GYNAECOLOGY Flashcards
What are fibroids?
BENIGN tumours of the myometrium
When are fibroids more common?
Around the menopause (regress after) and HRT can feed growth
When are fibroids less common?
If parous, if been on the combined pill
What are the 3 types of fibroids?
Intramural, subserosal, submucosal
What is fibroid growth dependent on?
Oestrogen and progesterone which is why they regress after menopause due to less circulating oestrogen (unless on HRT)
5 symptoms of fibroids?
50% asymptomatic. MENORRHAGIA DYSMENORRHOEA INTERMENSTRUAL loss URINARY symptoms if large SUBFERTILITY if tubes blocked or implantation failed
On examination of fibroids…
Solid palpable mass, either one mass continuous with uterus or several small masses
4 gynaecological risks/complications of fibroids
CALCIFY
TORT
DEGENERATE and cause pain/haemorrhage
0.1% malignant
4 obstetric risks/complications of fibroids
Premature labour
Malpresentation
Obstruction
Post partum haemorrhage
Investigations for fibroids (3/4)
Ultrasound, MRI
Laparoscopy
Possible hysteroscopy
4 medical treatments of fibroids (if large/symptomatic)
Tranexamic acis
NSAIDs
Progestens i.e. Mirena coil
GnRH agonists in short courses if not conceiving
4 surgical treatments of fibroids (if large/symptomatic)
Hysteroscopic surgery with presurgical GnRH agonists
Open/laparoscopic myomectomy
Hysterectomy
Artery embolisation/uterine ablation
When is endometrial cancer most common?
Age 60, 15% are premenopausal
What is the most common type of endometrial cancer
Adenocarcinoma of columnar endometrial gland cells
6 risk factors for endometrial cancer
High OESTROGEN production Oestrogens used unopposed by progestogens Obesity PCOS Nulliparity Late menopause Tamoxifen
2 protective factors for endometrial cancer
Combined oral contraceptive pill
Pregnancy
What premalignant disease occurs before endometrial cancer
Endometrial hyperplasia with atypia
4 symptoms of endometrial cancer
Postmenopausal bleeding
If premenopausal - irregular bleeding
Abdominal pain
Dyspareunia
Where does endometrial cancer spread (3) including lymph (2)
Cervix, upper vagina, ovaries
Pelvic and para aortic lymph nodes
Investigations for endometrial cancer (3)
Ultrasound
Pipelle endometrial biopsy
Hysteroscopy
Treatment for endometrial cancer (3)
Hysterectomy and bilateral sapingoopherectomy
Staged after hysterectomy, if high risk radiotherapy for lymph nodes
Chemo if advanced
5 types of ovarian malignancy
Epithelial tumours (50% Adenocarcinoma, 25% Endometrioid carcinoma, 10% Clear cell carcinoma)
Germ cell tumours i.e. teratoma
Sex cord stromal tumours
Define X cancer
A malignant neoplasm arising from the tissues of the X
When are epithelial ovarian tumours more common?
Postmenopausal women
May be borderline malignant first - surgical removal
When are germ cell tumours more common and what is the main type?
In younger women, progress more quickly and severely
Dysgerminoma most common type
What is a teratoma?
Type of germ cell tumour
Contains differentiated teeth and hair
If small, asymptomatic but if large rupture painful
What are the 4 most common primary cancers for ovarian metastases?
Breast
Stomach (Krukenberg tumour)
Bowel
Endometrial
Why does ovarian cancer present late?
