Gynaecology Flashcards
1
Q
A
- 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.
2
Q
When should endometriosis be suspected?
A
- 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.
3
Q
What investigation is suitable for women on tamoxifen with PMB?
A
- 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.
4
Q
How is premature ovarian insufficiency diagnosed?
A
- In women <40 - with menopausal symptoms and elevated FSH on two occasions 6 weeks apart.
5
Q
What is the screening for cervical cancer in the UK?
A
- 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
6
Q
How are cervical screening results interpreted?
A
- 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.
7
Q
What is the most common gynaecological cancer in the UK?
A
- endometrial cancer
8
Q
testosterone therapy is CONTRAINDICATED in women with a history of which cancer?
A
- hepatocellular
- long-term use of androgens may be associated with the development of liver tumours.
9
Q
What are the stepwise treatments for stress urinary incontinence?
A
- conservative - lifestyle - weight loss, reducing caffeine
- referral for pelvic floor muscle training
- duloxetine if not suitable for surgery
- surgery
10
Q
What is endometriosis?
A
- growth of endometrial tissue outside the womb.
11
Q
What are the risk factors for endometriosis?
A
- early menarche
- late menopause
- delayed childbearing
- nulliparity
- FHx
- vaginal outflow obstruction
- white ethnicity
- Low BMI
- Autoimmune disease
- late first sexual encounter
- smoking.
12
Q
How should endometriosis be investigated?
A
- 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.
13
Q
What is the initial management for endometriosis?
A
- short trial (3 months) - paracetamol or NSAID alone or in combination with hormonal treatment (COCP/progestogen/LNG-IUS)
14
Q
When should a patient with suspected endometriosis be referred?
A
- 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
15
Q
What are the causes of heavy menstrual bleeding?
A
- 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.
16
Q
When should abdominal, speculum and bimanual examination be done in women with menorrhagia?
A
- 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.
17
Q
How should HMB be investigated?
A
- 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
18
Q
How should HMB due to fibroids >3cm be managed?
A
- refer gynae
- TXA +/- NSAID whilst awaiting investigation
- Gynae may offer: LNG-IUS, COCP, cyclical oral progestogens, Uterine Artery embolisation, myomectomy, hysterectomy.
19
Q
What is perimenopause?
A
- 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
20
Q
What is the menopause?
A
- refers specifically to the last menstrual period (LMP) so this is a retrospective diagnosis
21
Q
What is postmenopause?
A
- starts one year after LMP
22
Q
What is the mean age of women who have a natural menopause?
A
- 51 years
23
Q
What is Premature Ovarian Insufficiency? What are the complications long term?
A
- 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.
24
Q
What are the symptoms of the menopause?
A
- 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
25
How should perimenopause be diagnosed?
* in healthy women aged >45 years: based on vasomotor symptoms and irregular periods
26
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.
27
What is early menopause?
when menopause occurs between 40 and 45 years of age
28
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.
29
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
30
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.
31
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
32
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.
33
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.
34
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
35
For how long can vaginal bleeding occur after starting HRT?
3 months
36
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
37
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.
38
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.
39
How should menopausal women be followed up?
* reiterate importance of breast and cervical screening
* Review after 3 months to assess response of any treatment and address side effects
* Review annually therafter
40
When should menopausal women be referred to menopause specialist?
* Those in whom HRT does not improve their symptoms
* Those who have troublesome side effects
* Those who have contra-indications to HRT
* If there is any uncertainty about the most suitable treatment option
41
How should HRT be stopped?
* There is no maximum length of time that a woman can take HRT for
* Woman who stop HRT can either have their HRT gradually reduced or stopped immediately
* Many women have menopausal symptoms after stopping HRT
* Reassure that this is not a withdrawal effect from stopping HRT. These are symptoms that would be present if they never took HRT
* In these cases many women may decide to continue their HRT for a longer period of time
* Lower dose preparations of HRT are available for older women
42
How should urogenital atrophy associated with menopause be managed?
* Topical vaginal oestrogen. Can be given alongside systemic HRT. Continue as long as needed to relieve symptoms. Give on repeat Script.
* Only contraindication to topical vaginal oestrogen - active breast cancer
* One years supply of topical oestrogen is equivalent to one tablet HRT.
* Vaginal moisturisers and lubricants - can be used alone or in combo with topical oestrogen.
43
How should POI be managed?
* offer HRT or COCP (unless contraindications)
* explain importance of hormonal treatment - need to continue until age of natural menopause
* Risks of HRT not applicable to these young women - applicable only over age 51.
44
How long do women require contraception for when peri/menopausal? What are the available options?
