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
17 yr old female with 6 month hx of excess menstrual bleeding, fatigue and pallor. Inestaigations?
Hx, bimanual exam
Speculum exam
FBC - Hb - iron deficiency
Coagulation/thyroid (rare haemostatic/VW)
Routine TVUS - endometrial thickness/polyps
If >10mm - do biopsy and hysteroscopy
What other features on the examination are you looking for in menorrhagia presentation?
Irregular enlargement of uterus = fibroids
Tenderness/enlargement = adenomyosis
Ovarian mass
Medical management of menorrhagia?
1st: IUS (coil) - contranceptive, secretes progesterone
2nd: COCP
Anti-fibrinolytics (tranexamic acid) with NSAID mefenamic acid (reduce prostaglandins)
3rd: High hose progesterone/GnRH agonist
Surgical management of menorrhagia?
Hyseroscopic polyp removal Transcervical resection of endometrium (fibroids) Radical: Endometrial ablation Myomectomy (fibroidectomy) Hysterectomy Uterine artery embolization
What symptoms might indicate underlying pelvic pathology?
Persistent postcoital bleeding Persistent intermenstrual bleeding Dyspareunia Dysmenorrhoea Pelvic pain Vaginal discharge
15 year old girl presents with intermenstrual bleeding and irregular periods. What might cause this and how might you investigate?
Anovulatory cycles
Pathology: fibroids, polyps, adenomyosis, ovariam cyst, malignancy
Ix: Hb, cervical smear
If 35+ - USS, endometrial biopsy w/ pipelle at hysteroscopy
Management of irregular bleeding?
Medical: If no pathology - anovulatory cycles - give IUS/COCP
HRT for menopausal eratic bleeding
Sx - for menorrhagia, avulse cervical polyp and histology
A 24 year old lady presents with post coital bleeding? What might cause this?
When cervix not covered in healthy squamous epithelium: carcinoma (most r/o), polyp, ectropion
cervicitis, vaginitis
How should post coital bleeding be managed?
Inspect cervix and smear
Polyp - avulse and histology
Ectropion - cryotherapy
Colposcopy smear - r/o malignancy
What is a functional cycts and how should it be managed?
Enlarged persistent follicle (follicular cyst)
or corpus luteum cyst (if pregnancy doesn’t occur, CL may fill w/ blood - may present w/ intraperitoneal bleeding
Usually resolves after 2/3 cycles
Causes pain, possibly peritonitis
Sx if bleed, COCP inhibits
35 yr old presents with large solid mass in her lower left abdomen. likely Dx? How likely to be malignant?
Mucinous cystadenomas
15%
If it ruptures - may cause pseudomyxoma peritonei
46 yr old lady presents bilateral mass in ovaries. Dx? How likely to be malignant?
Serous cystadenoma
25%
What is a dermoid cyst? Concern?
A mature cystic teratoma - contains skin/hair/teeth
Most likely to have torsion
A 26 year old lady pesents with with acute abdo pain whilst running, PV bleed, N&V, weakness and syncope. Likely Dx? Ix? Management?
Ruptured ovarian cyst (mid cycle follicular likely) Ix: R/o ectopic - hCG dip FBC, swabs USS Laparoscopy is diagnostic Rx: if stable - analgesia Unstable/bleeding - Sx
23 year old lady presents with acute abdo pain whilst cycling. Pain radiates to back, thigh and pelvis, N&V and fever. Likely Dx? What might fever indicate? Ix and Rx?
Ovarian torsion - usually enlarged ovary
Ix: r/o ectopic - hCG and dip, FBC, swabs
USS w/ colour Doppler analysis - may show free fluid
Rx: Laparscopy + analgesia - NSAIDs, opiates
Suspected ovarian torsion or cyst rupture. Now appears in hypovolaemic shock. Likely dx?
