Gynaecology Flashcards
What is the difference between primary and secondary amenorrhoea?
Primary= when the patient never developed periods Secondary= when the patient previously had periods but they have stopped.
Why may a patient be experiencing primary amenorrhoea?
Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads
(Hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology
What is secondary amenorrhoea due to?
Pregnancy
Menopause
Physiological stress (exercise, low body weight, psychosocial)
Polycystic ovarian syndrome
Medications- hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hypo or hyper)
Excessive prolactin- prolactinoma
Cushings
What is meant by abnormal uterine bleeding?
Irregularities in the menstrual cycle, affecting the frequency, duration, regularity of cycle length and volume of menses.
Irregular menstrual periods indicate either anovulation or irregular ovulation.
What is intermenstrual bleeding?
Bleeding between menses
What are the key causes of intermenstrual bleeding?
Hormonal contraception Cervical ectropion, polyps or cancer Sexually transmitted infection Endometrial polyps or cancer Vaginal pathology Pregnancy Ovulation can cause spotting in some women Medications- SSRIs, anticoagulants
What are the causes of Dysmenorrhoea?
Describes painful periods, causes are: . Primary Dysmenorrhoea (no underlying pathology) . Endometriosis/ adenomyosis . Fibroids . Cervical or ovarian cancer . Pelvic inflammatory disease . Copper coil
What is the cause of menorrhagia?
Dysfunctional uterine bleeding (cause unknown) Extremes of reproductive age Fibroids Endometriosis/ adenomyosis Pelvic inflammatory disease (infection) Contraceptives- copper cool Anticoagulants Von Willebrand disease Diabetes and hypothyroidism Connective tissue disorders Endometrial hyperplasia or cancer Polycystic ovarian syndrome
What could cause postcoital bleeding?
Red flag Key causes are: Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
What are the causes of pelvic pain?
. UTI . Dysmenorrhoea (painful periods) . IBS . Ovarian cysts . Endometriosis . Pelvic inflammatory disease (infection) . Ectopic pregnancy . Appendicitis . Pelvic adhesions . Ovarian torsion . Inflammatory bowel disease
What can be the cause of vaginal discharge?
Vaginal discharge is actually a normal physiological finding, however excessive, discoloured or foul smelling can indicate the following…
. Bacterial vaginosis . Trichomonas vaginalis . Foreign body . Cervical ectropion . Polyps . Malignancy . Pregnancy . Ovulation (cyclical) . Hormonal contraception
What is pruritus vulvae?
Itching of the vagina and vulva, causes include... Irritants Atrophic vaginitis Infections- candidiasis (thrush) and public lice Eczema Stress Vulval malignancy Pregnancy related vaginal discharge Urinary or faecal incontinence Stress
What is meant by hypogonadism?
Lack of sex hormones, oestrogen and testosterone
The lack of sex hormones, is due to one of two reasons…
1) hypogonadotropic hypogonadism- deficiency in LH and FSH
2) hypergonadotropic hypogonadism- a lack of response to LHand FSH by the gonads
What is meant by HYPOgonadotropic hypogonadism?
Deficiency in LH and FSH leading to deficiency in the sex hormones
LH and FSH= gonadotropins
No Gonadotropins to stimulate the gonads
What are the causes of hypogonadotropic hypogonadism?
Hypopituitarism
Damage to hypothalamus or pituitary for example: radiotherapy/surgery for cancer
Significant chronic conditions- temporarily delay puberty (CF, IBD)
Excessive exercise or dieting
Constitutional delay in growth and development
Endocrine disorders- GH deficiency, hypothyroidism, Cushing’s, hyperprolactinaemia, Kallman syndrome
What is Kallman syndrome?
Genetic condition causing hypogonadotropic hypogonadism, it is associated with anosmia.
What is hypergonadotropic hypogonadism?
Where the gonads fail to respond to stimulation from the gonadotropins, lack of negative feedback therefore leads to high levels of gonadotropins (hypergonadotropic) and low sex hormones (hypogonadism)
What are the causes of hypergonadotropic hypogonadism?
Previous damage to the gonads (torsion, cancer, infections like mumps)
Congenital absence of the ovaries
Turners syndrome
What is congenital adrenal hyperplasia?
Congenital deficiency of 21- hydroxylase enzyme, this causes underproduction of cortisol and aldosterone and overproduction of androgens from birth.
How does congenital adrenal hyperplasia present?
In severe cases, neonates are unwell shortly after birth, with electrolyte disturbances and hypoglycaemia
In mild cases, female patients can present later in childhood or at puberty, with typical features…
. Facial hair, deep voice, primary amenorrhoea, early puberty, tall for their age
What is androgen insensitivity syndrome?
Occurs in males, tissues are unable to respond to androgens, have female external genitalia but testes In the abdomen or inguinal canal.
What bloods should you do when someone is experiencing primary amenorrhoea?