* HRT does not provide contraception
* A woman is potentially fertile for 2 years after her LMP if aged <50 years, or 1 year after LMP if age >50 years
* All women can stop contraception at age 55
* All progestogen-only methods of contraception are safe to use alongside HRT
* The mirena coil offers endometrial protection as well as contraception.
* COCP can be used in women <50 years as an alternative to HRT for relief of menopausal symptoms. Should switch to progestogen only contraception at age 50.
45
What are the contraindications to HRT?
* current/suspected/past breast cancer
* known/suspected oestrogen-dependent cancer
* Undiagnosed vaginal bleeding
* Untreated endometrial hyperplasia
* current VTE, or previous idiopathic VTE
* Active/recent MI/angina
* Active liver disease
* Pregnancy
* Thrombophilic disorder
46
In which medical conditions are transdermal HRT preparations preferred to oral?
* increased risk of VTE
* CVS risk factors - obesity, HTN, High lipids
* hepatic enzyme inducing drug treatments (e.g. carbamazepine)
* GI disorder affecting oral absorption
* Migraine
* Gallbladder disease
* Lactose sensitivity
47
How long can a mirena coil be used for endometrial protection as part of HRT?
* 5 years, must be changed every 5 years.
48
What is normal menstrual bleeding?
* occurs every 24-38 days (start of one period to the start of the next)
* Normal cycles can vary in length by up to 7 days
* lasts <8 days
* doesn't occur between periods or after sex
* isn't painful
* doesn't interfere with QoL - modified activities, clothing or routine. Time off work/education.
* Clots bigger than 10p coin, or flooding - bleeding through to clothes/bedding are abnormal. Check how often changing pads/tampons. Are they needing both at the same time?
49
How should women with infrequent or irregular periods be managed?
* likely that ovulation is not happening regularly
* consider bloods for PCOS, thyroid disorders, hyperprolactinaemia
50
What are the risk factors for endometrial cancer?
* age >45
* Nulliparity
* PCOS
* unopposed oestrogen therapy
* obesity
* diabetes
* HTN
* Tamoxifen
* FHX breast, colon, endometrial cancer
51
When should women with abnormal uterine bleeding be referred for hysteroscopy +/- endometrial biopsy?
(not fulfilling 2ww criteria as age <55, or pre-menopausal)
To assess for polyps, endometrial hyperplasia, or malignancy
* AUB in woman at risk for hyperplasia/malignancy
* Abnormal US findings (thickened endometrium, polyps)
* 3-6 months medical management not helped.
52
When should women with AUB be referred to secondary care for possible surgical management?
Not fulfilling 2ww as <55, or pre-menopausal.
* AUB and pressure symptoms from abdominal mass
* Fibroids >3cm, or distorting uterine cavity - medical Mx unlikely to work
* AUB causing anaemia
* Women wanting to explore surgical options
53
What is first line treatment for dysmenorrhoea (painful periods)?
1. NSAID (or paracetamol if NSAID CI)
2. add paracetamol
3. 3-6 month trial of oral hormonal contraceptive (COCP 1st choice).
4. combination of NSAID/paracetamol and COCP
5. in addition - local heat patch, TENS may help
6. if not responding after 3-6 months/doubt re diagnosis - refer gynae
54
What is primary amenorrhoea?
* Failure to establish menstruation by the time of expected menarche.
* by age 16 (with normal 2ry sexual characteristics)
* by age 14 (with no 2ry sexual characteristics)
55
What is secondary amenorrhoea?
* the cessation of menstruation in women with previous menses.
* The cessation of menses for 3 cycles after the establishment of regular menses (3 months if a regular monthly cycle)
56
What are the causes of secondary amenorrhoea?
* ALWAYS consider pregnancy
* lactation
* Prolactinoma- also causes galactorrhoea, weight gain. Other causes of **hyper-prolactinaemia** -anti-psychotics, metoclopramide
* weight loss/stress/excessive exercise - functional **hypothalamic** amenorrhoea.
* Chronic systemic illness (hypothalamic)
* hypo/hyperthyroidism
* adrenal - cushing's
* ovary - **PCOS**, menopause, **POI **(idiopathic, chemo/radiotherapy, autoimmune, surgery)
* uterine/vaginal - intrauterine adhesions (asherman's), cervical stenosis.
* contraceptives
| most common in bold
57
Which investigations should be considered in primary care for amenorrhoea?
* Urinary pregnancy test.
* Follicle-stimulating hormone and luteinizing hormone.
* Oestradiol.
* Prolactin.
* Total testosterone.
* Thyroid-stimulating hormone.
