Gynaecology Flashcards
2 systemic disorders causing Menorrhagia
Hypothyroidism
Clotting disorders
Local pathology causing menorrhagia
Fibroids Polyps Endometrial carcinoma Endometriosis Pelvic inflammatory disease Dysfunctional uterine bleeding (diagnosis of exclusion)
Iatrogenic cause of menorrhagia
Copper IUD
Important red flag questions in menorrhagia
Intermenstrual bleeding
Post coital bleeding
How to subjectively assess abnormal uterine bleeding?
clots noctural soiling flooding wearing double sanitary protection interfear with work / social events
With AUB what condition to check they’re not suffering from as a result?
Anaemia - lethargy / breathlessness
Premenstrual dysmenorrhoea indicates?
endometriosis
How does PID present?
Fever
Pelvic pain
Dyspareunia
Vaginal discharge
What in the PMH could cause AUB?
PCOS
Thyroid disease
Clotting disorders
Contraceptive hx
What test should be performed in AUB in all women 45+
endometrial biospy
Two types of medical treatment for menorrhagia
Antifibrinolytics / haemostatics
Hormone therapy
Antifibrinolytic used in menorrhagia
Tranexamic acid
What is the risk with tranexamic acid?
Thrombosis
Other non hormone therapy used in menorrhagia
NSAIDS
Aspirin - prostaglandin inhibitor
What hormonal therapy is most useful for anovulatory menorrhagia?
Progestrogens
Hormonal therapies for menorrhagia
Porgestogens
IUS
COCP
Surgical treatments for menorrhagia
Hysterscopic ressection of interuterine pathology e.g. fibroids / endometrial polyps
Open myomectomy - fibroids
Endometrial ablation
Hysterectomy
Who is endometrial ablation not appropriate for?
women wishing to conceive
Complications of endometrial ablation
Uterine perforations
Fluid overload - non electrolyte sol. used in electrosurgery
Haemorrhage
Infection
Uterine fibroids are
benign tumour of the myometrium
What situation can cause fibroids to
- grow
- shrink
- pregnancy - hyperoestrogenic state
- menopause - hypo-oestrogenic state
what 3 things cause pain in women with fibroids?
degeneration of fibrois
associated pelvic varicosities
stretching of uterine ligaments
How can fibroids cause subfertility?
press on the cornual region of the fallopian tube
submucosal fibroids are hormonally active - may affect implantation and cause miscarriage
where may fibroids put pressure on
bladder - urinary symptoms
rectum - abdo bloating
4 types of fibroid
submucous
intramural
subserous
pedunculated
Risk factors for fibroids
Afro-caribbean women
Increasing age
Nulligravidity
Obesity
Protective factors from fibroids?
Smoking
Use of COCP
Full term pregnancy
Gynaecological complications of fibroids?
Degeneration
Torsion if pedunculated
Malignancy - v small risk of leimyosarcoma
How can fibroids effect pregnancy?
Infertility
Obstructed labour
Risk of PPH
First line imaging investigation for fibroids?
USS
Gold standard imaging for fibroids?
MR
3 indications for treating fibroids?
Symptomatic
Rapidly enlarging
Cause infertility
Adjunct to surgery for fibroids?
GnRH analogues - reversible, temporary, chemical menopause
Surgical options for fibroids
Transcervical resection - hysteroscopy - submucous fibroids
Myomectomy - open / closed
Hysterectomy
New treatment option for fibroids?
Uterine artery embolism
- less invasive than surgery
- radiological embolisation of fibroids
- catheter inserted into femoral artery
- inject microbeads into arteries supplying fibroids (thrombosis and fibroid infarction)
- complications - infection, pain, failed treatment, does not preserve fertility
4 important aspects of an early pregnancy complication hx?
LMP
Last cervical smear
Bleeding / discharge
Pain
Risk factors for ectopic pregnancy?
PID Tubal surgery Peritonitis / pelvic surgery Endometriosis IUCD in situ IVF pregnancy
What is cervical shock?
How does it present?
vagal response to dilation caused by products of conception distending the cervical canal
Pulse and BP would both be low
Signs of haemorrhage due to ectopic
Pulse weak and tachycardic
Reduced BP
Pt pale, sweaty, unwell and may collapse
Miscarriage abdo exam
Abdo soft and >12 weeks then uterus may be palpable
Ectopic pregnancy abdo exam
Uterus not palpable
Tenderness on the affected side
May be some guarding and rebound tenderness
ruptured ectopic pregnancy abdo exam
Entire abdomen tense, tender with guarding and rebound tenderness
What is an ectropian?
