Men’s And Women’s Health Flashcards
What is endometriosis ?
A common disorder characterised by the presence of endometrial glands and stroma outside of the endometrial cavity.
What are some risk factors for endometriosis ?
Obstruction to menstrual flow
Prolonged exposure to endogenous oestrogen
Short menstrual cycles
Low birth weight
Where are the most common sites for endometriosis ?
Ovaries
Pouch of Douglas
Uterosacral ligaments
What are some clinical features of endometriosis ?
Symptoms may be asymptomatic
Dysmenorrhoea
Dyspareunia
Chronic pelvic pain
Pain at time of ovulation
Infertility
Chronic fatigue
What are some differentials for endometriosis ?
Chronic pelvic inflammatory disease
Recurrent acute salpingitis
Ovarian tumour
Ectopic pregnancy
IBS
Urinary causes
What is the management of endometriosis ?
Analgesia - NSAIDs or paracetamol
Hormonal treatment
COCP
Surgical treatment
Define menopause
The permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognised to have occurred after 12 consecutive months of amenorrhea for which there is no other obvious pathological or physiological cause.
What age range does menopause occur in ?
40 - 58 years old
What are some clinical features of menopause ?
Hot flushes
Thinning of vaginal skin
Increased risk of UTI
Dysuria or nocturia
Irritability
Lethargy
Depression
Loss of libido
Increased risk of breast cancer
What is the management of menopause ?
HRT
Lifestyle measures
Gabapentin - reduces hot flushes
SSRI - alternative to HRT
Diet and supplements
What is infertility ?
The failure of conception in a couple having regular, unprotected coitus for one year, provided that normal intercourse is occurring not less than twice weekly.
What are the main causes of infertility ?
Unexplained infertility
Ovulatory disorders
Tubal damage
Factors affecting male infertility
Uterine or peritoneal disorders
What are some investigations for infertility ?
History and examination of both partners
Semen analysis
Assessment of ovulation
LH, FSH, TFT’s, testosterone level blood test
Assessment for tubal patency
What is the management of male infertility ?
Decrease smoking or drinking
Clomiphene citrate
What is the management for female infertility ?
Clomiphene citrate
Surgery for tubal damage
Intrauterine insemination
What are fibroids ?
The most common benign gynaecological tumour. Monoclonal tumours of the smooth muscle cells of the uterine myometrium.
What are some risk factors for fibroids ?
Race
Genetics
Age - rare before menarche
Early menarche
Obesity
High meat diet
Hypertension
Smoking
diabetes
What are some clinical features of fibroids ?
Abnormal uterine bleeding
Abdominal bloating
Urinary frequency and urgency
Urinary incontinence
Constipation
Pelvic pain
What may be felt on examination when suspecting fibroids ?
Very large fibroids may be palpated abdominally
Vaginal exam reveals a firm, irregularly enlarged uterus - non tender
What are some differentials for fibroids ?
Ovarian tumours - cysts, carcinoma and fibroma
Pregnancy
Uterine endometriosis
Diverticular disease
Colonic carcinoma
What are some investigations for fibroids ?
FBC - check Hb
Mid stream urine test
USS
MRI
Hysteroscopy
What are some complications of fibroids ?
Hyaline degeneration - muscle and fibrous tissue replaced by hyaline tissue
Fatty degeneration
Calcification
What is the management of fibroids ?
Majority are asymptomatic so require no treatment
NSAIDs
Oral contraceptives
Myomectomy - removal of fibroid
Hysterectomy
Uterine artery embolisation
What are the 3 main features of PCOS?
Irregular periods
Excess androgens
Polycystic ovaries - ovaries become enlarged and contain fluid filled sacs
What are some symptoms of PCOS ?
Irregular periods
Difficulty getting pregnant
Hirsutism
Weight gain
Thinning hair and hair loss
Oily skin and acne
What are the investigations performed when suspecting PCOS ?
Endocrine tests
Imaging of the ovaries - USS
What are some complications of PCOS ?
Infertility
DM
TIA / stroke
Obstructive sleep apnoea
What are the management options for people with PCOS ?
Lose weight, Clomiphene citrate for infertility
Anti-androgens or oestrogen for Hirsutism
Lose weight or Metformin for insulin resistance
COCP for menstrual irregularity
What is the ovarian cycle ?
The normal process whereby the ova mature and are released during the menstrual cycle.
At what day does ovulation occur and what happens after ?
Day 14
After ovulation the theca and granulosa cells proliferate and the luteal cells form the corpus luteum. These cells proliferate and produce oestrogen and progesterone.
If pregnancy does not occur the corpus luteum begins to degenerate.
What are the 3 phases of the uterine cycle ?
Proliferative
Secretory
Menstrual
What happens in the proliferative phase ?
The lining becomes thicker and the uterine glands become thicker. There is mitosis in both stromal and epithelial cells leading to growth of the glands and thickening of the endometrium.
What occurs in the secretory phase ?
