Gynaecology Flashcards
Where is FSH and LH released from?
Anterior pituitary gland
Role of FSH
Stimulates follicular activity promoting estradiol production from granulosa cells
Role of LH
Egg release Corpus luteum progesterone production
What are the different phases of the menstrual cycle?
FOLLICULAR PHASE 0-7 Menses 7-14 Proliferative phase
LUTEAL PHASE 14-28 Secretory phase
How long does an unfertilised egg live for?
How long does sperm survive for?
72 hours
5 days
What day of the menstrual cycle is there an egg released?
Day 14
What hormone test is best for measuring whether ovulation has occured?
Day 21 Progesterone (MID-LUTEAL)
What happens during the follicular phase?
Shedding- FSH surge- Follicle maturation- follicle release oestrogen- Thickening of endometrium
What happens during the luteal/secretory phase?
High oestrogen stimulates an LH surge
LH surge causes ovulation
Corpus luteum- Progesterone release
For how many days does the corpus luteum survive?
14
What happens after death of the corpus luteum
Progesterone decreases
Endometrial arteries constrict
Menstruation
How is progesterone production maintained after implantation?
Blastocyst implants in decidua causing HCG production which maintains CL progesterone production early on, placenta takes over prog production after 10-12 weeks
When is HCG production from the blastocyst detectable
9-10 days post-conception
What happens to HCG levels in the first few weeks of pregnancy?
Doubles every 48 hours
After ovulation when does implantation occur?
8-10 days (~D23 of cycle) estimated from LMP
What is dysmenorrhoea?
Excessive pain during the menstrual period
Causes of primary and secondary dysmenorrhoea?
Primary= No underlying pathology likely 1-2 years following menarche 50% of women! Secondary= Many years after menarche, underlying pathology, may have dyspareunia (Endometriosis, IUD, Adenomyosis, Fibroids, PID)
Management of primary dysmenorrhoea
NSAIDS- Mefenamic acid
Then COCP to suppress ovulation
What do you do if someone presents with secondary dysmenorrhoea
Refer to Gynae for investigation
Causes usually treated with contraception
What is Mettelschmerz
Mild pain
14 days before ovulation
How do you define menorrhagia?
Prolonged >7D and Heavy >80ml bleeding
Causes of menorrhagia
IUCD, Fibroids, Endometriosis, Adenomyosis, PID, Polpys, Hypothyroidsim, Coag disorders
Essential investigations for Menorrhagia
FBC!
+/- TVUS, Endometrial biopsy, Outpatient hysteroscopy
Management of menorrhagia
1) Mirena coil
2) Tranexamic acid, Mefenamic acid, NSAIDS,COCP
3) Ablation, Hysterectomy
Define Polymenorrhoea
An abnormally short interval between regular menses
<21 days
Define Oligomenorrhoea
What is most likely to cause this?
An abnormally long interval between regular menses
>35 days
?PCOS
What should post-menopausal bleeding be treated as until proven otherwise
Endometrial cancer (Number one cause is atrophic vaginitis)
Primary Amenorrhoea
Failure to start menstruating by 14
or 16 yrs with no breast development
What is secondary amenorrhoea
Periods stop for 6 months without pregnancy
What investigations should be done for secondary amenorrhoea?
TSH, Gonadotrophins, Prolactin, Beta-HCG, Androgen levels
Causes of secondary amenorrhoea
44% Hypothalamic-Pituitary-Ovarian axis disorders- COMPETITIVE ATHLETES
Hyperprolactinaemia
Ovarian insufficiency because Chemo/RT?
Ashermanns or Sheehans
Key causes of post-coital bleeding
Cervical ectropion
or… Cervicitis, Cancer, Polyps, Trauma
Key investigations if a women presents with abnormal bleeding
Rule out pregnancy related problems with PT Review Meds LFTs, Urinalysis, FBC + Haematinics Examination Clotting ?Uss ?biopsy?Scopy
What is Post-menstrual syndrome
Common and typically mild appearance of a myriad of cyclical symptoms that interfere with the day’s normal events
How do you manage post-menstrual syndrome
1) Supportive measures +/- COCP +/- Fluoxetine
2) Estradiol patches or Mirena
3) GNRH antagonists or HRT
4) Total Hysterectomy and BSO
How does PCOS impact the levels of different hormones
LH Chronically elevated
FSH suppressed
Increased circulating testosterone
What part of the menstrual cycle is fixed at 14 days
Luteal phase
What is the Rotterdam criteria for PCOS?
