Gynaecology Flashcards
Definition primary amenorrhoea
Failure to establish menstruation by;
- 15 if normal secondary sexual characteristics
- 13 if no secondary sexual characteristics
Definition secondary amenorrhoea
Cessation of menstrual for;
- 3-6 months in women with previously normal mensus
- 6-12 months in women with oligomenorrhoea
Causes primary amenorrhoea
- Gonadal dysgenesis
- Testicular feminisation
- Congenital malformations of the genital tract
- Functional hypothalamic amenorrhoea
- Imperforate hymen
Causes secondary amenorrhoea
- Hypothalamic amenorrhoea
- PCOS
- Hyperprolactinaemia
- Premature ovarian failure
- Thyrotoxicosis
- Sheehan’s syndrome
- Asherman’s syndrome
Cause functional hypothalamic amenorrhoea
Anorexia
Cause hypothalamic amenorrhoea
Secondary stress
Excessive exercise
What is Asherman’s syndrome
Intrauterine adhesions
Initial investigations primary amenorrhoea
- Exclude pregnancy
- FBC, U&E
- Coeliac screen
- TFTs
- Gonadotrophins
- Prolactin
- Androgen
- Oestradiol
Interpretation gonadotrophins in amenorrhoea
Low levels = hypothalamic cause
Raised levels = ovarian problem
Cause of amenorrhoea with raised androgen levels
PCOS
When is HRT useful in primary amenorrhoea
With primary ovarian insufficiency due to gonadal dysgenesis, e.g. Turners - prevents osteoporosis
What is androgen insensitivity syndrome
End-organ resistance to testosterone causing genotypically male children to have female phenotype
Inheritance androgen insensitivity syndrome
X-linked recessive
Features androgen insensitivity syndrome
Primary amenorrhoea
Little or no axillary and pubic hair
Undescended testes causing groin swellings
Diagnosis androgen insensitivity syndrome
Buccal smear or chromosomal analysis to reveal 46XY genotype
Testosterone levels in androgen insensitivity syndrome
After puberty, high-normal to slightly elevated for reference range for postpubertal boys
Management androgen insensitivity syndrome
- Counselling - raise child as female
- Bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
- Oestrogen therapy
Presentation atrophic vaginitis
- Vaginal dryness
- Dyspareunia
- Occasional spotting
First line treatment atrophic vaginitis
Vaginal lubricants and moisturisers
Second line treatment atrophic vaginitis
Topical oestrogen cream
Most common type of cervical cancer
Squamous cell
Symptoms cervical cancer
- Abnormal vaginal bleeding - postcoital, intermenstrual, postmenopausal
- Vaginal discharge
What serotypes HPV highest risk for cervical cancer
16, 18, 33
Other risk factors cervical cancer
- Smoking
- HIV
- Early first intercourse, many sexual partners
- High parity
- Lower socioeconomic status
- COCP
What kind of cervical cancer often not detected by screening
Adenocarcinoma
Screening age and frequency cervical cancer
25-49 - 3 yearly
50-64 - 5 yearly
In Scotland, 25-64 every 5 years
Can women over 65 be screened for cervical cancer?
