Gynaecology Flashcards
Define primary amenorrhoea
(2 definitions)
Not starting menstruation
a) by the age of 14, with no other evidence of sexual development
b) by the age of 16, with other signs of sexual development (e.g. breast bud development)
What age ranges does ‘normal’ puberty take place in
a) girls
b) boys
8-14 years
9-15 years
How does puberty normally progress in girls? Which changes occur and in which order?
(3)
Breast bud development (thelarche)
Pubic hair development (pubarche)
Periods starting (menarche)
How long does puberty normally take from start to finish?
4 years
How often does menarche typically occur after onset of puberty?
2 years from start of puberty
What is hypogonadotropic hypogonadism (secondary hypogonadism)?
Gonadal failure (underactive gonads) caused by lack of LH/FSH release from anterior pituitary
Where in the HPG axis is the problem in hypogonadotropic hypogonadism (secondary hypogonadism)?
What will you see on a hormonal profile (LH and FSH levels)?
In the hypothalamus or pituitary gland
Low LH and FSH levels
What is hypergonadotropic hypogonadism (primary hypogonadism)?
Gonadal failure (underactive gonads) due to impaired response of the gonads to FSH and LH stimulation
Where in the HPG axis is the problem in hypergonadotropic hypogonadism (primary hypogonadism)?
What will you see on a hormonal profile (FSH and LH levels)? Why?
In the ovaries (gonads)
High FSH and LH levels
No negative feedback from sex hormone production
Name some endocrine causes of primary amenorrhoea (excluding primary/secondary hypogonadism)
Hypothyroidism Hyperprolactinaemia Congenital adrenal hyperplasia Turners Syndrome Androgen insensitivity Syndrome
What investigations should be ordered for suspected primary amenorrhoea? (2)
Pelvic USS
Hormone tests - FSH, LH, TSH, Prolactin
What are some hypothalamic causes of primary amenorrhoea? (3)
Excessive exercise
Stress
Eating disorder
What is the management of primary amenorrhoea?
Treat underlying cause
Primary ovarian failure or PCOS —> COCP
What is a patient with primary amenorrhoea at risk of, due to low oestrogen levels?
What is the treatment for this, if the primary amenorrhoea has a permanent cause? (2)
Osteoporosis
Ensure adequate vitamin D and calcium
Hormone replacement therapy - e.g. COCP
Define secondary amenorrhoea
No menstruation for more than 3 (or 6) months after having previously started periods
What are the two most common causes of secondary amenorrhoea?
Pregnancy (most common)
Menopause
What are some hypothalamic causes of secondary amenorrhoea?
Excessive exercise
Low BMI
Eating disorder
Stress
State two pituitary causes of secondary amenorrhoea
Prolactinoma (pituitary tumour)
Pituitary failure (Sheehan syndrome)
What are some ovarian causes of secondary amenorrhoea? (3)
PCOS
Premature ovarian failure
Menopause
State a uterine cause of secondary amenorrhoea
Asherman’s Syndrome
What thyroid disorder is associated with secondary amenorrhoea?
Hypothyroidism
Why do high prolactin (hyperprolactinaemia) levels cause secondary amenorrhoea?
Prolactin prevents the release of GnRH from the hypothalamus
Increased prolactin —> Low GnRH —> Low FSH/LH —> hypogonadotropic hypogonadism (primary hypogonadism)
What is the most common cause of hyperprolactinaemia?
Pituitary adenoma secreting prolactin
If high prolactin levels are found on investigation of hyperprolactinaemia, what investigation is indicated?
CT/MRI head
What is the medical treatment for hyperprolactinaemia?
Dopamine agonists - e.g. bromocryptine
What LH/FSH levels are seen in…
a) primary ovarian failure
b) PCOS
High FSH
High LH (LH/FSH ratio)
What does a progesterone stimulation test, test for?
Whether there is sufficient oestrogen
What is the normal and abnormal result of a progesterone stimulation test?
Normal = withdrawal bleed within 7 days of stopping progesterone
Abnormal = no withdrawal bleed, low oestrogen is preventing build up of endometrium
What is androgen insensitivity syndrome?
Condition where there is insensitivity of the body to androgens (testosterone) so male characteristics do not develop normally
What is the external and internal sexual anatomy of someone with androgen insensitivity syndrome?
External - normal female genitalia, female breasts
Internal - testes, NO uterus/upper vagina/Fallopian tubes/ovaries
What is the management of androgen insensitivity syndrome? (3)
Generally raised as female - up to individual
Oestrogen therapy
Bilateral orchidectomy
In what pattern is androgen insensitivity syndrome inherited?
