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Y3 GP > Long term genital problems > Flashcards

Long term genital problems Flashcards

1
Q

Menarche

A

A woman’s first menstrual period.

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2
Q

Primary amenorrhoea

A

A patient has never had a period by the age of 16.

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3
Q

Secondary amenorrhoea

A

A patient has started having periods, but then subsequently menstruation has stopped. 6 months of not having a period.

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4
Q

Oligomenorrhoea

A

Menstruation that has reduced in frequency, leading to a cycle length of greater than 35 days, resulting in 4-9 periods a year.

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5
Q

Dysmenorrhoea

A

Painful periods

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6
Q

Menorrhagia

A

Heavy menstrual bleeding, >80ml or the patient is passing clots.

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7
Q

Metorrhagia

A

Irregular, non-menstrual bleeding between menstrual periods.

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8
Q

What should you think of with the following terms:

Missed period
Painful period
Heavy period

A

Pregnancy is the most likely cause
Could she be pregnant and having a miscarriage or ectopic?
Could she be pregnant and having a miscarriage?

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9
Q

What are some red flag symptoms/signs that make you think of ovarian cancer?

A
  • Abdominal distension
  • Appetite loss
  • Ascites
  • Abdominal or pelvic mass
  • IBS in women 50 or over
  • Unexplainable fatigue, change in bowel habit
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10
Q

What are some red flag symptoms/signs that make you think of endometrial cancer?

A

All in women aged 55 and over

  • Blood glucose levels high with visible haematuria in women age 55 and over
  • Haemoglobin levels low
  • Thrombocytosis
  • Vaginal discharge
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11
Q

What is breakthrough bleeding?

A

Irregular bleeding associated with hormonal contraception

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12
Q

What are some causes of post coital bleeding?

A
  • Infection
  • Cervical ectropion
  • Vaginal/Cervical cancer
  • Trauma or sexual abuse
  • Vaginal atrophic change
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13
Q

What are some causes of inter-menstrual bleeding?

A
  • Ectopic pregnancy
  • Vaginal spotting around the time of ovulation
  • Adenosis
  • Tumours
  • Infection (chlamydia, gonorrhoea)
  • Polyps
  • Endometritis
  • Tamoxifen
  • Missed oral contraceptive pills
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14
Q

With inter-menstrual and post-coital bleeding, what are two investigations you should always carry out?

A
  • Pregnancy test
  • Infection screen
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15
Q

What blood tests may you include with inter-menstrual and post-coital bleeding?

A
  • FBC
  • Clotting
  • TFT
  • FSH/LH levels
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16
Q

What is recommended for women with persistent PCB?

A

Colposcopy is often recommended because of it’s high sensitivity.

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17
Q

What is included in a menstrual history?

A
  • Last menstrual period- ask whether the last period was a normal period
  • Regularity and cycle length
  • Duration of abnormal bleeding- discuss prolonged versus recent change
  • Presence of menorrhagia
  • Timing of bleeding in the menstrual cycle
  • Associated symptoms- eg, abdominal pain, fever, vaginal discharge, dyspareunia
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18
Q

What questions should you ask in an obstetric history?

A
  • Previous pregnancies and deliveries, including time since last delivery/miscarriage/termination
  • Current breastfeeding
  • Risk of current pregnancy- gastroenteritis, forgotten pills
  • ## Risk factors for ectopic pregnancy- PID, endometriosis, IVF, IUCD
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19
Q

When should ultrasound ideally be done?

A

Postmenstrually as the endometrium is at it’s thinnest and polyps and cystic areas tend to be more obvious.

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20
Q

What is the recommended investigation for menorrhagia?

A

Hysteroscopy with endometrial biopsy, history is suggestive of fibroids, polyps or endometrial pathology.

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21
Q

What factors lead to a high risk of endometrial cancer?

A
  • Those with a family history of hormone-dependent cancer
  • Those with prolonged and irregular cycles
  • Those taking tamoxifen
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22
Q

What are local causes of menorrhagia?

A

Adenomyosis, fibroids and endometrial polyps

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23
Q

What are some systemic causes of menorrhagia?

