Gyny (causes, investigation & management) Flashcards
Menorrhagia - causes
Primary - DUB Secondary - Clotting problems (Factor V von lieden) - Structural (fibroids, polyp, ectropion) - Endometriosis - PID - Cancer - Hypothyroidism
Menorrhagia - Investigations
1) FBC 2) If indicated - TFTs 3) If indicated - Clotting screen 4) if indicated - TV USS 5) Cervical smear 6) Endometrial biopsy
Menorrhagia - management
1) Rule out 2* (otherwise treat) 2) IUS is first line 3) COCP OR Tranexamic/Mefanamic acid
Menstrual history
1) First day of last period 2) Duration of period -> length of bleeding/flow 3) Length & regularity 4) Abnormal bleeding - IMB/ICB 5) Menarche
Dysmenorrhooea - causes
1) endometriosis 2) adenomyosis 3) Fibroids 4) pelvic inflammatory disease 5) intrauterine devices*
Dysmenorrhoea - investigations
1) Pelvic ultrasound 2) Cervical smear 3) High vaginal swab
Dysmenorrhoea - management
1) NSAIDs - Ibuprofen/Menefamic acid 2) COCP 3) IUS
Amenorrhoea - Causes
1) Hypothalamic a) Kalmann syndrome - Primary b) Exercise, stress, eating - Secondary 2) Pituitary a) Sheehan syndrome b) Hyperprolactinaoma 3) Gonadal a) turner syndrome - primary b) CAH - primary c) PCOS - secondary d) Pregnancy - secondary e) Anovulation - secondary 4) Outflow tract a) Mullerian genesis b) Vaginal atresia
PCOS Path
Hyperinsulinaemia -> Raised LH -> Raised Oestrogen & Testosterone
PCOS Presenting
1) Outward -> Hirstuitism, alopecia, acne 2) Inward -> Oligoamenorrhoea/amenorrhoea/infertiltiy 3) Physical -> Polycystic ovaroes
PCOS Investigations
1) FSH, LH, Testosterone, TSH, Prolactin 2) OGTT
PCOS Management
1) Lifestyle -> Lose weight, exercise more 2) Menstrual -> COCP 3) Infertility -> Clomiphene
Ectopic Pregnancy Presenting
1) Abdominal/Pelvic pain (first symptom) 2) Amenorrhoea or missed period 3) Vaginal bleeding (brown) 4) Shoulder tip pain, breast tenderness, urinary symptoms
Ectopic Pregnancy Examination
1) Pelvic tenderness 2) Pallor/tachycardia 3) Cervical motion tenderness
Ectopic Pregnancy Investigations
1) Pregnancy Test 2) TV USS 3) Serial HCG (if surgery)
Ectopic Pregnancy Management
1) Methotrexate 2) Surgical (Salpingotomy) 3) Anti-D Prophylaxis
Ectopic Pregnancy criteria for Methotrexate
1) No sig pain 2) <35mm and no HB 3) No IUP 4) Serum HCG <1500
Ectopic Pregnancy criteria for surgery
1) Significant pain 2) >35mm 3) Fetal HB on scan 4) Serum HCG >5000
Methotrexate use in Ectopic - Actions
1) LFTs and serial HCGs 2) Warn pelvic pain 2-3 days afterwards 3) Warn do not get pregnant for 6-months
Chlamydia screening (3)
1) Anyone in GUM clinic 2) Sexually active <25 annually 3) Sexual partners
Chlamydia symptoms (In Chlamydia you get the D!)
Chlamydia 1) Discharge 2) Dysuria 3) Deep dyspareunia 4) Duff bleeding (IMB or PCB)
Chlamydia management
1) Partner notification 2) Screening for other STIs 3) Management 1g Azithromycin OR 75mg Doxcycline (7-days)
Gonorrhoea symptoms (In Gonnorrhoea you get the D!)