2/3 needed
1) Polycystic ovaries on USS
2) Hyperandrogenism- Body hair, Acne
3) Oligo/Anovulation
Key features of PCOS starting with the most common
Menstrual irregularities Subfertility Hirsutism Obesity Acne, Acanthosis Nigricans
What does PCOS look like on USS
String of pearls appearance
Management of PCOS if wanting to promote fertility
Weight loss
Ovulation induction- CLOMIFENE
Metformin to improve insulin sensitivity and improve fertility
?Anti-androgen
PCOS management if not wanting to promote fertility
COCP- Dianette and Yasmin both good at ameliorating androgenic symptoms
Regular 3/12 withdrawal bleeds
Wx loss
Complications of PCOS
Endometrial cancer Insulin resistance/T2DM HTN/CVD/Dyslipidaemia/Strokes Weight Gain Ovarian hyperstimulation risk if IVF etc
Average age of the menopause
52 years (51-54)
What increases the risk of an early menopause
Smoking
Hysterectomy
How do you diagnose the menopause
Retrospective
>50= 12 months later
<50= 24 months later
What is the physiology of the menopause
Termination of ovarian follicular development despite high FSH and LH
Gonadotrophin/LH/FSH rise to try and stimulate, but this fluctuates therefore not useful as a reading
What are the menstrual irregularities associated with the menopause
Mostly 4-5 years of varying cyle length
10% cease abruptly
What are the early changes associated with the menopause
Vasomotor symptoms- Sweats, Tiredness, mood, Cognitive, Concentration
Loss of collagen- Joints, skin
Fat redistribution
What are the medium term changes associated with the menopause
Vaginal atrophy, dyspareunia, soreness
Bladder frequencey, dysuria, UTis
Bleeding
What are the long term changes associated with the menopause
Osteoporosis
CVD
What are the hypoestrogenic changes associated with the menopause?
Vasomotor instability 5-7years decreases with age
Osteoporosis
Genital atrophy
Mood disturbance
What are the benefits of HRT
Improves vasomotor symptoms
Improves urogenital/Sexual function
Decreases OP related fractures
Decreases CRC risk
What are the disadvantages of HRT
Endometrial hyperplasia and adenocarcinoma
Breast cancer
VTE risk
CI to HRT
Liver disease, Thromboembolic disorders, Oestrogen dependent cancer, Pregnancy/Breast feeding
Apart from HRT, How can the menopause be managed
Diet and exercise good for symptom relief Mirena coil if menorrhagia SSRIs for vasomotor symptoms Calcium, Vit D, Bisphos for OP Contraception until >1 yr amenorrhoea
Indication of oestrogen only HRT in the menopause
Absent uterus
Indication for continuous combined HRT in the menopause
Benefits?
> 54 or >1 year amenorrhoea
NO BLEEDING
What is sequential combined cyclical HRT
Daily oestrogen and then progesterone for last 10-14 days of the cycle
There is a withdrawal bleed
What is sequential long cyclical HRT
Oes for 3 months
Prog for the 2nd half of the 1st month
has 3 monthly withdrawal bleeds
Which HRT is associated with the highest risk of breast cancer?
E+P> Tibolone>E only
What is premature ovarian failure
Menopausal symptoms (1 yr meses cessation) and inc Gondotrophin levels before 40 yrs
How is premature ovarian failure confirmed
FSH test where levels are v.High
Risk factors for premature ovarian failure
Chemo, RT
Although can be idiopathic
What 3 key factors must be considered when deciding the best HRT?
1) Uterus present?
2) Perimenopausal or menopausal?
3) Systemic or local effect required?
What HRT is best if someone is Perimenopausal and amenorrhoea <1 yr
Cyclical combined
Can track periods as there will be withdrawal bleeds
When is continuous combined HRT most appropriate
> 1 yr since LMP or taken cyclical for >1 yr
There will likely be No bleeds
What type of HRT has a strictly local effect?