No
Cervical screening in pregnancy
Usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
Cervical screening if never sexually active
Very low risk, so may wish to opt out of screening
Management cervical screening if negative HPV
Return to normal recall
Management cervical screening with positive HPV with abnormal cytology
Colposcopy
Management cervical screening with positive HPV and normal cytology
Repeat in 12 months
Management cervical screening - first repeat test after positive HPV and normal cytology
If now HPV negative, return to normal recall
If still HPV +ve and cytology still normal - repeat test 12 months later
Management cervical screening - second repeat test after positive HPV and normal cytology
If negative - return to normal recall
If positive - colposcopy
Management cervical screening if sample inadequate
Repeat sample in 3 months
If 2 consecutive inadequate samples - colposcopy
Follow up patients treated for CIN
Screen 6 months after treatment - test of cure
Treatment CIN
Large loop excision of transformation zone
Cause delayed puberty with short stature
Turner’s syndrome
Prader-Willi syndrome
Noonans syndrome
Cause delayed puberty with normal stature
Polycystic ovarian syndrome
Androgen insensitivity
Kallmans syndrome
Klinefelters syndrome
What is primary dysmenorrhoea
Painful periods with no underlying pelvic pathology
Features primary dysmenorrhoea
- Pain typically starts just before or within few hours of period starting
- Suprapubic cramping, may radiate to back or down thigh
First line management dysmenorrhoea
NSAIDs, e.g. mefenamic acid, ibuprofen
Second line management dysmenorrhoea
COCP
When does primary dysmenorrhoea usually develop
Within 1-2 years of menarche
When does secondary dysmenorrhoea develop
Many years after menarche
When does the pain start secondary dysmenorrhoea
3-4 days before the onset of period
Causes secondary dysmenorrhoea
- Endometriosis
- Adenomyosis
- PID
- Copper coil
- Fibroids
Management secondary dysmenorrhoea
Refer gynae for investigation
Features ectopic pregnancy
- 6-8 weeks amenorrhoea
- Lower abdominal pain - usually constant, may be unilateral
- Vaginal bleeding - usually less than normal period, may be dark brown
- Dizziness, fainting, or syncope
Features of peritoneal bleeding in ectopic pregnancy
- Shoulder tip pain
- Pain on defecation/urination
Abdominal findings ectopic pregnancy
Abnormal tenderness
Cervical excitation
What suggests an ectopic pregnancy in pregnancy of unknown location
Serum bHCG >1500R
Risk factors ectopic pregnancy
- Damage to tubes, e.g. PID, surgery
- Previous ectopic
- Endometriosis
- IUCD
- Progesterone only pill
- IVF
Investigation of choice ectopic pregnancy
Transvaginal USS
What happens in expectant management ectopic pregnancy
Close monitoring over 48 hours - if hCG rise or symptoms manifest, intervention
Criteria for expectant management ectopic pregnancy
- Size <35mm
- Unruptured
- Asymptomatic
- No fetal heartbeat
- hCG <1,000
Criteria medical management ectopic pregnancy
Size <35mm
Unruptured
No significant pain
No fetal heartbeat
hCG <1,5000
Willing to attend FU
Indications surgical management ectopic pregnancy
- Size <35mm
- Ruptured
- Pain
- hCG >5000
What management options for ectopic pregnancy are compatible with another intrauterine pregnancy
Expectant or surgical
First line surgical option ectopic pregnancy
Salpingectomy
When to consider salpingotomy ectopic pregnancy
Risk factors for infertility, e.g. contralateral tube damage
Limitation of salpingotomy
1/5 patients need further treatment (methotrexate +/- salpingectomy)
Risk factors endometrial cancer
- Excess oestrogen (nulliparity, early menarche, late menopause), unopposed oestrogen
- Metabolic syndrome - obesity, diabetes, PCOS
- Tamoxifen
- Hereditary non-polyposis colorectal cancer
Protective factors endometrial cancer
- Multiparity
- COCP
- Smoking
Features endometrial cancer
- Bleeding - postmenopausal, menorrhagia, intermenstrual bleeding
- Pain uncommon (signifies extensive disease), vaginal discharge unusual
Referral endometrial cancer
All women ≥55 with postmenopausal bleeding
First line investigation endometrial cancer
Transvaginal ultrasound - normal endometrial thickness (<4mm) has high neg predictive value
Investigation if USS suspicious endometrial cancer
Hysteroscopy with endometrial biopsy
First line management endometrial cancer