The endometrium becomes more vascular and the glandular component become coiled and tortuous. This is stimulated by oestrogen and progesterone.
What occurs in the menstrual phase ?
Regression of the corpus luteum and loss of hormonal support, necrosis and subsequent bleeding and sloughing of the endometrium occurs.
What is menstruation ?
Normal menstruation occurs as the endometrium sloughs from the uterus, with consequent bleeding. The flow usually lasts for 3 - 5 days. This marks the start of the new menstrual cycle.
What is the follicular phase and what hormones are involved ?
First phase of the cycle.
FSH stimulate growth in follicles
Inhibin is produced and FSH starts to decline
Increase in oestrogen
What hormones are involved in ovulation ?
LH surge causes ovulation. LH surge is caused by a rise in oestrogen.
Meiosis is completed in the oocyte as a result of the LH surge.
What is the luteal phase ?
Occurs after the release of the ovum.
The follicle forms the corpus luteum and starts to produce progesterone, androgens and oestrogen.
The corpus luteum regresses after 9 - 11 days unless pregnancy occurs.
A massive rise in progesterone results in ?
Preparation of the endometrium for implantation
Suppression in growth of the new follicles past the preantral stage
What are the most common penile disorders affecting ?
The foreskin
What is balanitis ?
Inflammation of the glans penis.
Common in young boys with non-retraction foreskin and in elderly men.
How does balanitis present ?
Irritation or pain in the penis and discharge beneath the foreskin.
Inflammation is usually visible.
Recurrent balanitis may cause phimosis with disturbance of micturition.
What is the management of balanitis ?
Avoid contact with any potential skin irritants
Keep area clean by bathing twice daily with weak saline solution
If fungal - topical anti fungals imidazole
If bacterial - oral antibiotics flucloxacillin
Referral for consideration for circumcision may be necessary
What is phimosis ?
The inability to retract the foreskin because of a narrow preputial ring.
What are some causes of phimosis ?
Primary physiology - congenital ( rare )
Recurrent balanitis
Traumatic retraction of the foreskin
How does phimosis present ?
Poor stream
Ballooning of the foreskin on Micturition
Spraying on Micturition
Recurrent attacks of balanitis
Pain on intercourse
What is the management of phimosis ?
Topical steroids
Circumcision
What is paraphimosis ?
The inability to pull the foreskin forward that has been retracted behind the glans penis.
Can occur at any age
How does paraphimosis present ?
Substantial pain
Penile swelling
Treated as a medical emergency
What is the treatment of paraphimosis ?
Manual reduction after applying anaesthetic jelly
In difficult cases a dorsal slit is made
Circumcision should be performed when inflammation has resolved.
What is benign prostatic hypertrophy ?
A histological diagnosis characterised by non-malignant proliferative process of the prostatic stromal cells. Affecting the transition zone
What are some clinical features of BPH ?
LUTS - frequency, urgency, poor stream, post-micturition dribble
Retention
Overflow incontinence
Haematuria
Infections
What is felt on examination in BPH ?
Smooth and symmetrical prostate
Enlarged
What investigations are performed when suspecting BPH ?
Urine dipstick
Cystoscopy
FBC
MSU
PSA
What is the treatment for BPH ?
Pelvic floor exercises
Alpha blockers
5-alpha reductase inhibitors
TURP
What are some complications of BPH ?
Chronic retention
Infection
Overflow incontinence
Calculi
Bilateral hydronephrosis
Renal failure
What are some risk factors of prostatic cancer ?
Increasing age
Ethnically origin - black African or black Caribbean
Family history
Diet
Obesity
Smoking
How does a prostatic carcinoma spread ?
Direct local invasion - seminal vesicles, bladder and urethra
Lymphatics -
Haematogenous - usually to bone and can be liver and lung
What are some clinical features of prostatic cancer ?
May be asymptomatic
Outflow obstruction
Haematuria
Back pain
Constipation
What are some signs that prostatic cancer has metastasised ?
Bone pain
Jaundice and pain in RUQ
Fits - spread to brain
Swollen legs - pelvic lymph nodes
Lung - usually incidental finding
How does prostatic cancer feel on examination ?
Asymmetrical
Nodular
Enlargement
Stony hard
What investigations are performed when suspecting prostate cancer ?
PSA test
DRE
Transrectal USS
MRI
MSU to see if infection
U&E to assess renal function
What is the management plan for localised prostate cancer ?
Low risk - Active surveillance
Higher risk - radical prostatectomy or radiotherapy or chemotherapy
What is the management plan for advanced metastatic prostate cancer ?
Bilateral orchidectomy
LHRH agonist
Anti-androgen mono therapy
Chemotherapy
Bisphosphonates
What is prostatitis ?
Inflammation of the prostate gland and is usually caused by coliform bacteria. It is uncommon and is characterised into acute and chronic.
What is acute prostatitis ?
An acute focal or diffuse suppurative inflammation of the prostate gland. It is a bacterial infection needing prompt treatment.
