Gynaecology/Women's Health Flashcards
For someone on a combine ORAL contraception, if they miss a pill what advice should you give them?
(3 scenarios)
- If < 24 hours, then take the missed pill as soon as remembered and then take the next one at the usual scheduled time
- If over 24 hours AND patient has been using active pills AND no intercourse then.. take the next pill straight away and the next scheduled pill. PLUS use condoms for 7 days
- If over 24 hours AND patient has used fewer than 7 active pills OR had UNPROTECTED intercourse in the last 5 days Then… consider emergency contraception in addition to taking the missed and next scheduled pill
What is this?
What is the most serious complication that can arise?
How can you treat this initially?
Vulval Lichen Sclerosus
Squamous Cell Carcinoma
Should get a referral to a gynaecologist, can start ULTRAPOTENT topical corticosteroids for 4 weeks
General measures to deal with vulval lichen sclerosus
Wash gently once or twice daily using water or a non-soap cleanser.
Try to avoid tight clothing, rubbing and scratching.
Activities such as riding a bicycle or horse may aggravate symptoms.
If incontinent, seek medical advice and treatment.
Apply emollients to relieve dryness and itching, and as a barrier to protect sensitive skin in genital and anal areas from contact with urine and faeces.
Apart from vasomotor symptoms and urogenital symptoms of Menopause, list other symptoms of menopause
Low libido
Anxiety
Depression
Poor concentration
Sleep disturbance
Mastalgia
Central body fat accumulation
Formication (bugs)
Irregular Vaginal bleeding in post menopause
What formulations of HRT is available for someone under 50 and with a low cardiovascular risk and who is in a menopausal transition stage?
(3)
- Low dose combined oral contraception
- Continuous estrogen with cyclical progeterone on 10-14 days each month
- Continuous estrogen (patch or oral) with a 52mg levongestrel intrauterine device
Causes of Secondary Amennorhea- list them.
(4)
Primary ; when a girl does not menstruate by age 15.
Secondary causes (lack of menstruation after initially starting to menstruate):
-premature ovarian insufficiency (<40 years)
-PCOS
-Hypoprolactinemia
-Hypothyroidism
-Hypothalmic amennorrhea (excessive stress, excessive weight loss or exercise)
What is the difference between premature menopause and primary ovarian insufficiency?
With primary ovarian insufficiency - the ovaries stop working normally before age 40. normally irregular periods or reduced fertility occurs after 40. There is still some chance of getting pregnant.
Premature menopause. There is a complete cessation of menses before age 40. This can occur just because, but also due to things like disease, surgery, chemo or radiotherapy.
What are causes for abnormal uterine bleeding?
“PALM-COEIN”
This is in reference to reproductive age, non pregnant women who have already started menstruating.
Not referring to bleeding before menarche, post menstrual bleeding or bleeding during pregnancy.
Polyps
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy (Factor 8 deficiency, VwD)
Ovulatory Dysfunction (PCOS, start of ovulation, perimenopause, obesity, hypothyroid)
Endometrial Disorders
Iatrogenic (COPC, other contraception, anti-depressants)
Not yet classified
What parameters should you define when trying to classify what is or is not normal menstrual bleeding?
(4)
Regularity (Regular menstrual
bleeding should be 9 days or less in variation
from the beginning of one menses to the
beginning of the next one; however, this is
age dependent so that women between 26
and 41 years old should have variation of 7
days or less in menstrual cycle length).
- consider PCOS if not regular or premenopause in the right context.
-also obesity and hypothyroidism (but unsure why this causes irregularity)
Duration (how long does she bleed for?) More than 8 days is considered prolonged
Frequency (every 24-38 days)
is the amenorrhoea?
is there bleeding in-between cycles?
Volume (this is largely subjective)
is defined as excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, or material quality of life.
If ovulation is normal, this is just heavy peroids.
Anovulatory cycles usually present as irregular bleeding with irregular flow patterns (minimal to excessive), and potentially the patient has an estrogen dominant state.
What is the approach to those <35 versus >35?
Initial investigations (discussed elsewhere) assumed to be normal.
- If under 35 or adolescent and NO risks of endometrial cancer can proceed to treat with COPC or otherwise.
