Gynaecology Conditions 1 Flashcards
Define abnormal uterine bleeding?
Any bleeding that is either:
• Abnormal in volume (excessive duration or heavy)
• Irregularity, timing (delayed or frequently)
• Non-menstrual bleeding – IMB, PCB, PMB
Define amenorrhoea?
Absence of menstruation
Define primary amenorrhoea? When to suspect it?
Failure to start menstruating
Suspect and assess when girls have not established menstruation by age of 13 (if no secondary sexual characteristics) or 15 (if normal secondary sexual characteristics)
Causes of primary amenorrhoea?
- Often due to late puberty (familial)
- May be pregnant
- Structural abnormalities of external/internal genitalia
- Hypothalamic-Pituitary-Ovarian causes (common)
- Hyperprolactinaemia
- Ovarian causes:
- Uterine causes:
- Turner’s syndrome or androgen insensitivity syndrome
What causes HPO problems in primary amenorrhoea?
o Stress, emotions, exams, increased exercise, weight loss
Causes of hyperprolactinaemia in primary amenorrhoea?
o May have galactorrhoea
o Thyroid problems
o Renal failure
Causes of ovarian failure in primary amenorrhoea?
o PCOS
o Ovarian insufficiency/failure
Causes of uterine causes of primary amenorrhoea?
o Pregnant
o Asherman’s syndrome (uterine adhesions after D&C)
o Post-pill amenorrhoea
Define secondary amenorrhoea?
Previous normal menstruation but stops for 3-6 months or more, 6-12 months in women with irregular periods
Causes of secondary amenorrhoea?
- Physiological
- Hypothalamic-Pituitary-Ovarian causes (common):
- Hyperprolactinaemia
- Ovarian causes:
- Uterine causes:
Physiological causes of secondary amenorrhoea?
o Pregnancy
o Menopause
o During lactation
HPO causes of secondary amenorrhoea?
o Stress, emotions, exams, professional athletes, increased exercise, weight loss
Hyperprolactinaemia causes of secondary amenorrhoea?
o May have galactorrhoea
o Thyroid problems
o Renal failure
Ovarian causes of secondary amenorrhoea?
o PCOS
o Ovarian insufficiency/failure
Secondary to chemotherapy, radiotherapy or surgery
Genetic disorders – Turner’s
Uterine causes of secondary amenorrhoea?
o Asherman’s syndrome (uterine adhesions after D&C)
o Post-pill amenorrhoea
Tests in amenorrhoea?
BhCG to exclude pregnancy
Serum free androgen index (PCOS)
FSH/LH (low if HP axis cause)
• If FSH>20IU/L – premature menopause – karyotyping
Prolactin (Increased by stress, hypothyroidism, prolactinomas, metoclopramide)
• If >1000IU/L – MRI scan
TFTs
Testosterone levels
• >5nmol/L indicate androgen secreting tumour or late-onset CAH
Treatment of amenorrhoea?
Related to cause
Refer to secondary care for specialist investigations
Treatment of amenorrhoea if mild HPO malformation?
o Medroxyprogesterone acetate (10mg/24h for 10 days) challenge will stimulate endometrium production and cause period
o Reassurance and diet advice, stress management
o Psychiatric help if depression indicated
o Still use contraception as ovulation may occur at any time
o Clomifene – restores period in mild cases
Treatment of amenorrhoea if shut-down HPO malformation?
o Stimulation by gonadotrophin-releasing hormone (goserelin)
o Used in specialist fertility clinics only
Treatment of amenorrhoea if premature ovarian failure?
Premature ovarian failure needs HRT and pregnancy can be achieved using IVF or oocyte donation
Complications of amenorrhoea?
Osteoporosis • May need Vit D and Ca supplements • Offer HRT or COCP if needed CVD Infertility Psychological stress
Define olgimenorrhoea? Most common cause?
o Menses occurring less frequently than every 35 days
o More common in extremes of reproductive life
o Common cause is PCOS
Define menorrhagia? How common?
o Excessive menstrual blood loss which interferes with QoL, social or emotional life
o Defined as >80ml/cycle but impossible to measure
o 30% of women report heavy periods
Causes of menorrhagia?
