Gynaecology Flashcards
- Levonorgestrel intrauterine system (LNG-IUS)
- Tranexamic acid, NSAIDs (mefenamic acid) - alone or together (taken during menses)
- Hormonal: COCP or cyclical oral progestogens e.g. norethisterone, medroxyprogesterone acetate (provera).
- Treatment may be offered without physical examination or imaging in women without a pelvic mass, pain or abnormal bleeding pattern.
- Pelvic examination is required prior to LNG-IUS insertion.
- Pharmacological treatment has equal efficacy to surgical treatment in most cases.
- In most women with heavy menstrual bleeding no uterine pathology can be found.
- Cancers are very rare in women with heavy menstrual bleeding.
When should endometriosis be suspected?
- triad of: chronic pelvic pain, dysmenorrhoea, deep dyspareunia.
- Cyclical GI symptoms, especially painful bowel movements
- Cyclical urinary symptoms, esp. haematuria or dysuria
- infertility in assoc with one or more of the above.
- on examination: reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions.
What investigation is suitable for women on tamoxifen with PMB?
- Referral for hysteroscopy and endometrial biopsy
- tamoxifen can cause changes which mimic endometrial thickening on US (so US not useful)
- Tamoxifen increases risk of endometrial cancer.
How is premature ovarian insufficiency diagnosed?
- In women <40 - with menopausal symptoms and elevated FSH on two occasions 6 weeks apart.
What is the screening for cervical cancer in the UK?
- Women between 25 and 64 years
- invited for smear test every 3 years until 49
- then every 5 years until 64
- Sample tested for high risk HPV first. Cytological examination only if HPV positive.
- Should be delayed until 12 weeks post-partum as there is an increased risk of an inadequate smear prior to this
How are cervical screening results interpreted?
- If hrHPV negative - return to normal recall.
- hrHPV positive - cytological examination done. If cytology abnormal - colposcopy.
- If cytology normal - smear repeated at 12 months. If HPV negative at 12 months - back to normal recall. If HPV positive again and cytology normal - repeat at 12 months later. If HPV positive at 24 months - for colposcopy.
- If sample inadequate - repeat sample in 3 months. If two consecutive samples inadequate - for colpscopy.
What is the most common gynaecological cancer in the UK?
- endometrial cancer
testosterone therapy is CONTRAINDICATED in women with a history of which cancer?
- hepatocellular
- long-term use of androgens may be associated with the development of liver tumours.
What are the stepwise treatments for stress urinary incontinence?
- conservative - lifestyle - weight loss, reducing caffeine
- referral for pelvic floor muscle training
- duloxetine if not suitable for surgery
- surgery
What is endometriosis?
- growth of endometrial tissue outside the womb.
What are the risk factors for endometriosis?
- early menarche
- late menopause
- delayed childbearing
- nulliparity
- FHx
- vaginal outflow obstruction
- white ethnicity
- Low BMI
- Autoimmune disease
- late first sexual encounter
- smoking.
How should endometriosis be investigated?
- definitive diagnosis - laparoscopic visualisation of the pelvis. Consider even if USS normal. If laparoscopy normal - woman should be advised - not got endometriosis.
- pain and symptom diary
- Consider TVUS - can identify endometriomas and endometriosis affecting bowel/bladder/ureter.
What is the initial management for endometriosis?
- short trial (3 months) - paracetamol or NSAID alone or in combination with hormonal treatment (COCP/progestogen/LNG-IUS)
When should a patient with suspected endometriosis be referred?
- if initial hormone treatment or analgesia does not work
- severe recurrent/persistent symptoms
- pelvic signs of endometriosis
- suspected deep endometriosis involving the bowel, bladder or ureter
What are the causes of heavy menstrual bleeding?
- 50% have no identifiable pathology
- Uterine fibroids (more common in afro-caribbean, obese, nulliparous, Fhx)
- endometrial polyps
- endometriosis
- increases with age
- adenomyosis
- systemic: coagulation disorder eg. von willebrands, hypothyroidism, DM
- meds: anticoags, antiplatelets, NSAIDs, SSRIs.
- smoking and alcohol increase blood loss
- endometrial cancer (rare in under 40)
Structural :PALM
Polyps
Adenomyosis (endometrial tissue in the uterine muscle)
Leiomyoma (fibroids - benign tumours of the myometrium - often multiple, most women have them before the menopause. Then reduce after menopause. COCP protective against fibroids)
Malignancy
Non-structural: COEIN
Coagulopathy (von Willebrands most common)
Ovulatory dysfunction - common at extremes of menstrual life (e.g. also PCOS, hypothyroidism)
Endometrial
Iatrogenic (progestogen only contraception, Copper IUD, antoicoags, anticonvulsants.
Not otherwise classified - uterine AVMs, uterine C-section scar.
When should abdominal, speculum and bimanual examination be done in women with menorrhagia?
- pelvic pain outside of periods
- pressure symptoms
- dyspareunia
- PCB and IMB
- if considering LNG-IUS as a treatment.
IMB, pelvic pain, pressure symptoms - will then need TVUS & likely referral for hysteroscopy and biopsy.
Symptoms of cervical pathology - PCB, erratic IMB, unusual discharge. Chlamydia testing. Consider colposcopy referral.
In regular, heavy menstrual bleeding with no risk factors or symptoms above (which suggest structural pathology), physical and pelvic examination is unnecessary. FBC advised.
How should HMB be investigated?
- FBC
- pregnancy test (if any deviation from normal bleeding pattern)
- clotting if FHx bleeding disorder - sisters/mum heavy periods. If heavy bleeding since menarche Plus PPH or, surgical bleeding or bleeding after dental work. Or bruising, nosebleeds, gum bleeding. Refer haem for further Ax if coagulopathy suspected.
