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5th Year Specialties > Gynaecology Part 1 > Flashcards

Gynaecology Part 1 Flashcards

1
Q

Primary Amenorrhoea Definition

A
  1. Aged 13 with no periods with no other signs of pubertal development
  2. Aged 15 with no periods with other signs of pubertal development
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2
Q

Causes of Primary Amenorrhoea

A
  1. Hypogonadism (could be hypergonadotrophic or hypogonadotrophic)
  2. Kallmann Syndrome
  3. Congential Adrenal HYperplasia
  4. Structural Pathology
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3
Q

Difference between hypergonadotrophic and hypogonadotrophic hypogonadism

A

Hypo is issue with either the hypothalamus or the anterior pituitary, meaning lack of FSH/LH secretion and/or GnRH secretion

Hyper is when the issue is with the ovaries so you keep producing the LH and FSH but there’s no oestrogen being produced to cause negative feedback

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4
Q

Causes of hypogonadotrophic hypogonadism

A
  • Damage to the hypothalamus/pituitary e.g. surgery, radiotherapy, cancer
  • Hypopituitarism
  • Kallmann Syndrome
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5
Q

Causes of hypergonadotrophic hypogonadism

A
  • Damage e.g. torsion, cancer, mumps
  • Congenital absence of ovaries
  • Turner’s syndrome
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6
Q

How does congenital adrenal hyperplasia contribute to amenorrhoea?

A

absence of the 21-hydroxylase enzyme causes an underproduction of cortisol and aldosterone, and overproduction of androgens

  • so you get too much testosterone
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7
Q

Structural pathology causing amenorrhoea

A
  • imperforate hymen
  • transverse vaginal septum
  • absent uterus
  • female genital mutilation
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8
Q

Management of primary amenorrhoea

A
  1. Bedside = Look for evidence of pubertal development
  2. Bloods = FBC for anaemia, anti-TTG for anaemia, FSH and LH, insulin-like growth factor for GH deficiency, prolactin for hyperprolactinaemia, testosterone raised in PCOS, CAH
  3. Imaging = x-ray of wrist for bone age and constitutional delay, US-abdo for ovaries, MRI head for hypothalamus and pituitary

Treatment = treat the underlying cause

Replace the hormones

Give pulsatile GnRH if hypogonadotrophic hypogonadism

COCP for same effect if pregnancy not wanted and for ovarian causes of amenorrhoea

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9
Q

Secondary amenorrhoea definition

A

No menstruation for more than 3 months after previous regular periods

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10
Q

Causes of secondary amenorrhoea

A
  • Pregnancy
  • Menopuase or premature ovarian failure
  • Hormonal contraception
  • Hypothalamic or pituitary pathology
  • PCOS
  • Asherman’s syndrome (scar tissue in the uterus)
  • Reduced GnRH production in response to physiological or psychological stress
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11
Q

Management of secondary amenorrhoea

A
  • Test for hCG in urine of blood
  • Prolactin
  • LH and FSH
  • TSH
  • Testosterone
  • Treat the underlying cause
  • Give replacement hormones
  • Vitamin D and calcium if low oestrogen due to osteoporosis risk
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12
Q

What is premenstrual syndrome?

A

Psychological, emotional and physical symptoms which occur during the luteal phase of the menstrual cycle, resolves once menstruation occurs

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13
Q

What causes premenstrual syndrome?

A
  • fluctuation of oestrogen and progesterone during the cycle
  • possibly due to increased sensitivity to progesterone or an interaction between sex hormones and neurotransmitters serotonin and GABA
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14
Q

How does premenstrual syndrome present?

A

Common: low mood, anxiety, mood swings, irritability, bloating, fatigue, headaches, breast pain, reduced confidence, cognitive impairment, clumsiness, reduced libido

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15
Q

Can PMS still occur without menses?

A

yes after a hysterectomy, endometrial ablation, or on the mirena coil as the ovaries are still functioning and the normal hormonal cycle continues

can also occur secondary to COCP or cyclical hormone replacement therapy containing-progesterone, as is progestrone-induced PMS

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16
Q

How is PMS diagnosed?

A
  • Symptom diary spanning two menstrual cycles which should demonstrate cyclical symptoms and resolve after the onset of menstruation
  • Definitive = GnRH analogue will halt the cycle and induce menopause temporarily which will resolve the symptoms
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17
Q

How is PMS treated?

A
  1. Lifestyle (stress, alcohol, caffeine, smoking, exercise, sleep)
  2. COCP
  3. SSRIs if severe
  4. CBT
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18
Q

What is the definition of menorrhagia?

