Gynaecology Week Flashcards
define heavy menstrual bleeding
excessive menstrual blood loss which interferes with a woman’s physical, emotional, social and material quality of life
what is DUB
dysfunctional uterine bleeding not associated with any organic disease of the genital tract
what is uterine leiomyoma also known as
fibroids - benign growths which can cause heavy regular period
what is endometriosis
a condition where endometrial tissue can be found outside of the uterus. Causes painful peroids, persistent pain in the pelvic area and infertility
what is dysmenorrhoea
painful menstrual periods
primary tends to be idiopathic
secondary tends to be due to endometriosis or pelvic inflammatory disease
under what circumstances would NICE recommend biopsy of the endometrium
persistent intermenstrual bleeding
women aged > 40
failure of treatment
according to NICE under what circumstances should ultrasound imaging be used?
abdominally palpable uterus
PV reveals pelvic mass of uncertain origin
failure of pharmaceutical treatment
if US inconclusive hysteroscopy may be used
what symptoms may be suggestive of structural/histological abnormality in pts complaining of menorrhagia
intermentrual bleeding
post-coital bleeding
pelvic pain/pressure symptoms
what pharmaceutical agents are available for women with HMB
the merina IUD tranexamic acid mefenamic acid COC GnRH analogues
(Norethisterone should NOT be used for regular menorrhagia)
what is tranexamic acid
it is an anti-fibrinolytic which can be taken during menses (1g tds) to reduce bleeding by around 50%
it is good for women unable to tolerate hormonal therapies
what is mefenamic acid
it is an NSAID with minor anti-inflammatory properties.
it can be used to menorrhagia and dysmenorrhoea as it is an analgaesic and reduces heavy bleeding (500mg tds).
NSAIDs work by reducing prostaglandin production by inhibit cyclo-oxygenase
what is norethisterone?
a progesterone which can be used to promote regular cycles (NOT to treat menorrhagia)
15mg od on days 5 -> 26 of the mentrual cycle.
in high doses can stop very heavy bleeding short term
under what circumstances might GnRH analogues such as leuprorelin or triptorelin be used
pre-op to shrink fibroids or if surgery is contraindicated
pt may require HRT as can experience hot flushes and bone demineralisation
limited to 6-12 months use
what are the surgical options for a woman with HMB
endometrial ablation (HMB + uterus 10wks) Hysterectomy
what happens in endometrial ablation
destruction of the endometrium down to the basal layer
decreases fertility but increases the chances of complications in pregnancy –> should use contraception
80-90% of women have significant improvement in symptoms and 30% become amenorrhoeic
20% will require a further procedure by 5 yrs
when might a hysterectomy be considered
other treatment options have failed/been declined
wish for amenorrhoea
upon woman’s request
no long wish to retain fertility
what are the red flag symptoms for ectopic pregnancy
pelvic tenderness
adnexal tenderness
abdominal tenderness
cervical motion tenderness
if combined with a positive pregnancy test must be urgently refered to early prenancy assessment service
what is the incidence of ectopic pregnancy
11 per 1000 pregnancies
what are the predisposing factors to ectopic pregnancy
previous PID (UK: chlamydia; world: gonorrhoea) previous ectopic pregnancy tubal surgery smoking increasing maternal age
what investigations can be used to detect ectopic pregnancy
serum hCG (likely intrauterine if increased by >63% in 48hrs) TV US (locate foetal pole and heartbeat)
what are the common presenting symptom of ectopic pregnancy
abdo/pelvic pain amenorrhoea/missed period vaginal bleeding dyspareunia cervical excitation
when would conservative treatment of ectopic pregnancy be appropriate
hCG< 1000 and unknown location
50% resolve spontaneously
monitor via weekly scan and twice weekly hCG assay
what is the first line medical treatment of ectopic pregnancy
systemic methotrexate (folate antagonist)
indicated if:
- no significant pain
- unruptured pregnancy with adnexal mass < 1500
how does methotrexate work and what are its side effects
folate antagonist -> prevents DNA/RNA/protein synthesis in rapidly dividing cells SE: - abdo pain - GI upset - risk of tubal rupture
under what conditions would surgery be considered first line treatment in ectopic pregnancy
- significant pain
- adnexal mass >35mm
- visible foetal heartbeat
- ectopic with serum hCG > 5000
what should be offered to all rhesus negative women who have a surgical proceedure to manage an ectopic pregnancy or miscarriage
anti-rhesus prophylaxis
what would you expect to see if a pregnancy if viable
foetal heart beat
crown-rump length >7mm
gestational sac >25mm
what would be the medical management of a missed or incomplete miscarriage
vaginal/oral administration of misoprostol
what is misoprostol