FBC and ferritin for anaemia
U and E’s for CKD
Anti TTG or anti EMA for coeliac
Hormonal blood tests;
. FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
. TFTs
. Insulin like growth factor (screening for GH deficiency)
. Prolactin (raised in hyperprolactinaemia)
. Testosterone (raised in PCOS, androgen insensitivity syndrome and congenital adrenal hyperplasia)
. Genetic testing- microarray test to look for genetic conditions such as: turners
. Imaging- X-ray of wrist to assess bone age and diagnosis of constitutional delay
Pelvic US to assess ovaries and other pelvic organs
MRI of the brain to look for pituitary pathologyj
How do you treat patients with hypogonadotropic hypogonadism causing primary amenorrhoea ?
Pulsatile GnRH
Or replacement sex hormones in the form of COCP if pregnancy not wanted
How do you treat a patient with amenorrhoea due to ovarian cause ( PCOS, damage or absence of ovaries?)
COCP
How does physiological stress lead to secondary amenorrhoea?
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea, this is the hypothalamus responding to situations where the body is not fit for pregnancy!
What are the pituitary causes of secondary amenorrhoea?
Pituitary tumours- prolactin secreting prolactinoma
Pituitary failure- trauma, radiotherapy, surgery, Sheehan syndrome
What is the most common cause of hyperprolactinaemia and why does it cause secondary amenorrhoea?
Pituitary adenoma secreting prolactin
Patients with amenorrhoea, associated with low oestrogen levels are at risk of osteoporosis, therefore what should they be treated with?
When amenorrhoea lasts more than 12 months…
. Ensure adequate vit D and calcium intake
. HRT/ COCP
What is premenstrual syndrome?
Psychological, emotional and physical symptoms which occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.
The symptoms resolve once menstruation begins
What is the presentation of premenstrual syndrome?
Long list of symptoms, but common ones include... . Low mood . Anxiety . Mood swings . Irritability . Bloating . Fatigue . Headaches . Breast pain . Reduced confidence . Cognitive impairment . Clumsiness . Reduced libido
How is diagnosis of premenstrual syndrome made?
Symptom diary over two menstrual cycles
What is the treatment of PMS?
General healthy lifestyle changes (improving diet, exercise, alcohol, smoking, stress)
SSRIs antidepressants
CBT
COCPs with Drospirenone (yasmin) due to its anti mineralcorticoid effects
What should you ask about in a history of heavy menstrual bleeding?
age at menarche Cycle length, days menstruating and variation Intermenstrual bleeding and post coital bleeding Contraceptive history Sexual history Possibility of pregnancy Plans for future pregnancies Cervical screening Migraines with or without aura PMH and past drug history Smoking and alcohol history Family history
How do you assess patients with heavy menstrual bleeding?
If they are at low risk…
Age <45 years old
No inter menstrual bleeding
No risk factors for endometrial cancer
Then you would do history, examination and full blood count and start them in first line treatment
If they are at high risk Age >45 years Inter menstrual bleeding Suspected pathology Risk factors for endometrial cancer
Then you would do history, examination, full blood count, ultrasound scan, hysteroscopy and biopsy
What investigations should be done if someone is experiencing heavy menstrual bleeding?
Pelvic examination with a speculum and bimanual should be performed, unless straightforward history of HMB and no risk factors/ symptoms
FBC- iron deficiency anaemia
Hysteroscopy if suspected fibroids, endometrial pathology, persistent intermenstrual bleeding.
USS if large fibroids, obesity, adenomyosis is suspected
Consider: swabs, coagulation screen, ferritin if they are clinically anaemic, TFTs
How do you treat heavy menstrual bleeding (medical management) ?
Tranexamic acid- when there’s no associated pain
Mefenamic acid- when there’s associated pain (NSAID reduces both bleeding and pain)
Management when contraception is acceptable/ wanted…
1) mirena coil
2) COCP
3) cyclical oral progesterone (norethisterone- however this cannot be used long term!)
Progesterone only contraception can be tried- POP, implant, depo injection
What are the surgical options for HMB?
Endometrial ablation and hysterectomy.
What are fibroids?
Benign tumours of the smooth muscle of the uterus, they are also called uterine leiomyomas, they are oestrogen sensitive.
What are the different types of fibroids you can get?
Intramural (within the myometrium)
Subserosal (just below outer layer of uterus)
Submucosal (just below the endometrium)
Pedunculated (on a stalk)
What is the presentation of fibroids?
Prolonged menstruation Abdo pain Bloating, feeling full in the abdomen Urinary or bowel symptoms Deep dyspareunia Reduced fertility .
What are the investigations of fibroids?
Hysteroscopy- investigation for fibroids presenting with heavy periods
Pelvic ultrasound- bigger fibroids
MRI scanning -may be considered before surgical options
How do you treat fibroids less than 3cm?
This is the same treatment as heavy menstrual bleeding..
. mirena coil (first line)
. Tranexamic acid and NSAIDD
. COCP
. Cyclical oral progestogens
Surgical options for small fibroids include endometrial ablation, resection of submucosal fibroids during hysteroscopy
Hysterectomy
How do you treat larger fibroids?
Referral to gynae
Medical management is the same
Surgical options- myomectomy, uterine artery embolisation, hysterectomy
GnRH can be used to reduce the size of fibroids before surgery by reducing the amount of oestrogen needed to maintain fibroids
What is the only surgical option known to improve fertility in patients with fibroids?
