Gynaecology Flashcards
causes of primary amenorrhoea
Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology
causes of secondary amenorrhoea
Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hyper or hypothyroid)
Excessive prolactin, from a prolactinoma
Cushing’s syndrome
irregular menstruation causes
Extremes of reproductive age (early periods or perimenopause)
Polycystic ovarian syndrome
Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
causes of intermenstrual bleeding
Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants
causes of dysmenorrhoea
Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer
causes of menorrhagia
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cance
Polycystic ovarian syndrome
causes of postcoital bleeding
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
causes of pelvic pain
Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)
causes of vaginal discharge
Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
pruritis vulvae definition
itching of vulva and vagina
pruritus vulvae causes
Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress
primary amenorrhoea definition
defined as not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development
puberty girls
8-14
breast bud, pubic hair, menstrual periods
pubertal growth spurt earlier than boys
hypogonadotropic hypogonadism
lack of LH and FSH
hypergonadotropic hypogonadism
lack of response to LH and FSH by gonads (testes and ovaries)
causes of hypogonadotropic hypogonadism
Hypopituitarism (under production of pituitary hormones)
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome
causes of hypergonadotropic hypogonadism
Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)
kallman syndrome clinical fx
delayed puberty
anosmia
CAH hormones
lack of cortisol and aldosterone
overproduction of androgens
CAH inheritance
aut rec
congenital deficiency of the 21-hydroxylase enzyme
clinical fx of CAH
neonates - hypoglycaemia, electrolyte disturbances
childhood - Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
AIS in males patho
the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop
AIS clinical fx
female phenotype - normal female external genitalia and breast
internally - undescended testis and absent uterus etc
if ovaries unaffected by pathology…
typical secondary sexual characteristics develop but no periods
structural pathology causes of absent periods
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation
ix for primary amenorrhoea
FBC and ferritin - anaemia
U+E - CKD
anti-TTG and anti-EMA - coeliac
FSH and LH
TFT
IGF-1 - GH def
prolactin - hyperprolactinaemia
testosterone - high in PCOS, AIS, CAH
genetic testing - turners
x ray of wrist - constituional delay
pelvis USS
MRI of brain
tx of hypogonadotropic hypogonadism
pulsatile GnRH - esp if want to induce fertility
or COCP to replace sex hormones
tx of ovarian causes of primary amenorrhoea
can give COCP ot induce regular menstruation and prevent sx of oestrogen def
causes of secondary amenorrhoea
Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
when can hypogonadotropic hypogonadism be induced to cause secondary amenorrhoea
Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress
pituitary causes of secondary amenorrhoea
Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
hyperprolactinaemia causing secondary amenorrhoea patho
High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism
true or false, galactorrhoea a common sign of hyperprolactinaemia
false -, only 30% of women
most common causes of hyperprolactinaemia
pituitary adenoma secreting prolactin
ix for hyperprolactinaemia
CT/MRI of brain
tx for hyperprolactinaemia
dopamine agonist - bromocriptine, cabergoline
ix for secondary amenorrhoea
USS of pelvis (PCOS)
beta hCG
LH and FSH
prolactin
TSH
testosterone
LH:FSH ratio interpretation
High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome
tx of PCOS
require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed
when vit D required in secondary amenorrhoea
low oestrogen levels so amenorrhoea lasts for more than 12 months…risk of osteoporosis
PMS occurs at which part of menstrual cycle
luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation
cause of PMS
caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA
clinical fx of PMS
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
causes of PMS without menstruation
after a hysterectomy, endometrial ablation or on the Mirena coil
combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.