Often silent and detected when they are very large and cause abdominal distension
Vague symptoms
Risk factors for ovarian cancer (4)
ANYTHING THAT INCREASES NO. OF OVULATIONS Early menarche Late menopause Nulliparity BRCA1/2, HNPCC genes
Protective factors for ovarian cancer (3)
Pregnancy
Lactation
COCP
Symptoms of ovarian cancer (6)
Abdominal distension Early satiety Increased urinary urgency/frequency Vaginal bleeding Altered bowel habit i.e. constipation Abdominal/pelvic pain
3 signs of ovarian cancer O/E
Abdominal/pelvic mass
Ascites
Cachexia
Investigations for ovarian cancer (4)
Ca125 if over 50 and symptomatic
If raised, USS
Alpha fetoprotein and beta hCG for germ tumours
CT for metastases
How is risk of ovarian cancer calculated
USS score, if menopausal and Ca125 levels
Treatment of ovarian cancer (4)
Laparotomy and total hysterectomy, bilateral salpingoopherectomy and partial omentectomy (if young preserve uterus and other ovary if possible)
Peritoneal and lymph node biopsies
Chemotherapy if advanced
Radiotherapy for germ cell tumours
Complications of ovarian cysts (3)
Rupture
Haemorrhage
Torsion
How are ovarian cysts detected?
If silent, on USS
If large, cause distension
Pain from complications
What is an endometriotic cyst? (endometrioma)
Caused by endometriosis leading to accumulation of blood in ‘chocolate’ cysts
What is a functional cyst?
Follicular cyst - persistently enlarged follicles
Lutein cyst - persistently enlarged corpus luteum
Only found before menopause
COCP protective as inhibits ovulation
Small chance of malignant change
What is endometriosis and where does it commonly occur?
The presence and growth of tissue similar to endometrium outside the uterus
Uterosacral ligaments and on the ovaries
When is endometriosis more common?
Age 30-45
If nulliparous
What is endometriosis dependent on?
Oestrogen - regresses in pregnancy and after menopause
Complications of endometriosis (4)
Inflammation
Progressive fibrosis
Adhesions
Rupture
What is a theory of endometriosis aetiology
Retrograde menstruation - when menstruating some tissue goes up and escapes through fallopian tubes then spreads
Individual factors determine if it grows
Symptoms of endometriosis (5)
Often absent Chronic, cyclical pelvic pain Dysmenorrhoea Deep dyspareunia Subfertility Dyschezia during menses Cyclical haematuria/rectal bleeding if severe
Signs on examination of endometriosis (3)
Tenderness/thickening behind uterus or in adnexa
Advanced - retroverted uterus
Advanced - Immobile rectovaginal nodule
Investigations for endometriosis (4)
Bloods for anaemia, hormones
Laparoscopy with biopsy
TV USS if ?ovarian endometrioma
MRI if ?extensive spread
Treatment of symptomatic endometriosis
Pain relief - NSAIDs, opiates
Medical - GnRH analogues, COCP, progestogens
Surgical - diathermy resection, remove adhesions, remove endometriomas
Last resort hysterectomy and bilateral salpingoopherectomy
What is an ectopic pregnancy?
When the embryo implants outside the uterus, most commonly in the fallopian tube in the ampulla
These sites are not able to sustain trophoblast invasion so bleeding or rupture can occur
Risk factors for ectopic pregnancy (8)
Older age Low socioeconomic class Factors damaging the tubes - Pelvic inflammatory disease Assisted conception Pelvic surgery especially tubal Previous ectopic Smoking Copper IUD (as only prevents uterine pregnancy)
Symptoms of ectopic pregnancy (5)
Abnormal PV bleeding Pain in lower abdomen Collapse Shoulder tip pain Amenorrhoea 4-10 weeks
On examination signs of ectopic pregnancy (6)
Hypotension Tachycardia Rebound tenderness of abdomen Cervical excitation causes pain Adnexal tenderness Closed cervical os and smaller uterus than expected for gestation
Investigation of ectopic pregnancy (4)
Urine hCG pregnancy test
TV USS detects uterine pregnancies over 5 weeks
Serum hCG - declining or slower rising (<50% in 48hr) suggests not intrauterine
Laparoscopy gold standard
3 types of management of ectopic pregnancy and when indicated
Conservative observation if small, unlikely to rupture
Medical if clinically stable, unruptured with no fetal cardiac activity and <3000 hCG
Surgical if haemodynamically unstable or severe symptoms
What is medical management of ectopic pregnancy
Single dose methotrexate
Monitor hCG
Second dose or surgery may be needed
What is surgical management of ectopic pregnancy
Laparoscopy/laparotomy gold standard
Salpingectomy to remove tube
Salpingostomy just to remove ectopic (increased risk for RPC and future ectopic but preserves fertility if other tube damaged)
Define miscarriage
When the foetus dies or delivers dead before 24 completed weeks of gestation (majority before 12), occurring in around 20% of pregnancies
What causes miscarriage
Increased maternal age
Isolated chromosomal abnormalities (>60%)
If recurrent, may be from genetic abnormality, anatomical problem, antiphospholipid antibodies, infection, smoking, PCOS
Name 6 types of miscarriage
Threatened miscarriage (25% miscarry) Inevitable miscarriage Incomplete miscarriage Complete miscarriage Septic miscarriage Missed miscarriage
Describe threatened miscarriage
Bleeding
Foetus alive
Uterus expected size
Cervical os closed
Describe inevitable miscarriage
Miscarriage that is about to occur.