If irregular bleeding continues proceed to endometrial biopsy. - if > 35 with suspected annovulation or <35 with other risks of endometrial cancer then proceed to endometrial biopsy (this will be a referral, the end)
Initial investigations for abnormal uterine bleeding?
- pregnancy test
- TSH
- PRL
- ? FAI if suspicious of PCOS on history +/- US
- U/S - especially if risk of endometrial cancer or symptoms haven’t resolved after 3 months of medical treatment or concerned about endometriosis.
- Coagulation studies (if menorrhagia, especially if in adolescents)
- Ferritin (for anaemia)
- (if high risk for endometrial cancer then consider straight up gynae referral +/- saline infusion sonohystography)
Who are at high risk of ENDOMETRIAL cancer?
Three options for management of heavy periods.
Dosing please
(3)
- Transexemic acid 1-1.5g PO 6-8 hourly for the first 3 to 5 days of each cycle
- Norethisterone 5 mg orally, 2 to 3 times daily on days 5 to 26 of a 28-day cycle. Review choice of therapy at 6 months
- NSAIDs for example
naproxen 500 mg orally initially, then 250 mg every 6 to 8 hours. Maximum daily dose 1250 mg. Start just before or at onset of menstrual bleeding and continue for up to 5 days
Can also use Ibuprofen at normal dose TDS continued for 5 days.
What are initial investigations for CYCLICAL heavy menstrual bleeding?
CST opportunistically
Pregnancy Test
Ferritin
FBC
Consider TSH and Coagulation Profile
What increases the risk of endometrial cancer?
(10)
Nulliparity
PCOS
Late menopause > 52 years
Overweight
Obesity (more risk than being overweight)
Diabetes Mellitus
Unopposed estrogen therapy
Tamoxifen exposure
Atypical endometrial hyperplasia
Strong family history of endometrial or colon cancer (Lynch syndrome)
What important parts of the history do you want when assessing menorrhagia or dysmenorrhoea?
Age
Length of cycle, duration, regularity
Contraceptive use, sexual activity, likelihood of pregnancy
Pain with menstruation
Volume of blood loss
Pelvic pain or pressure
Gynae history
CST history
Personal or family history of Endometriosis
Symptoms of anaemia
Presence of dyspareunia, heavy menstrual bleeding, intermenstrual bleeding, post coital bleeding
Has there been a treatment trial for at least 3 months and what is the response
When should an U/S for menorrhagia be performed?
On days 5-10 of the cycle.
For a patient with Menorrhagia, NOT LOOKING TO conceive. what is the preferred management option?
Levonogestrel releasing intrauterine device 52mg. Inserted into the uterus. Replaced every 5 years.
There can be initial bleeding spotting in the first few months.
If bleeding persists past 6 months then refer
When would you use transexemic acid (for what indication), and what is the dose?
What is an alternative?
For management of menorrhagia in those patients still looking to conceive.
Transexemic acid 1-1.5grams, orally, 6-8 hourly for the first 3-5 days of each cycle.
An alternative is NSAIDs
Ibuprofen 400mg, orally, 6-8 hourly, started just before onset of menstrual bleeding and continued for 5 days
OR
Mefenamic acid 500mg, orally, 8 hourly, taken just before onset of bleeding and for 5 days into the cycle.
OR
Naproxen 500mg, orally initially then 250mg, 6-8 hourly, oral, Start just before or at onset of menstrual bleeding and continue for up to 5 days
When should you consider referral for menorrhagia, including findings on U/S?
(And assume you’ve begun with a TVUS)
when there’s concurrent dysmenorrhoea that is severe
concurrent dysmenorrhoea that hasn’t resolved after 3 months of medical therapy
fibroids > 3cm
In individuals wishing to conceive
any endometrial polyps
any increased risk of endometrial cancer (see previous question)
radiological findings i.e. endometrium >12mm in premenopause or >5mm in perimenopausal.
When should you consider ordering an U/S in primary dysmenorrhoea?
basically if it is likely to be secondary to something else, evidenced by (potentially any of):
when concurrent menorrhagia
abnormal bleeding: dysparaunia, intermenstrual bleeding, post coital bleeding
failure of treatment trial after 3 months
symptoms of endometriosis or fx of endometriosis
late onset of menarche >20years old
irregular periods.