Surgery
Localised disease - total abdo hysterectomy with bilateral salpingo-oophrectomy
High risk - post-op radiotherapy
Treatment endometrial cancer in women not suitable for surgery
Progesterone therapy
Features endometriosis
Chronic pelvic pain
Secondary dysmenorrhoea
Deep dyspareunia
Subfertility
Urinary symptoms - dysuria, urgency, haematuria
Dyschezia
Pelvic examination findings endometriosis
Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometriotic lesions
Investigation endometriosis
Laparoscopy
First line treatment endometriosis
NSAIDs and/or paracetamol
Second line treatment endometriosis
COCP or progestogens, e.g. medoxyprogesterone acetate
Referral endometriosis
- Diagnostic uncertainty
- Failure of second line management
- If fertility a priority
Secondary care treatments endometriosis
- GnRH analogues
- Surgery
SEs GnRH analogues in endometriosis
Induce a ‘pseudomenopause’ due to due oestrogen levels
Management endometriosis if trying to conceive
Laparoscopic excision or ablation of endometriosis plus adhesiolysis
Ovarian cystectomy
Definition menorrhagia
Total blood loss >80ml/menses
Menorrhagia causes
- Dysfunctional uterine bleeding (no underlying pathology)
- Anovulatory cycles
- Uterine fibroids
- Hypothyroidism
- Copper coil
- PID
- Bleeding disorders, e.g. VWD
Indications for transvaginal ultrasound scan in menorrhagia
Symptoms suggesting structural or histological abnormality:
- Intermenstrual or postcoital bleeding
- Pelvic pain
- Pressure symptoms
Abnormal pelvic exam findings
First line treatment menorrhagia if contraception not required
Mefanamic acid 500mg TDS (esp if dysmenorrhea as well), or tranexamic acid 1g TDS started on first day of period
Second line treatment menorrhagia if contraception not required
Try the other drug whilst awaiting referral
First line treatment menorrhagia when contraception required
Mirena
Other treatment options menorrhagia when contraception required
COCP
Long-acting progestogens
Short term option for rapid treatment of heavy menstrual bleeding
Norethisterone 5mg
SEs HRT
Nausea
Breast tenderness
Fluid retention and weight gain
What conditions does HRT increase the risk of
- Breast cancer
- Endometrial cancer
- VTE
- Stroke
- IHD
Effect of addition of progesterone to HRT of risk of cancer
Increases risk of breast cancer
Decreases risk of endometrial cancer
How breast cancer risk is affect by time taking HRT
Increased risk with increased duration of use
Risk begins to decline when HRT stopped, by 5 years is same as woman who has never taken HRT
Effect of addition of progesterone to HRT to risk of VTE
Increases risk
Which route of administration of HRT does not increase risk of VTE
Transdermal
Management HRT in women at high risk of VTE
Should be referred to haematology (even for transdermal)
When does HRT increase risk of IHD
If taken more than 10 years after menopause
Risk factors hyperemesis gravidarum
- Increases beta-hCG - multiple pregnancy, trophoblastic disease
- Nulliparity
- Obesity
- Family or personal history of NVP
When to admit hyperem
- Continued N&V and unable to keep down liquids or oral anti-emetics
- Continued N&V with ketonuria and/or weight loss, despite treatment with oral antiemetics
- Confirmed or suspected co-morbidity
Lower threshold for admission if woman has co-existing condition, e.g. diabetes, that may be affected by N&V
Diagnostic criteria hyperm
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
First line management hyperem
- Anti histamines - oral cyclizine or promethazine
- Phenothiazines - oral prochlorperazine or chlorpromazine
Second line management hyperem
- Oral ondansetron
- Oral metoclopramide or domperidone
Limitation of ondansetron hyperem
When used during first trimester associated with a small increased risk of cleft lip/palate - need to counsel
Limitation metoclopramide hyperem
Can cause extrapyramidal side effects, so should not be used for more than 5 days
Complications hyperem
- Dehydration
- Weight loss
- Electrolyte imbalance
- AKI
- Wernicke’s encephalopathy
- Oesophagitis, Mallory-Weiss tear
- VTE
Basic investigations infertility
Semen analysis
Serum progesterone 7 days prior to expected period (day 21 on type cycle)
Interpretation on serum D21 progesterone
<16 - repeat, if consistently low refer to specialist
16-30 - repeat
>30 - ovulation
How long after last period to use contraception?