Ovarian cyst hameorrhage
25 year old presents with vague abdo symptoms such as bloating, early satiety, anorexia, urinary urgency/frequency, PV bleed, lower back, abdo & pelvic pain, dyspareunia, change in bowel habbit (diarrhoea). O/E you suspect some ascites. ikely Dx? Risk factors/cause?
Ovarian cancer - most (85%) epithelial serous carcinoma, others sex cord (granulosa) or germ cell (dysgerminosa/teratoma)
RF: Increased ovualtions (early menarche, late menopause, null parity
BRCA1/2, HNPCC gene mutations
Protective factors of ovarian Ca?
COCP Parity Anovualtion Pregnancy Lactation POP/Mirena
Management of suspected Ovarian Ca?
CA125 (under, suspect IBS if under 35 Under 35 - AFP, HCG - germ cell tumour Referral based on Risk of Malignancy Index (RMI) - USS score (U) (1 or 3 if more than 1 cytic feature), pre or post menopause (M) (1 or 3): If U x M x CA125 > 250 --> Gyn Onco MDT CT and laparoscopy for staging Surgery + chemotherapy
How is Ovarian Ca staged?
1) Limited to ovaries
2) Limited to pelvis
3) Limited to abdomen
4) Distant mets outside abdo
57 year old lady presents with post menopausal bleeding, pain, watery discharge and weight loss. Likely Dx and case? Risk factors?
Endometrial cancer
90% adenocarcinoma, 10% adenosquamous
Rf: obesity, DM, nulliparity, early menarche, late menopause, ovarian tuours, HRT (unopposed oestrogen), pelvic irradiation, Tamoxifen, PCOS
Management of suspected endometrial ca?
Ix: TV USS - endometrial thickening (<4mm - r/o), hysteroscopy w/ endometrial biopsy
CXR and MRI for spread
Rx: If limited to uterus/cervix = total hysterectomy and bilateral salpingo-oophorectomy
Pelvic lymph node clearance
Radiotherapy and progestogens eg medroxyprogesterone (if spread)
Poor prognostic indicators of endometrial Ca?
Older age
Advanced stage
Deep myometrial invasion
Adenosquamous histology
29 year old lady presents with post-coital bleeding, and other PV bleed such as when micturating, dyspareunia, offensive vaginal discharge, painless haematuria, leg oedema. likely Dx, cause and RF?
Dx: Cervical cancer - 80% squamous cell carcinoma, 200% adenocarcinoma from columnar epithelium
RF: HPV - human papillomavirus 16/18/33 (E6/E7 oncoproteins - inhibits tumour suppressor genes), early age intercourse, multiple partners, STIs, multiparity, COCP, other neoplasia
Ix of suspected cervical Ca?
Smear at squamous-columnar junction and HPV screen
Smear done every 3 yrs 25-49, every 5 yrs 50-64 - liquid based cytology (LBC)
Refer to colposcopy if:
1) Borderline dyskaryosis AND HPV +ve
2) Moderate/severe dyskaryosis
Treatment of cervical ca?
Dysplasia - laser therapy/cryotherapy w/ cone biopsy
Stage 1B+ - Trachelectomy (removal of uterine cervix) and chemotherapy
Stage 2B+ - Chemoradiotherpay, pelvic lymph node clearance
55 year old presents with vulval itching and soreness, a persistent lump on labia majora, bleeding, dysuria, past hx of Lichen sclerosis. RF? Dx? Cause? Management?
Vulval cancer - 90% squamous
RFs: HPV, vulval intraepithelial neoplasia, immunosuppression, lichen sclerosis
Rx: Surgical resection/radical
Radiotherapy
21 year old presents with acute pelvic pain, lower abdo pain, deep dyspareunia, fever, dysuria, abnormal vaginal bleeding and discharge, RUQ pain. PMH of multiple sexual partners and endometriosis.
O/E she is tachycardic, bitleral adnexal tenderness, cervical excitation (pain on moving cervix). A small pelvic abscess may be palpable. Likely Dx? Cause?