Hormonal Treatment for primary dysmenorrhoea?
Hormonal
COPC
e.g. LEVLEN ED 30-150
LNG-IUD 52mg
or Implanon etonogestrel 68mg, replaced every 3 years
What NSAID options are available to treat primary dysmenorrhoea?
(3)
- Ibuprofen 400mg, oral, 8 hourly, 48 hours prior to bleeding and for 48-72 hours into menstruation
- Naproxen 500mg initially, then 250mg, 8 hourly, orally 48 hours prior to onset of menstruation then for 48-72 hours into bleeding
- Mefenamic acid 500 mg orally, 3 times daily. Started 48 hours prior to onset of bleeding and Continued for first 48 to 72 hours of menstruation
Non medical options for dysmenorrhoea?
TENS
Local heat
Accupressure,
accupuncture
Spinal manipulation
Herbal dietary preparations
Exercise
Psychological therapies
What can post coital bleeding or intermenstrual bleeding signify?
what is the definition of postcoital bleeding?
- Cervical Cancer
- Chlamydia infection
definition
Post Coital Bleeding is defined as persistent non-menstrual bleeding that occurs within 24 hours of vaginal intercourse.
A. What investigations should be done for post-coital bleeding?
B. what should be done after investigations
A. Investigations
Transvaginal pelvic U/S
CO-TEST for HPV and Liquid based cytology
Endocervical PCR swab for STI screening of chlamydia, gonorrhoea, Trichomonas and mycoplasma.
B. Referral to a gynaecologist
With only a single episode and a normal CST and U/S it is unlikely to be urgent/seen quickly but can still do the referral.
If recurrent then more urgent referral
and off course abnormal CST/LBC or TVUS then urgent referral
Basically any patient presenting with abnormal vaginal bleeding or bleeding at all, whom is post menopausal should be referred to a gynaecologist, having done an U/S first.
However in what set of circumstances might it be ok for the GP to monitor without referral?
U/S with endometrial thickness <4mm (i.e. anything above 4mm gets immediate referral)
AND
no anaemia
AND
no risk factors (see risk for endometrial cancer)
AND
not persistently bleeding
Then only can GP survellience be utilised without referral.
Initial tests in abnormal uterine bleeding in PRE menopause?
FBE
CST –> colposcopy if needed
STI screen
Coagulation
TFT
Pregnancy test
Note that an TVUS is not needed unless there is persistent bleeding, anaemia chronic anovulation, PCOS or erratic bleeding.
When ordering a TVUS for post menopausal bleeding, what 2 important things should you include on the request form, aside from patient details ?
- Current status of bleeding: pre, peri or post menopause
- Make sure to request endometrial thickness specifically
What would considered a “conservative” treatment for abnormal vaginal bleeding according to RANZCOG
(2 treatments)
- Hormonal therapies like a mirena or COPC
- Non hormonal therapies like transexemic acid or NSAIDs
For the pre-menopause patient, in their first episode of abnormal vaginal bleeding, when would it be ok for GP survelliance without an U/S?
If they were low risk of endometrial cancer
AND
there was no risk of anaemia
AND
it was definitely the first time it was abnormal
AND
Conservative therapies (hormonal or non) have worked
THEN
it’s ok for GP surveillance without even an U/S yet .
Again only for PRE menopausal or peri NOT applicable to post-menopausal.
In a pre or peri menopausal patient after an U/S, who should definitely get a gynae referral and who is it ok to manage with GP surveillance?
- Any focal lesion on U/S –> referall
- If pre-menopause endometrial thickness is >12mm, or peri-menoapause endometrial thickness is >5mm then –> refer
- Only if <12 (or 5mm premenopause) then trial a conservative approach and if bleeding stops then GP surveillance is ok. otherwise if bleeding continues then refer.
In a post menopausal women, after an U/S which woman are ok for conservative management/GP surelliance?
NOT on Tamoxifen
AND
Endometrial thickness < 4mm
AND
No endometrial cancer risk factors
ONLY THEN
GP surveillance and reassessment with a biopsy if persistent bleeding
Practice points. Post menopausal bleeding.