12 months if >50
24 months if <50L
Lifestyle modifications to manage hot flushes in menopause
Regular exercise
Weight loss
Reduce stress
Lifestyle modifications to manage sleep disturbance in menopause
Avoiding late evening exercise
Maintaining good sleep hygiene
Lifestyle modifications to manage mood changes in menopause
Sleep
Regular exercise
Relaxation
Lifestyle modifications to manage cognitive symptoms in menopause
Regular exercise
Good sleep hygiene
Contraindications HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Non-HRT management of vasomotor menopausal symptoms
Fluoxetine, citalopram, or venlafaxine
Non-HRT management of vaginal dryness in menopause
Vaginal lubricant or moisturiser
Non-HRT management of psychological symptoms of menopause
Self-help groups
CBT
Antidepressants
Treatment urogenital atrophy
Vaginal oestrogen
How long to continue HRT for vasomotor symptoms
2-5 years (with regular attempts to stop)
Indications for referral to secondary care in menopause management
- Ineffective treatment
- Ongoing SEs
- Unexplained bleeding
Menstrual phase days
1-4
Follicular phase days
5-13
Ovulation phase days
14
Luteal phase days
15-28
Histological changes during follicular phase
A number of follicles develop, one follicle becomes dominant around mid-follicular phase
Proliferation of endometrium
Hormones in follicular phase
Rise in FSH → rise in oestradiol → rise in LH → ovulation
Cervical mucus in follicular phase
Following menstruation, mucus is thick - forms plug across os
Just prior to ovulation, mucus becomes clear, acellular, low viscosity, stretchy
Basal body temp in follicular phase
Falls prior to ovulation due to influence of oestradiol
Histological changes luteal phase
Corpus luteum forms in ovaries
Endometrium changes to secretory lining
Hormones in luteal phase
Progesterone secreted by corpus luteum - rises through luteal phase
If fertilisation doesn’t occur, corpus luteum degenerates → fall in progesterone
Oestradiol levels rise during luteal phase
Cervical mucus in luteal phase
Thick, scant, tacky
Basal body temp in luteal phase
Rises following ovulation
Features threatened miscarriage
Painless vaginal bleeding - often less then menstruation
Cervical os closed
Features missed miscarriage
Gestational sac containing dead fetus
May have light vaginal bleeding/discharge, symptoms of pregnancy disappear
Not usually pain
Cervical os closed
What is blighted ovum/anembryonic pregnancy
When gestational sac >25mm and no embryonic/fetal part seen
Features inevitable miscarriage
Heavy bleeding with clots and pain
Cervical os open
Features incomplete miscarriage
Not all products of conception expelled
Pain and vaginal bleeding
Cervical os open
First line treatment miscarriage
Expectant management (wait for spontaneous miscarriage)
How long do you wait in expectant management for miscarriage
7-14 days
When is expectant management of miscarriage not appropriate
- Increased risk of haemorrhage, e.g. late in first trimester, coagulopathies, unable to have transfusion
- Previous adverse and/or traumatic experience with pregnancy, e.g. stillbirth, miscarriage, antepartum haemorrhage
- Evidence of infection
Medical management missed miscarriage
Oral mifepristone
48 hours later - vaginal, oral, or sublingual misoprostol (unless gestational sac already passed)
Safety netting medical management missed miscarriage
If bleeding not started within 48 hours of misoprostol, contact their healthcare professional
Medical management incomplete miscarriage
Single dose of oral, vaginal, or SL misoprostol
Follow up medical management of miscarriage
Pregnancy test after 3 weeks
Options for surgical management miscarriage
- Vacuum aspiration
- Surgical management in theatre
Presentation mittelschmerz
Sudden onset pain in eihter iliac fossa → generalised pelvic pain
Not severe, varies in duration - minutes to hours