Acute pelvic inflammatory disease
Note - 10% cases get RUQ pain - called Fitz-Hugh Curtis syndrome
Ascending infection from vagina/cervix
Sexual - multiple partners, STIs - Chlamydia trochomatis, Neisseria gonorrhoea,
Uterine instrumentation - abortion, laparoscopy, ERCP
Can be endometritis, salpingitis, parametritis (parametium = connective tissue around uterus)
Management of PID including Ix?
Endocervical swabs - for chlamydia/gonococcus, cultures, FBC - raised WCC/CRP
USS - exclude cyst/abscess
hCG
Urine dipstick - if nitrites/leucocytes - MSU
gold standard = laparoscopy/fimbrial biopsy/culture
Rx: analgesia
Abx - IM ceftriaxone + PO ofloxacin + PO doxycycline + PO metronidazole
IV if febrile
If no improvement- laparoscopy and abscess drain
Complications of PID?
Abscess
Tubal obstruction and subfertility
Ectoptic pregnancy more likely
Chronic pelvic pain
35 yr old w/ 2 month hx of pelvic pain, dysmenorrhoea, deep dyspareunia, irregular menses, chronic vaginal discharge
O/E there appear to b dense pelvic adhesions, abdo and adnexal tenderness and a fixed retroverted uterus.. Dx, Ix, Rx?
Chronic PID
Ix: USS show fluid collection in fallopian tube, laparoscopy
Rx: analgesia, abx if infection, removal of affected tube (salpingectomy)
What is uterovaginal prolapse?
RFs?
Descend of uterus/vagina or its walls beyond normal anatomical confines.
Occur due to weakness of supporting structures eg pelvic floor (muscular/fascial structures)
Increasing age, multiparity = vaginal deliveries, obesity, spina bifida
What is a urethrocoele?
Prolapse of lwer anterior vaginal wall - urethra only
What is a cyctocoele?
Prolpase of upper anterior vaginal wall - bladder (also urethra = cystourethrocoele
What is an apical prolapse?
Prolapse of upper vagina, cervix, uterus
What is an enterocoele?
Prolapse of posterior wall of vagina - pouch of small loop of bowel
What is a rectocoele?
Prolapse of posterior wall of vagina - anterior wall of rectum
How is prolapse graded?
ICS Pelvic Organ Prolapse (POP) scoring system
0-4
67 year old lady presenst with a dragging/pressure sensation of lump which is worse at the end of the day, increased urinary frequency, occasional difficulty defacating. What is likely dx? What predisposes?
Uterovaginal prolapse
Child birth - esp if prolonged 2nd stage of labour, instrumental delivary
Congenital - abnormal collagen metabolism - EDS
Menopause - deterioration of collagenous connective tissue
Predisposing - intra abdo P increase - obesity, cough, constipation, heavy lifting, high parity (vaginal deliveries)
Iatrogenic - pelvic surgery eg hysterectomy
Ix for prolapse?
Pelvic USS for cause/mass
Urodynamic testing if incontinence complaint
Fitness for surgery - ECG, CXR, FBC, renal fucntion
Prevention for prolapse?
Recognise obstructed labour, avoid long 2nd stage
Pelvic floor exercises after child birth
Non surgical management of prolapse?
Ring pessary - act as artificial pelvic floor - change 6-9 mo Post menopausal women - HRT Weight reduction Physiotherapy (pelvic floor exercises) Discourage smoking
Surgical management of prolapse?
Uterine prolapse - vaginal hysterectomy/sacrohysteropexy - lift to normal position
fix vault to sacrum using mesh
Vaginal wall - wall repair w/ mesh (cystocele -> anterior colporrhaphy, rectocele -> posterior colporrhaphy)
Urodynamic stress incontinence - tenson free vaginal tape, trans obturator tape
40r old woman has constant dull ache that’s worse at the end of the day, after long periods of standing, after intercourse, before periods, dysmenorrhoea, pain. O/E the uterus appears large. She has 2 children. What is ikely dx and what causes it?