Heavy bleeding
Foetus may be alive, but will die
Cervical os open
Describe incomplete miscarriage
Heavy bleeding
Some foetal tissue passed, some retained
Cervical os open
Describe complete miscarriage
All foetal tissue passed
Bleeding diminished or stopped
Uterus small
Os closed
Describe septic miscarriage
Uterus infected causing endometritis
Offensive vaginal loss
Tender uterus
Possible abdominal pain, peritonism, fever
Describe missed miscarriage
Foetus did not develop or died in utero
Not recognised until bleeding, or USS
Uterus smaller than expected
Os closed
2 general symptoms of miscarriage
Bleeding
Pain from contractions
Investigations of miscarriage (3)
USS
Blood hCG levels (increasing <66%/48hr if viable intrauterine)
Rhesus group bloods
General management of miscarriage (5)
Admit if suspected ectopic, sepsis, heavy bleeding
Removal of products in the os
IM ergometrine to contract uterus and stop bleeding if non viable
IV ABx if infected
Anti-D if rhesus -ve
Expectant management of miscarriage is…
successful in 80% within 2-6 weeks if incomplete, lower if missed
Medical management of miscarriage
Prostaglandin misoprostol (possibly with progesterone mifepristone before) successful in >80% if incomplete, lower if missed
Surgical management of miscarriage
Evacuation of retained products of conception under GA with vacuum aspiration
>95% successful
What is CIN?
Cervical intraepithelial neoplasia (cervical dysplasia)
Premalignant condition of the cervix where atypical cells are found in the squamous epithelium
Can be mild I moderate II or severe III
Significance of CIN to cervical cancer
Dyskaryotic, frequently mitosing cells
Malignancy ensues if severe dysplasia
1/3 of CIN II/III will develop cancer in 10 years if untreated
Cause of CIN?
Risk factors
Cause - Human papilloma virus RFs - Number of sexual encounters COCP Smoking Immunocompromise
What is the cervical screening programme
Vaccine for teenage girls
Cervical smears from 25-49 every 3 years then every 5 years from 49-64
If CIN II/III present, excise transformation zone with diathermy (LLETZ) and take biopsy for cancer
What are the two types of cervical cancer
90% squamous cell carcinomas
10% columnar cell adenocarcinomas
What are the two peaks of incidence of cervical cancer
30s and 80s
Most present between 25-49
What is the cause of cervical cancer
Same as CIN - HPV found in all cases
Symptoms of cervical cancer (3)
Postcoital bleeding
Offensive vaginal discharge
Postmenopausal or intermenstrual bleeding
Give 3 late stage symptoms of cervical cancer
Uraemia
Haematuria
Rectal pain and bleeding
Sign on examination of cervical cancer
Palpable mass or ulcer on cervix
Investigations of cervical cancer (4)
Biopsy
Examination under anaesthetic
Cystoscopy if ?bladder involvement
MRI for staging and spread
Management of cervical cancer
Stage 1a - cone biopsy/LLETZ, hysteroscopy if older
Stage 1/2a - if negative nodes, hysterectomy and node clearance
If positive nodes chemoradiotherapy
If negative nodes and want to reserve fertility, trachelectomy - removes most of cervix and upper vagina and reinforces internal os with stitches
Severe or if older, unfit for surgery - radio and chemotherapy even if nodes negative
Types of vaginal carcinoma
Primary squamous cell carcinoma - quite rare
Secondary common from cervix, uterus, vulva
Symptoms of vaginal carcinoma (3)
Bleeding
Discharge
Mass/ulcer
Treatment of vaginal carcinoma
Radiotherapy
Possible surgery
What is the premalignant disease to vulval carcinoma?