1) Discharge 2) Dysuria 3) Deep dyspareunia 4) Duff bleeding (IMB or PCB)
Diagnosis Chlamydia & Gonorrhoea
Women - VVS Men - First catch urine
Gonorrhoea management
1) Partner notification 2) Screening for other STIs 3) Management - Ceftriaxone 500mg IM - Azithromycin 1g orally
How do you differentiate gonorrhoea and chlamydia?
Gonorrhoea is a gram-‘ve intracellular diplococci on microscopy
Trichomoniaisis Vaginalis symptoms
- Itchy, sore vulva/vagina - dyspareunia - Frothy green fishy discharge
Diagnosis of TV
VVS
Management TV
Metronidazole
Bacterial vaginosis symptoms
White/grey foul smelling discharge
Bacterial vaginosis diagnosis & microscopy
Increased pH Clue cells & lactobacilli
Bacterial vaginosis management
Metronidazole
HSV symptoms
- multiple painful blisters which burst to leave erosions
HSV management
Aciclovir
HPV 6 & 8 symptoms
Genital warts
HPV 6 & 8 management
Freeze warts
Candidiasis management
Clotrimazole cream
Pelvic inflammatory disease investigations
1) B HCG 2) Endocervical swabs for Chlamydia & N gonorrhoea 3) CRP 4) Urine dip & culture
Pelvic inflammatory disease complications
Fitz-hugh curtis Ectopic pregnancy Reiter’s syndrome Tuboovarian abscess Asherman sydrome
Pelvic inflammatory disease management
Ceftriaxone IM + Doxycycline + Metronidazole
Syphillis stages
Primary - painless chanchre Secondary - Flu like illness, widespread rash Tertiary - neurological/cardiac
Syphillis diagnosis
1) HIV test 2) Treponemal enzyme immunoassay 3) Pregnancy test
Syphillis management
1) Bezathine penicillin
Syphillis in pregnancy
Causes miscarriage & still birth
Genitourinary Prolapse - types by compartment
Anterior
- Cystocoele
- Urethrocoele
Middle
- Uterine prolapse
- Vaginal vault prolapse
- Enterocoele
Posterior
- Rectocoele
Genitourinary Prolapse Symptoms
Vaginal
- Fullness
- “Coming down”
- Pain
Urinary
- Frequency, urgency, incotinence
Rectal
- Splinting (pushing through vagina to enable defecation)
Coital
- Dyspareunia, loss of senstation
Genitourinary Prolapse Management
Conservative
1) Watchful waiting, lifestyle modification, pelvic floor
2) Vaginal Pessary
3) Surgery/Mesh repair
Genitourinary examination
1) Examine standing and in left lateral position
2) Bivalve speculum
Write definitions for the following miscarriage types:
Complete
Incomplete
Threatened
Inevitable
Missed
Complete - products of conception expelled, cervical os closed, no IUP on USS
Incomplete - Products of concepts only partially expelled, cervical os opened, POC visualised in vaginal canal
Threatened - Cramps, bleeding, cervical os closed, IUP confirmed (90% grow to normal getation)
Inevitable - Vaginal bleeding, cramping, cervical os opened, no POC passed yet
Missed - None viable IUP has remained within womb, cervical os closed, USS confirmed.
Define miscarriage
Pregnancy loss <24 weeks
Early <12 weeks
Later 13 - 25 weeks
Key questions to ask on presentation of miscarriage
Symptoms:
- Amenorrhoea
- Vaginal bleeding (details regarding quantity and pattern) +/- syncope (indicating significant blood loss)
- Cramping abdominal pain
- Passage of any fetal tissue
- Fever ?septic miscarriage
Menstrual cycle: LMP / cycle length / days bleeding / clots / flooding
If known to be currently pregnant: dating based on LMP / USS results
Investigations miscarriage (After speculum examination & Bimanual)
1) USS - confirm whether pregnancy IUP
2) Serial HCG (>63% increase indicates viable pregnancy, >50% decrease indicates failing)
Outline three types of management in miscarriage
Expectant
- No action, repeat pregnancy test 14 days later
Medical
- Misoprostol (missed & incomplete miscarriage). Pregnancy test in 3-weeks. Present if symptoms get worse.
