestrogen (cream, pessaries, ring)
What is menopause?
retrospective clinical diagnosis made when a woman has had no periods for 12 months
Average age of menopause in Ireland?
51 years
What is considered to be premature menopause?
menopause before the age of 40
due to premature ovarian failure
Symptoms of menopause?
due to a lack of oestrogen
vasomotor (hot flushes, headaches, night sweats, palpitations, insomnia)
urogenital (atrophy, vulvitis, incontinence, prolapse, dyspareunia)
psychological (concentration, memory loss, irritability, depression, anxiety, libido loss)
cutaneous (skin, nails, hair)
Long-term risks associated with menopause?
osteoporosis
CVD
ischaemic CVA
POP
urinary incontinence
Contraception during the perimenopausal period?
necessary for 12 months after LMP >50
necessary for 24 months after LMP <50
3 questions to ask when prescribing HRT?
oestrogen-only or combined?
cyclical or continuous?
mode of delivery?
When is oestrogen-only HRT indicated?
**only acceptable if the woman has had a hysterectomy
unopposed oestrogen increases risk for endometrial hyperplasia and ca and thus progesterone is added as protection
When is there an increased risk of breast cancer in HRT?
when it is combined
no increased risk in oestrogen only HRT
When to used cyclical vs continuous HRT and why?
cyclical used for women who have had a period in the last 12 months >50 or last 24 months <50
period-like bleeding occurs during the oestrogen-only phase of HRT
otherwise -> irregular breakthrough bleeding may occur on continuous HRT -> unnecessary investigations because of ‘PMB’
Types of oestrogen?
tablet, patch, gel, vaginal oestrogen, spray
Types of progesterone?
Mirena
pill
patch
Benefits of HRT?
symptomatic treatment
lowers osteoporosis risk
decreases CVD risk (if started before 60)
decreases colorectal ca risk
diminished risk of T2DM
Risks of HRT?
endometrial hyperplasia and ca (oestrogen-only)
VTE (oral tablets only)
CVD (when commenced in women >60 or with pre-existing CVD)
stroke (when oral HRT commenced in women >60)
breast ca (when progesterone is added)
Contraindications to HRT?
endometrial hyperplasia or ca
breast ca
abnormal bleeding
uncontrolled HTN
VTE
liver disease
active CVD
pregnancy
migraine with aura (oral)
Non-hormonal alternatives to HRT?
lifestyle changes
SSRIs
venlafaxine (SNRI)
gabapentin
clonidine
CBT
natural remedies (evening primrose oil, ginseng) -> caution drug interactions
What is premature ovarian insufficiency?
menopause before the age of 40
presents with perimenopausal symptoms
Hormonal blood tests in premature ovarian failure?
low oestrogen
high LH and FSH
Causes of premature ovarian failure?
idiopathic
iatrogenic (chemo, radiation, oophorectomy)
autoimmune
genetic
infections (mumps, TB, CMV)
Management of premature ovarian failure?
HRT until at least 50
traditional HRT or COCP
no incr. risks as same hormones as anyone else
slight VTE risk increase in oral HRT
How many couples will fail to conceive after 1yr of UPSI?
1 in 7
When to investigate for infertility?
after 12 months of UPSI
can be reduced to 6 months in women >35 as their ovarian stores are more likely to be reduced
Causes of infertility?
sperm problems
ovulation problems
tubal problems
uterine problems
unexplained
often mixed male and female factors
General advice for couples trying to get pregnant?
400mcg folic acid daily
healthy BMI
avoid smoking and excess alcohol
reduce stress
intercourse every 2-3 days
avoid timing intercourse
Investigations for infertility?
BMI
chlamydia screening
semen analysis
female hormone testing
rubella immunity in mother
pelvic US
hysterosalpingogram
laparoscopy and dye test
Female hormone testing in infertility?
serum LH and FSH on day 2-5 (high LH indicates PCOS, high FSH poor ovarian reserve)
serum progesterone on day 21 (if 28 day cycle) (indicates ovulation occurring if raised)
anti-Mullerian hormone (high level show good ovarian reserve)
TFTs
prolactin
Management of anovulation?
weight loss if indicated
clomifene
letrozole
gonadotropins
ovarian drilling (PCOS)
metformin
Management of tubal factors causing infertility?
tubal cannulation during hysterosalpingogram
laparoscopy to remove adhesions or endometriosis
IVF
Mx of uterine problems causing infertility?
Sx to correct polyps, fibroids, adhesions or structural abnormalities
Mx of sperm problems causing infertility?
surgical sperm retrieval
surgical correction of blockage in vas deferens
intra-uterine insemination
intracytoplasmic sperm injection
donor insemination
Causes of anovulation infertility?
hypogonadotropic hypogonadism (hypothalamus, Kallmann)
PCOS
premature ovarian failure
Tubal causes of infertility?