Self limiting, resolves within 24 hours of onset
Most common type of ovarian cancer
Serous carcinoma
Risk factors ovarian cancer
BRCA1/2 mutations
Many ovulations - early menarche, late menopause, nulliparity
Clinical features ovarian cancer
- Abdominal distention and bloating
- Abdominal and pelvic pain
- Urinary symptoms, e.g. urgency
- Early satiety
- Diarrhoea
Initial investigation ovarian cancer
CA125
Other causes of raised CA125
- Endometriosis
- Menstruation
- Benign ovarian cysts
Management raised CA125
Urgent ultrasound of abdomen/pelvis
Definitive diagnosis ovarian cancer
Diagnostic lap
Management ovarian cancer
Combination of surgery and platinum based chemo
Types of physiological ovarian cysts
- Follicular (most common)
- Corpus luteum
Most common type of ovarian tumour in women under 30
Dermoid cyst (mature cystic teratoma)
Presentation dermoid cyst
Usually asymptomatic
Torsion more likely than other ovarin tumours
Types of benign epithelial tumours of ovary
- Serous cystadenoma
- Mucinous cystadenoma
Feature mucinous cystadenoma
Typically large, may become massive
Complication mucinous cystadenoma
If ruptures may cayse pseudomycoma peritoni
Features suggesting benign ovarian cyst on USS
- Small (<5cm)
- Simple (unilocular)
Management ovarian enlargement on USS in premenopausal women
If appears benign on ultrasound:
Repeat USS 8-12 weeks
Referral if persists
Management ovarian enlargement on USS in postmenopausal women
Refer all to gynae for assessment
Infertility treatments with highest risk ovarian hyperstimulation syndrome
Gonadotropin or hCG treatment
Features mild ovarian hyperstimulation syndrome
Abdominal pain
Abdominal bloating
Features moderate ovarian hyperstimulation syndrome
Abdominal pain
Abdominal bloating
Nausea and vomiting
Ultrasound evidence of ascites
Features severe ovarian hyperstimulation
Abdominal pain and bloating, N&V
Clinical evidence of ascites
Haematocrit >45%
Hypoproteinaemia
Features critical ovarian hyperstimulation syndrome
Abdominal pain and bloating, N&V
Clinical evidence of ascites
Haematocrit >45%
Hypoproteinaemia
Thromboembolism
ARDS
Anuria
Tense ascites
Most common organism PID
Chlamydia trachomatis
Other organisms PID
Neisseria gonorrhoae
Mycoplasma genitalium
Mycoplasma hominis
Features PID
- Lower abdominal pain
- Fever
- Deep dyspareunia
- Dysuria and menstrual irregularities
- Vaginal or cervical discharge
- Cervical excitation
First line treatment PID
Stat IM ceftriaxone + 14 days PO doxy + PO metronidazole
Second line treatment PID
PO ofloxacin and PO metronidazole
Management PID with intrauterine devices
Consider removal
Complications PID
Perihepatitis (Fitz-Hugh Curtis syndrome)
Infertility
Chronic pelvic pain
Ectopic pregnancy
Presentation ovarian torsion
Sudden onset unilateral lower abdominal pain
Onset may coincide with exercise
N&V common
Unilateral, tender adnexal mass on examination
Features PCOS
- Subfertility and infertility
- Menstrual disturbances - oligomenorrhoea and amenorrhoea
- Hirsuitism, acne
- Obesity
- Acanthosis nigricans
Hormonal investigations PCOS
Raised LH:FSH ratio
Prolactin normal or mildly elevated
Testosterone normal or mildly elevated
SHBG normal to low
Diagnostic criteria PCOS
Diagnose if 2 of 3 present:
- Infrequent or no ovulation
- Clinical and/or biochemical signs of hyperandrogenism
- Polycystic ovaries on USS - ≥12 follicles in one or both ovaries, and/or ovarian volume >10
First line treatment hirsuitism in PCOS
COCP - third gen has fewer androgenic effects, or co-cyprindiol has anti-androgen action
Second line treatment hisuitism in PCOS
Topical eflornithine
Specialist options for treatment of hirsuitism in PCOS
Spironolactone
Flutamide
Finasteride
Management infertility PCOS
Weight reduction if appropriate
Specialist management
Clomifene or metformin
Most common cause post-coital bleeding
Cervical ectropion