Vulval intraepithelial neoplasia
What is the most common type of vulval carcinoma
Squamous cell carcinoma
Risk factors of vulval carcinoma (5)
Lichen sclerosis Smoking Age Immunosuppression Paget's disease of vulva
Symptoms of vulval carcinoma (4)
Itching
Bleeding
Discharge
Possible mass
Investigations of vulval carcinoma
Biopsy
Assess fit for surgery
Treatment of vulval carcinoma
Stage 1a - wide local excision
Other - wide local excision and groin lymphadenectomy
Possible adjuvant radiotherapy before surgery
What is the age range for vaginal and vulval carcinomas
Older women over 60
What are polycystic ovaries?
Polycystic describes the appearance of multiple small follicles in an enlarged ovary on TVUSS
20% of woman have polycystic ovaries but normal cycles
Prevalence of PCOS and relation to infertility
5% have PCOS
Makes up 80% anovulatory infertility
Diagnostic criteria for PCOS (2 of 3)
Polycystic ovaries on USS
Irregular periods >35 days apart
Hirsutism
What is hirsutism
Raised testosterone, acne, excess hair
What causes PCOS?
Genetic susceptibility Disordered LH and raised insulin Increased androgen production Disrupted folliculogenesis and ovulation Obesity (also increases insulin and androgens)
Symptoms of PCOS (5)
Obesity Acne Excess hair Oligo/amenorrhoea Subfertility
Investigations for PCOS(4)
Test FSH, prolactin, TSH for anovulation
Serum testosterone
LH levels may be raised
USS
Treatment for PCOS (5)
Lose weight COCP Anti androgens - spironolactone Metformin reduces insulin, hirsutism, promotes ovulation Eflornithine for hirsutism
Treatment for PCOS if conceiving (4)
Clomifene to induce ovulation - limit 6 months
Ovarian diathermy
Gonadotrophins
IVF
Define dysmenorrhoea
Painful menstruation
Causes of dysmenorrhoea (3)
High prostaglandin levels in endometrium
Uterine contractine
Uterine ischaemia
Define primary dysmenorrhoea
When no organic cause is found, usually coincides with the start of menstruation, affects 50% of women
Treatment for primary dysmenorrhoea
NSAIDs
COCP - ovulation suppression
Define secondary dysmenorrhoea
Pain due to pelvic pathology, often precedes menstruation and relieved by onset
Other symptoms of secondary dysmenorrhoea
Deep dyspareunia
Menorrrhagia
Irregular menstruation
Investigations for dysmenorrhoea
Pelvic USS
Laparoscopy
Causes of secondary dysmenorrhoea
Fibroids Adenomyosis Endometriosis PID Ovarian tumours
What is premenstrual syndrome?
