INTRO TO GYNAE: Dysmenorrhoea, Menorrhagia, Dyspareunia, IMB, PCB, Amenorrhoea Flashcards
What are RFs for primary dysmenorrhoea?
- early age at menarche
- heavy menstrual flow
- nulliparty
- FHx of dysmenorrhoea
What can cause secondary dysmenorrhoea?
- endometriosis
- adenomyosis
- fibroids
- PID
- IUD insertion
Should always exclude these before diagnosing primary dysmenorrhoea
How is primary dysmenorrhoea identified and treated?
FEATURES = pain before or within a few hrs of period starting, lower abdominal pain radiating to back or thighs, assoc. w/vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache
Rx = NSAIDs, COCP
What is endometriosis?
Endometrial tissue found outside uterine cavity
Sx = secondary dysmenorrhoea, deep dyspareunia, subfertility, urinary sx
O/E reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions
How is endometriosis investigated and managed?
IX = laparoscopy
MX =
1. NSAIDs/paracetamol
2. COCP/POP
3. GnRH analogues, surgery
What is adenomyosis?
Endometrial tissue found in myometrium
Sx = secondary dysmenorrhoea, menorrhagia, enlarge, boggy uterus
How is adenomyosis investigated and treated?
IX = TVUSS or MRI
MX =
1. NSAIDs/paracetamol/tranexamic acid
2. GnRH agonists
3. Uterine artery embolisation
4. Definitive = hysterectomy
What is dysfunctional uterine bleeding?
Menorrhagia in the absence of underlying pathology
What are underlying causes of menorrhagia?
Fibroids, hypothyroidism, IUD, PID, bleeding disorders
Unless there is underlying pathology, mx = reduce bleeding
How is menorrhagia investigated and managed?
IX = FBC, TVUSS etc.
MX =
No contraception needed - tranexamic acid, mefenamic acid
Contraception needed - Mirena coil, COCP, long-acting progestogens e.g. Depo-Provera
What are fibroids and how are they investigated?
Benign smooth muscle tumours of the uterus
SX = menorrhagia, bulky related sx, subfertility
IX = TVUSS
How are fibroids managed?
Asx = nil
Sx = LNG-IUS, NSAIDs, tranexamic acid, COCP, oral/injectable progestogen
Shrinking fibroids =
- GnRH agonists
- myomectomy, ablation, hysterectomy, uterine artery embolisation
What is candidiasis?
Vaginal infection due to Candida albicans
Sx = cottage cheese discharge, superficial dyspareunia, dysuria, itch
Ix = clinical diagnosis
What are RFs for candida?
DM, drugs (abx, steroids), pregnancy, immunosuppression
How is candida managed?
PO fluconazole
If CI then clotrimazole pessary (e.g. in pregnancy)
Summarise atrophic vaginitis
Thinning and drying of the vaginal walls
Features:
Vaginal dryness, dyspareunia, occasional spotting
Ix: Speculum – pale and dry vaginal wall
Mx:
Vaginal lubricants and moisturisers
Topical oestrogen cream
Summarise CIN
CIN: abnormal changes of cells that line cervix
Mild/moderate dyskaryosis
CIN 1: 1/3 of depth of surface of cervix
CIN 2: 2/3 of depth of surface of cervix
CIN 3: whole thickness of surface of cervix
Mx (for CIN 2/3):
- LLETZ
- Cone biopsy
Summarise cervical cancer features and investigation?
Highest incidence in people aged 25-29 years old
2 types, SCC (80%), adenocarcinoma (20%)
Risk factors:
HPV, smoking, HIV, early first intercourse, many sexual partners, high parity, lower socioeconomic status, COCP
Features:
Abnormal vaginal bleeding (PCB, IMB, PMB), vaginal discharge
Ix: Screening programme
What is the cervical cancer screening system?
HPV first system:
- 25-49 years: 3-yearly screening
- 50-64 years: 5-yearly screening
- Delayed until 3 months post-partum
- Can opt out if never sexually active
Negative HPV – return to normal recall
Positive HPV – check cytology
- Normal = repeat in 12 months
- Abnormal = colposcopy, then management
Inadequate sample – repeat in 3 months
What is endometrial hyperplasia?
Abnormal proliferation of endometrium
Types:
- simple
- complex
- simple atypical
- simple complex
Features:
Abnormal vaginal bleeding (e.g. IMB)
How is endometrial hyperplasia managed?
Management without atypia:
- Oral or local intrauterine (LNG-IUS) progestogens for 6 months
- Continuous progestogens for women who decline the LNG-IUS
- Hysterectomy
- Bilateral salpingo-oophorectomy should be added for postmenopausal women
Management with atypia:
- Laparoscopic total hysterectomy
- Bilateral salpingo-oophorectomy should be added for postmenopausal women
Summarise endometrial cancer
Usually seen in post-menopausal women
Good prognosis due to early detection
Risk factors:
Excess oestrogen
Features:
Postmenopausal bleeding or intermenstrual bleeding
Ix:
Suspected cancer pathway if:
>=55 years old with post menopausal bleeding
TVUSS
Hysteroscopy with endometrial biopsy
Mx:
Surgery
What is cervical ectropion?
Transformation zone: area between the native and unaffected columnar epithelium of the endocervical canal and native squamous epithelium
Squamo-columnar junction: abrupt change from columnar cells to squamous cells (changes with time)
Location depends on:
Age
Hormonal status
Birth trauma
Contraceptives
Pregnancy
Summarise cervical ectropion
Larger area of columnar epithelium present on the ectocervix
Caused by elevated oestrogen levels
Features:
Vaginal discharge, PCB
Ix: speculum
Mx:
Asymptomatic: no treatment
Symptomatic: cauterization with silver nitrate or cold coagulation
Summarise amenorrhoea investigations and management
Primary: absence of periods by 15 years old with normal secondary sexual characteristics OR absence of periods by 13 years old with no secondary sexual characteristics
Secondary: absent period for 3 to 6 months in women with previous normal and regular menses OR absent period for 6 to 12 months in women with previous oligomenorrhoea
Investigations:
Exclude pregnancy – urinary or serum b-HCG
Bloods – FBC, U&Es, coeliac screen, TFTs
Special bloods – gonadotrophins, prolactin, androgen levels, oestradiol
Management:
Primary:
Investigate and treat any underlying cause
Potentially HRT (e.g. Turner’s)
Secondary:
Exclude pregnancy, lactation, menopause
Treat underlying cause