Other causes post-coital bleeding
Cervicitis
Cervical cancer
Polyps
Trauma
Definition premature ovarian insufficiency
Onset of menopausal symptoms and elevated gonadotrophin levels before 40 years
Most common cause premature ovarian insufficiency
Idiopathic
Other causes of premature ovarian insufficiency
Bilateral oophrectomy
Radiotherapy
Chemotherapy
Infection, e.g. mumps
Autoimmune disorders
Resistant ovary syndrome
Does hysterectomy with preservation of ovaries cause premature ovarian insufficiency
Yes
Cause resistant ovary syndrome
FSH receptor abnormalities
Hormone test findings resistant ovary syndrome
Raised FSH and LH levels
Low oestradiol
Management premature ovarian failure
HRT or COCP until average age of menopause (51y)
Management mild premenstrual syndrome
Lifestyle advice - frequent (2-3 hourly) small balanced meals rich in complex carbohydrates
Management moderate premenstrual syndrome
New generation COCP, e.g. Yasmin
Management severe premenstrual syndrome
SSRI - continuously or just during luteal phase (e.g. days 15-28)
Definition recurrent miscarriage
3 or more consecutive spontaneous miscarriages
Causes recurrent miscarriage
- Antiphospholipid syndrome
- Endocrine disorders - poorly controlled diabetes, thyroid disorder, PCOS
- Uterine abnormality, e.g. uterine septum
- Parental chromosomal abnormalities
- Smoking
Non-drug management of urge incontinence
Bladder retraining (minimum of 6 weeks)
Drug management of urge incontinence
Antimuscarinics - oxybutynin, tolterodine, darifenacin
Drug management of urine incontinence in frail elderly patients
Mirabegron
Avoid immediate release oxybutynin
Non-drug management of stress urinary incontinence
Pelvic floor muscle training
Surgical management stress incontinence
Retro mid-urethral tape
Drug management stress incontinence
Duloxetine
Used if surgery is declined
How can fibroids cause polycythaemia
Due to autonomous production of erythropoietin
Options for management of menorrhagia secondary to fibroids
- Levonorgestrel intrauterine system
- NSAIDs, e.g. mefenamic acid
- Tranexamic acid
- COCP
- Oral or injectable progestogen
Limitation of use of levonorgestrel intrauterine system for management of menorrhagia secondary to fibroids
Cannot be used if distortion of uterine cavity
Medical treatment to shrink fibroids
GnRH agonists
Limitation use GnRH agonists in treatment of fibroids
Usually short term due to side effects - menopausal symptoms, loss of bone mineral density
Surgical treatment fibroids
- Myomectomy
- Hysteroscopic endometrial ablation
- Hysterectomy
- Uterine artery embolisation
Presentation vaginal thrush
- Cottage cheese non offensive discharge
- Vulvitis - superficial dyspareunia, dysuria
- Itch
- Vulval erythema, fissuring, satellite lesions
First line treatment vaginal thrush
Oral fluconazole 150mg single dose
Treatment thrush if oral contraindicated
Clotrimazole 500mg intravaginal pessary as single dose
Treatment thrush if vulval symptoms
Topical imidazole
Management vaginal thrush in pregnancy
Only local treatments - oral treatments contraindicated
Definition recurrent vaginal candidasis
4 or more episodes per year
Management recurrent vaginal candidiasis
- Check compliance with treatment
- Confirm diagnosis - HVS for microscopy and culture
- Consider blood glucose to exclude diabetes
- Consider use of induction-maintenance regime
Induction maintenance regime for recurrent vaginal candidiasis
Induction - oral fluconazole every 3 days for 3 doses
Maintenance - oral fluconazole weekly for 6 months
Features trichomonas
Offensive, yellow/green, frothy
Vulvovaginitis
Strawberry cervix
Features discharge BV
Offensive
Thin
White/grey
Fishy
Risk factors vulval carcinoma
HPV infection
Vulval intraepithelial neoplasia
Immunosuppression
Lichen sclerosus
Features vulval carcinoma
Lump or ulcer on labia majora
Inguinal lymphadenopathy
Itching, irritation