Psychological and physical symptoms that get worse in the luteal phase
Define menorrhagia
Excessive menstrual bleeding in an otherwise normal cycle, interfering with physical/emotional/social quality of life, possibly occurring with other symptoms
80mL blood loss
Affects 1/3 of women, most subclinical
Causes of menorrhagia (6)
Fibroids/polyps Chronic pelvic infection Ovarian/endometrial/cervical malignancies Prostaglandin changes Anticoagulants, Von Willebrands Thyroid disease
Symptoms of menorrhagia (4)
Flooding and clots is excessive loss
Anaemia
Irregular enlarged uterus if fibroids
Tender uterus if adenomyosis
Investigations of menorrhagia (6)
Check Hb Check coagulation TFTs Pelvic TVUSS Endometrial pipelle biopsy Hysteroscopy
Treatment of menorrhagia (7)
1 - progestogen IUS (mirena)
2 - tranexamic acid for 4 days during menstruation
2 - NSAIDs (inhibit prostaglandin synthesis)
2 - COCP
3 - oral/IM progestogens
3 - GnRH agonists for 6 months
4 - Surgical ablation/hysterectomy
Define amenorrhoea
Absence of menstruation
Define primary amenorrhoea
Menstruation has not started by age 16 - may be manifestation of delayed puberty (no secondary sex characteristics by 14) or problem with menstrual outflow
Define secondary amenorrhoea
Previously normal menstruation ceases for 6 months or more
Causes of primary amenorrhoea - non pathological (2)
Constitutional delay, medications (progestogens, GnRH analogues, antipsychotics)
Causes of primary amenorrhoea - pathological (11)
Anorexia Athleticism Psychological Hyperprolactinaemia Hypo/hyperthyroid Adrenal tumours/hyperplasia PCOS Premature ovarian failure Turner's/gonadal dysgenesis Androgen insensitivity Imperforate hymen, vaginal septum
Causes of secondary amenorrhoea - non pathological (4)
Pregnancy, lactation, menopause, medications
Causes of secondary amenorrhoea - pathological (10)
Anorexia Athleticism Psychological Hyperprolactinaemia Hyper/hypothyroid Adrenal tumour PCOS Premature ovarian failure Asherman's syndrome Cervical stenosis
Mechanism by which anorexia/athleticism causes amenorrhoea and treatment
Hypothalamic hypogonadism - GnRH and so LH/FSH reduce and so does oestrogen. Treat with COCP
Causes of hyperprolactinaemia and treatment
Pituitary hyperplasia, benign adenomas, hypo/erthyroidism. Prolactin inhibits GnRH. Treat with bromocriptine, surgery, thyroid hormones
Define chronic pelvic pain
Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse
Causes of chronic pelvic pain (7)
Endometriosis/adenomyosis Adhesions IBS Interstitial cystitis Depression, sleep disorders PID Pelvic venous congestion
Treatment of chronic pelvic pain
Treat cause i.e. diet and antispasmodics for IBS, analgesia, COCP, GnRH agonist, HRT, IUS, laparoscopy if unresolved, possible gabapentin or amitriptyline
What is pelvic inflammatory disease
Sexually transmitted pelvic infection, usually coexisting with endometritis
Risk factors for PID (4)
Young age
Low socioeconomic class
Sexually active (multiple partners, no condoms)
Nulliparous
Cause of PID
Ascending bacteria in the vagina/cervix, sexual factors account for 80%
Can be from descending infection from pelvis
What can cause STI spread to pelvic
Spontaneous
Uterine instrumentation
Childbirth or miscarriage complications
Most common STI causes of PID
Chlamydia and gonorrhoea
Frequently polymicrobial
Symptoms of PID (5)
Many asymptomatic Subfertility Menstrual disturbance Bilateral lower abdominal pain Deep dyspareunia Abnormal PV bleeding/discharge
Signs of PID (4)
Tachycardia and fever if severe Signs of peritonism if severe Bilateral adnexal tenderness Cervical excitation PV bleeding or discharge
Investigations for PID (5)
Endocervical swabs Blood cutures if fever WBC, CRP Pelvic USS Laparoscopy (+biopsy and culture)
Treatment of PID
Analgesia
Antibiotics - ceftriaxone IM single dose, doxycycline, metronidazole BD 14 days orally
Complications of PID (5)
Abscess Tubal damage Subfertility Ectopic pregnancy Chronic infection and pain
What is chronic PID
A persisting infection due to no treatment or inadequate treatment. Treat with analgesia and different antibiotics
Symptoms of chronic PID (7)