severe form of PMS
premenstrual dysphoric disorder
diagnosis of PMS
symptom diary for two menstrual cycles
cyclical sx
definitive - administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve
mx of PMS
General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP) - containing drospirenone, continuous use
SSRI antidepressants
Cognitive behavioural therapy
continuous transdermal oestrogen patches + low dose cyclical progestogens or mirena to prevent endometrial hyperplasia
GnRH + HRT = menopause
hysterectomy and b/l oophorectomy - induce menopause
danazole and tamoxigen - cyclical breast pain
spironlactone - breast swell, water retention and bloating
menorrhagia definition
> 80 ml
based on sx - changing pads every 1-2 hrs, bleeding lasts more than 7 days, clots
causes of menorrhagia
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
hx of menorrhagia
Age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening history
Migraines with or without aura (for the pill)
Past medical history and past drug history
Smoking and alcohol history
Family history
ix of menorrhagic
pelvic exam with speculum and bimanual -> fibroids, ascites and cancers
FBC - iron def anaemia
outpatient hysteroscopy - fibroids, endometrial hyperplasia or cancer, peristent intermenstrual bleeding
pelvic and transvaginal USS - large fibroids, adenomyosis, hard to examine
swabs - infection
coag screen
ferritin
TFT
mx of menorrhagia
mx causes
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
first line contraception with menorrhagia
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
when refer menorrhagia to secondary acree
further ix or mx
tx unsuccessful
sx severe
large fibroids >3cm
last choice options in menorrhagia
endometrial ablation and hysterectomy
fibroids definition
benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas
fibroids risk fx
later reproductive years
black women
why fibroids grow
in response to oestrogent
types of fibroids
Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.
clinical fx of fibroids
asx
Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
ix for fibroids
abdo and bimanual exam - palpable pelvic mass or enlarged firm non tender uterus
hysteroscopy - submucosal
pelvic USS - larger
MRI - surgical decision
medical mx of smaller fibroids
< 3 cm
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
surgical mx of smaller fibroids
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
medical mx of larger fibroids
referral to gynaecology!
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens
surgical mx for larger fibroids
Uterine artery embolisation
Myomectomy
Hysterectomy
before surgery - GnRH agonists to reduce size of fibroids
potential complications of fibroids
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)
define red degeneration of fibroids
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy
red degeneration of fibroids clinical fx
severe abdo pain, low grade fever, tachycardia and vomit
red degeneration of fibroids mx
rest
fluid
analgesia
endometriosis definition
a condition where there is ectopic endometrial tissue outside the uterus
define endometrioma
A lump of endometrial tissue outside the uterus
if in ovaries - ‘chocolate cysts’
define adenomyosis
endometrial tissue within the myometrium (muscle layer) of the uterus
one theory for aetiology of endometriosis
during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity
pathophysiology of sx of endometriosis
pelvic pain….The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis
blood in urine or stools - deposits of endometriosis in bladder or bowel
Adhesions lead to a chronic, non-cyclical pain
reduced fertility - adhesions, blocking release of eggs or kinking fallopian tubes
clinical fx of endometriosis
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria
urinary or bowel sx
O/E endometriosis
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa
diagnosis of endometriosis
pelvic USS - large endometriomas and chocolate cysts
laprascopic surgery - gold standard…biopsy of lesions
staging of endometriosis
ASRM
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
hormonal mx of endometriosis
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
surgical mx of endometriosis
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (improve fertility) (adhesiolysis)
Hysterectomy
how hormonal meds help endometriosis
Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening
GnRH agonists
induce menopause
adenomyosis risk fx
later reproductive years
multiparous
clinical fx of adenomyosis
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
infertility
pregnancy related complications
O/E enlarger and tender uterus
fibroids v adenomyosis
O/E - adenomyosis softer than fibroids
diagnosis adenomyosis
transvag USS 1st line
MRI nad transabdo USS
Gold standard - histological exam of uterus after hysterectomy
mx adenomyosis without contracpetion
tranexamic acid
mefenamic acid
mx adenomyosis for contraception
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens
specialist mx for adenomyosis
GnRH analogues to induce a menopause-like state
Endometrial ablation
Uterine artery embolisation
Hysterectomy
adenomyosis associations in pregnancy
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
menopause definition
point at which menstruation stops
postmenopause definition
describes the period from 12 months after the final menstrual period onwards.
perimenopause definition
refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
premature menopause definition and cause
menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
menopause caused by
lack of ovarian follicular function-
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
menopause patho
The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH.