* Coeliac screen
* Ultrasound scan (if PCOS is suspected/ in primary amenorrhoea to confirm presence of vagina and uterus in young girls/unable to do examination).
Refer all suspected primary amenorrhoea to secondary care for specialist investigation.
| results not reliable if on any form of hormonal treatment.
58
What do high FSH and LH signify in secondary amenorrhoea?
* POI in women younger than 40
* oligo/amenorrhoea plus raised FSH on two samples 6 weeks apart
There will be low oestradiol, normal prolactin, normal/low testosterone.
59
What do normal or low FSH/LH levels signify in secondary amenorrhoea?
* hypothalamic causes: weight loss, excessive exercise, stress, or rarely, a hypothalamic or pituitary tumour
There will be low oestradiol, normal/low prolactin, normal/low testosterone.
60
What hormonal blood test results support a diagnosis of PCOS?
* elevated LH:FSH ratio. (FSH is normal, LH slightly increases)
* Prolactin - increased in 50%
* Testosterone- usually increased, free androgen index increased.
* oestradiol - can be normal/low/high
61
When should patients with secondary amenorrhoea be referred to gynaecology?
* Suspected POI (high FSH and LH) in woman <40 years
* Recent uterine or cervical surgery (curettage, C-section, myomectomy, endometritis) - concern for Asherman's/cervical stenosis
* Infertility
* Suspected PCOS but unclear diagnosis or complications.
62
When should patients with secondary amenorrhoea be referred to an endocrinologist?
* hyperprolactinaemia
* Low FSH and LH - to exclude hypopituitarism or pituitary tumour (though stress/exercise/weight loss more likely - need to rule out serious causes first)
* High testosterone not explained by PCOS. ?androgen secreting tumour, CAH, Cushing's)
* Other features of Cushing's syndrome or late onset congential adrenal hyperplasia
If eating disorder suspected - urgent referral to specialist service.
63
When should a 2ww referral be made for suspected ovarian cancer?
| Applies to women aged 18 and over
* physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
* ultrasound scan suggests ovarian cancer
Women with suspected ovarian cancer should have an abdominal and pelvic examination.
64
When should a serum CA125 be checked for possible ovarian cancer?
If a woman (especially if aged 50 or over) reports **any of the following symptoms on a persistent or frequent basis**:
* persistent abdominal distension (women often refer to this as 'bloating')
* feeling full (early satiety) and/or loss of appetite
* pelvic or abdominal pain
* increased urinary urgency and/or frequency.
In any **woman aged >=50 who has experienced symptoms that suggest IBS within the last 12 months** (IBS rarely presents for the first time in women this age)
Consider CA125 if a woman reports unexplained weight loss, fatigue, changes in bowel habit.
65
What is the cut off for serum CA125 where an Ultrasound abdo-pelvis scan shuold be arranged?
* If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
66
What should a woman be advised if the serum CA125 is less than 35, or was above 35 but the USS abdo pelvis is normal?
* assess her carefully for other clinical causes of her symptoms and investigate if appropriate
* if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent
67
What are other causes for a raised serum CA125?
* Peritoneal trauma, disease, or irritation.
* Other cancers: primary peritoneal cancer, lung cancer, pancreatic cancer.
* Endometriosis.
* PID
* Ovarian cyst torsion, rupture, or haemorrhage.
* Pregnancy.
* Heart failure
68
What are the risk factors for ovarian cancer?
* FHx: mutations of the BRCA1 or the BRCA2 gene
* many ovulations: early menarche, late menopause, nulliparity
* increasing age
* small increased risk with use of HRT
* personal Hx of breast, bowel cancer. Endometriosis. DM
* smoking, obesity, asbestos
69
What reduces the risk of ovarian cancer?
Conditions that decrease the number of ovulatory cycles, including:
* A higher number of pregnancies.
* Breastfeeding.
* Use of the COCP (reduced number of ovulations)
* Tubal ligation and hysterectomy.
70
What are the 2ww referral criteria for suspected endometrial cancer?
* Aged >=55 with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)
* Consider 2ww referral in women <55 with post-menopausal bleeding.
71
When should a direct access USS be requested for suspected endometrial cancer?
Women >=55 with:
Unexplained vaginal discharge PLUS one of:
* presenting with this for the first time
* thrombocytosis
* haematuria
Women >=55 with:
Visible haematuria PLUS one of:
* low Hb levels
* thrombocytosis
* high blood glucose levels
71
What are the risk factors for endometrial cancer?