What karyotype will he possess?
X-linked condition
46 XY - male karyotype
What is premenstrual syndrome caused by?
Fluctuations in hormones during the premenstrual period (especially fall in oestrogen and progesterone)
What are common symptoms of premenstrual syndrome? (6)
Bloating Headaches Backache Anxiety Low mood Irritability
When in the cycle do symptoms of premenstrual improve?
With onset of menstruation
When symptoms of premenstrual syndrome are severe and have significant effect on quality of life, it is called…
Premenstrual dysphoric disorder
What is the management of premenstrual syndrome?
Lifestyle changes
COCP
SSRIs
What are some common causes of menorrhagia?
FIbroids
PCOS
Hyperthyroidism
Contraceptives
Connective tissue disease - e.g. Ehlers-Danlos syndromes
Bleeding disorders - e.g. Von Willebrand disease
Endometrial cancer
What examination should be performed in cases of menorrhagia?
Pelvic examination
State some indications for pelvic/transvaginal USS
Abnormal pelvic examination
Post-coital bleeding
IMB
Other pelvic symptoms - e.g. pelvic pain
What is the non-contraceptive medical management for menorrhagia? (2)
Tranexamic acid
Mefanamic acid
What is the difference between tranexamic and mefanamic acid?
(Type of medication and symptoms it improves)
Tranexamic = anti-fibrinolytic, reduces bleeding
Mefanamic = NSAID, reduces bleeding AND associated pain
What is the contraceptive management of menorrhagia?
Mirena coil
COCP
POP
Depo injection
What is the final (last resort) management for menorrhagia? (2)
Endometrial ablation
Hysterectomy
What is a fibroid? What is another name for them?
Tumour of the smooth muscle of the uterus
Uterine leiomyoma
What is the most common age for development of fibroids?
Late reproductive age (pre-menopause)
What ethnicity are fibroids most common in?
Afro-Caribbean
What hormone affects the growth of fibroids?
Oestrogen causes fibroids to grow
Name 4 types of fibroids based on its location in the uterus
Intramural
Subserosal
Submucosal
Pedunculated
Where is an intramural uterine fibroid located?
Within the myometrium
Where is a subserosal uterine fibroid located?
How do they typically grow?
Just below outer layer of myometrium
Outwards, becoming very large and filling abdominal cavity
Where is a submucosal uterine fibroid located?
Below the endometrium
What is a pedunculated uterine fibroid?
A fibroid on a stalk
What are the symptoms associated with uterine fibroids? Which symptom is the most common?
Menorrhagia (most common)
Longer menstruation > 7 days Abdominal pain, worse on menstruation Bloating Urinary or bowel symptoms Deep dyspareunia Reduced fertility
Through which investigation are uterine fibroids diagnosed?
Pelvic/transvaginal USS
What is included in the conservative management of uterine fibroids?
Analgesia
Tranexamic acid
Mirena coil
COCP
GnRH agonists - e.g. goserelin
How does goserelin work in the treatment of uterine fibroids? What is its mechanism of action?
Reduces size of fibroids by inducing menopause and reducing oestrogen supply to fibroid
GnRH agonist
Name some invasive procedures for the management of uterine fibroids
Uterine artery embolisation
Myomectomy
Hysteroscopic endometrial ablation
Hysterectomy
How does uterine artery embolisation work in the treatment of uterine fibroids?
Blocks blood supply to fibroid, causing it to shrink
What are some complications of uterine fibroids?
Menorrhagia —> anaemia
Infertility
Pregnancy complications - e.g. Premature labour, miscarriages
Constipation
Urinary outflow obstruction/UTIs
Red degeneration
What is red degeneration?
Complication of uterine fibroids
Haemorrhage infarct of the fibroid
Typically occurs in pregnancy
What are the symptoms of red degeneration of a uterine fibroid?
What is the management?
Abdominal pain
Low grade fever
Vomiting
Conservative
What are some differential diagnoses for post-coital bleeding? (6)
Idiopathic Cervical ectropion Infection Cervical cancer Polyp/fibroids Other cancers - endometrial, vaginal
What are some differential diagnoses for IMB? (6)
Cervical ectropion Polyp/fibroids Endometrial cancer Cervical cancer STI Contraception
What is cervical ectropion?
When the columnar epithelium of the endocervix is displayed on the ectocervix and is visible on speculum examination
What causes cervical ectropion?
Increased oestrogen levels
What are some symptoms of cervical ectropion?