A

Clotting problems and hypothyroidism

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24
Q

When should you carry out a physical examination in a patient with heavy menstrual bleeding?

A

When there are other related symptoms such as:

  • Persistent intermenstrual bleeding
  • Pelvic pain
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25
Q

What would raise suspicion of a clotting disorder (von Willebrand’s) in a patient with heavy menstrual periods?

A
  • Have had HMB since their periods
  • Have a personal or family history suggesting a coagulation disorder
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26
Q

What are management options of menorrhagia if the cause is dysfunctional uterine bleeding?

A
  • Mirena coil (releases levonorgestrel)
  • Tranexamic acid
  • Hormonal contraception (COCP)
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27
Q

What is Adenomyosis?

A

Presence of endometrial tissue within the muscular wall of the uterus. This condition can cause the uterus to become enlarged, tender and may result in heavy or prolonged menstrual bleeding.

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28
Q

What are secondary causes of dysmenorrhoea (painful periods)

A
  • Endometriosos/adenomyosis
  • Fibroids (myomas)
  • Pelvic inflammatory disease
  • Ectopic pregnancy
  • Ovarian cancer
  • Cervical cancer
    -IUD insertion
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28
Q

When is primary dysmenorrhoea more likely?

A
  • Pelvic exam is normal
  • Other gynaecological symptoms are NOT present
  • Nausea, vomiting, diarrhoea, fatigue, irritability, headache, lower back pain are present
  • Pain starts shortly before the onset of menstruation and lasts for up to 72 hours, improving as the menses progresses.
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29
Q

If a patient has primary amenorrhoea and they have secondary sexual characteristics present, what are some causes of that?

A
  • Constitutional delay
  • Imperforate hymen/Mullerian agenesis
  • Testicular feminisation
  • Hyperprolactinaemia
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30
Q

If a patient has primary amenorrhoea and they do not have secondary sexual characteristics present, what are some causes of that?

A
  • Ovarian failure
  • Hypothalamic failure (anorexia nervosa)
  • Tumours involving the hypothalamus or pituitary
  • Kallman’s syndrome (cannot produce gnrh)
  • CAH
  • Empty sella syndrome, Prader-Willi syndrome and Laurence-Moon syndrome
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31
Q

What is the most common cause of secondary amenorrhoea?

A

Pregnancy

32
Q

If there are signs of androgen excess with secondary amenorrhoea, what conditions do you think of?

A
  • PCOS
  • Cushing’s syndrome
  • Late-onset congenital adrenal hyperplasia
  • Adrenal or ovarian carcinoma
33
Q

What conditions do you think of with secondary amenorrheoa if there are no signs of androgen excess?

A
  • Pregnancy, lactation and menopause
  • Premature ovarian failure (before the age of 40)
  • Contraception
  • Cervical stenosis and intrauterine adhesions (Asherman’s syndrome)
  • Hypothalamic dysfunction
  • Thyroid disease. Hypothyroidism or hyperthyroidism.
34
Q

What investigations should be carried out in amenorrhoea/oligomenorrhoea?

A
  • Pregnancy test
  • FSH and LH
  • Prolactin
  • Total testosterone and sex hormone-binding globulin
  • TFTs
  • Pelvic ultrasound
35
Q

What can you prescribe after a year of amenorrhoea for bone protection?

A

COCP

36
Q

How do you distinguish between peri-menopause and menopause?

A

Peri-menopause, women still have their periods.

Menopause hormones tend to balance out

37
Q

What are symptoms of perimenopause/

A
  • Hot flushes
  • Night sweats
  • Vaginal dryness
  • Reduced libido
  • Problems with orgasm
  • Dyspareunia
  • Depression
  • Anxiety
  • Reduced concentration
38
Q

Under what circumstances should you consider testing the FSH to diagnose menopause?

A
  • Patients aged over 45 years with atypical symptoms
  • Patients between 40-45 years with menopausal symptoms
  • Patients younger than 40 years in whom premature menopause is suspected
39
Q

What are storage symptoms?