The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.
perimenopausal sx
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
risks from lack of oestrogen in menopause
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
diagnosis menopause
> 45 - typical sx- clinical diagnosis
<40 or 40-45 - FSH blood test
how long contraception required for in regards to menopause
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
contraceptive first lines for women approaching menopause
hormonal - suppress sx so…
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation
cocp in over 40
up to 50 years old if no c/i
containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options
s/e of progesterone depot injection
weight gain osteoporosis
c/i of progesterone depot injection
> 45 as osteoporosis
mx of perimenopausal sx
No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants, such as fluoxetine or citalopram
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers, such as Sylk, Replens and YES
primary ovarian insufficiency def
menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age.
hormone analysis of POI
hypergonadotropic hypogonadism
Raised LH and FSH levels (gonadotropins)
Low oestradiol levels
causes of POI
Idiopathic (the cause is unknown in more than 50% of cases)
Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic, with a positive family history or conditions such as Turner’s syndrome
Infections such as mumps, tuberculosis or cytomegalovirus
clinical fx of POI
irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness
diagnosis of POI
younger than 40 years with typical menopausal symptoms plus elevated FSH
FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis
—can be hard to diagnose if taking hormonal contraceptives
associations POI
Cardiovascular disease
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
mx of POI
HRT until age at which go rhough menopause - can give traditional HRT or COCP
HRT s/e
an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches)
HRT given with which drug
progesterone to women that have a uterus…prevent endometrial hyperplasia
when be on cyclical HRT
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.
when go on continuous combined HRT
Postmenopausal women with a uterus and more than 12 months without periods
non hormonal x for menopausal sx
Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
Cognitive behavioural therapy (CBT)
Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
SSRI antidepressants (e.g. fluoxetine)
Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
Gabapentin
clonidine moa
an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication
indications clonidine
vasomotor sx and hot flushes
used when c/i to HRT
s/e of clonidine
dry mouth
headaches
dizziness
fatigue
sudden withdrawal - rapid increases in BP and agitation
alternative remedies for sx control of menopause and s/e
Black cohosh, which may be a cause of liver damage
Dong quai, which may cause bleeding disorders
Red clover, which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers
Evening primrose oil, which has significant drug interactions and is linked with clotting disorders and seizures
Ginseng may be used for mood and sleep benefits
indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
benefits of HRT
Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced the risk of osteoporosis and fractures
risks of HRT
Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
Increased risk of endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
oestrogen only HRT adv
no risk of coronary artery disease
reduce risks of VTE
using patches not pills of HRT
c/i to HRT
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
assessment before HRT
Take a full history to ensure there are no contraindications
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Encourage lifestyle changes that are likely to improve symptoms and reduce risks
choosing HRT formulation
Step 1: Do they have local or systemic symptoms?
Local symptoms: use topical treatments such as topical oestrogen cream or tablets
Systemic symptoms: use systemic treatment – go to step 2
Step 2: Does the woman have a uterus?
No uterus: use continuous oestrogen-only HRT
Has uterus: add progesterone (combined HRT) – go to step 3
Step 3: Have they had a period in the past 12 months?
Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT
switching from cyclical to continuous HRT
You can switch from cyclical to continuous HRT after at least 12 months of treatment in women over 50, and 24 months in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.
progesterone how given alongside HRT for women WITH uterus
as require endometrial protection-
Oral (tablets)
Transdermal (patches)
Intrauterine system (e.g. Mirena coil)
types of progesterone
Progestogens refer to any chemicals that target and stimulate progesterone receptors
Progesterone is the hormone produced naturally in the body
Progestins are synthetic progestogens
s/e of progesterone
C19 progesterones s(norethisterone) - useful for reduced libido
C21 progestogens - useful if women have depressed mood or acne
example regimes in women with no uterus
Oestrogen-only pills, for example, Elleste Solo or Premarin
Oestrogen-only patches, for example, Evorel or Estradot
examples regimes in a perimenopaursal woman with periods
Cyclical combined tablets, for example, Elleste-Duet, Clinorette or Femoston
Cyclical combined patches, for example, Evorel Sequi or FemSeven Sequi
Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot
examples regimes in postmenopaursal woman with uterus
Continuous combined tablets, for example, Elleste-Duet Conti, Kliofem or Femoston Conti
Continuous combined patches, for example, Evorel-Conti or FemSeven Conti
Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot
tibolone what
a synthetic steroid that stimulates oestrogen and progesterone receptors. It also weakly stimulates androgen receptors. The effects on androgen receptors mean tibolone can be helpful for patients with reduced libido.