Dysfunctional uterine bleeding (DUB)
Anovulatory cycles
IUCD
Pathological causes
Dysfunction uterine bleeding causing menorrhagia?
- No pathology, 40-60%
* Diagnosis of exclusion
Anovulatory cycles causing menorrhagia?
• Extreme reproductive life
Pathological reasons causing menorrhagia?
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not classified
Iatrogenic reasons causing menorrhagia?
IUCD
Key history pieces in menorrhagia history?
Note cycle bleeding and length
• Heavy, prolonged vaginal bleeding
Change in volume (clots, floods, etc)
Worsening impact on life – school, work, home, sexual
Enquire about other symptoms: premenstrual syndrome, IMB, PCB, dyspareunia, pelvic pain
Signs in menorrhagia?
Anaemia Abdomen exam • Masses Ensure smear up to date Inspect cervix and take swabs if needed If indicated bimanual examination
Investigations in menorrhagia?
Pregnancy test Bloods – FBC, (TFTs, clotting (if indicated)) Smear if due & STI screen USS Hysteroscopy Endometrial sampling
When to refer to secondary care in menorrhagia? Investigations?
• Criteria
o Persistent IMB
o Symptoms failed to improve on medical management
o Women >45 with heavy bleeding, endometrial pathology
o Abnormal examination
o Risk factors for endometrial cancer
• TVUS and hysteroscopy if abnormal
1st line medical management of menorrhagia?
Mirena IUS
Release levonorgestrel – leading to atrophy of endometrium
Reduces bleeding and 30% amenorrhoeic at 12 months
SE – irregular bleeding for 1st 4-6 months and progestogenic effects
2nd line medical management of menorrhagia?
NSAIDs (mefenamic acid)
Taken during days of bleeding
Tranexamic Acid
Useful in those trying to conceive as non-hormonal
CI – thromboembolic disease
COCP
Effective but think CIs
3rd line medical management of menorrhagia?
Progestogens
Medroxyprogesterone acetate (IM every 12 weeks)
Norethiserone PO (Used short-term to stop heavy bleeding)
GnRH rarely used, only in secondary care
When to use surgical management of menorrhagia?
2 drugs tried and failed
Surgical management of menorrhagia? When performed? SE?
Endometrial ablation
o 1st line, if uterus is <10 weeks of gestation on palpation
o Removing the full thickness of endometrium with superficial myometrium and basal glands using diathermy/thermal balloon
o Performed with hysteroscopy
o SE – bleeding, infection, uterine perforation, vaginal discharge, infertility
o Need contraception post-operation
Alternative surgical managements and when performed?
Uterine Artery Embolisation or Myomectomy
o If uterus is >10 weeks in size or fibrois >3cm, retain ferility
Hysterectomy
o Women not wishing to retain fertility, who have fibroids >3cm
o Vaginal hysterectomy preferred, may need abdominal
Define dysmenorrhoea? How common?
o Low anterior pelvic pain, occurring with periods
o 50% women complain of moderate pain, 12% of severe
Pathology of dysmenorrhoea?
Imbalance of prostaglandins and leukotrienes in menstrual fluid which produces vasoconstriction and uterine contractions
May be responsible for diarrhoea, nausea and headache
Description of primary dysmenorrhoea?
- Pain without organ pathology
- Often starts with onset of ovulatory cycles
- Pain begins with period and last 2-3 days
Description of secondary causes of dysmenorrhoea? What are they?
• Pelvic pathology o Years after onset of menstruation o Precede start of period by several days and may last throughout period o Associated dysparenunia o Caused by: Endometriosis PID Fibroids Adhesions IUCD
Symptoms of dysmenorrhoea?
Crampy pain with ache in groin or back
Worse in first few days (primary)
Constant through period (secondary), deep dysparenunia
Investigations in dysmenorrhoea?
Abdominal/Vaginal exam
Speculum and may need swabs/smear if due
If mass – pelvic USS
General advice in dysmenorrhoea?
- Stop smoking
- TENS may help
- Tea may help
- Abdominal/back massage and lying down
Pharmacological management in dysmenorrhoea?