Pelvic pain syndrome
Varicose veins in lower abdomen
Pregnancy worsens
Venous congestion in pelvis
Management of pelvic pain syndrome?
Ix: USS, laparsopy, CT venogram
Rx: NSAIDs, embolization to stop flow of varicose veins
What is chronic pelvic pain?
Intermittent/constant pain in lower abdomen/pelvis for over 6 months. not excessive on mensturation or sexual intercourse
Often associated w/ migraine, lower back pain, economic burden
Causes of chronic pelvic pain?
Endometriosis/adenomyosis
Pelvic adhesions
Psychological: depression/childhood sexual abuse
Pelvic congestion syndrome
How would you manage a lady with chronic pelvic pain
Hx, exam, TVUS, laparoscopy, MSU, MRI, swabs
Analgesia
IBS - antispasmodics/refer to dietician
Cyclic pain: COCP/GnRH/progesterone IUS
Counselling/therapy
amitriptyline/gabapentin
If fail: laparoscopy: cut adhesions, treat cause
History points for chronic pelvic pain?
Timing Nature/site of pain Menstruation Dyspareunia Sexual/contraceptive hx GI sypmtoms Any recent pelvic infections
Examination points for chronic pelvic pain?
General appearance, pulse
Abdomen - tenderness, bowel sounds
Pelvic: inspect, vulva, speculum, bimanual, adnexal tenderness
Define a spontaneous miscarriage
A foetus dies/delivers dead before a 24 wk pregnancy
Describe 2 possible appearances on EPAU TVUS
7 wk gestational sac seen but no fetal pole
Fetus seen but no cardiac activity
What is a threatened miscarriage?
Vaginal bleeding before 24 weeks (usually 6-9)
but foetus still alive
Uterus is size expected for dates
Os closed
What is an inevitable miscarriage?
Heavy bleeding, clots & pain
Os open
Miscarriage about to occur
What is an incomplete miscarriage?
Some fetal parts passed
Pain & vaginal bleeding
os open
What is a complete miscarriage?
All fetus tissue passed
Uterus not enlarged
Os closed
What is a septic miscarriage?
Contents of uterus infected –> endometritis
Offensive vaginal discharge
Fever
Tender uterus/abdo/peritonitis
What is a missed miscarriage?
Gestational sac contains dead fetus before 20 weeks w/o symptoms of expulsion
Light bleeding/discharge
Not recognised until USS
Os closed
‘Blighted ovum’/’anembryonic pregnancy’ = gestational sac >25mm & no fetal parts seen - The crown-rump length is greater than 7mm OR
The gestational sack is greater than 25mm
Recently pregnant woman now has vaginal bleeding and has lower abdominal pain. Likely dx? Investiagtions?
Miscarriage
EPAU
TVUS - check viability of foetus
hCG - if viable foetus - increase by >66%
Management of miscarriage?
Admission if ectopic, septic, rescusitation
IV access and colloid
Cross match blood
IM ergometrine
Anti-D if Rh -ve
Prostaglandins - If >12 weeks - anti-progesterone (mifepristone) then (36-48hr) - prostaglandin vaginal misoprostol
If <12 weeks - vaginal misoprostol
Give antiemetics & pain relief
Surgical - manual vacuum aspiration under LA or GA - previously ERPC
Complications of miscarriage?
Infection
Ashermans syndrome if manual vacuum aspiration
Define recurrent miscarriage
When 3 or more miscarriages (result in spontaneous abortions) occur in succession
Management of reuccrent miscarriage?
Support and counselling
High risk monitoring w/ USS in future pregancies
Causes of recurrent miscarriage and rx?