Tibolone is used as a form of continuous combined HRT.
testosterone uses menopause
Menopause can be associated with reduced testosterone, resulting in low energy and reduced libido (sex drive). Treatment with testosterone is usually initiated
transdermal
how long for meds to work in menopause
3-6 months
f/u in 3 months
how long before surgery stop HRT
4 weeks
other causes of sx of menopause
thyroid
liver disease
DM
1st line contraception with HRT
Mirena coil
Progesterone only pill, given in addition to HRT
oestrogenic s/e
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
progestogenic s/e
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
unscheduled bleeding with HRT
Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.
STOPPING hrt
NO SPECIFIC REGIME
can just stop
gradually reduce so reduce risks of sx occuring
criteria used to diagnose PCOS
2/3 of…
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
presentation of PCOS
oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
other fx and complications PCOS
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
ddx of hirsutism
medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
insulin resistance in PCOS
When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles
ways to reduce insulin resistance
diet
exercsise
weight loss
ix when suspecting PCOS
Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone
Pelvic USS
transvaginal USS - gold standard ‘string of pearls’
hormonal blood test PCOS +ve
Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels
pelvic USS diagnosis PCOS
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
screening test of choice for DM with PCOS
a 2-hour 75g oral glucose tolerance test (OGTT)
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
general mx of PCOS
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
complications of PCOS
Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety
ways for weight loss PCOS
orlistat - lipase inhibitor - stops absorption of fat in the intestines
risk fx for endometrial cancer for people with PCOS
Obesity
Diabetes
Insulin resistance
Amenorrhoea
PCOS ovulation
Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation…endometrial cancer
indications for pelvis USS PCOS
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness
manage fertility PCOS
weight loss - restores regular ovulation
specialist involvement - Clomifene, Laparoscopic ovarian drilling, In vitro fertilisation (IVF)
metformin and letrozole - restore ovulation
ovarian drilling using diathermy or laser therapy - regular ovulation
options for reducing the risk of endometrial cancer
Mirena coil for continuous endometrial protection
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
manage hirsutism PCOS
weight loss
co-cyprindiol (COCP) - anti-androgenic
topical eflornithine
electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)
1st line mx for acne in PCOS
co-cypyrindiol - anti-androgen
Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)
ovarian cyst when
premenopausal women - benign
postmenopausal women - malignancy
presentation of ovarian cyst
asx - found incidentally
vague sx->
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
complications of ovarian cyst
ovarian torsion, haemorrhage or rupture of the cyst.
2 types of functional cysts
follicular cyst
corpus luteum cyst
follicular cyst definition
represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.
harmless
thin walls and no internal structures
corpus luteum cysts definition
occur when the corpus luteum fails to break down and instead fills with fluid
clinical fx corpus luteum cysts
pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy
other types of ovarian cysts
serous cystadenoma
mucinous cystadenoma
endometrioma
dermoid cyst/germ cell tumour
sex cord-stromal tumour
serous cystadenoma
benign tumours of the epithelial cells.
mucinous cystadenoma
benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen
endometrioma definition
lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
dermoid cyst definition
benign ovarian tumours…teratomas
dermoid cyst clinical fx and associations
contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.
sex cord stromal tumours definition
can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
red flag sx of ovarian cyst
Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
risk fx for ovarian malignancy
Age
Postmenopause
Increased number of ovulations - early periods, late menopause, nullparity
Obesity
Hormone replacement therapy
Smoking
Breastfeeding (protective)
Family history and BRCA1 and BRCA2 genes
ix for ovarian cyst
Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
CA-125
under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
causes of raised CA 125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
risk of malignancy index define
estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
mx of ovarian cyst
complex cysts or raised CA125 - 2WW
dermoid cyst - referral for further ix or surgery
simple ovarian cyst in pre - <5cm will resolve, 5-7cm - USS monitor, >7cm - MRI/surgical evaluation
if <5cm with normal Ca125 in postmenopausal woman - monitor 4-6mths
if persistent or enlarging - surgery - ovarian cystectomy or oophorectomy
complications of ovarian cyst
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum
meig’s syndrome triad
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
ovarian torsion definition
a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
causes of ovarian torsion
ovarian mass >5cm
most likely due to benign tumours
normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
main risk of ovarian torsion
Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency,
clinical fx of ovarian torsion
sudden onset severe unilateral pelvic pain
N+V
can untwist causing intermittent pain
localised tenderness
palpable mass in pelvis (not always)
diagnosis of ovarian torsion
pelvis USS- whirpool sign - free fluid in pelvis and oedema of ovary
doppler - lack of blood flow
transvaginal USS
definitive - laparascopic surgery
mx of ovarian torsion
EMERGENCY ADMISSION
laparascopic surgery -> detorsion or oophorectomy
complications of ovarian torsion
loss of function…infertility and menopause
Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.
