Gynaecology Flashcards
What is amenorrhoea?
Absence of menses
Define primary amenorrhoea
Failure to start menstruation by 16 (14 if no other secondary sexual characteristics)
Define secondary amenorrhoea
Previous menses, no menstruation for >6mo.
If previous oligomenorrhoea - for 12 mo
Not pregnant
Name of staging for pubertal development?
Tanner stages
Causes of primary amenorrhoea?
Constitutional delay (familial)
GU abnormalities - imperforated hymen/transverse vaginal septum - blood accumulates in vagina/uterus
Hypothalamic hypogonadism - often from low weight (Kallman’s syndrome - GnRH deficiency –> high FSH/LH (also anosmia, cranio-facial abnormalities)
Gonadal failure - Turners syndrome (45X) -neck webbing, short stature, obesity
Hyperprolactinaemia from pituitary hyperplasia/benign tumour/hypothyroidism
PCOS
Congenital adrenal hyperplasia
Causes of secondary amenorrhoea?
Premature ovarian failure - (low oestrogen, high FSH/LH and -ve feedback)
HPO axis - stress, exercise, weight
Hyperprolacinaemia (Sheehans syndrome - pituitary necrosis after severe PPH)
Ovarian: PCOS, tumour, menopause)
Iatrogenic - depot, implant, post COCP
Obstruction - cervical stenosis, Asherman’s syndrome (uterine adhesions from excessive curettage of ERPC)
Virilising adrenal/ovarian tumour
Hyper/hypothyroidism
Ix for Amenorrhoea?
hCG - r/o pregnancy FSH/LH - high in premature ovarian failure, low in hypothalamic Testosterone/sex hormone binding protein - PCOS Prolactin TFT Pelvic USS - PCOS, haematometra, POF Karyotype - Turners CT/MRI - visualise pituitary fossa
Management of amenorrhoea?
Treat cause
Hyperprolactinaemia - bromocriptine (D2 agonist)
PCOS - COCP
Tract - cervical dilation, incision of hymen
HPO - HRT.OCP
What is dysmenorrhoea?
Painful cramping in lower abdomen before/at the start of menstruation
What is primary dysmenorrhoea?Aetiology and pathology?
Absence of of identifiable pelvic pathology
Fall in progesterone
Increased prostaglandins in endometrium
Uterine contraction and ischaemia
What is secondary dysmenorrohoea and what causes it?
Secondary to underlying pelvic pathology - usually starts many years after menarche.
Endometriosis, fibroids, adenomyoisis, PID, endometrial polyps, malignancy, adhesions from previous sx
Features of dysmenorrhoea?
Deep dyspareunia, menorrhagia, irregular menses
Ix of dysmenorrhoea?
Mx of primary?
Pelvic USS, laparoscopy
Mx: NSAIDs - mefanamic acid + ibuprufen (prostaglandin inhibitors)
2nd line: COCP
What is endometriosis?
The presence and growth of ectopic endometrial tissue outside the uterine cavity
Common sites of endometriosis and why?
Pelvis: common due to retrograde menstruation (Samsons) - bowel, pouh of douglas, bladder, fallopian tube, ovaries (get chocolate cysts - dark blood accumulated)
Extra-pelvic - spread through haematogenous (Halbans theory), metaplasia (Meyers’ theory) –> URT eg lungs, orophraynx
Presentation of endometriosis?
Chronic pelvic pain, affects fertility
Dysmenorrhoea before, during and after menses
Acute pain on rupture of chocolate cyst
deep dysspareunia
Non gynae: Dyschezia (painful bowel movements), dysuria, urgency, haematuria
Exam: reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions seen
Ix of for ?endometriosis?
Laparoscopy - gold standard
Abdo/pelvic USS, examination, swabs
r/o ovarian carcinoma - CA125
Management of endometriosis?
Medical: NSAIDs, paracetamol Triphasing (3 mo, break) OCP (combined or progesteorne - eg medroxyprogesterone) - uninterrupted causes glandular hypertrophy
GnRH analogue - initial gonadotrophin secretion then pituitary down growth –> inhibit secretion -> ‘pseudomenapuase’
HRT to avoid osteoporosis
Progesterone - depot/IUD
Surgical: Ablation/excision - laser treatment
Oophorohysterectomy if completed family
40 year old woman presents with cyclical pain that is quite constant. Laparascopy shows no endometriosis. Obstetric hx of 3 children. Likely dx? and cause? Ix? Management?
Adenomyosis - endometrial tissue in myometrium
Laparotomy/USS
Rx: GnRH agonists, hysterectomy
Name 2 differetials for bleeding and infertility?
Fibroids
Uterine polyps
27 old Afro-caribbean woman has hx of pelvic cramping pain esp around menstruation, constipation, bloating, urinary frequency and urgency, menorrhagia, subfertility. O/E she has a bulky non-tender uterus. Possible diagnosis? How might you investigate
Fibroids - benign uterine tumours (Leiomyoma) of smooth muscle (myometrium)
Transvaginal USS
On Pelvic USS, fibroids are found. What possible locations might there be? Management?
Pedunculated Subserosal Intra-mural Submucosal Intracavitary Rx: <3 cm - levonorgestrel IUS 1st line COCP/Tranexamic acid GnRH agonists can be used short term to reduce fibroid size >3cm - myomectomy, hysterectomy, transcervical resection of fibroids, hysteroscopic endometrial ablation, uterine artery embolisation
Define menorrhagia
Excessive menstrual blood loss that interferes with a womans physical, emotional, social or material quality of life OR >80mL in otherwise normal cycle
Causes of menorrhagia?
50% - no cause = Dysfunctional uterine bleeding
Fibroids
Polyps
Anovulatory cycles - common in extremes of woman’s reproductive life
Chronic infection
Ovarian, cervical, endometrial malignancy
IUD - copper coils
Bleeding disorders - eg von Willebrands disease
PID
Hypothyroidism