Antiphospholipid antibodies –> LMWH
Chromosomal abnormalities –> refer to geneticist, chorionic villus sampling/amniocentesis
Endocrine - DM, thyroid, PCOS
Uterine abnormalities
Infection - treat bacterial vaginosis, or uterine septum - surgery
Smoking - cessation
23 year old woman presents to EPAU with lower abdo unilateral colicky pain which is constant. Amenorrhoea for 6-8 weeks. She has now collapsed. Was complaing of shoulder tip pain & pain on defacation.
O/E she is tachycardic, hypotensive, pain on abdo palpattion. cervical excitation, cervical os is closed, Likely dx and cause?
Ectopic pregnancy
Fertilized ovum implants outside uterus (fallopian tube wall) and thinned wall unable to cope w/ trophoblastic invasion –> rupture, intraperitoneal bleeding, peritonis
Shoulder tip/defecation pain due to intraperitoneal bleeding
RF: damage to tubes (salpingitis, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic)
Ix of ectopic pregnancy?
hCG - v high (>1500)
TVUS to detect foetal location
Quantitative serum hCG - Shows declining/slow rising levels in ectopic
Laparoscopy- most sensitive but invasive
Management of ectopic?
NBM
IV access and Cross match blood
Laparoscopy
Anti-D if Rh -ve
If haemodynamically unstable - resuscitation and surgery - esp if B-hCG >1500, salpingectomy
If stable: salpingostomy (remove ectopic from fallopian tube)
If unruptured and no cardiac activity & B-hCG <1500 - methotrexate. If small and low hCG, asymptomatic - watch and wait - closely monitor B-hCG
A 29 year old woman presents with vaginal bleeding, a large uterus, severe N&V, an uncomfortable pelvis, vaginal discharge. A pregnancy test is performed and very high hCG levels are found. What mimght be the cause? What could be done about it?
Molar pregnancy: Non viable fertilized egg implants into uterus. No fetus, all genetic material is paternal.
If beta hCG fail to come down –> methotrexate
A 27 year old lady presents to EPAU (8-12) weeks pregnant with excessive vomiting, v high B-hCG. She is now dehydrated and has abnormal U&Es. TVUS shows twins. Likely dx and rx?
Hyperemesis gravidarum
RF: multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
Mx: 1st line: antihistamines (promethazine/cyclizine)
2nd line: Antiemetics - metroclopramide, ondansetron
Admission if IV fluids for dehydtration required
Thiamine - prevent neuro complications
Psychological support
Complications: Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinosis, acute tubular necrosis
What is the characteristic TVUS of PCOS?
Multiple (>12) small (2-8mm) cystsin an enlarged ovary (>10mL)
A 17 year old girl presents with acne, excessive body hair, oligomenorrhoea, acanthosis nigrans and is overweight. What is the liely dx? What would confirm this?
Polycystic ovary syndrome - Rotterdam Criteria:
PCO on TVUS
Irregular periods (>35 days apart) - Check FSH (high in ovarian failure, low in hypothalamic disease), prolactin - may be raised
Evidence of hirsutism - serum testosterone - can be high but if v high - consider cause to be androgen secreting tumour/congenital adrenal hyperplasia)
LH high in PCOS
Hyperinsulinaemia & impaired glucose tolerance
Management of PCOS?
Treat weight - diet and exercise
Treat hirsutism: COC pill, eflornithine topically, metformin (lower insulin and thus androgens)
Under specialist supervision: spironolactone, flutamide, finasteride
COCP to regulate menstruation
Infertility: weight reduction, clomifene (risk of multiple pregnancies w/ anti-oestrogens).
A 67 year old lady presenst with involuntaqry leaking of urine, urgency, frequency, nocturia, high BMI, high parity. PMH - hysterectomy What is the cause and pathology?
Overactive bladder - due to detrusor over activity
What causes involuntary leakage of urine when coughing, lifting, laughing, exercise etc?
Stress incontinence - sphincter weakness
How should incontinence be assessed?