Often asymptomatic
Discharge
Post-coital bleeding
What is the treatment in symptomatic cases of cervical ectropion?
Silver nitrate therapy
Diathermy
What is the transformation zone of the cervix?
The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
What is endometriosis?
The presence of ectopic endometrial tissue outside the uterus
What is the theory for the cause of endometriosis?
During menstruation, there is backflow of the endometrial lining through Fallopian tubes and into the pelvis (retrograde menstruation)
It then seeds itself at locations around the pelvis
When in the menstrual cycle are endometriosis symptoms the worst?
During menstruation
What are the symptoms of endometriosis? (5)
Cyclical abdominal/pelvic pain
Deep dyspareunia
Cyclical bleeding from other sites - e.g. haematuria
Fertility problems
What is the gold standard investigation for endometriosis?
Diagnostic laparoscopy for abdominal endometrial tissue
What are some management options for endometriosis? (5)
How do they work?
Analgesia - symptom treatment
COCP - regulate cycle
Depo injection (long term progesterone) - can stop menstruation
GnRH agonist (goserelin/Zoladex) - induces ‘menopause’
Laparoscopic surgery to dissect/cauterise ectopic tissue
What is the last resort treatment of endometriosis?
Hysterectomy and bilateral salpingo-opherectomy
Not guaranteed to resolve symptoms
What is the triad associated with a diagnosis of PCOS?
Polycystic ovaries on scan
Anovulation
Hyperandrogenism
What is a tumour marker for the detection of ovarian cancer?
CA125
Ovarian cysts are typically asymptomatic, what symptoms can they present with?
Pelvic pain
Bloating
Pelvic mass on examination if large
How are ovarian cysts typically diagnosed?
Incidentally on pelvic USS
Name 5 types of ovarian cyst
What is the most common?
Functional cysts - follicular (most common) or corpus luteum
Serous cystadenoma
Mucinous cystadenoma
Dermoid cyst
What causes a follicular ovarian cyst?
What is the prognosis?
When a developing follicle fails to rupture
Harmless and usually disappear after a few cycles
What causes a corpus luteum ovarian cyst?
Follicle releases the egg, but the corpus luteum persists and fills with fluid
What is a serous cystadenoma?
Benign tumour of the epithelial cells
What is a mucinous cystadenoma?
Another type of benign tumour of epithelial cells, can become very large
What is a dermoid cyst?
Benign ovarian tumours (teratomas)
Originate from germ cells and can fill with various tissue types (hair and bone)
What is the main complication of dermoid cysts?
Torsion
What are the complications of ovarian cysts? (3)
Torsion
Haemorrhage
Rupture
What is ovarian torsion?
Where the ovary twists on itself and the blood supply is disturbed
What can cause ovarian torsion? (2)
Usually secondary to other ovarian pathology
Cyst
Tumour
In what aged women, does ovarian torsion typically occur?
Women of reproductive age
What are some symptoms of ovarian torsion?
What is sometimes seen on examination?
Acute unilateral iliac fossa pain
Nausea
Vomiting
Tenderness
Palpable mass and tenderness on examination
How is ovarian torsion diagnosed?
USS
- Ideally transvaginal
What are some complications of ovarian torsion? (4)
Pain
Infection
Rupture
Loss of function of ovary (other ovary can usually compensate)
What are some symptoms of PCOS? (5)
Weight gain Hirsutism - male pattern hair growth Oligomenorrhoea /amenorrhoea Acanthosis nigricans Impaired glucose tolerance
What LH, FSH, insulin and testosterone levels are seen?
LH - raised
LH:FSH - raised
Insulin - raised
Testosterone - raised
What criteria is used for diagnosis of PCOS?
Any two of the following three
Infrequent or absent ovulation
Hyperandrogenism
Polycystic ovaries on USS
How can insulin resistance as a result of PCOS be treated?
How does it work?
Metformin
Improves insulin resistance and reduces circulating insulin levels
What effect do high levels of insulin have on androgen levels?
Promotes the release of androgens from ovaries and adrenal glands
Increases them
What is the general management for PCOS? (2)
Weight loss
COCP
What is the stepwise approach to the management of infertility as a result of PCOS?
Weight loss
Metformin
Clomifene
What are some medications that can be used to treat hirsutism as a result of PCOS?
Dianette (anti-androgen contraceptive)
Spironolactone
Finasteride
How is the menopause diagnosed?
Cessation of periods for 12 months after last menstrual period
How long is contraception recommended for women after their last menstrual period?
2 years for women under 50
1 year for women over 50
How are oestrogen, progesterone, LH and FSH levels affected by the menopause?