A
  • Urgency
  • Daytime urinary frequency
  • Nocturia
  • Urinary incontinence
  • Feeling the need to urinate again after just passing urine
40
Q

What are voiding symptoms?

A
  • Hesitancy
  • Weak or intermittent urinary stream
  • Terminal dribbling
41
Q

What are post-micturition symptoms?

A
  • Post-micturition dribble and the sensation of incomplete emptying
42
Q

What is a normal amount of urine to pass during a day?

A

3L

43
Q

What are some causes of lower urinary tract symptoms in women?

A
  • UTI
  • Menopause
  • Urge incontinence
  • Stress incontinence
  • Diabetes mellitus
  • Bladder stones
  • Bladder cancer
  • Neurological conditions (multiple sclerosis)
  • Medications (antidepressants, lithium)
44
Q

What are common investigations for LUTS?

A
  • Urine dipstick
  • Blood test for glucose
  • Ultrasound scan of bladder
  • Urodynamic studies
45
Q

How do you manage stress incontinence in women?

A

Conservative
- Avoid caffeine, fizzy and sugary drinks
- Pelvic floor exercises

Medical
- Duloxetine

Surgical
- Pessaries
- Bulking agents
- Slings

46
Q

How do you manage urge incontinence?

A

Conservative
- Avoiding caffeine, fizzy and sugary drinks
- Pelvic floor exercises
- Bladder training

Medical/surgical
- Oxybutynin/Fesoterodine
- Bladder instillation (botox)
- Sacral nerve stimulation

47
Q

How would a urological cancer present?

A
  • Prostate that is hard and irregular
  • Unexplained haematuria
  • Lower back pain
  • Bone pain
  • Weight loss
48
Q

What are infectious causes of LUTS in men?

A
  • Prostatitis
  • Pyelonephritis
  • Urethritis
  • Sciatica
49
Q

What anti-muscarinic drugs can be administered in an overactive bladder?

A

Oxybutynin (not in frail older men), tolterodine or darifenacin

50
Q

What is the IPSS?

A

International prostate symptoms score.
A tool for classifying the severity of lower urinary tract symptoms and assessing the impact of LUTS on quality of life.

51
Q

What medication should you commence if a patient has an IPSS score of 8?

A

Offer an alpha blocker

52
Q

When should you offer a 5-alpha reductase inhibitor?

A

If the man has an enlarged prostate and is considered to be at high risk of progression.

53
Q

What are biological causes of erectile dysfunction?

A

Vascular
- CVD
- Hypertension
- Metabolic syndrome

Neurogenic
- Multiple sclerosis
- Parkinson’s

Anatomical
- Penile cancer
- Micropenis
- Phimosis

Endocrine
- Diabetes
- Primary or secondary hypogonadism
- Cushing’s disease

Psychogenic
- Lack of arousal
- Depression
- Anxiety

54
Q

What drugs can cause erectile dysfunction?

A
  • Beta blockers
  • Diuretics
  • SSRIs
  • TCAs
  • 5-alpha reductase inhibitors
55
Q

How do you evaluate erectile dysfunction?

A

Evaluating erectile dysfunction includes:

A detailed sexual and psychological history to identify potential contributing factors.
Generally, if there is acute onset, the cause is most likely psychogenic and if the onset is more gradual there is more likely to be an organic cause (e.g. atherosclerosis).

Blood tests: Full blood count, urea and electrolytes, thyroid function tests, lipid profile, testosterone, and prolactin to evaluate overall health and hormonal status.

ED can sometimes be the first presentation of sequalae of cardiovascular disease and so presentation should prompt investigation of cardiovascular health.

56
Q

What are management options for erectile dysfunction?

A

Psychosexual therapy to address any underlying psychological factors.
Oral phosphodiesterase inhibitors, such as Sildenafil, to enhance the effect of nitric oxide, increasing blood flow to the penis.
Side effects - headache, flushing, hypotension, blue tinge to vision (memory aid: little blue pill).
Vacuum erection devices to draw blood into the penis by applying negative pressure.
Intra-cavernosal injections to directly increase blood flow.
Penile prostheses for cases resistant to other treatments.