Bladder diary for minimum 3 days
Vaginal exam - r/o pelvic organ prolapse
Urodynamics studies A frequency volume chart - voided vol, frequency of urination, quantity leaked, fluid intake, diurnal variation
Residual volume measurement using USS/catheter
Urinalysis & culture
Questionnaire on urinary/bowel/sexual symptoms
Management of stress incontinence?
Conservative - physiotherapy - pelvic floor exercises to compress urethra (8 contractions TDS for 3/12
Surgery: retropubic mid-urethral tape procedures - to restore pressure transmission to urethra
Management of overactive bladder?
Bladder retraining - for 6/52, increase intervals between voiding)
Drugs: Anticholingergics - M2/M3 antagonists eg oxybutynin, tolterodine - immediate release - (SE dry mouth, blurred vision, drowsiness, avoid oxybutynin in frail older women)
Mirabegron - beta3 agonist - relaxes detrusor (concerns over anti-cholinergic SE in elderly)
Bladder drill
Indwelling catheter
Botox
Lifestyle: weight loss, smoking cessation, reduce caffeine
Local vaginal oestrogen
What is menopause? Average age?
Cessation of menstruation
51
How is menopause diagnosed?
After 12 months of amenorrhoea
4 perimenopausal symptoms?
Irregular periods Hot flushes & night sweats Mood swings Urogenital atrophy & urinary incontinence Anxiety & depression Memory problems
Central and local symtoms? Why?
Due to low oestrogen?
Central: Vasomotor - hot flushes/swats - last 2-7 years, impacts sleep, mood
Joints/muscle aches, headavhe, loss of memory/concentration
Local: Vaginal dryness, atrophy, dyspareunia, recurrent UTIs, post menopausal bleeding
Lon term effects of menopause?
Osteoporosis
CVD
Dementia
Management of Menopuase?
Holistic - lifestyle advice, reduce risk factirs, exercise, good sleep hygiene
Inform about options - HRT (Oral or transdermal to reduce unopposed oestro n (risk of endometrialca), vaginal oestrogens
CBT
HRT - relief of menopause symptoms, bone mineral protection, prevent slong term morbidity
Psychological: fluoxetine/citalopram - helps vasomotor symptoms also
Vaginal dryness: lubricants
Vaginal atrophy - topical oestrogen (CI In HRT)
Risks of HRT?
Breast ca (if have, discontinue, do not offe)
Ovarian ca
VTE - If have thromboohilia, refer to haematologist
Stroke increased risk
CVD - if started <60, risk not increased
How is HRT prescribed?
Progesterone used for 12-14 days every 4 weeks - as proetects endometrium from unopposed oestrogen
Mirena
Tibolone - not suitable within 12 mo of LMP
PO estradiol if intact uterus
Transdermal patches if gastric upset/Crohns/increased VTE risk/older women
What is premature ovarian insufficiency (POI) and what might cause it?
Menopuase in <40yrs & elevated Gonadotrophins
Natural: chromosome abnormalities eg FSH receptor gene polymorphisms, inhibin B mutations
Iatrogenic: surgery, chemo/radiotherapy
Autoimmune
Dx of POI?
FSH <25 IU/L in 2 samples >4 weeks apart from each other
4 mo of amenorrhoea
Rx of POI?
Oestrogen replacement: HRT/COCP - HRT alleviates symptoms and minimises risks (European Menopause and Andropause Society)
Androgen replacement - testosterone gel
Fertility: donor egg
When might contraception be needed with menopausal women?
If <50: remain fertile for 2 years
If >50: remain fertile for 1 yr
A married couple are trying to conceive for their first baby. They have been trying for 9 months and have not yet conceived. What advice would you give them?
See partners together Kep trying - get referral after a year. Early referral if woman >35 Intercourse 2-3 times a week Folic acid Smear for rubella Smoking cessation Stop alcohol consumption (women) Keep BMI 20-25
Factors contributing to female subfertility?
>35 yrs Menstrual disorder PID/STD Previsu pelvic/abdo Sx - tubal problem b Abnormal pelvic examination
Factors contributing to male subfertility
Previous genital pathology, urogenital surgery, STI
Systemic illness
Investigations for females with subfertility?