• NSAIDs (mefenamic acid) during menstruation • Paracetamol • If not wanting to conceive: o COCP o POP o Depot medroxyprogesterone acetate o Mirena IUS
Surgical management in dysmenorrhoea?
• If women completed family – hysterectomy in severe, refractory cases
Define IMB?
o Vaginal bleeding (other than postcoital) at any time during menstrual cycle other than normal menstruation
Causes of IMB?
Cervical polyps Ectropion Fibroids Carcinoma Cervicitis/Vaginitis IUCD Hormonal contraception • May get breakthrough bleeding when starting Chlamydia Pregnancy related
Assessment of IMB?
o Symptom that needs further investigations
o Assessment
Take menstrual, gynaecological, sexual history (obstetric if indicated)
Abdominal and PV exam
Investigations in IMB?
Exclude pregnancy and STIs • Pregnancy test • Infection screen (chlamydia and gonorrhoea) Smear if overdue Bloods • FBC, clotting, TFT, FSH/LH TVUS if structural abnormality thought of Biopsy
Referral in IMB?
Abnormal cervix (2 week wait)
Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), >45 with IMB
Management of IMB?
Depends on cause If cancer suspected • Urgent referral for investigation Infection • Abx depending on disease and organism • Contact tracing and treatment of sexual partners
Hormonal contraception changes in management of IMB?
• Common in 1st 3 months after starting contraception
• May need speculum examination if >3 months
o Women >45 need biopsy
• COCP
o Stick with pill for 3 months, use pill with dose of ethinylestradiol to provide cycle control
o Different COCP may be tried
• POP
o Different POP tired
• PO implants/depot/IUS
o First line – COCP for up to 3 months continuously or in usual cycle regimen – repeat as often as needed
Management of cervical ectropions, polyps and fibroids in IMB?
Cervical Ectropion’s
• May resolve if COCP stopped or following pregnancy
• Thermal cautery or silver nitrate if needed
Cervical polyps
• Avulsed and sent for histology
Fibroids
• Small removed hysterscopically
• Uterine artery embolization
• Large – drugs, vascular embolization or surgery
Define PCB? How common?
- Postcoital bleeding
o Non-menstrual bleeding through vagina immediately after sexual intercourse
o Around 5% women experience PCB
Causes of PCB?
Infection Cervical ectropion Cervical/Endometrial polyps Vaginal/Cervical cancer Sexual abuse Atrophic change
Assessment of PCB?
Take menstrual, gynaecological, sexual history (obstetric if indicated)
Abdominal and PV exam
Investigations in PCB?
Exclude pregnancy and STIs • Pregnancy test • Infection screen (chlamydia and gonorrhoea) Smear if overdue Bloods • FBC, clotting, TFT, FSH/LH TVUS if structural abnormality thought of Biopsy Persistent PCB needs colposcopy
When to refer PCB?
Abnormal cervix (2 week wait)
Cervical polyp, pelvic mass, high risk of endometrial cancer (FHx, prolonged cycles, tamoxifen), no cause of PCB
Management of PCB?
Depends on cause If cancer suspected • Urgent referral for investigation Infection • Abx depending on disease and organism • Contact tracing and treatment of sexual partners
Management of cervical ectropions, polyps and fibroids in PCB?
Cervical Ectropion’s
• May resolve if COCP stopped or following pregnancy
• Thermal cautery or silver nitrate if needed
Cervical polyps
• Avulsed and sent for histology
Fibroids
• Small removed hysterscopically
• Uterine artery embolization
• Large – drugs, vascular embolization or surgery
Hormonal management in PCB?
• Common in 1st 3 months after starting contraception
• May need speculum examination if >3 months
o Women >45 need biopsy
• COCP
o Stick with pill for 3 months, use pill with dose of ethinylestradiol to provide cycle control
o Different COCP may be tried
• POP
o Different POP tired
• PO implants/depot/IUS
o First line – COCP for up to 3 months continuously or in usual cycle regimen – repeat as often as needed
Define premenstrual syndrome?
o Distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease
o Recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation
How common is PMS?
