Gynaecology Flashcards
PCOD causes + criteria for diagnosis
Rotterdam criteria: 1) irregular or absent periods 2) hyperandrogenism = acne, body hair, alopecia, raised testosterone 3) polycystic ovaries on USS Caused by genetics, insulin resistance, obesity
PCOS + insulin relationship
Disordered LH production, peripheral insulin resistance, raised insulin levels
Raised LH + insulin = increased androgen production
Raised insulin = reduced hepatic production of steroid hormone binding globulin (SHBG) = increased free androgens
Increased androgens = disrupt folliculogenesis = small ovarian follciles/ cysts + absent periods
Increased peripheral androgens = hirsutism
S+S PCOS
Asymptomatic Acne, hirsutism, alopecia
Obesity Irregular/ absent periods
Infertility
Recurrent miscarriage
Acanthosis nigricans
Long term health consequences of PCOS
IHD DM2 GDM Endometrial hyperplasia + carcinoma (due to unopposed oestrogen from 2’ amenorrhoea)
Investigations for PCOS
TVUSS
FSH raised in ovarian failure, low in hypothalamic disease + normal in PCOS
LH - raised in PCOS
Testosterone
Management of PCOS
Diet, exercise COCP + metformin Anti-androgens Clomifene or gonadotrophins for fertility
Menopause + perimenopause
Menopause = permanent cessation of menstruation after 12 months of amenorrhoea (this period is perimenopausal)
Climaceric phase
Phase from transition from reproductive state to non-reproductive
S+S menopause
Hot flushes, night sweats Sexual dysfunction Depression, anxiety, irritability, mood swings
Long term effects of menopause
Osteoporosis CV disease Urogenital atrophy
HRT - which to use + SE
Hysterectomy = oestrogen alone Uterus still intact = oestrogen + progesterone SE of oestrogen: fluid retention, bloating, breast tenderness, nausea, headaches, leg cramps, dyspepsia SE of progesterone: fluid retention, breast tenderness, headache, mood swings, depression, acne, backache Combined: irregular bleeding, weight gain
Benefits of HRT
Reduced vasomotor + urogenital symptoms Reduced risk of osteoporosis + colorectal cancer
Risks of HRT
Risk of breast cancer (greatest with combined) Risk of endometrial cancer with unopposed oestrogen Risk of VTE + gallbladder disease
PMS - what is it, treatment
Symptoms during luteal phase of cycle Regression with onset of period Psychological, physical + behavioural Use COCP, oestrogen, GnRH analogues, SSRIs + CBT
Endometriosis pathology + investigations
Presence of endometrial tissue outside uterine cavity
Oestrogen dependant
Adenomyosis = ectopic endometrial tissue within myometrium
Investigations: laporoscopy
Endometriosis S+S
Secondary dysmenorrhoea, deep dysparaeunia, pelvic pain, infertility
Cyclical pain, can get bleeding from other organs (haematuria)
Endometriosis complications
Fibrosis, scarring, infertility, endometroma (chocolate cysts)
Endometriosis O/E findings
Adnexal masses Nodules in posterior vaginal fornix Thickening behind uterus Fixed retroverted uterus Rectovaginal nodules Investigate with laparoscopy
Management of endometriosis
Expectant 1st line
COCP, GnRH analogues, POP 2nd line
Surgery: ablation, resection, TAHBSO
Treatment of subfertility in endometriosis
Remove endometriomas surgically
PID causes
Infection which has spread from cervix to pelvis Usually STD, TOP or dilatation + curettage
RF for PID
Young, previous STD, new sexual partner, postpartum endometritis
S+S PID
Asymptomatic Lower abdo pain Discharge Deep dyspareunia Adnexal tenderness
PID complications
Fitz-Hugh-Curtis syndrome - perihepatitis (RUQ pain) Tubero-ovarian abscess Ectopic pregnancy Infertiltiy
PID treatment
Ceftriaxone IM + oral doxycycline + metronidazole Partner to have doxycycline for 1 week
Fibroids - what are they?