Dense adhesions, obstructed and fluid filled tubes Chronic pain Dysmenorrhoea Deep dyspareunia Heavy/irregular bleeding Chronic PV discharge Subfertility
Signs of chronic PID (3)
Abdominal tenderness
Adnexal tenderness
Retroverted uterus
Investigations of chronic PID (2)
Transvaginal USS
Laparoscopy
What is utero-vaginal prolapse
Descent of the uterus and/or vaginal walls beyond anatomical confines, occurring as a result of weakness in supporting structures
Types of prolapse (5)
Urethrocoele Cystocoele Apical prolapse Enterocoele Rectocoele
What is a urethrocoele
Prolapse of the lower anterior vaginal wall, including the urethra
What is a cystocoele
Prolapse of the upper anterior vaginal wall, including bladder (+urethra=cystourethrocoele)
What is an apical prolapse
Prolapse of uterus, cervix and upper vagina
What is an enterocoele
Prolapse of upper posterior vaginal wall, including small bowel
What is a rectocoele
Prolapse of lower posterior vaginal wall, including anterior rectum
Causes of prolapse (8)
Pregnancy and vaginal delivery - 50% of all parous women have some prolapse Large baby Prolonged labour Instrumental delivery Obesity Chronic cough or constipation Pelvic mass Surgery Abnormal collagen disorder - Ehler Danos
Symptoms of prolapse (4)
Dragging or lump sensation - worse at end of day or when standing
Bleeding, discharge
Problems during intercourse
Urinary symptoms
Investigations of prolapse (4)
Abdominal and bimanual examination
Speculum
Pelvic USS
Urodynamic tests
Treatment of prolapse (4)
Weight reduction and physio
Pessaries - ring, shelf, with topical oestrogen
Vaginal hysterectomy
Hysteropexy - mesh to fix structures
Describe physiological vaginal discharge
Non offensive, no itch, clear discharge
Increases around ovulation, pregnancy, if on pill
MAY be due to cervical ectropion (give cryotherapy)
Symptoms, treatment of atrophic vaginitis
Redness
Raised pH
Increased discharge
Treat with oestrogen
Discharge symptoms of malignancy
Bloody offensive discharge
What is stress incontinence?
Involuntary leakage of urine on effort or exertion, or sneezing/coughing, main cause of incontinence in women
Main cause of stress incontinence?
Urethral sphincter weakness
Risk factors for stress incontinence? (5)
Pregnancy and vaginal delivery Prolonged labour/instrumental Age Obesity Previous hysterectomy
Mechanism of incontinence?
Increase in intra-abdominal pressure, bladder is compressed and pressure rises
If bladder neck has slipped below the pelvic floor because its support is weak, bladder pressure will be greater than bladder neck pressure
Unless pelvic floor muscles can compensate
Symptoms of stress incontinence? (4)
Leakage of urine on exertion
May coexist with faecal incontinence
May have prolapse
May have urge incontinence
Investigations of stress incontinence?
Urine dipstick
Cystometry to exclude overactive bladder
Management of stress incontinence? (6)
Lose weight Treat cough e.g. stop smoking Pelvic floor muscle training for 3 months Vaginal cones/sponges 2nd line duloxetine (SNRI) Surgery - mid urethral sling
What is overactive bladder?
Urgency, with or without urge incontinence, usually with frequency or nocturia in the absence of proven infection
Causes of overactive bladder? (3)
Detrusor overactivity - involuntary contractions in filling
Can follow operations for USI
Possible neuropathy - MS, spinal cord injury causing bladder contractions
Mechanism of overactive bladder?
Urgency, bladder pressure may overcome urethral pressure and patient leaks
Can be spontaneous or with provocation - running tap, coughing
Symptoms of overactive bladder? (4)
Urgency
Frequency
Nocturia
May coexist with faecal urgency or prolapse
Investigations of overactive bladder? (2)
Diary - frequent passage of small volumes of urine esp. at night
Cystometry shows contraction on filling
Management of overactive bladder? (7)
Reduce fluid intake, avoid caffeine
Bladder training - resist urgency, void to a timetable
Anticholinergics (antimuscarinics) relax detrusor
Oestrogen
Botulinum toxin A weakens muscle
Neuromodulation and sacral nerve stimulation
Surgery for very severe or resistant
What is a vaginal fistula?