Check ovulation (mid luteal progesterone taken 7 days prior to expected period) - (day 21) - if >30nmol/L - ovulation, <16 - anovulation. Between - further ix Test for PCOS (Rotterdam criteria) Test ovarian reserve - test FSH, antral follicle count, antimullerian hormone
Ix for males w/ subfertility?
Semen analysis Clinical exam - secondary sexual characteristics/testicular size Endocrine: FSH, prolactin Testicular biopsy (azoospermia) Imaging - vasogram, USS, urology
Treatment for male subfertility?
Mild: intrauterine insemination
Moderate: IVF
Severe: Intracytoplasmic sperm injection
Azoospermia - surgical sperm recovery, donor insemination
Epididymal block - surgery
Hormonal - hypogonadotrophic hypogonadism - bromocriptine
Treatment for female subfertility?
Treat PCOS
Treat tubal disease: tubal laparoscopy - salpingostomy, proximal anastomosis, tubal catheterisation
Assisted conception: ovulation induction, stimulated intrauterine insemination
IVF (risk of multiple pregnancy, miscarriage/ectopic)
Donar egg/embryo/surrogacy
What might affect the success of conception?
Age Cause of infertility Previous pregnancys Duration of infertility Specific medical conditions
Define FGM
All procedures involving partial or total removal of female external genetalia or other injury to female organs for non medial reasons
Why is FGM performed in some cultures?
Bring status Preserve chastity/virginity Rite of passage Communty Family honour Cleanses woman
Law surrounding FGM?
Illegal to perform or help carry out FGM under the Childrens Act 1989
Gynae complications of FGM?
Dyspareunia, sexual dysfunction Chronic pain Keloid scar formation Dysmenorrhoea Urinary outflow obstruction/UTI PTSD
Obstetric complications of FGM?
Fear of childbirth
Increased likelihood of C section/PPH
Difficulty monitoring fetus
Treatment of FGM?
Reversal of infibulation procedure Specialist FGM clinics Report cases Ensure families know illegality status Psychotherapy
What is the COCP and advanatges?
Oestrogen and progesterone
Reversible and reliable, regular cycles, decrease dysmenorrhoea/menorrhagia, protective against ovarian, endometrial and colorectal ca, doesn’t interfere with sex
Disadvantages of COCP?
Risk of VTE Drug interractions Decreased efficacy after D&V No STI protection Small breast/cervical ca risk
Describe how contraceptive patches (Evra) work
Oestrogen and progesterone
Worn 3 weeks then break for 1 week
Expensive
What is the POP and advantages?
Progesterone only pill
Thickens cervical mucous and thins endometrium
Prevent oestrogenic SE eg breast tenderness, headache
Though can have heavy affect on periods
Advantages of condoms?
Prevent pregnancy and STI
But failure if poor technique
How does the injectable contraception work?
Depo-Provera
IM progesterone - inhibits LSH/LH - given every 12 weeks
Reversible
May help PMS
BUT may increase appetite - weight gain, irregular bleeding
How do implants work?
Nexplanon - slow release progesterone
Easy to remove and insert
Affects periods - irregular
How does the intrauterine device work?
copper contained causing foreign body reaction with uterus - toxic to sperm and egg fertilizing chances
May cause menstrual irregularities, spotting, menorrhagia, PID risk, risk of ectopic
How does the intrauterine system work
Mirena - contains progesterone
For menorrhagia
Though causes endometrial atrophy
How does the emergency contraception work?
Progesterone only - Levonelle = levonorgestrel
Decrease viability of ova
Take asap - must be taken within 72hrs
IUD can be inserted within 5 days
How is female sterilization undertaken?
Hysterectomy/hysteroscopic sterilisation
Irreversible
GA
How is male sterilization undertaken
Vasectomy
Permanent
Cut and cauterise vas deferens