Excess oestrogen:
* nulliparity
* early menarche, late menopause
* unopposed oestrogen: eg HRT without a progestogen, tibolone (synthetic oestrogen)
Tamoxifen - likely has oestrogen-like effect on endometrium.
Metabolic syndrome:
* obesity
* DM
* PCOS
Hereditary non-polyposis colorectal carcinoma (lynch syndrome)
Endometrial polyps
72
What are the 2ww referral criteria for suspected cervical cancer?
* women - on examination, the appearance of their cervix is consistent with cervical cancer.
73
What are the risk factors for cervical cancer?
*** HPV - serotypes 16, 18, 33 **
Others:
* early first intercourse, many sexual partners
* lower SE status
* HIV
* smoking
* COCP
74
How can cervical cancer be prevented?
* encourage cervical screening
* encourage girls aged 12-13 to receive HPV immunisation (should be given before becomes sexually active)
* advise re importance of barrier (condoms) to reduce risk of HPV infection - reduces risk but does not fully eliminate
75
What clinical symptoms suggest a diagnosis of cervical cancer?
* persistent unexplained abnormal vaginal bleeding- IMB or PCB
* Unexplained persistent vaginal discharge
* Pelvic pain and/or dyspareunia
* PMB not on HRT, or change in bleeding if on HRT
* abnormal cervix on speculum - inflamed, friable appearance with contact bleeding, or a vesible ulcerating/necrotic lesion.
76
What are the 2ww criteria for suspected vulval cancer?
* unexplained vulval lump, ulceration or bleeding.
77
What are the 2ww criteria for suspected vaginal cancer?
* unexplained palpable mass in or at the entrance to the vagina.
78
What are the clinical features of PCOS?
* subfertility and infertility
* menstrual disturbances: oligomenorrhoea and amenorrhoea
* hirsutism, acne (due to hyperandrogenism)
* obesity
* acanthosis nigricans (due to insulin resistance)
79
Which investigations should be done in primary care if PCOS is suspected?
* total testosterone: normal-elevated
* sex-hormone-bingding globulin (SHBG): normal-low
* calcuate free-androgen index: total testosterone/SHBG. normal-elevated
Rule out other causes of oligo/amernorrhoea:
* LH & FSH
* prolactin - may be mildly elevated
* TSH
Refer for USS - to assess for polycystic ovaries. 20 or more follicles in at least 1 ovary. Does not establish diagnosis alone. Should not be used for diagnosis in adolescents.
| hormone tests not reliable if on hormonal contraception
80
What are the criteria for diagnosis of PCOS?
Two of the following:
* ovulatory dysfunction (oligo/amenorrhoea)
* clinical/biochemical hyperandrogenism: hirsutism, acne, elevated testosterone
* polycystic ovaries on USS
Polycystic ovaries do not need to be present to make the diagnosis.
The diagnosis is lifelong.
81
How is PCOS managed in adults?
* healthy lifestyle advice
* assess CVS risk
* offer COCP (helps acne)
* if prolonged amenorrhoea (less than one period every 3 months) - request TVUS to assess endometrial thickness. Start cyclical progestogen, COCP, or IUS. If unwilling - refer- will likely need regular USS to assess endometrial thickness.
82
What is infertility?
failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse
primary - in couples who have never conceived
secondary - in couples who have conceived at least once before (with same or different partner)
83
What are the risk factors for infertility?
* age
* STIs
* Obesity
* low body weight
* smoking, stress
* exposure to pesticides, nitrous oxide, metals, solvents, formaldehyde
Drugs in women:
* NSAIDs - may inhibit ovulation
* Chemotherapy - may induce ovarian failure
* Drugs which increase prolactin - metclopramide, antipsychotics, sertraline, fluoxetine
* cannabis and cocaine - affect ovulatory and tubal function.
Drugs in men:
* sulfasalazine and antifungals
* some antipsychotics, antidepressants, antihypertensives - retrograde ejaculation and orgasmic dysfunction
* long term opiate use
* 5-ARIs can cause sexual dysfunction
* steroid horone/testosterone supplements - inhibit spermatogenesis
* cocaine
84
What are the common causes of infertility?
* male factor 30% (testicular failure, obstructive azoospermia, ejaculatory/E.D, abnormal sperm function and quality.)
* unexplained 25%
* ovulation disorders 25% (hypothalamic-pituitary failure e.g. low body weight, excessive exercise, Kallmann syndrome. H-P-O axis e.g. hyperprolactinaemia, PCOS. Ovarian failure e.g. POI. Others: thyroid disorder, Cushing's , CAH , chronic diseases.
* tubal damage 20% (PID, appendicitis, diverticulitis, endometriosis)
* uterine or peritoneal disorders 10% (adhesions, polyps, fibroids)
85
What is the chance of conception in the general population?