57
Q

Who is sildenafil contraindicated in?

A
  • Patients taking nitrates
  • Hypertension
  • Arrhythmias
  • Unstable angina
  • Stroke
58
Q

What is menorrhagia called if there is no underlying disease found?

A

Dysfunctional uterine bleeding

59
Q

What is the first line management option in menorrhagia?

A

Levonorgestrel intrauterine system

60
Q

What is a down side to Levonorgestrel intrauterine system?

A

Not suitable for a patient if she is planning for pregnancy soon

61
Q

What are the 3 main causes of menorrhagia?

A
  • Normal
  • Hormonal
  • Pathological
62
Q

What are treatment options for menorrhagia?

A

Tranexamic acid- stops the clots being broken down so less bleeding occurs.
Mefenamic acid (NSAID)

63
Q

What are the symptoms of menopause?

A
  • Vasomotor symptoms (hot flushes/night sweats)
  • Memory impairment
  • Anxiety/depression
  • Changes in menstrual pattern (cycle length/amount of blood loss)
  • Vaginal dryness and atrophy
  • Urinary frequency
  • Altered sexual function (dysparaeunia/loss of libido)
64
Q

How long do symptoms of menopause usually last?

A

7 years

65
Q

What are lifestyle modifications for menopause?

A
  • Regular exercise
  • Good sleep hygiene
  • Stress reduction
66
Q

How long should you follow up the patient after you prescribe HRT?

A

3 months

67
Q

What are the risks associated with HRT?

A
  • VTE (only associated with oral HRT)
  • Coronary heart disease and stroke
  • Breast cancer
  • Endometrial cancer (if patient has not had a hysterectomy, give oestrogen and progesterone is protective against endometrial cancer)
68
Q

What are voiding symptoms?

A

Poor stream
Hesitancy (having to wait for the urine flow to start)
Intermittent flow
Straining when passing urine
Dribbling

69
Q

What are storage symptoms?

A

Increased frequency and urgency of passing urine
Urge incontinence
Nocturia
Needing to pass urine again after just emptying the bladder

70
Q

What are some less common causes of LUTS?

A

Diabetes
UTIs
Prostate cancer
MS
Antidepressants

71
Q

What is the first line for urinary incontinence due to BPH?

A

Tamsulosin

72
Q

With BPH, what medication should you add if the patient has an enlarged prostate and is at a high risk of progression?

A

5-alpha reductase inhibitor
Finasteride

73
Q

What is a surgical option for BPH?

A

TURP

74
Q

What medication should you add if a patient has a mixed picture of storage symptoms and voiding symptoms?

A

Oxybutynin

75
Q

What investigations should you do with LUTS?

A

Urine dipstick: blood, glucose, protein, leucocytes and nitrites
eGFR and creatinine
Consider PSA
Uroflowmetry
Cystoscopy
Urodynamic pressure
USKUB

76
Q

Explain the cervical screening results simply

A

HPV Testing First: Instead of examining cervical smears for dyskaryosis first, the NHS now tests for high-risk strains of human papillomavirus (hrHPV) initially.
Management of Results:
Negative hrHPV: Patients go back to regular screening, except for certain cases where further tests are needed.
Positive hrHPV: Samples are then checked for abnormal cells. If abnormal, the patient is referred for colposcopy (a closer look at the cervix). If normal, the HPV test is repeated in a year. If still positive after a year, the patient might need colposcopy.
Inadequate Samples: If the sample is not good enough, it’s repeated in three months. If two samples are still inadequate, the patient is referred for colposcopy.
Treatment of CIN: Large loop excision of the transformation zone (LLETZ) is the usual treatment for cervical intraepithelial neoplasia (CIN). It’s a simple procedure where abnormal cells are removed. Sometimes, cryotherapy (freezing) is also used.
So, the big change is starting with HPV testing, which helps decide who needs further examination or treatment, making the screening process more effective.

77
Q
A

Y3 GP (13 decks)

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