- Post menopausal Women being treated with tamoxifen, what is the next step?
- Post menopausal women treated with HRT, when is intermittent bleeding not yet considered a concern?
- on tamoxifen, patients need an endometrial biopsy ASAP, as a TVUS is not sensitive
- In the first 6 months of starting therapy, it can be considered normal to have some bleeding. after 6 months investigation should begin.
In a patient deemed appropriate for GP surveillance of abnormal vaginal bleeding, is a repeated TVUS necessary?
No, without persistent symptoms, repeated TVUS is not recommended
What is the definition of primary and secondary ammenorrhoea?
Primary
either bleeding that hasn’t occurred by
1. age 13 without breast development
2 age 15 with breast development but no menarche
3. 5 years after breast development - that began < 10
Secondary
Either
Absence of periods for
1. 3 months in a woman with previously regular peroids
2. 6 months in a woman with previously irregular cycles
what are causes of hypothalmic amenorrhoea?
Stress
Excessive exercise
Systemic illness
eating disorders
very low BW
What are the broad groups of causes for primary amenorrhoea?
(4)
- Hypogonadotrophic
a. Constitutional
b. hypothalmic
c. pituitary : PRL/ tumours - Hypergonadotropic
e.g. Turner syndrome, premature ovarian insufficiency, ovarian dysgenesis - Anatomical outflow tract abnormalities
Mullerian Agenesis
Imperforate hymen - PCOS causing excess androgen production
What investigations would you order for primary amenorrhoea and why?
- Pregnancy test- obviously causes amenorrhoea
- TSH- as thyroid issues can impact menstrual bleeding
- FSH/LH and estradiol. So to figure out if cause is gonadal, or from the pituitary or even hypothalamus
- TVUS - to assess presence of uterus/outflow tract/vagina.
Causes of secondary amenorrhoea?
Pregnancy
Perimenopause
PCOS
Hypogonadotrophic reasons: stress, exercise, pituitary tumours
Interuterine adhesions
Medications: opioids, corticosteroids, COPC, medications like antipsychotics and metoclopramide, domperidone and SSRIs that can cause raised PRL
What is Turner Syndrome?
How does it present?
(5)
Absence or partial absence (i.e. some cells have it) of an X chromosome
Short stature
Webbed neck
Absent breast development
Widely spaced nipples
Broad chest
What is needed for the diagnosis of PCOS?
Two of the following
- Menstrual disturbance including secondary oligoamenorrhea or amenorrhoea.
- clinical or biochemical hyperandrogenism
- Polycystic ovaries on U/S
Clearly you DON’T NEED an U/S to diagnose PCOS if the other two conditions are met
Given the diagnostic criteria for PCOS includes hyperandrogenism clinical features. What are these? (5)
1 Acne
2. Alopecia
3. Hirsutism
4. weight loss or muscular increase
5. Virilisation (male pattern hair loss or deepening voice)
If a female patient presents with menstrual disturbances, ______, insulin resistance and obesity, this would make you suspicious of ______.
A. Subfertility
B. PCOS
Which is the preferred biochemical test to aid in diagnoses of PCOS?
Free Androgen Index
What is the consequence of anovulatory menstrual cycles in someone with PCOS?
- irregular bleeding and variable volume
- if there is no shedding build up / profileration of the endometerium increases risk for cancer
- sub fertility
Aside from menstrual disturbance in PCOS , which can be treated with COCPs, what other complications need addressing and how?
(5)
Insulin resistance - start metformin i high risk individuals (obesity, asian, fx of GD etc) even if invx is normal
Cardiovascular risks- Assess risk factors as per calculator and treat as needed
Weight control - lifestyle measures, metform to prevent gain,
Hirsutism- specialist
Mental health concerns- consider referral to a psychologist
What are some symptoms of endometriosis?
(7)
Dyspareunia
Dyschesia
Cyclical haematuria
Chronic pelvic pain
Menorrhagia
Infertility
Dysmenorrhoea
When should you suspect endometriosis in adolescence?
What single factor would increase their risk of having endometriosis?
when they are having a-cyclical symptoms
A first degree relative with endometriosis increases the risk 10 fold
What treatment can be trialed for endometriosis pain?