Benign tumours from the myometrium of the uterus Usually made of smooth muscle
Types of fibroids
Submucus: >50% projection into endometrial cavity
Intramural = within myometrium
Subserous: >50% of fibroid mass extends outside the uterus
Endometrial polyps - what are they, treatment
Adenoma Focal overgrowth of the endometrium - treatment is resection
S+S fibroids
Asymptomatic Dysmenorrhoea Menorrhagia Pressure symptoms (frequency) Pelvic pain Infertility Pain in pregnancy - from growth
Management of fibroids
GnRH (ulipristal acetate) shrink fibroids pre surgery Myomectomy Hysterectomy Uterine artery embolisation
Types of ovarian cyst
Enlarged follicular or corpus luteum cysts (functional cysts) Benign cystic teratomas = arise from germ cells Endometriomas = chocolate cysts
RF for ovarian cysts
Obesity Infertility Hypothyroidism Early menarche Tamoxifen therapy
S+S ovarian cysts
Chronic dull ache Pressure on organs - bowel disturbance or frequency Dyspareunia Bleeding, torsion, rupture Mass in abdo
Investigations for ovarian cysts
USS + CA125 = RMI
Management of cysts
Analgesia Laparotomy if acute abdo, ?torsion, rupture, haemorrhage
Overflow incontinence - what is it, investigations
Bladder is large + flaccid, little detrusor tone Usually due to injury Diagnosed when urinary residual is more than 50% of bladder capacity Bladder leaks when full
Continuous urinary incontinence - causes
Continuous leakage due to fistula or congenital abnormality
Management of stress incontinence
Weight reduction, stop smoking, reduce caffeine Pelvic floor for 3 months Duloxetine - enhances urethral sphincter activity. SE: nausea Periurethral injections Transvaginal tape
Management of urge incontinence
Anticholinergic drugs (oxybutynin) SE: dry mouth, constipation, dry eyes, urinary retention Imipramine (TCAs) Surgery Botulinum toxin A - injected into detrusor
Types of prolapse
Urethrocele (anterior, involves urethra) Cystocele (anterior, involves bladder) Apical (uterus, cervix + vagina) Enterocele (posterior, pouch of douglas) Rectocele (posterior, anterior wall of rectum)
Grading of prolapse
0 = no descent of pelvic organs 1 = surface of prolapse does not descend below 1cm above the hymenal ring 2 = extends from 1cm above to 1cm below the hymenal ring 3 = extends more than 1cm below the hymenal ring 4 = vaginal completely everted
Management of prolapse
Physio = pelvic floor Pessary Surgical repair
What are teratomas?
Dermoid cysts
Benign neoplasms derived from germ cell layers
Include skin, hair, blood, fat, teeth etc
Have Rokitansky’s protuberance
Most common causes of recurrent miscarriage
Antiphospholipid syndrome (15% of women with recurrent miscarriages)
Endocrine disorders eg diabetes, thyroid disorders, PCOS
Uterine abnormality
Chromosomal abnormalities
Smoking
What is tolterodine?
Muscarinic antagonist
Used for urge incontinence
First line pain relief for periods
NSAIDs d
Causes of primary amenorrhoea
Turners
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of repro system
Causes of secondary amenorrhoea
PCOS
Hypothalamic amenorrhoea (stress, excess exercise)
Hyperprolactinaemia
Premature ovarian failure
Thyroid issues
Sheehans (excessive blood loss causing ischaemic nerosis)
Asherman’s (intrauterine adhesions)
Symptoms of Sheehan’s
Agalactorrhoea
Amenorrhoea
S+S of hypothyroidism + hypoadrenalism
Lichen planus vs sclerosus
Sclerosus - intense itching, white plaques, postmenopausal commonly
Increased risk of squamous cell carcinoma
Lichen planus = itchy red-brown rash
Both treated with topical steroids
Managment of cervical ectropion
Cryotherapy with AgNO3
What are condyloma lata?
Wart like lesions on genitals, sign of secondary syphilis
How to do a smear?
Rotate clockwise 5 times
What is the average age of menopause, and what blood test is used if needed?
52 - FSH >30 indicates menopause
What is the rASRM score?
Grading for endometriosis - takes into account location, size, depth, adhesions
When is clomifene given to improve fertility + how does it work?
Days 2-6 - increases FSH levels via negative feedback
What is normal semen volume, concentration + motility?
>2ml
>50%
>15 million sperm
What is urodynamics?
measuring pressure/ volume relationship during filling + voiding + straining. Combined with ambulatory urodynamic monitoring
Management for HMB
Mefenamic acid, TXA or IUS 1st line
Endometrial ablation 2nd line
What investigations to do in HMB?
FBC
USS
Hysteroscopy if irregular or thickened
Endometrial biopsy using Pipelle
When should a intrauterine pregnancy show on USS?
bhCG >1500
TVUSS before 7 weeks
Adenomyosis S+S
Picked up on scan as incidental finding
S+S ovarian cysts
Unilateral pain, intermittent
When ruptured: sudden, lower abdo pain, afebrile, bleeding, increased urinary frequency