a prostaglandin used to induce a labour for medical abortion
it can also be used vaginally to ripen the cervix before surgical abortion
it also has antisecretory and protective properties in the stomach lining
what changes occur in the cervical mucous plug during ovulation
becomes alkaline, hypocellular and more elastic to allow the passage of sperm
name 4 diiferent types of sperm dysfunction
azoospermia - absence of sperm in ejaculate
oligozoospermia - decreased sperm concentration
asthenozoospermia - poor sperm motility
teratozoospermia - abnormal shaped sperm
what are the causes of ovulation disorders
hypothalamic pituitary dysfunction (eating disorders, excessive exercise, adenoma, prolactinoma, drugs)
PCOS (increased androgens leads to absence of ovulation)
what are the features of PCOS
oligo/anovulation
infertility
excess androgens (hirsutism)
treatment of PCOS
oestrogen antagonists (chlomipjene citrate) synthetic FSH +bhCG ovarian drilling
what might cause tubal disorders
infection (chlamydia/gonorrhoea)
inflammation (endometriosis)
trauma/surgical damage
treatment of tubal disorders
cuff salpingostomy
ablation of endometriosis
IVF
what might be used for the induction of a late medical abortion
gemeprost
usually misoprostol following pre-treatment with mifepristone which sensitizes the uterus to prostaglandins
how might bleeding due to incomplete miscarriage or abortion be controlled
ergometrine or oxytocin IM
in severe post partum haemorrhage carboprost
what is mifepristone
an antiprogestogenic steroid
during which days of the menstrual cycle is the follicular phase
days 1-14
also known as the proliferative phase
oestrogen is produced from testosterones in the granulosa cells under the influence of FSH
testosterones are produced in the theca interna cells under the infleunce of LH
what does oestrogen stimulate in the follicular phase
growth of endometrial lining
development of follicles
watery secretions at the cervix to allow the passage of sperm
what effect does oestrogen have on LH secretion
increased oestrogen at the follicular phase inhibits LH secretion (alpha receptor)
once oestrogen level pass a threshold then it begins to stimulate LH production by activating the oestrogen beta receptor
what happens at ovulation on day 14
LH peak leads to release of ovum
increased testosterone levels due to LH surge causes other follicle to undergo atresia
what happens to the ruptured follice post ovulation
it becomes a corpus luteum
theca cells undergo atrophy
granulosa cells under go hypertrophy
during which days of the menstrual cycle is the luteal phase
days 15-28
the corpus luteum produces progesterone
what does progesterone stimulate
further growth and maintenance of the endometrium
change in cervical secretions to prevent the entry of further sperm
during which days of the menstrual cycle is menstruation
days 1-7
corpus luteum undergoes luteolysis
menstruation occurs due to progesterone withdrawal
why does the corpus luteum undergo luteolysis in menses
decreased LH as progesterone inhibits its secretion
increased secretions of oxytocin and prostaglandins by the uterus
what is the definition of the menopause
the 365th day after the start of a womans LMP
what are fibroids
benign tumours of the myometrium formed from smooth muscle with fibrous elements
which factors increase the risk of developing fibroids
african ethnicity tamoxifen early onset of menarche nuliparity age obesity FHx HTN
name three types of fibroid
subserous - project externally out of the uterus, can become pedunculated
intramural - within the myometrium
submucous - project into the endometrium, can become pedunculated
what are the pregnancy associated problems with fibroids
red degeneration
pre-term labour
malpresentation
post partum haemorrhage
which haematological disorders can be symptoms of fibroids
anaemia
polycythenia - some fibroids may produce EPO
which options are available for the medical treatment of fibroids
esmya (ulipristal acetate)
GnRH agonists
mirena IUD - no direct effect on fibroid but will decrease bleedign
how do GnRH agonist work on fibroids
shrinks fibroid and decreases vascularity
can cause menopausal symptoms (osteoporosis risk)
how does esmya work
- on the fibroid: blocks progesterone receptors which inhibits cell proliferation and stimulates apoptosis
- on the pituitary gland: selectively blocks progesterone activity which reduces LH and FSH levels causing amenorrhoea
- on the endometrium: direct effects and reduces uterine bleeding
EMBRYOTOXIC- pregnancy must be excluded
what are the surgical options available in fibroids
myomectomy
hysterectomy
UAE
what are the complications associated with fibroids
degeneration ( haline change, calcification, red)
torsion of pedunculated fibroids
infections with pyometria
malignancy (RED FLAGS: rapid growth; post menopausal and not on HRT; poor response to GnRH agonists)