A
  • excessive bleeding during menstruation of at least 80ml
19
Q

Causes of menorrhagia

A
  • dysfunctional uterine bleeding
  • extremes of reproductive age
  • fibroids
  • endometriosis and adenomyosis
  • pelvic inflammatory disease
  • contraception esp. copper coil
  • anticoagulants
  • bleeding disorders
  • connective tissue disorders
  • PCOS
  • endometrial hyperplasia or cancer
20
Q

Diagnosis of menorrhagia

A
  • based on symptoms
  • changing pads every 1-2 hours, bleeding more than 7 days, passing large clots
21
Q

Investigations for menorrhagia

A

Pelvic exam with a speculum and bimanual to assess for fibroids, ascites, and cancers

  • FBC
  • Outpatient hysteroscopy if suspected fibroids or endometrial pathology
  • Pelvic and transvaginal US if large fibroids, adenomyosis, exam difficult
  • Swabs, ferritin, coagulation screen, TFTs
22
Q

How is menorrhagia managed?

A
  • exclude anaemia, fibroids, bleeding disorders, cancer
  • If no contraception needed: give tranexamic acid (if no pain - antifibrinolytic) or mefenamic acid (if pain - NSAID)
  • If contraception wanted then 1. Mirena 2. COCP 3. Cyclical oral progestogens
23
Q

What are fibroids?

A

Benign tumours of the smooth muscle of the uterus

24
Q

What stimulates growth of fibroids?

A

oestrogen

25
Q

What is an intramural fibroid?

A

grows within the myometrium and can distort the uterus

26
Q

What is a subserosal fibroid?

A

one which grows just below the outer layer of the uterus

27
Q

What is a submucosal fibroid?

A

one which grows just below the endometrium, bit like intramural but closer to endometrium

28
Q

What is a pedunculated fibroid?

A

one which grows with a stalk

29
Q

How might fibroids present?

A

can be asymptomatic
- menorrhagia is most common
- prolonged menstruation
- adbo pain worse during menstruation
- bloating
- urinary or bowel issues due to increased pelvic pressure
- deep dyspareunia
- reduced fertility

30
Q

How should suspected fibroids be investigated?

A
  • abdo and bimanual may reveal palpable mass or enlarged non-tender uterus
  • hysteroscopy is initial for submucosal fibroids with menorrhagia
  • pelvic US for big ones
31
Q

How should fibroids less than 3cm be managed?

A
  • same treatment as menorrhagia
32
Q

How should fibroids over 3cm be managed?

A
  • refer to gynae
    1. Symptomatic management
    2. Mirena coil
    3. COCP
    4. Cyclical oral progestogens
33
Q

What are some surgical options for fibroids?

A
  • hysteroscopic surgery to remove submucous fibroids
  • uterine artery embolisation if no fertility needed
  • myomectomy (if fertility wanted)
  • hysterectomy with GnRH agonist
  • can give GnRH agonists such as goserelin before to reduce the size of the fibroid by inducing a menopause-like state
34
Q

How does uterine artery embolisation work?

A
  • catheter put into artery (usually femoral) which is then passed to the uterine artery under X-ray guidance. Inject substance into the artery to starve the fibroid of oxygen
35
Q

Which surgical option for fibroids will improve fertility?

A

myomectomy

36
Q

What is red degeneration?

A

ischaemia, infarction and necrosis of the fibroid

  • more likely of over 5cm and during 2nd or 3rd trimester
  • fibroid rapidly grows during pregnancy but outgrows the blood supply
  • severe abdo pain, low-grade fever, tachycardia, vomiting
  • rest, fluid, analgesia
37
Q

What is endometriosis and what might cause it?

A
  • ectopic endometrial tissue outside the uterus
  • no clear cause but could be due to retrograde menstruation
  • could be due to embryogenic cells remaining outside the uterus
  • high risk of recurrence
38
Q

What are the symptoms of endometriosis?

A
  • pelvic pain from irritation and inflammation as the tissue still responds to hormones so will shed and bleed
  • blood in urine/stools if tissue is in bladder or bowel
  • adhesions from scar tissue binding organs together
  • reduced fertility
39
Q

Typical presentation of endometriosis

A
  • abdominal or pelvic pain which is cyclical
  • deep dyspareunia
  • dysmenorrhoea
  • urinary or bowel issues associated with menstrual cycle
40
Q

Investigations for endometriosis

A
  • speculum
  • fixed cervix on bimanual
  • tenderness in the vagina
  • laproscopic surgery is gold standard with biopsy to confirm
41
Q

Staging of endometriosis

A

1 = small superficial
2 = mild, but deeper than 1
3 = deeper lesions and on ovaries and adhesions
4 = same as 3 but deeper and bigger lesions with extensive adhesions

42
Q

Management of endometriosis

A

Initial = Analgesia NSAIDs or Paracetamol

Hormonal = COCP (21 days with a 7 day break, may be more effective if tricycled) , progestogens (if COCP not suitable, basically induces amenorrhoea, don’t give if want to conceive), mirena coil, GnRH agonists (risk of osteoporosis if over 6 months use)

Surgical = laparoscopic surgery to excise or ablate the tissue and remove adhesions or a hysterectomy

43
Q

Why does progesterone need to be given to women taking replacement oestrogen?

A
  • progesterone prevents endometrial hyperplasia and endometrial cancer secondary to unopposed oestrogen
44
Q
A

5th Year Specialties (2 decks)

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