Columnar epithelium present in the vaginal portion of the cervix
Not pathological
Bleeds easily
Common in pregnancy due to oestrogen changes
Bleeds more if irritated e.g. due to infection
take swabs and treat infection
Threatened miscarriage =
bleeding occurring before 24 weeks
cervix closed on examination
Inevitable miscarriage =
bleeding before 24 weeks
cervix is OPEN on examination
Missed / delayed / silent miscarriage =
scan shows no viable fetus / empty intrauterine sac
Cervix closed on exam
Patient may not have any bleeding
Complete miscarriage =
no products of conception on scan
patient has had bleeding
cervix closed on exam
Incomplete miscarriage =
scan shows products of conception left in the uterus
patient has had bleeding
cervix is open on exam
Contributing factors to miscarriage
Fetal abnormality Infection Maternal age Abnormal uterine cavity Maternal illness Intervention e.g. amniocentesis and CVS
Surgical management of miscarriage -
Evacuation of retained products of conception
Complication of ERPC
Endometritis
Endometritis presentation =
fever, malaise, lower abdo pain, change in vaginal bleeding
Up to what week can watch and wait management be given for miscarriage
13
If it's not clear whether a patient had an ectopic pregnancy what test should be done? What results would be expected - viable pregnancy - miscarriage - ectopic
Beta HCG test 48hrs apart
- doubled
- significantly reduced
- increased or stayed the same but not doubled
Two surgical options for ectopic pregnancy
Salpingectomy - especially if ruptured
Salpingotomy
Medical treatment for tubal ectopic
Methotrexate, IM 50mg/m2
What needs to be discussed with the mother who has an ectopic pregnancy ?
respectful disposal of fetal tissue
Criteria for expectant management of ectopic preg
minimal symptoms
patient stable
low / falling hCG
Mass <4cm on USS
Criteria for medical management ectopic preg
static / rising hCG
No contraindications to methotrexate
Advice about methotrexate
can’t get pregnant for 3m after
criteria for surgical management of ectopic pregnancy
patient clinically unstable hCG <5000 US mass >4cm failed medical treatment previous IVF/ ectopic
STI causes of vaginal discharge
Chlamydia
Trichomas vaginalis
Neisseria gonorrhoea
Non STI causes of vaginal discharge
Candida albicans
Bacterial vaginosis
inflammatory causes of vaginal discharge
atrophic changes
allergic reaction
post op granulation tissue
Malignant causes of vaginal discharge
Vulval carcinoma
Cervical carcinoma
Uterine carcinoma
Other causes of vaginal discharge
Foreign body
Fistula
Investigations if suspect infectious cause of vaginal discharge
microbiology swabs
MSU
Laprascopy - PID
Suspect malignant cause of vaginal discharge - investigations to carry out..
vulval biopsy cervical smear / biopsy pelvic uss endometrial sampling hysteroscopy
Endometriosis =
growth of endometrial tissue outside of the uterine cavity
clinical features of endometriosis
chronic pelvic pain
dysmenorrhoea
Deep dyspareunia
Subfertility
gold standard investigation for endometriosis
laparascopy
Medical management of endometriosis
What does it not achieve
NSAIDs Progestrogens COOP GnRH analouges Mirena coil
They do not improve subfertility
surgical options for endometriosis
Laporoscopic excision
Laser treatment of endometriotic ovarina cysts
When can a diagnosis of menopause be made
Women >50 y/o
Woemn < 50 y/o
12 m after LMP
24m after LMP
Contraindications to HRT
Undiagnosed PV bleeding Pregnancy Oestrogen dependent cancer Acute liver disease Uncontrolled HTN
History of breast cancer
VTE
Recent stroke / MI / angina
Long term benefits of HRT
reduced osteoporosis
reduce risk of coronary artery disease
Risks of HRT
VTN Stroke ovarian cancer if used 5+ yrs breast cancer endometrial cancer
Bacterial vaginosis treatment
oral metronidazole 5-7 days
Presentation of trichomonas vaginalis
frothy yellow / green discharge
offensive
vulvovaginitis
strawberry cervix
treatment for trichomonas vaginalis
metronidazole
presentation of candida infection
cottage cheese discharge vulvitis burning with urination pain with sex redness round the vagina
Risk factors for cervical cancer
HPV infection Early age of first intercourse high number of sexual partners lower socioeconomic group smoking partner with protatic / penile cancer
Symptomatic presentations of cervical cancer
intermenstrual bleeding
post coital bleeding
persistant vaginal discharge
post menopausal bleeding
Management of cervical smear with borderline changes / low grade dyskaryosis
Reflext HPV test
+ve - refer for colposcopy in 6 weeks
-ve - return to routine screening
High grade dyskaryosis / suspected cancer management t
refer to colposcopy within 2 weeks
treatment of cervical intraepithelial neoplasia
large loop excision
needle excision
core biopsy
ovarian hyperstimulation syndrome pathology
high oestrogen levels
vascular permeability
build up of fluid in the 3rd space
leads to intravascular fluid depletion
ovarian hyperstimulation syndrome severe presentation
N&V
Painful abdominal distension
fluid shift - ascites and pleural effusions
Risks with ovarian hyperstimulation syndrome
Hepatorenal failure
ARDS
increased risk of VTE
What is associated with PCOS
insulin resistance
metabolic syndrome
increased risk of T2D
Common features of PCOS
Hirsutism Acne Irregular / infrequent periods Weight gain Infertility Scalp hair loss
What can be found on examination with PCOS
Hirsutism
Sweating / oily skin
Acne
Acanthosis nigricans
Risk factors for endometrial cancer
Obesity
Tamoxifen
Early menarche / late menopause
Lynch syndrome
Most common feature of endometrial cancer presentation?
