Gynaecology Flashcards
What is amennorhoea?
A lack of periods
What are three main groups of causes for primary amennorhoea?
Problems with hypothalamus or pituitary, problem with the gonads or structural (e.g imperforate hymen)
What the most common cause of amennorhoea?
Pregnancy
What are some other causes of secondary amennorhoea?
PCOS, Cushing’s, menopause, anorexia/stress, thyroid dysfunction, hormonal contraceptives, hyperprolactinaemia, premature ovarian failure
What are common causes of intermenstrual bleeding?
Cervical ectropion, hormonal contraception, STI, endometrial polyps or cancer, vaginal pathology, pregnancy, medications (e.g SSRIs and anticoagulants)
What is the word for painful periods?
Dysmenorrhoea
What can cause dysmenorrhea?
Endometriosis, fibroids, PID, copper coil, cervical/ovarian cancer, primary dysmennorhoea
What is the word for heavy periods?
Menorrhagia
What is it referred to when there is no identifiable cause for menorrhagia?
Dysfunctional uterine bleeding
What are some causes of menorrhagia?
Extremes of reproductive age, fibroids, endometriosis and adenomyosis, PID, copper coil, anticoag meds, bleeding disorders, connective tissue disorders, endometrial hyperplasia, PCOS
What are the key causes of postcoital bleeding?
Cervical cancer (+endometrial or vaginal), cervical ectropion, trauma, atrophic vaginitis
What is the term for cyclical pain felt during ovulation?
Mittelschmerz
How is primary amenorrhoea defined?
Not starting period by 13 when there’s no other signs of pubertal development
Not starting period by 15 where there are other signs of puberty
When do we typically seen girls starting periods in relation to starting puberty?
Puberty is normally between 8-14 for girls
Menarche usually starts 2 years after start of puberty
What cause of hypogonadotropic hypogonadism is associated with anosmia?
Kallman syndrome
What are some structural causes of amenorrhoea?
Imperforate hymen, female genital mutilation, transverse vaginal septae, vaginal agenesis, absent uterus
What will the levels of LH and FSH be like in hypogonadotropic hypogonadism and hypergonadotropic hypogonadism?
Hypogonadotropic= low LH and FSH
Hypergonadotropic= high LH and FSH
What hormonal blood tests can be used to investigate amenorrhoea?
FSH and LH
Thyroid
Testosterone (raised in PCOS, androgen insensitivity and CAH)
Prolactin
Insulin-like growth factor (used in screening of GH deficiency)
In patient with hypogonadotropic hypogonadism, how can we treat them if they want t be fertile and where pregnancy is not wanted?
Pulsatile GnRH can be used to induce ovulation and menstruation- can induce fertility
Pregnancy not wanted- combined contraceptive pill can induce regular menstruation
How is secondary amenorrhoea defined?
No menstruation for greater than 3 months after regular menstrual periods
Why does physiological or psychological stress lead to amennorhoea?
It reduces the production of GnRH. This is so the boys doesnt have a pregnancy when the body may not be fit for it
What medications can be used to reduce prolactin production?
Dopamine agonists like bromocriptine or cabergoline
In a patient with amenorrhoea, what would a high LH or a high FSH suggest as the cause?
High LH/ high LH:FSH ratio - indicates PCOS
High FSH - indicates primary ovarian failure
Why do women with PCOS require a withdrawal bleed every 3-4 months?
To reduce the risk of endometrial hyperplasia and endometrial cancer
What is the peak age group affected by endometrial cancer?
64-74
what increases the risk of endometrial cancer?
Early menarche/late menopause, nulliparity, PCOS, BRCA 1/2, endometrial polyps
hat lowers the risk of endometrial cancer?
COCP, HRT, physical activity
What is the pre-malignant condition associated with endometrial cancer?
Endometrial hyperplasia
What percentage of women with endometrial hyperplasia will develop cancer within 10 years?
20%
How is endometrial hyperplasia treated?
Progestagens and surgery
What are the types of endometrial carcinomas?
Type 1: endometrial adenocarcinoma
Type 2 clear cell, papillary serous, carcinosarcoma
what staging is used for endometrial carcinoma?
FIGO
What investigations are useful in diagnosing endometrial cancer?
Endometrial sampling, hysteroscopy (gold standard), transvaginal ultrasound
What factors will determine the primary treatment for endometrial cancer?
Stage, age, fitness for surgery and patient preference
What is the peak age for ovarian cancer?
70-74
What are the most common times of ovarian tumour?
Serous, mucinous and teratomas
What are risk factors for developing ovarian cancer?
Nulliparity, early menarche, late menopause, unopposed estrogen, FHx, BRCA 1/2, endometriosis
Ovarian cancer presents with non-specific symptoms, what symptoms is it likely to present with?
Abdominal bloating, pain, anorexia, N+V, weight loss, vaginal bleeding
What tumour marker is measured in ovarian cancer?