- 80% have mild or moderate PMS
- 5% have severe PMS
Pathology of PMS?
- Suggestion abnormal response to normal progesterone excursions
- Affects GABA receptors
- Neurons in PMS preferentially metabolise progesterone into pregnenolone (heightens anxiety) rather than allopregnanolone (anxiolytic)
Risk factors for PMS?
o FHx of PMS
o High BMI
o Stress
o Traumatic events
Symptoms of PMS?
- Mood swings
- Irritability
- Depression
- Stress/Tension
- Bloating and breast tenderness
- Headache
- GI upset
Classifying moderate PMS?
o Severe PMS involves disruption of interpersonal/work relationships or interference with normal activities
DSM-IV criteria for severe PMS?
o >5 symptoms present for most of the luteal phase and absence of symptoms post menses (at least one symptom must be from the first 4):
Markedly depressed mood, feelings of hopelessness or self-deprecation.
Marked anxiety, tension (being ‘on edge’)
Marked affective lability (e.g. feeling suddenly sad or tearful)
Persistent and marked anger/irritability/increased conflicts.
Decreased interest in usual activities.
Subjective sense of difficulty in concentrating.
Lethargy, easy fatigability/lack of energy.
Marked change in appetite, overeating or specific food cravings.
Hypersomnia or insomnia
Subjective sense of being overwhelmed or out of control.
Other physical symptoms (breast tenderness or swelling, headaches, joint or muscle pain, a sense of ;bloating;, weight gain).
Investigations in PMS?
• Exclude underlying organic/psychiatric causes
o BP, pulse, thyroid and breast examination
• Symptoms diary filled in over 2 cycles (2-3 months)
General measures in PMS?
• Improve Healthy Diet
o Less fat, sugar, salt, caffeine and alcohol.
o Regular, frequent small balanced meals rich in complex carbohydrates
• Increase exercise
• Stop smoking
• Schedule stressful tasks to better half of month if needed
• Stress reduction
o Relaxation techniques
o Yoga
o Meditation
o Breathing techniques
1st line management in moderate PMS?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
1st line management in severe PMS?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
• SSRI (fluoxetine/sertraline/citalopram)
o Continuous or just for luteal phase of menstruation
o Give 3 months, if benefit then continue for 6-12 months
Secondary care medical management of PMS?
- Progesterone or progestogens used alone.
- Antidepressants other than SSRIs
- Alprazolam.
- Diuretics
- Danazol
- Transdermal oestrogen
- GnRH analogues +/- addback HRT
Complementary therapies in PMS treatment?
o Vitamin B6, calcium and vitamin D, magnesium, evening primrose oil
Surgical management of PMS?
- Hysterectomy including oophorectomy with oestrogen-only HRT, last resort for severe PMS
Define PCOS?
o Hyperandrogenism, oligomenorrhoea and polycystic ovaries on US without other causes of polycystic ovaries
How common is PCOS?
• Most common endocrine disorder in women:
- Prevalence = 10% of women at childbearing age.
- Responsible for ~80% of anovulatory subfertility
Pathology of PCOS?
- Excess androgens
- Androgens are steroid hormones (e.g. testosterone) that stimulates or controls the development and maintenance of male characteristics
Insulin resistance leads to hyperinsulinemia
Effect of excess androgens in PCOS?
o Hypersecretion of LH (increased frequency and amplitude of LH pulses).
o LH stimulates androgen secretion from ovarian thecal cells
Effect of steroid hormones in PCOS?
o Increased androgens in the ovary disrupt folliculogenesis lead to excess small ovarian follicles (hence the cysts) and irregular/absent ovulation.
o Increased peripheral androgens cause hirsutism (acne/body hair).
Effect of insulin resistance in PCOS?
Hyperinsulinaemia
o Reduced sex hormone binding globulin (SHBG) in liver so increased free testosterone
o Increased androgen production
When do symptoms commonly present in PCOS?