LH/FSH = HIGH, in response to drop in gonadal hormones
Oestrogen/Progesterone = LOW
What hormonal changes cause the menopause?
Drop in oestrogen and progesterone
What are some peri-menopausal symptoms?
Hot flushes Mood swings Premenstrual syndrome Irregular periods Heavier or lighter periods Reduced libido Vaginal dryness
What are some of the management options for peri-menopausal symptoms? (3)
HRT
SSRIs - e.g. fluoxetine, citalopram
CBT
What are some non-hormonal treatments for peri-menopausal symptoms?
Lifestyle advice
SSRIs
SSNRI - Venlafaxine
Clionidine
How should medical management differ when treating a peri-menopausal woman compared to post-menopausal?
Peri = cyclical treatment
Post = continuous
Oestrogen is combined with progesterone in women with a uterus to reduce the risk of…
Endometrial cancer
Oestrogen combined with progesterone increases the risk of…
Breast cancer
When can oestrogen be given unopposed to menopausal women?
If they have had a hysterectomy
As well as reducing the symptoms of the menopause what is another benefit of HRT?
Reduced osteoporosis
What are some risks associated with HRT? (4)
Breast cancer Endometrial cancer Stroke Coronary artery disease Thrombosis
What are some side effects of HRT? (4)
Bloating Breast swelling Breast tenderness Weight gain Headaches
What is FGM?
Surgically changing the female genitals for non-medical reasons
Is FGM illegal?
YES
Legal requirement to report any discovered cases to the police
Which country has the highest levels of FGM?
Somalia
What are the 4 types of FGM?
1 = removal of the clitoris
2 = removal of clitoris and labia minora
3 = narrowing or closing vagina orifice
4 = any other unnecessary procedures to the female genitalia
What is pelvic organ prolapse? What causes it?
Descent of pelvic organs into the vagina
Weakness and laxity of ligaments and muscles surrounding the uterus
What is a uterine prolapse?
Where the uterus itself prolapses into the vagina?
What is a rectocoele?
Defect in the posterior vaginal wall causing the rectum to prolapse into the vagina
What symptom is a rectocoele particularly associated with?
Constipation
+ Urinary retention
What is a cystocoele?
A defect in the anterior vaginal wall causing the bladder to prolapse in to the vagina
What are the grades of uterine prolapse?
Grades 0 - 5
Grade 0 = normal
Grade 1 = remains above introitus by more than 1cm
Grade 2 = less than 1cm above or below introitus
Grade 3 = between 1cm below the introitus and at least 2cm of vagina left above introitus
Grade 4 = full eversion of the vagina
What are some risk factors for pelvic organ prolapse?
Multiple vaginal deliveries Traumatic vaginal deliveries Increasing age Obesity Chronic constipation Connective tissue disorder
What symptoms do patients with pelvic organ prolapse present with?
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Feeling of something coming down
On what movements do pelvic organ prolapses typically get worse?
Straining
Bending down
What are the 3 management options for pelvic organ prolapse?
Conservative management
Vaginal pessary
Surgery
Outline the conservative management of pelvic organ prolapse (4)
Physiotherapy - pelvic floor exercises
Lifestyle changes based on symptoms
Medications for symptoms - e.g. stress incontinence
Vaginal oestrogen cream
How do vaginal pessaries work? How often should they be changed/cleaned?
Inserted inside the vagina to provide support for the uterus
Cleaned regularly and changed every 4 months
What are some side effects of vaginal pessaries?
Vaginal irritation/erosion
What complication has been associated with the use of mesh repairs in the surgical management of pelvic organ prolapse?
Chronic pelvic pain
What is urge incontinence?
Leakage of urine due to detrusor overactivity
What is stress incontinence?
Leakage of urine on increased intra-abdominal pressure (laughing/coughing), due to weakness of pelvic floor muscles and sphincters
What are some risk factors for developing incontinence?
Increase age Increased alcohol Increased caffeine Increased carbonated drinks Increased BMI Previous pregnancies Previous vaginal deliveries
What are some investigations that can be undertaken for urinary incontinence? ($)
Urinalysis
Bladder diary
Post void bladder scan
Urodynamic studies
What is the management of stress incontinence? (5)
Weight loss Pelvic floor exercises Reduced fluids, caffeine, alcohol, carbonated drinks Medical management - duloxetine Surgery - tension free vaginal tape
What is the management of urge incontinence? (2)
Bladder retraining
Anti-muscarinic medications - e.g. oxybutynin, tolterodine