Ca125
Is CA125 specific to ovarian cancer?
No, can be raised in other gynae conditions like endometriosis, menstruation and any inflammatory condition in abdominal area
What ages are most affected by cervical cancer?
Bimodal distribution affecting women in 30s and 80s
what types of cervical cancer are most common?
Most are squamous cell carcinoma, adenocarcinomas also common
What are risk factors for cervical cancer?
Early age at first intercourse, multiple sexual partners, unprotected sex, smoking, long term COCP use, immunosupression/HIV
What lowers your risk of cervical cancer?
Regular cervical screening attendance and HPV vaccine
What are common presentations for cervical cancer?
Abnormal vaginal bleeding (Post coital bleeding, post menopausal bleeding, intermenstrual bleeding, blood stained vaginal discharge)
Vaginal discharge, pelvic pain and dyspareunia
What treatment options are available for CIN?
LLETZ (large loop excision of the transformation zone), cold knife cone, cryocautery, diathermy,
What is the pre-malignant condition associated with vulval cancer?
Vulvar intraepithelial neoplasia
What are the treatment options for vulvar intraepithelial neoplasia?
Conservative= antihistamines for itching
Medical= imiquimod
Surgical= excision
What are risk factors of vulval cancer?
HPV, herpes simplex, smoking immunosupression, chronic vulvar irritation, lichen sclerosus
What cancers is HPV associated with?
Cervical, anal, vulval, penile, throat, mouth
What strains of HPV are most responsible for cervical cancers?
Type 16 and 18
How does HPV promote the development of cancer?
By producing proteins (E6 and E7) which inhibit tumour suppressor genes
What do the different levels of cervical intraepithelial neoplasia refer to regarding amount of dysplasia?
CIN 1= mild dysplasia
CIN 2= moderate dysplasia
CIN3= severe dysplasia
What do the different levels of cervical intraepithelial neoplasia refer to regarding thickness of epithelial layer affected?
CIN1= 1/3
CIN2= 2/3
CIN3= all
What do the different levels of cervical intraepithelial neoplasia refer to regarding what happens if not treated?
CIN 1= likely to return to normal without treatment
CIN2= likely to progress to cancer if not treated
CIN3= very likely to progress to cancer if not treated
what are risk factors for genital prolapse?
pregnancy and vaginal delivery, menopause, increased intrabdominal pressure (obesity, chronic cough, constipation, heavy lifting), pelvic surgery e.g hysterectomy
what are symptoms of genital prolapse?
heaviness or feeling of something coming down, dyspareunia, constipation, urinary problems
what different structures are likely to prolapse into the anterior, posterior and apical vaginal wall?
anterior= bladder or urethra
posterior= rectum or small bowel
apical= uterus or vaginal vault collapse
what conservative measures can be advised for patients with genital prolapse?
pelvic floor muscle exercises, weight loss, smoking cessation, avoiding heavy lifting
what management can women with genital prolapse who are unfit for surgery be offered?
pessaries
what surgical options are available for genital prolapse?
anterior colporrhaphy
posterior colporrhaphy
hysterectomy
why are mesh repairs now used as a last resort?
associated with increased morbidity and complications
does trandermal or oral HRT have a higher risk of VTE?
oral has 2-3 greater risk of VTE
transdermal patches are no associated with increased risk of VTE
why is progesterone also given alongside oestrogen in HRT?
to reduce risk of endometrial cancer
what is the most appropriate from of HRT in perimenopausal women?
monthly cyclical HRT
what is the most appropriate form of HRT in post-menopausal women?
continuous combined HRT
what are the oestrogen related side effects of HRT
breast tenderness, leg cramps, bloating, nausea, headaches
what are progesterone related side effects of HRT?
pre-menstrual syndrome like symptoms: mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain
what are general risks of HRT?
increased risk of breast Ca, endometrial Ca, VTE, stroke, ischaemic heart disease. PMS, leg cramps bloating
what is lichen sclerosus?
a chronic inflammatory skin disease of anogenital region
when can discomfort with lichen sclerosus be exacerbated?
urination and sex due to irritation of affected area
how is lichen sclerosus managed?
topical corticosteroids, emollients, avoiding soaps in affected areas to prevent irritation
how does lichen sclerosus classically present?
patches of thin, white, itchy, wrkinkled looking skin predominantly around the genitals and anus, more common in post-menopausal women
what kind of steroids are used for vulval lichen sclerosus?
potent topical steroids like dermovate or clobetasol propionate
what are clinical features of lichen sclerosus?
white atrophic patches, clitoral hood fusion, fusion of labia minora to majora, posterior fusion resulting in introitus narrowing
what are uterine causes of heave menstrual bleeding?
fibroids, endometriosis, adenomyosis, endometrial hyperplasia or cancer, PID
what are non uterine causes of heavy menstrual bleeding?