• Often present in peripubertal period – mid-20s
Symptoms of PCOS?
o Asymptomatic
o Oligomenorrhoea (irregular periods, <9 per year) or amenorrhoea (no periods)
o Signs of hyperaldosteronism: acne, hirsutism, alopecia.
o Obesity
o Psychological: mood swings, depression, anxiety
o Sub/infertility
o Recurrent miscarriage
Sings of PCOS?
o Male-pattern baldness, alopecia
o Obesity (usually central)
o Acanthosis nigricans (areas of increased velvety skin pigmentation which occur in the axillae and other flexures)
o Clitoromegaly, increased muscle mass, deep voice - severe
Long term complications of PCOS?
- Obesity, insulin resistance and dyslipidaemia risk factors for IHD.
- Higher rate of T2DM, GDM
- Long periods of secondary amenorrhea (unopposed oestrogen) risk factor for endometrial hyperplasia and carcinoma
Investigations performed in PCOS?
o Bloods: Total testosterone (normal or slightly raised) Free testosterone (may be raised if >5nmol/L – exclude androgen-secreting tumours and CAH – 17-hydroxyprogesterone) SHBG (normal or low in PCOS) LH (elevated) & FSH (normal) TFTs Prolactin Lipids • To exclude a prolactinoma o Ovarian USS o Screen for diabetes o BMI
What is the criteria for PCOS?
Rotterdam criteria for diagnosing PCOS:
- Requires the presence of 2 out of 3 of:
• Polycystic ovaries on US
• 12 or more follicles or ovarian volume >10 on USS
• Oligo-ovulation or anovulation
• Clinical/biochemical features of hyperandrogenism
Acne, excess body hair, alopecia
Raised serum testosterone
DDx of PCOS?
- Thyroid dysfunction
- Hyperprolactinaemia
- Late-onset CAH
- Androgen secreting tumours
- Cushing’s syndrome
General management of PCOS?
o Weight loss o Diet o Exercise o Stop smoking o Sleep apnoea advice • Psychological support
If not planning pregnancy, management of PCOS?
o Improving insulin resistance: Metformin (not licensed so risks and benefits weighed up) o Ensuring withdrawal bleeds every 3-4 months: (reduces endometrial cancer risk) COCP cyclical IUS If not taking pill (norethisterone 5mg TDS PO for 10 days) o Hirsutism Co-cyprindol 2mg/d Waxing, shaving Eflornithine facial cream Spironolactone • Avoid in pregnancy, teratogenic
If presenting with subfertility and wanting to conceive, management of PCOS?
o Clomifene citrate Induces ovulation Use for <6 cycles Need US monitoring o Metformin added on o Laparoscopic Ovarian Drilling Needlepoint diathermy in 4 places per ovary to reduce steroid production When clomifene not working
Complications of PCOS?
- Infertility
- Endometrial hyperplasia and cancer
- CVD risk
- T2DM – screening offered if obese, FHx, >40
- GDM – screen in pregnancy 24-28 weeks
Define post-menopausal bleeding?
- Bleeding occurring >1 year after last period where menopause can be expected
What is post-menopausal bleeding considered to be?
- Considered endometrial carcinoma until proven otherwise (10%)
Management of post-menopausal bleeding?
Referral to gynaecologist within 2 weeks Investigations for endometrial carcinoma
o TVUS (shows endometrial thickening >4mm)
o Biopsy as out-patient (Pipelle method - side-opening cannula with vacuum sucks biopsy) or hysteroscopy with biopsy
o If cancer – need CT/MRI
Other causes of post-menopausal bleeding?
- Vaginitis (atrophic commonly)
- Foreign bodies (pessaries)
- Carcinoma of cervix or vulva
- Endometrial/cervical polyps
- Oestrogen withdrawal (HRT)
How is atrophic vaginitis treated?
lubricants/moisturisers and HRT or topical oestrogen
What is functional/chronic pelvic pain?
Intermittent or constant pelvic pain >6 months with no pathological cause
Common conditions associated with chronic pelvic pain?
IBS and interstitial cystitis
Sexual/Physical abuse
Management of chronic pelvic pain?
Address psychological/social issues
Trial of OCP, GnRH analogue for 3-6 months, Mirena IUS
Antispasmodics, analgesics, pain clinic
Laparoscopy