asherman’s syndrome definition
adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
causes of asherman’s syndrome
after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).
asx adhesions…
NOT classified as asherman’s syndrome
clinical fx of asherman’s syndrome
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
infertility
diagnosis of asherman’s syndrome
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan
mx of asherman’s syndrome
dissecting the adhesions during hysteroscopy
cervical ectropion definition
also be called cervical ectopy or cervical erosion. Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum.
risks of cervical entropion
more likely to bleed with sexual intercourse…postcoital bleeding
cervical ectropion associations
higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.
transformation zone defintion
the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).
presentation of cervical ectropion
asx
increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex)
O/E cervical ectropion
well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix.
mx of cervical ectropion
typically resolve
can be tx if problematic bleeding with cauterisation of ectropion using silver nitrate or cold coagulation
nabothian cysts definition
fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts
nabothian cysts risk of cancer
harmless
patho nabothian cysts
The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.
presentation of nabothian cysts
found incidentally
if large can feel fullness in pelvis
O/E - smooth rounded bumps on cervix, near os usually, range from 2mm to 30mm, whitish/yellow appearance
mx of nabothian cysts
reassured
no tx
can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied
pelvic organ prolapse definition
refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
uterine prolapse
uterus descends into vagina
vault prolapse definition
occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina
rectocele caused
a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina
particularly associated with constipation
rectocele clinical fx
can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.
rectocoele mx
use finger to press lump back
cystocele cause
caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
prolapse of urethra
urethrocele
prolapse of both bladder and urethra
cystourethrocele
risk fx for pelvic organ prolapse
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
presentation pelvic organ prolapse
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
how examine pelvic organ prolapse
empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.
sim’s speculum - supports anterior or posterior vaginal walls while other vaginal walls are examined
grades of uterine prolapse
pelvic organ prolapse quantification (POP-Q) system:
Grade 0: Normal
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
uterine procidentia definition
A prolapse extending beyond the introitus
mx of uterine prolapse
conservative -
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
surgery - definitive option - hysterectomy
types of pessaries
Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries are a cube shape
Donut pessaries consist of a thick ring, similar to a doughnut
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina
complications of pelvic organ prolapse surgery
Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex
potential complications of mesh repairs
Chronic pain
Altered sensation
Dyspareunia (painful sex) for the women or her partner
Abnormal bleeding
Urinary or bowel problems
stress incontinence due to
weakness of the pelvic floor and sphincter muscles
overflow incontinence causes
anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries
risk fx for urinary incontinence
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
how assess severity of urinary incontinence
Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing
O/E urinary incontinence
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
how assess urinary incontinence
sk the patient to cough and watch for leakage from the urethra.
The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers.
modified oxygen grading system urinary incontinence
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
ix for urinary incontinence
bladder diary
urine dipstick
post voidal residual bladder volume
urodynamic testing
urodynamic testing how done
Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.
catheter inserted into bladder and another into rectum…pressures in the bladder and rectum
terms of urodynamic tests
Cystometry measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
Post-void residual bladder volume tests for incomplete emptying of the bladder
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
mx of stress incontinence
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
surgical options to tx stress incontinence
tension-free vaginal type
autologous sling procedure
colosuspension
IM urethral bulking
artificial urinary sphincter
mx of urge incontinence
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails
mirabegron c/i
uncontrolled HTN
mirabegron moa
beta-3-agonist
mirabegron increased risk
TIA and stroke
hypertensive crisis
invasive options for overactive bladder
Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
atrophic vaginitis
refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen
atrophic vaginitis patho
The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry
presentation atrophic vaginitis
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
atrophic vaginitis when consider
recurrent urinary tract infections, stress incontinence or pelvic organ prolapse
O/E atrophic vaginitis
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
mx of atrophic vaginitis
vaginal lubricants
topical oestrogen ->
Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months
topical oestrogens c/i
breast cancer
angina
VTE
bartholin’s gland definition
a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
bartholin’s cyst patho
When the ducts become blocked, the Bartholin’s glands can swell and become tender, causing a Bartholin’s cyst.