3 groups. no dosing required
- Analgesia with anti-inflammatories
- Hormonal therapies
- Neuropathic pain treatment
How can you treat pain related to endometriosis? First line
assuming you can figure out the cycle and that there is cyclical pain (with period) then treat as for primary dysmenorrhoea
ibuprofen 200-400mg, TDS, orally, taken ideally 48 hours before expected period and for 48-72 hours after the start of menstruation
Or mefanamic acid or naproxen
What is first line for neuropathic pain that can be used for endometriosis?
First line
Pregabalin 25 to 75 mg orally, at night initially. Increase to twice daily after 3 to 7 days. If needed, continue to increase the dose as tolerated and according to response, at 3-to 7-day intervals up to 600 mg in 24 hours.
or gabapentin
100 to 300 mg orally, at night initially. Increase to twice daily, then 3 times daily at 3-to 7-day intervals as tolerated and according to response. If needed, continue to increase the dose at 3-to 7-day intervals up to 3600 mg in 24 hours
What hormonal options are available to treat endometriosis?
COCP such as
levenogestrel /ethinylestradiol 150/50mg orally, daily.
Depot injections of progesterone
Long acting oral progesterone: noristhisterone 5-10mg, orally, once daily. Can be increased to 12 hourly if spotting occurs
When should you consider referral to a gynaecologist in dealing with endometriosis?
(4)
Persistent and significant symptoms
Symptoms that don’t respond to first line treatment in the first 3 months
A pelvic mass or nodule
Suspicion of bowel or bladder involvement
With regards to PCOS:
Prolonged __(a)__ stimulation of the endometrium during anovulatory cycles, without progestogen-induced shedding, causes endometrial thickening. This can result in heavy bleeding when menstruation does occur, and increases the risk of __(b)__ ____ 2-to __(c)__-fold
a. estrogenic
b. endometrial cancer
c. 6
In patients with PCOS and who are at high risk of developing T2DM, what medication can be started?
Metformin MR 500 mg orally, daily with evening meal as an initial dose; increase daily dose by 500 mg every 1 to 2 weeks as tolerated, up to a maximum of 1500 mg daily.
In a low risk post menopausal woman, (ie. low risk factors for endometrial cancer AND endometrial thickness < 4mm), what other diagnoses can be considered for post menopausal bleeding?
(3)
- Atropic Vaginiitis
- Cervical polyps
- Endometrial polyps
When is the best time to do a TVUS as an investigation for abnormal uterine bleeding in a premenopausal women?
days 5-10 of a cycle
Secondary amenorrhoea is defined as the absence of menstruation for:
more than (A) months in females with previously regular menstrual cycles
more than (B) months in females with previously irregular menstrual cycles.
A. 3
B. 6
what is the normal length of a menstrual cycle?
(1)
What would be a definite abnormal cycle?
(2)
28 days plus or minus 7 days.
However this only applies to women after 3 years POST menarche up until perimenopause
Part b
A cycle <21 days or over 35 days in someone 3 years post menarche (OR < 8 cycles a year) would be abnormal
Any cycle after 1 year of menarche that is > 90 days would be abnormal and consider PCOS.
With PCOS what is the biggest risk posed to the patient, and why
Endometrial cancer.
Especially if cycles > 90 days. Because the endometrium doesn’t shed and can cause hyperplasia increasing the risk of cancer.
What are three pregnancy related causes of heavy menstrual bleeding?
Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
There are 8/9 causes of non - pregnancy related menorrhagia.
What are they.
There is a pneumonic
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogeni
Not yet classified
When should you consider coagulopathy screening for heavy menstrual bleeding?
Causes for postmenopausal bleeding?
- hormone (oestrogen) therapy
- atrophy of the vagina or uterus
- uterine or cervical polyps
- endometrial hyperplasia
- cancer of the uterus, cervix, or vagina
What is the definition of primary dysmenorrhia?
What do you need to exclude to make this diagnosis?
Always establish if primary (starting within 12mo onset of menses) or secondary.
Diagnosis of primary dysmenorrhoea requires exclusion of secondary causes such: asendometriosis,
pelvic inflammatory disease,
fibroids,
adenomyosis,
endometrial polyps,
intrauterine devices and
congenital abnormalities