Surgical
- General anaesthetic. Indications retained tissue, trophoblastic, excessive bleeding. MUST BE GIVEN ANTI D.
How does misoprostol work?
Prostaglandin, causes softening of cervix and uterine contraction
What is classed as recurrent miscarriages?
x 3 miscarriages in a row
Counselling stat for miscarriage
Miscarriage occurs in 12-24% of recognised pregnancies.
Causes of recurrent miscarriages (5+ investigations)
Antiphospholipid syndrome
- anticardiolipin antibodies
Genetic - non-disjunction
- Karyotyping
Structural (Asherman’s syndrome, septate uterus, cervical weakness)
- USS
Endocrine - PCOS
- PCOS investigations
Infections
- BV, TORCH screening
How to manage antiphospholipd syndrome?
Low molecular weight heparin
Define infertility
Inability to conceive in <1 year in a couple having regular sexual intercourse without contraception
Female causes of infertility
ENDOCRINE
1) PCOS
2) GENETIC: TURNER, KALLMAN
3) SHEEHAN SYNDROME
* *OVARIAN**
1) PREMAURE OVARIAN FAILURE
TUBES & STUFF
1) PID - TUBOVARIAN ABSCESS
2) STRUCTURAL - ASHERMAN’S, SEPTATE UTERUS, FIBROIDS
3) ENDOMETRIOSIS
Male causes of infertility
TESTES
1) Cryptorchidism
2) Kallman syndrome
3) Varicoele
How often is infertility male? (bonus point for naming the other bits)
30%
Unexplained infertility (no identified male or female cause) (25%).
Ovulatory disorders (25%).
Tubal damage (20%).
Factors in the male causing infertility (30%).
Uterine or peritoneal disorders (10%).
Investigations for couple trying to conceive but not being successful
1) Semen analysis
2) Day 21 progesterone
3) PCOS investigations
4) Genetic testing
Semen analysis values
Volume 1.5ml
Total sperm 39
Sperm conc 15
Motility 40%
Progressive motility 32%
Vitality 58%
Morphology 4%
How to assist in ovulation?
Lifestyle
- Abstain from alcohol, smoking, lose weight
Medications
- Folic acid
Ovulation/Sperm
- Intrauterine insemination
- Clomiphene citrate
Define hyperemesis gravidarum
- >10% weight loss
- Clinical dehydration
- Metabolic abnormalities (hyponatraemia, hypokalaemia)
Management hyperemesis gravidarum
1) Fluid & electrolyte replacemetn
2) Anti-emetic -> Cyclizine
3) Thromboprophylaxis
Outline complete and incomplete hydatidiform mole
Complete - 46 chromosomes, 2x sperms and empty egg
Incomplete - 69 chromosomes 2x sperm + 1x egg
Three ways in which gestational trophoblastic disease can present
1) Bleeding after miscarrige
2) Large for dates uterus
3) Routine USS - snowstorm appearance
Investigations for Molar pregnancy
1) Urinary and serum B HCG
2) USS for snowstorm appearance
3) Tissue histology
Management of hydatidiform mole
1) B HCG three weeks after evacuation, and at two week intervals for 6 months
2) Anti-D prophylaxis
3) Suction curretage
Indications for chemotherapy in GTD
- Plateaued or rising hCG levels after evacuation.
- Histological evidence of choriocarcinoma.
- Evidence of metastases in the brain, liver, or gastrointestinal (GI) tract, or radiological opacities >2 cm on CXR.
Management of fibroid
1) Myomectomy
2) Hysterectomy
3) GnRH analogue
Complications of fibroid in pregnancy
1) Early preg bleeding
2) PROM
3) PPH