- pelvic USS - suspect large fibroids as uterus palpable abdominally, examination difficult/inconclusive
- TVUS - significant dysmenorrhoea, bulky tender uterus ?adenomyosis ?endometriosis
How should HMB due to fibroids >3cm be managed?
- refer gynae
- TXA +/- NSAID whilst awaiting investigation
- Gynae may offer: LNG-IUS, COCP, cyclical oral progestogens, Uterine Artery embolisation, myomectomy, hysterectomy.
What is perimenopause?
- also called the menopause transition
- is the interval in which many women have irregular menstrual cycles before the menopause up to one year after her last period
What is the menopause?
- refers specifically to the last menstrual period (LMP) so this is a retrospective diagnosis
What is postmenopause?
- starts one year after LMP
What is the mean age of women who have a natural menopause?
- 51 years
What is Premature Ovarian Insufficiency? What are the complications long term?
- When loss of normal ovarian function occurs under age 40. Many do not have typical menopausal symptoms.
- 1% of women reach menopause before the age of 40 in the UK
- cessation of ovarian function may not always be permanent. In majority of cases - no cause found.
- Untreated POI - at risk of osteoporosis, CVD, dementia.
What are the symptoms of the menopause?
- 80% of women experience menopausal symptoms
- vasomotor symptoms - may last over 10 years
- MSK - joint and muscle pain, itchy dry skin
- Mood - mood swings, low mood, anxiety, ‘brain fog’, tiredness.
- Urogenital - vaginal dryness, itching, increased urinary frequency. Symptoms of UTI.
- Sexual - loss of libido, dyspareunia
How should perimenopause be diagnosed?
- in healthy women aged >45 years: based on vasomotor symptoms and irregular periods
How should menopause be diagnosed in women >45 years?
- women who have not had a period for 12 months, and are not using hormonal contraception.
- in women without a uterus - based on menopausal symptoms.
What is early menopause?
when menopause occurs between 40 and 45 years of age
When should an FSH test be used to diagnose menopause? How should it be done?
- Women aged 40-45 with menopausal symptoms, incl change in menstrual cycle
- Women aged <40 years when POI suspected
- Two FSH tests at least 6 weeks apart.
Why should FSH not be tested in perimenopause?
FSH measurements in the perimenopause cannot be precise as it fluctuates considerably over short periods of time
Can FSH be tested to diagnose menopause in women on contraception?
- FSH can be tested if using a Mirena coil, or taking progesterone only contraceptives
- DO NOT do FSH test if using combined oestrogen and progestogen contraception or high-dose progestogen.
- Stop Combined hormonal contraception for 6 weeks before checking FSH.
Which tests should be done in women aged <40 with suspected POI? How is the diagnosis made?
- Menopausal symptoms - no/infrequent periods AND elevated FSH on two samples taken 6 weeks apart.
- Also check: TFTs
- Prolactin
- May also need: karyotype, adrenal antibodies, DEXA, TVUS
How should vasomotor symptoms of the menopause be managed?
- lifestyle - regular exercise, weight loss, lighter clothing, turning down central heating, sleepng in cooler room, using fans, reducing stress, avoiding triggers e.g. spicy food, caffeine, smoking, alcohol.
- HRT most effective treatment (oral or transdermal)- improves vasomotor symptoms in 90% of women.
- if HRT contraindicated/not tolerated/ not chosen: SSRIs or SNRIs can be trialled for 2 weeks. Clonidine. CBT.
- Some evidence that isoflavones or black cohosh can reduce hot flushes - but different preps/safety varies. So not recommended.
How should psychological symptoms of the menopause be managed?
- oral or transdermal HRT
- self-help resources and trial of CBT for low mood/anxiety.
- antidepressant if depression/anxiety confirmed.
When can continuous combined HRT be given?
- Women who have not had a period for >1 year
- Women who have taken a sequential preparation for >1 year
For how long can vaginal bleeding occur after starting HRT?
3 months
What are the benefits of HRT?
- Up to age 60, benefits generally outweigh the risks.
- Improves vasomotor symptoms and reduced libido
- CVS benefits. CVS risk increases after menopause. HRT with oestrogen alone- no/reduced risk CHD. Combined HRT - little/no increase in risk of CVD.
- HRT does not increase CVD risk when started in women younger than 60 years.
- Transdermal HRT does not increase risk of stroke
- Bone protection. Oestrogens increase BMD - reduced risk of fragility fractures in women taking any HRT. This effect decreases once Rx stopped.
- Skin, hair, joints and wellbeing improve
What are the risks of HRT?
- **VTE **- risk increased with oral HRT. (9 more per 1,000 within 1st year, then 7 more over 5 years).
- Dydogesterone and micronised progesterone are associated with a reduced VTE risk compared to other progestogens
- Transdermal preparations should be considered for those women with a higher risk of VTE, including those with a BMI >30 kg/m2. Risk of VTE not increased with transdermal use.
- **Breast cancer **- risk depends on type of HRT. Oestrogen only HRT - little/no change in risk. Combined HRT - increased risk (20 more cases per 1000 over 10 years. Risk related to duration, and reduces after stopping. Other risk Fx for breast cancer: FHx, obesity, alcohol must be considered.
- **Stroke **- oral oestrogen - small increased risk of stroke. (not transdermal)
- Ovarian cancer - small increased risk with long term use of all types of HRT.
If a woman is at high risk of VTE and considering HRT, how should they be managed? (strong family hx, hereditary thombophilia)
- refer to haematologist before considering HRT.
How is the mid-luteal progesterone result interpreted?