Creams and pessaries
Key side effects of HRT to tell patients
Nausea, erratic PV bleed, headaches, leg cramps, Dyspepsia, Bloating, Breast tenderness
What is the difference between endometriosis and adenomyosis?
Endometriosis is ectopic endometrial tissue outside the uterine cavity
Adenomyosis is endometrium within the myometrium
How does adenomyosis look on an MRI
Enlarged and boggy
Where is the most common site of endometrial tissue
Ovary
then- Peritoneum, pouch of douglas
What age range is endometriosis likely to present? When does it regress?
Post menarche likely ~20s
Regression post-menopause (oestrogen dependent)
Key hallmark feature of endometriosis
CYCLICAL PAIN
Aside from cyclical pain, what other features does endometriosis present with?
Abnormal bleeding- PCB, IMB Deep dyspareunia Dyschezia Enlarged tender adnexa Sub-fertility
What position is the position of the uterus likely to be in endometriosis? Why?
FIXED RETROVERTED
The scar tissue reduces mobility
Gold standard diagnosis of endometriosis
Laparoscopy for direct visualisation
How can endometriosis cause free fluid in the abdomen?
Rupture of an endometrioma
+ Intense pain
What is the goal of treatment for endometriosis?
Suppression of ovulation and induction of amenorrhoea
Medical management of endometriosis
1) NSAIDS
2) COCP Back to back or Mirena Coil
3) GnRH Antagonists (Chemical menopause)
When is surgical management for endometriosis good?
Young women desiring fertility
Surgical management of endometriosis
Laparoscopic excision or laser
Definitive is Hysterectomy with BSO + HRT after
Presentation of PID
Bilateral lower abdominal pain, adnexal tenderness, perihepatitis Fever Purulent discharge Deep dyspareunia IMB, PCB, Menorrhagia
What core history points must you cover in ?PID
O+G Hx, Sexual Hx
Key Core investigations for ?PID
Pregnancy test to exclude ectopic
Bimanual- Cervical motion tenderness, mass
Speculum- VVS, HVS, EC
Urine dip, Obs, MSU?
Core criteria for diagnosis of PID
One of: T>38, Leucocytosis, ESR>15
One of: Adnexal pain, Cervical motion tenderness, Adnexal mass
Complications of PID
Ectopic, Infetility, Chronic dyspareunia/pain, Fitz Hugh Curtis, Abscess
In a PID what would a palpable adnexal mass suggest?
Abscess
Especially if systemically unwell
How do you manage PID?
Treat as if it is an STI
Rest
Analgesia
Consider IUD removal
Advice on sexual intercourse for a PID patient
No sex until both you and your partner are treated
Top 2 causes of PID
1) chlamydia
2) Gonorrhoea
What are the RF for PID
<25yrs, Multiple partners, vaginal douching, unprotected sex, IUD, ToP
In a patient with chronic pelvic pain and abnormal VE findings what must be done?
Diagnostic laparoscopy or uss
Presentation of a threatened miscarriage
Bleeding +/- Pain
OS= Closed
Uterine size= Correct for gestational age
What % of threatened miscarriages actually miscarry
25%
Presentation of inevitable miscarriage
Heavy clotted vaginal bleeding
OS= Open
Presentation of a complete miscarriage
Presents with bleeding that has no lessened
OS= Closed
Uterine size= Returned to Normal size
Presentation of an incomplete miscarriage
OS= Open
Uterine scan shows mixed debris
Presentation of a missed or delayed miscarriage
Entire gestational sac in uterus No growth No fetal heart beat OS= Closed Light discharge Uterus is small for GA
When is a miscarriage defined as recurrent
3+ times
When do most miscarriages present
<12 weeks
MOST FIRST 12-14 DAYS
Best way to investigate a miscarriage
TV USS
USS Dx criteria for miscarriage
No FHB + CRL> 7mm or Ges.Sac size>25mm
What is a miscarriage
Loss of pregnancy before 24 weeks
General presenting features of a miscarriage
Vaginal bleeding, Abdominal pain, Regression of pregnancy related symptoms
1st line management for miscarriage? When is a PT done?
Expectant
7-14 days
PT 3/52 after