if become infected - abscess
bartholin’s cyst clinical fx
swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm
mx of bartholin’s cyst
resolve with simple tx -good hygiene, analgesia and warm compresses. Incision is generally avoided
biopsy if vulval malignancy
if abscess - abx, swab and culture…e.coli is the most common cause, specific swabs for chlamydia and gonorrhoea
surgical - word catheter (local anaesthetic), marsupialisation (GA)
lichen sclerosus definition
a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin
lichen sclerosus associations
autoimmune -> type 1 diabetes, alopecia, hypothyroid and vitiligo
diagnosis of lichen sclerosus
clinical diagnosis
vulval biopsy
lichen simplex definition
chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
lichen planus definition
an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
presentation lichen sclerosus
asx
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
koebner phenomenon
refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.
appearance lichen sclerosus
fissures
cracks
erosions
haemorrhages
“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques
mx of lichen sclerosus
cannot be cured
mx and f/u in 3-6 mths
potent topical steroids are mainstay - clobetasol propionate …reduce risk of malignancy
emollient used regularly
complications lichen sclerosus
s.c.c of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings
FGM law
female Genital Mutilation Act 2003
epidemiology of FGM
somalia
ethiopia
sudan
eritea
yemen
indonesia
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.
risk of FGM
Pregnant women with FGM with a possible female child
Siblings or daughters of women or girls affected by FGM
Extended trips with infants or children to areas where FGM is practised
Women that decline examination or cervical screening
New patients from communities that practise FGM
immediate complications FGM
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
long term complications FGM
Vaginal infections, such as bacterial vaginosis
Pelvic infections
Urinary tract infections
Dysmenorrhea (painful menstruation)
Sexual dysfunction and dyspareunia (painful sex)
Infertility and pregnancy-related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening
mx of FGM
mandatory to repot in pts under 18 to police
Social services and safeguarding
Paediatrics
Specialist gynaecology or FGM services
Counselling
>18 - risk assessment whether to report
de-infibulation
re-infibulation
basic embryological development of female system
The upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina. Errors in their development lead to congenital structural abnormalities in the female pelvic organs
basic embyronic development of male
In a male fetus, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear.
bicornuate uterus definition
where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance
- USS
typical complications of bicornuate uteus
Miscarriage
Premature birth
Malpresentation
imperforate hymen definition
where the hymen at the entrance of the vagina is fully formed, without an opening.
imperforate hymen clinical fx
menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.
imperforate hymen tx
incision
complications of imperforate hymen
retrograde menstruation…endometriosis
transverse vaginal septae definition
caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed).
TVS sx
Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use. Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation.
TVS complications
infertility and pregnancy related complications
TVS tx and complications
surgery but can result in vaginal stenosis or recurrence of septae
vaginal hypoplasia and agenesis definition
Vaginal hypoplasia refers to an abnormally small vagina. Vaginal agenesis refers to an absent vagina.
vaginal hypoplasia patho
occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix.
vaginal hypoplasia ovaries
unaffected
if AIS then testis rather than ovaries
mx of vaginal hypoplasia
vaginal dilator or surgery
Androgen insensitivity syndrome definition
a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.
AIS inheritance
x linked rec
caused by a mutation in the androgen receptor gene on the X chromosome
AIS patho
Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. It was previously known as testicular feminisation syndrome.
clinical fx of AIS
genetically male, with XY sex chromosome. However, the absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue.
Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
The insensitivity to androgens also results in a lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed.
partial androgen insensitivity syndrome definition
where there the cells have a partial response to androgens. This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics
ways AIS can present
hernia
primary amenorrhoea
hormonal levels AIS
Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)
mx of AIS
Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
generally raised as female
psychological input
gonorrhoea gram stain
gram negative diplococci
Neiserria gonorrhoeae
complications of LLETZ
increased risk of late miscarriage
premature nirth
cervical stenosis
what lab based test is done on HPV postitive smear
liquid based cytology
where smear taken
transformation zone
c/i to COCP
prev VTE
BP >160/110
AF
35 yrs and more than 15 a day
herpes pain mx
topical lidocaine
vaseline
herpes tx
aciclovir for 5 days