* over 80% of couples will conceive within 1 year if woman aged <40 and they have regular (every 2-3 days) unprotected sexual intercourse. This increases to 90% in the second year.
86
What lifestyle advice should be given to those concerned about infertility?
* advice about regular intercourse every 2-3 days.
* quit smoking
* reduce alcohol - may affect semen quality
* BMI >30 may increase time to conceive. Losing weight increases chance of conception
* If BMI <19 - advise increasing weight increases chances. Aim BMI 20-25.
* Drugs - cannabis, cocaine. R/V Px drugs
* Stress management - increases libido & frequency of intercourse.
* Start folic acid: 0.4mg/day. 5mg a day if previous NTD, AEDs, DM.
* test rubella status. If susceptible - vaccinate (wait 1 month to conceive after)
* ensure cervical cancer screening UTD
87
What initial investigations should be done in the woman for infertility? Both partners should be simultaneously investigated. When should the Ix be started?
* start investigations in couples who have not conceived after 1 year of regular unprotected SI. Early Ix for certain cases.
* Mid-luteal phase progesterone (7 days prior to expected next period)- day 21 of a 28 day cycle. For ALL women. Confirms ovulation.
* Screen for chlamydia - needed before any uterine instrumentation.
* LH & FSH in women with irregular cycles.
* TFTs if any symptoms
* Prolactin - suspected PCOS, galactorrhoea, suspected pit tumour.
88
What initial investigations for infertility should be done in the man?
* semen analysis. If first sample abnormal, repeat 3 months later. If both samples abnormal - refer to secondary care.
89
When should a couple with infertility be routinely referred to secondary care?
* in woman <36 years old, history, examination and investigations are normal in both partners, but not conceived within 1 year. For additional Ix and Mx.
90
When should earlier referral be considered for couples presenting with infertility?
In women:
* Age >=36 - refer after 6 months
* Oligo/Amenorrhoea
* Prev abdo/pelvic surgery
* Prev PID
* Prev STI
* Abnormal pelvic exam
* Known reason for infertility- eg prior chemotherapy.
In Men:
* Prev genital pathology
* Prev urogenital surgery
* Prev STI
* Varicocele
* Significant systemic illness
* Abnormal genital exam
* Two abnormal semen results
* Known reason for infertility eg. prior Chemotherapy.
91
How is the mid-luteal progesterone result interpreted?
92
What assisted reproduction techniques are available?
* Intrauterine insemination
* IVF
* Intracytoplasmic sperm injection
* Donor insemination
* Oocyte donation
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What are the possible complications after assisted conception?
* Ovarian hyperstimulation syndrome (OHSS): potentially life-threatening complication of superovulation. Symptoms: bloating, abdo pain, N&V, oliguria, oedema, ascites, thomboembolism, ARDS. Refer specialist urgently.
* ectopic pregnancy
* pelvic infection
* multiple pregnancy
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What is the management for genital lichen sclerosus?
* if diagnosis in doubt - refer 2ry care
* Dermovate cream/ointment (clobetasol). Adults: once a day for 1 month, alternate days for a month, twice weekly for a month, then review. Children> OD for 3 months. Maintenance then needed once-twice/wk. Increase if flare. This improves symptoms and stops scarring.
* Others: topical protopic.
* Review annually for malignant transformation to VIN or SCC - 5% risk. persistent area of well-defined erythema, bleeding/ulceration, or skin thickening/lump .
95
What are the risk factors for VIN and Vulval SCC?
Vulval intraepithelial neoplasia (VIN) is a pre‐malignant condition that may progress to vulval squamous cell carcinoma.
* two forms of VIN, undifferentiated and differentiated - different aetiologies and prognostic factors
* Undifferentiated VIN: younger women, smoking, HPV types 16 and 18, HIV infection/immunosuppression. Multifocal. Diverse appearance: plaques, warty, similar appearance to SKs
* Differentiated VIN: older women. Lichen sclerosus, erosive lichen planus. Unifocal, erythematous hyperkeratotic lesion on BG of dermatoses.
* SCC: nodular, ulcerated, warty appearance.
* Refer all patients to specialist vulval clinic.
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How long can a LNG-IUS remain in situ for contraception and/or heavy menstrual bleeding in older women?
* If it was inserted at or over the age of 45: it can remain in situ until age 55 for contraception and/or HMB.
* If before age 45, it is licenced for contraception for 8 years
* If just for HMB - indefinite ( i.e not needed for contraception)
(only licenced for 5 years for HRT)