PID
endometriosis
previous sterilisation
Uterine causes of infertility?
endometriosis
adhesions (Asherman’s)
uterine fibroids
uterine anomalies
Semen analysis includes?
semen volume
pH
sperm concentration
total sperm number
total motility
vitality
sperm morphology
Causes of male factor infertility?
pre-testicular causes i.e., low testosterone (pathology of pituitary or hypothalamus, suppression due to stress, chronic illness or hyperprolactinaemia, Kallman syndrome)
testicular causes (mumps, undescended testes, trauma, chemo, radiation, cancer, Klinefelter syndrome)
post-testicular causes (vas deferens damage, ejaculatory duct obstruction, retrograde ejaculation, scarring from epididymitis, absence of vas (CF))
Further analysis of males when abnormal semen analysis?
hormonal analysis with LH, FSH, testosterone
genetic testing
imaging (transrectal US, MRI)
vasography
testicular biopsy
Complications of IVF?
failure
multiple pregnancy
ectopic pregnancy
ovarian hyperstimulation syndrome
collection procedure:
pain
bleeding
pelvic infection
damage to bladder or bowel
Steps involved in IVF?
suppressing the natural menstruation cycle
ovarian stimulation
oocyte collection
insemination / ICSI
embryo culture
embryo transfer
What is ovarian hyperstimulation syndrome?
complication of ovarian stimulation during the IVF process
associated with the use of HCG to mature the follicles in the final steps of ovarian stimulation
Risk Factors for ovarian hyperstimulation syndrome?
younger age
lower BMI
raised anti-Mullerian hormone
higher antral follicle count
PCOS
raised oestrogen levels during ovarian stimulation
Features of OHSS?
abdo pain and bloating
N&V
diarrhoea
hypotension
hypovolaemia
ascites
pleural effusions
renal failure
peritonitis from rupturing follicles
prothrombotic state (DVT, PE risk)
Types of urinary incontinence?
stress incontinence
urge incontinence
overflow incontinence
functional incontinence
mixed incontinence
RFs for urinary incontinence?
incr. age
postmenopausal status
incr. BMI
prev. pregnancies and vaginal deliveries
POP
pelvic floor sx
neurological conditions (MS)
cognitive impairment and dementia
What is urge incontinence?
caused by overactivity of the detrusor muscle
OAB
suddenly feeling the urge to pass urine, and happening straight away
What is stress incontinence?
occurs due to weakness of the pelvic floor and sphincter muscles
leakage of urine when laughing or coughing
What is overflow incontinence?
chronic urinary retention resulting in leakage of urine without the urge to pass urine
more common in men
caused by anticholinergics, fibroids, pelvic tumours or neurological conditions
Assessment of urinary incontinence?
Hx
assess for modifiable lifestyle factors
severity and QOL
Exam (pelvic tone, look for atrophic vaginitis, POP, ask patient to cough and look for leakage, modified Oxford grading system)
What is the modified Oxford grading system used for?
to assess the strength of the pelvic floor muscles
Grades to modified Oxford grading system?
0- no contraction
1- faint contraction
2 - weak contraction
3 - moderate contraction with some resistance
4- good contraction with resistance
5 - strong contracting, drawing finger inwards
Investigations for urinary incontinence?
bladder diary
urine dipstick testing
post-void residual bladder volume
urodynamic testing
Urodynamic testing includes?
cytometry
uroflowmetry
leak point pressure
post-void residual bladder volume
video urodynamic testing
Mx of stress incontinence?
lifestyle factors
weight loss if appropriate
pelvic floor exercises
Sx (tension-free vaginal tape, autologous sling procedures, colposuspension, intramural urethral bulking)
duloxetine
artificial urinary sphincter
Mx of urge incontinence?
bladder retraining
anticholinergic meds (oxybutynin, tolterodine)
mirabegron alternatively (beta-3-agonist)
Sx (Botox injection, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion)
Mx of mixed incontinence?
discover which form of incontinence is affecting the woman more and treat as such
Types of POP?
anterior compartment prolapse (urethrocele, cystocele)
posterior compartment prolapse (enterocele, rectocele)
apical compartment prolapse (vault prolapse, uterine prolapse)
What is pelvic organ prolapse?
the herniation of the pelvic organs to or beyond the vaginal walls
What are the levels to De-Lancey’s Biomechanical Support?
Level 1 -> the uterosacral/ cardinal ligament complex
Level 2 -> pubocervical fascia, rectovaginal fascia, levator ani muscle (through the tendinous fasciae pelvis)
Level 3 -> perineal membrane, urogenital diaphragm
What does defects in each layer of support cause?
level 1 -> suspension defect, apical prolapse
level 2 -> attachment defect, cystocele, rectocele
level 3 -> fusion defect, deficient perineum, urethrocele
RFs for POP?
multiple vaginal deliveries
instrumental, prolonged or traumatic deliveries
advanced age
postmenopausal
obesity
chronic resp disease causing chronic cough
chronic constipation
Presentation of POP?
feeling of ‘something coming down’
dragging or heavy sensation
urinary symptoms
bowel symptoms
sexual dysfunction
Investigations for POP?
clinical exam using Sim’s speculum
empty bladder and bowel
held to the anterior wall to look for rectocele and posterior wall to look for cystocele
Grading system for pelvic organ prolapse?
Baden-Walker system
Baden-Walker system for grading POP?
Grade 0 -> no prolapse
Grade 1 -> descent halfway to the hymen
Grade 2 -> descent to the hymen
Grade 3 -> descent halfway past the hymen
Grade 4 -> maximal descent
What is a uterine procidentia?
when a prolapse extends past the introitus
Mx options for POP?
conservative (lifestyle, weight loss, physio, symptomatic, oestrogen cream)
pessary
surgical
Sx management of POP?
reconstructive (anterior colporrhaphy, posterior colporrhaphy, sacrolopoplexy)
obliterative (LeFort colpocleisis)
hysterectomy