PCOS, extremes of reproductive age, copper coil, anticoagulant meds, bleeding disorders, hypothyroidism
what investigations can be considered for heavy menstrual bleeding?
FBC, abominal/transvaginal USS, hysteroscopy +/- biopsy,
if a woman has non-painful heavy periods and does not need contraception, what would help her symptoms?
tranexamic acid
if a woman has painful heavy periods and does not need contraception, what one medication could help her symptoms?
mefenamic acid
what contraception methods can help with heavy menstrual bleeding?
1st line = mirena coil
COCP
cyclical oral progestogens
when would you refer heavy menstrual bleeding to secondary care?
treatment in primarycare unsuccessful, symptoms are severe, large fibroids >3cm
what further management options are available for heavy menstrual bleeding when medical options have failed?
endometrial ablation (balloon thermal ablation) and hysterectomy
which ethnic group are fibroids most common?
black women
what are different types of fibroids?
intramural- in the myometrium
submucosal- just underneath the endometrium
subserosal- just underneath outer layer of uterus
pedunculated- on a stalk
what are surgical options for management of large fibroids?
uterine artery embolisation, myomectomy, hysterectomy
how can GnRH antagonists be used for fibroid treatmnt?
used short term to induce menopause state reducing oestrogen levels so fibroids shrink before myomectomy
which fibroid surgical management option improves fertility?
myomectomy
what are complications of fibroids?
heavy menstrual bleeding and anaemia
reduced fertility
constipation, urinary outflow obstruction and UTIs
red degeneration
torsion (usually pedunculated)
malignant change (rare <1%)
what three features define hyperemesis gravidarum?
5% pre-pregnancy weight loss, dehydration and electrolyte imbalance
what are typical blood results in PCOS?
raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG (sex hormone binding globulin) is normal to low
What are features seen on clinical examination with an adnexal torsion?
General- pyrexia, tachycardia
Abdominal- rebound tenderness localised guarding
Vaginal- cervical excitation, adnexal tenderness, adnexal mass
Who is ovarian hyper stimulation syndrome likely to occur in? How can it present?
In women undergoing IVF who are having ovulation induction
Bloating, pelvic pain, nausea+vomiting
What is premature ovarian insufficiency?
Menopause before the age of 40
What conditions are women with premature ovarian insufficiency more at risk of?
CVD, stroke osteoporosis, cognitive impairment
Do women with premature ovarian insufficiency still require contraception?
There is still a small of pregnancy so contraception still required
Would HRT given before 50 to women with premature ovarian insufficiency increase the risk of breast cancer?
No as this would be replacing the oestrogen level to what they would’ve been
How do we define chronic pelvic pain?
Intermittent or constant pain, over 6 months, not occuring exclusively with menstruation, intercourse or pregnancy
What is the concept of visceral hyperalgesia?
Persistent pain leads to changes within CNS which magnify the original signal making the viscera more sensitive to pain than normal
What are some differentials for chronic pelvic pain?
Endometriosis and adenomyosis, PID, IBS, interstitial cystitis, MSK pain, nerve entrapment, adhesions
What are the three main theories for endometriosis aetiology?
Retrograde menstruation- endometrial tissue goes out into other structures through retrograde flow during menstruation
Coelomic metaplasia- tissue transforms into endometrial tissue
Mullerian remnants- embryological remenants find themselves outside of uterus
How strong is the correlation between disease severity and symptom severity in endometriosis?
There is little correlation
How can endometriosis appear on laparoscopy?
Chocolate cysts, adhesions and peritoneal deposits (powder burn deposits, red flame lesions)
What examination findings are indicative of adenomyosis?
An enlarged, tender and boggy uterus
What are typical examination findings with endometriosis?
A fixed, retroverted uterus, uterosacral ligament nodules, general tenderness, forniceal and uterine tenderness
What medical management is available for endometriosis?
COCP, continuous progesterone therapy, GnRH analogues
How do GnRH analogues work?
They increased stimulation of the receptors in anterior pituitary which eventually desensitises them so pituitary stops producing LH and FSH
How do we define infertility?
An inability to conceive after 12 months of regular unprotected intercourse
How do we define infertility?
An inability to conceive after 12 months of regular intercourse
In fertility investigations when would we check folliculr phase LH, FSH and luteal phase progesterone levels?
Day 2- LH and FSH
Day 21- progesterone
What advice can be given around natural management of menopause?
Exercise: running, swimming and yoga are recommended
Smoking cessation
Reducing alcohol and caffeine helps with hot flushes and night sweats
Mediterranean diet
What medications are available to management menopausal symptoms?
HRT- combined, oestrogen only, sequential and cyclical
SSRIs for mood and hot flushes
Clonidine, gabapentin used for hot flushes
Vaginal oestrogen creams and lubricants for dryness