Abnormal opening to bladder, bowel or rectum allowing urine or stool to leak through vagina
Types of vaginal fistula (6)
Vesicovaginal (to bladder) Uterovaginal Urethrovaginal Rectovaginal Colovaginal Enterovaginal (to small intestine)
Causes of vaginal fistula? (5)
Abdominal surgery - C section, hysterectomy Malignancy IBD, diverticulitis Infection Trauma
Treatment of vaginal fistula? (3)
If small, catheter to drain and allow to heal
Antibiotics if infected
Most need surgery - mesh repair
What is ovarian torsion?
Twisting of the ovary around its ligamentous supports, blocking adequate blood supply
Symptoms of ovarian torsion? (4)
Abdo pain
Abdo mass
Nausea
Vomiting
Management of ovarian torsion? (2)
Possible TVUSS with Doppler to identify
Laparoscopic diagnosis and treatment - surgical emergency to detort and fix in place
What is lichen sclerosis?
Vulval epithelium thinning with loss collagen
Cause of lichen sclerosis?
Autoimmune basis, thyroid disease may coexsit
Postmenopause
Symptoms of lichen sclerosis? (5)
Severe pruritis
Trauma from scratching - bleeding, skin splitting
Dyspareunia
Pink-white papular fissured skin
Possible adhesions narrowing vaginal opening
Treatment of lichen sclerosis? (2)
Topical steroids
Biopsy to exclude vulval cancer
What is adenomyosis? (3)
Presence of the endometrium and its underlying stroma in the myometrium
Associated with endometriosis, fibroids
Oestrogen dependent
Symptoms of adenomyosis?
Menorrhagia
Dysmenorrhoea
Enlarged uterus - may have pockets of menstrual blood within myometrium
Management of adenomyosis? (5)
MRI to diagnose Progesterone IUS COCP NSAIDs Hysterectomy often needed
What is abnormal uterine bleeding?
Irregular uterine bleeding (outside normal period) in the absence of recognisable pelvic pathology, systemic disease, or pregnancy
Cause of abnormal uterine bleeding?
Imbalance in sex hormones
Disease causes of abnormal uterine bleeding?(4)
PCOS
Endometriosis
Polyps/fibroids
STIs
Symptoms commonly coexisting with abnormal uterine bleeding? (4)
Mennorhagia
Intermenstrual bleeding
Pelvic pain
Breast pain
Management of abnormal uterine bleeding? (4)
Diagnosis of exclusion COCP IUS, implant Clomifene - resets menstruation Surgery - D and C, ablation
What is androgen insensitivity syndrome?
A person who is genetically male (who has one X and one Y chromosome) is resistant to male hormones (androgens).
The person has some or all of the physical traits of a woman, but the genetic makeup of a man
What are endometrial polyps?
Small, usually benign tumours that grow into the uterine cavity from the endometrium
Causes of endometrial polyps?
High oestrogen levels
Tamoxifen
Symptoms of endometrial polyps? (3)
Menorrhagia
Intermenstrual bleeding
Occasional prolapse
Management of endometrial polyps? (3)
Diagnosed at USS or at hysteroscopy often
Biopsy for carcinoma
Resect polyp with diathermy
What are congenital uterine malformations?
Abnormalities resulting from differing degrees of failure of fusion of the two Mullerian ducts at around 9 weeks gestation
A spectrum, mainly asymptomatic
Symptoms of congenital uterine malformations? (3)
May be diagnosed at pregnancy - cause malpresentations, recurrent miscarriage, retained placenta
Sexual problems if vaginal septum (didelphys)
Amenorrhoea if imperforate hymen
Types of congenital uterine malformations? (6)
Didelphys - total failure to fuse, 2 uterine cavities and 2 vaginas
Bicornuate - partially divided
Unicornuate - one side only developed
Hypoplastic
Septate - thin dividing tissue in uterus
Arcuate - concave shape towards the fundus
Treatment of congenital uterine malformations? (3)
Hysteroscopic resection if small septa
Possible surgery for other types
Assisted reproduction
What is Asherman’s syndrome?