Myomectomy (removal of the fibroid via. Laparoscopic surgery or laparotomy)
What is endometrial ablation?
Used to destroy the endometrium
What is hysterectomy?
Removing the uterus and fibroids
What are the complications of fibroids?
Heavy menstrual bleeding (often with iron deficiency anaemia)
Reduced fertility
Pregnancy complications- miscarriages, premature labour, obstructive delivery
Constipation
Urinary outflow obstruction and UTI
Red degeneration of fibroids
Torsion of fibroid
Malignant change to a leiomyosarcoma is very rare
What is red degeneration of fibroids?
Refers to ISCHAEMIA, infarction and necrosis of the fibroid due to a disrupted blood supply
Usually occurs in larger fibroids (above 5cm) during the second and third trimester of pregnancy
Fibroids grow rapidly in pregnancy outgrowing it’s blood supply and becoming ischaemic, or the expansion and change in the shape of the uterus causing a kinking in blood vessels.
How does red degeneration of fibroids present?
Severe abdominal pain, low grade fever, tachycardia, vomiting
What is endometriosis?
Ectopic endometrial tissue outside the uterus
What is an endometrioma?
A lump of endometrial tissue outside the uterus.
What is an adenomyosis?
Endometrial tissue within the myometrium (Muscle layer of the uterus)
What is the main symptom of endometriosis?
Pelvic pain, the cells of the endometrial tissue outside the uterus responds to hormones in the same way as endometrial tissue in the uterus. During menstruation as the endometrial tissue in the uterus shreds its lining and bleeds, the same thing happens to endometrial tissue elsewhere in the body
What are some complications of fibroids?
Localised bleeding and inflammation can lead to adhesions, inflammation causes damage and development of tissue that binds the organs together.
Adhesions lead to chronic, no cyclical pain, sharp, stabbing or pulling and associated with nausea.
Reduced fertility
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites- Haematuria, blood in stools
How do you diagnose endometriosis?
Pelvic ultrasound may reveal large endometriosis and chocolate cysts but often unremarkable
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis, definitive diagnose can be established with a biopsy of the lesions during laparoscopy, laparoscopy can allow the surgeon to remove deposits of endometriosis and potentially improve symptoms
How would you manage endometriosis?
Pain relief- NSAID and paracetemol
Hormonal options-
COCP (used back without a pill free period if helpful)
POP
Medroxyprogesterone acetate injection (depo provera)
Nexplanon implant
Mirena coil
GnRH agonists
Surgical management- laparoscopic surgery to excise/ablate endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy (removal of uterus)
Give examples of GnRH agonists and side effects of these drugs…
They induce a menopause like state (useful in endometriosis where the menopause helps with symptoms)
Goserelin, leuprolerin
Inducing the menopause has side effects- hot flushes, night sweats, risk of osteoporosis
What is the presentation of adenomyosis?
Dysmenorrhoea, menorrhagia and dyspareunia
On examination, uterus may be tender and enlarged
How do you diagnose adenomyosis?
Trans vagina ultrasound
MRI and transabdominal ultrasound
What are the treatments for adenomyosis?
Depends on symptom, age and plans for pregnancy
When the woman doesn’t 2ant contraception- tranexamic acid and mefenamic acid can be used
If contraception is wanted/ accepted…
. Mirena coil (first line)
. COCP
. Cyclical oral progestogens
What complications can you have with adenomyosis and pregnancy?
Infertility, miscarriage, preterm birth, gestational age, malpresentation, postpartum haemorrhage, c section.
What is menopause?
Made after a woman has had no periods for 12 months
What is postmenopause?
This is from the final menstrual period to 12 months after
What is perimenopause?
Time around the menopause, where woman may be experiencing vasomotor symptoms and irregular periods, time leading up to the last menstrual period and the 12 months after.
What is premature menopause?
Menopause before the age of 40, it is the result of premature ovarian insufficiency
What changes to the sex hormones occur in menopause?
LH and FSH levels are high in response to absence of negative feedback from oestrogen
Oestrogen and progesterone levels are low
What are perimenstrual symptoms?
These include vaginal atrophy/dryness Hot flushes Lack of libido Emotional liability or low mood Heavier or lighter periods Joint pains Irregular periods Premenstrual syndrome
What conditions does a lack of oestrogen increase the risk of?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
What investigations could you do for menopause and when would you do them?
FSH levels in blood
In a woman under 40 years with a suspected premature menopause
Woman aged 40-45 with menopausal symptoms or a change in menstrual cycle
When can you not give the depot injection?
In over 45 year olds as it reduces bone mineral density.
It also causes weight gain
For how long after the menopause should woman still take contraception for?
If they are under 50 then 2 years after the last menstrual period
If they are over 50 then 1 year after the last menstrual period
What is premature ovarian insufficiency?
Menopause before the age of 40
For premature ovarian insufficiency, what will hormonal analysis show?
LH and FSH high
Low oestradiol levels
Why is menopause considered hypergonadotropic hypogonadism ?
Under activity of the gonads means there is a lack of negative feedback on the pituitary gland.