post menopausal bleeding
Ovarian cancer presentation
bloating abdo pain early satiety loss of appetite (>12 times in a month)
Main blood test in ovarian cancer?
Ca125
Imaging in ovarian cancer?
USS firstly
then MR/CT to stage
US - “snowstorm” description likely to be?
molar preg
How may vulval and vaginal carcinomas present?
itching / bleeding
lesions on that area
What drug is a risk factor for endometrial hyperplasia
tamoxifen
Most common cause of PID
Chlamydia
4 parts of a gynae history
Periods
Urology
Sexual hx
Questions about periods
Length Regular How much ? heavy Pain - when Bleed after sex Intermenstrual bleeding Smear hx
Urology questions in gynae
UTIs
Incontinence
Obstetric hx
How many children Types of deliveries Traumatic deliveries HTN Diabetes Terminations Miscarriages Ectopics
Sexual
CONTRACEPTION Pain Bleeding How many partners Any STIs
Medical hx in gynae
Clotting
Thyroid
PCOS
Red flag for endometrial cancer
Post menopausal bleeding
Cervical cancer red flag
Looks abnormal
1st line for menorrhagia
progesterone coil
HRT if no oestrogen
continuous oestrogen-only therapy is given
HRT if <1 yr since LMP and uterus
cyclical combined HRTW
When is continuous HRT used?
taken cyclical combined for at least 1 year or
it has been at least 1 year since their LMP or
it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)
Menopause definition
Absence of menses for 12 months
Menopause symptoms
Amenorrhoea / irregular cycles Hot flushes Night sweats Vaginal symptoms Mood changes Sleep disturbance
Tests when suspect menopause
Pregnancy test
FSH
Serum estradiol
Initial treatment of menopause
Lifestyle changes
- loose weight
- exercise more
- avoid caffeine / alcohol
Treatment of menopause symptoms in women with uterus
Amenorrhoea >12 m
Continuous combined regimen - oestrogen & progestin
oral / patch
In women with high thrombotic risk, which type of oestrogen is preferred to treat menopause?
Transdermal
1st line Treatment of menopause symptoms in women without a uterus / progesterone coil inserted in last 5 years
Oestrogen alone
Treatment of menopause symptoms in women with uterus with menstural irregularity and periods of irregularity
Sequential regimen
2nd line Treatment of menopause symptoms in women without a uterus / progesterone coil inserted in last 5 years
SSRI
Treatment of reduced libido
Oestrogen and androgen combined
Treatment for urogenital atrophy only
Vaginal oestrogen +/- vaginal moisturiser
Classification of dysmenorrhoea
Primary - absence of pelvic pathology
Secondary
Common causes of secondary dysmenorrhoea
Endometriosis
Chronic PID
Fibroids
Polyps
When does primary dysmenorrhoea usually start
6-12m after onset
Investigations in dysmenorrhoea
Preg test
Swabs
Clotting, FBC, CRP
Ultrasound (usually TV)
Menorrhagia definition
excess volume and or duration of menstrual bleeding
People with which condition need annual cervical smear screening?
HIV +ve
menopause treatment - 3 categories
life style
hormone replacement
non hormone replacement
lifestyle modifications in menopause
Hot flushes
regular exercise, weight loss and reduce stress
Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene
Mood
sleep, regular exercise and relaxation
Cognitive symptoms
regular exercise and good sleep hygiene
contraindications to HRT
Contraindications: Current or past breast cancer Any oestrogen-sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia
How long do the symptoms of menopause usually last?
2-5 years
Risks with HRT
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined
HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.
Management without HRT in menopause
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