Uncommon consequence of excessive curettage at ERPC after miscarriage/delivery causing adhesions in the uterus
Symptoms of Asherman’s syndrome (3)
Reduction in menstrual flow
Infrequent periods
Infertility
Management of Ashermans syndrome (2)
Hysteroscopy to diagnose
Dissection of adhesions - common recurrence
What is a prolactinoma?
Benign noncancerous tumor of the pituitary gland that produces a hormone called prolactin
Symptoms of prolactinoma? (5)
Infertility Amenorrhoea Irregular periods Vaginal dryness Lactation (galactorrhoea)
Diagnosis of prolactinoma? (2)
Bloods - prolactin level, TFTS
MRI to diagnose
Treatment of prolactinoma? (2)
Dopamine agonists - bromocriptine (inhibits prolactin)
Surgery, possible radiation
What is premenstrual syndrome?
Encompasses psychological, behavioural and physical symptoms that are experienced regularly during the luteal phase of the menstrual cycle, resolve by end of menstruation
How common is PMS?
95% experience, only 5% severe
Cause of PMS?
Differing neurochemical responses to ovarian function and sex hormones e.g. progesterone
Symptoms of PMS? (6)
ALL CYCLICAL Tension/irritability Depression Loss of control Bloating GI upset Breast pain
Management of PMS? (5)
SSRIs either continuously or in second half of cycle
COCP
Oestrogen patches
GnRH and oestrogen - pseudomenopause
Bilateral oopherectomy if severe - with HRT/COCP after
Medical methods of TOP?
Mifepristone - antiprogesterone
with Misoprostol - prostaglandin 2 days later
Labour is initiated
When is medical TOP done?
Up to 24 weeks.
If after 22 weeks potassium chloride injected into the fetal heart to prevent live birth
Surgical methods of TOP?
Suction curretage
Dilatation and evacuation
When is surgical TOP done?
Up to 24 weeks
Suction curretage between 7-13
D+C above 13 weeks
Complications of TOP? (4)
Haemorrhage
Infection
Uterine perforation
Abortion failure
What is menarche?
Onset of menstruation, normally the last manifestation of puberty in the female, average 13 years
Hormone axis controlling menstruation?
Hypothalamic-pituitary-gonadal axis
GnRH pulses, releasing FSH and LH
Stimulates ovarian oestrogen release
Purpose of menstruation?
Hormones cause ovulation and induce changes in the endometrium preparing it for implantation if fertilisation occurs
Days 1-4 of the menstrual cycle? (2)
First day of the cycle is the first day of menstruation
Endometrium shed as hormonal support withdrawn - possible painful contraction
Days 5-13 of the menstrual cycle? (4)
Pulses of GnRH from the hypothalamus stimulate LH and FSH release which induce follicular growth
Follicles produce oestradiol and inhibin which suppress FSH so only 1 oocyte matures
When oestradiol levels are very high, LH surge occurs and ovulation follows after 36 hours
Oestradiol encourages proliferative myometrium
Days 14-28 of the menstrual cycle? (4)
The follicle from the released egg becomes the corpus luteum which produces oestrogen progesterone
Secretory changes in the endometrium
Corpus luteum regresses if egg is not fertilised
As hormonal support fails, endometrium breaks down and cycle restarts
What are the phases of the menstrual cycle?
Menstruation
Proliferative (follicular) phase
Secretory (luteal) phase
What is menopause?
Permanent cessation of menstruation following from loss of ovarian follicular activity, normally around 51 years
After 12 months of amenorrhoea
What is premature menopause?
Permanent amenorrhoea <40 years
What is perimenopause?
Time preceding menopause where periods become erratic
Symptoms of menopause?
Hot flushes Insomnia Skin and breast atrophy Hair loss Atrophic vaginitis Prolapse Urinary symptoms Osteoporosis CV disease
Investigations for menopause?
Low anti-Mullerian hormone
Raised FSH
Treatment for menopause?
HRT to alleviate symptoms - risk of breast cancer
Bisphosphonates for osteoporosis
What is HRT?
Use of exogenous oestrogens when endogenous secretion absent