What is usually the causative pathogen in acute prostatitis ?
E. Coli
Proteus species
Klebsiella species
What are some complications of acute prostatitis ?
Acute urinary retention
Chronic prostatitis
Prostatic abscess
Epididymitis
Pyelonephritis
What are some clinical features of acute prostatitis ?
Fever
Chills
Muscle pain
Perineal pain
Bladder outflow obstruction
Haematuria
Pain
What is seen on examination when suspecting acute prostatitis ?
Tender and swollen
Prostatic massage may cause pus to be exuded from the urethra.
What is the management of acute prostatitis ?
Ciprofloxacin orally for 14 days
Second line Trimethoprim for 1 days
What investigations are performed when suspecting acute prostatitis ?
MSU - mid stream sample
What causes chronic prostatitis ?
Inflammation most commonly resulting from inadequately treated acute prostatitis or genito-urinary TB.
How does chronic prostatitis present ?
Low grade perineal pain
Pain exacerbated by sitting on a chair
Low back pain - may extend down the leg
Dysuria
Mild bouts of fever
What is seen on examination when suspecting chronic prostatitis ?
Enlarged firm and irregular prostate
Massage exuded a purulent urethral discharge
What is the treatment for chronic bacterial prostatitis ?
Ciprofloxacin for 4-8 weeks
What is Menorrhagia ?
Regular excessive menses occurring over several consecutive cycles in an otherwise normal menstrual cycle.
More than 80mL in an otherwise normal menstrual cycle.
What are some causes of Menorrhagia ?
Pelvic endometriosis
PID
Endometrial hyperplasia
Uterine fibroids
Hypothyroidism
Copper IUD
Dysfunctional uterine bleeding - if other causes have been excluded
What should be covered in a history for heavy bleeding ?
Nature of the bleeding
Any other related symptoms - intermenstrual bleeding or post - coital bleeding, pelvic pain
Impact on the quality of life
Previous history of Menorrhagia
What are some investigations for Menorrhagia ?
Blood tests - FBC, clotting studies, ferritin levels,
TFT’s
Cervical smear
HVS, chlamydia screen
What is the management for Menorrhagia ?
Levonorgestrel releasing IUS - first line
Tranexamic acid or NSAIDs
COCP or POP
What is HRT ?
Hormone replacement therapy aims to replace oestrogen in post menopausal women and reverses the adverse effects of a lack of oestrogen.
The type of HRT depends on which factors ?
Whether the individual has had a hysterectomy
Menopause status
Preference for type of treatment - oral or not
PMH
Current medications
What are some clinical indications for HRT ?
Perimenopausal or early postmenopausal women
Over 50 years old ( over 60 risks start to outweigh benefits )
Experiencing trouble some vasomotor symptoms
Why would you start someone on HRT ?
Perimenopausal or recently postmenopausal symptomatic women where risk factors for CVD or thromboembolic are low
At risk of fractures
What should be discussed before starting HRT ?
Modifiable factors for CVD - alcohol, smoking, DM, hypertension
Risks and benefits
Breast and cervical screening should be up to date
What are some benefits from starting HRT ?
Decreases flushing
Improves headaches and insomnia
Reverses genital tract atrophy
Reduces osteoporosis and fracture rate
May be protective against Alzheimer’s disease
What are some side effects of HRT ?
Nausea and breast tenderness
Weight gain and fluid retention
Headaches
Bloated sensation
Leg cramps
Glucose intolerance may be impaired
Slight increased risk of cholelithiasis
What complications are there for unopposed oestrogen replacement therapy ?
Endometrial hyperplasia
Endometrial carcinoma
Abnormal bleeding patterns
What complications can occur if a person is on HRT for longer than 5 years ?
Increased risk of breast cancer
What are some contraindications of HRT ?
History of breast cancer
History or know risk of venous or arterial thromboembolic disease, stroke or CVD
Uncontrolled hypertension
Which conditions require caution when using HRT ?
Abnormal vaginal bleeding
Abnormal liver function
Migraines
High risk of gall bladder disease
What is stress incontinence ?
The involuntary loss of urine through an intact urethra secondary to an increase in intra-abdominal pressure and in the absence of detrusor activity ( coughing or straining ).
What are the most common situations that cause stress incontinence ?
Following childbirth
After menopause
What assessments should be taken when suspecting stress incontinence ?
History
Physical exam
Assess pelvic organ prolapse
Bladder pressure tests
What are some management options for stress incontinence ?
Caffeine reduction
Fluid intake modifications
Pelvic floor training
Bladder training
What is urgency incontinence ?
The sudden need to pass urine, which if ignored, may produce incontinence.
What are the combined hormonal contraceptions ?
COCP
Combined transdermal patch
Combined vaginal ring
What are some progestogen only contraception ?
POP
Progestogen only implant
Progestogen only injectable
What are some intrauterine contraception ?
Copper IUD
Levonorgestrel IUS - marina coil
What are the sterilisation methods for contraception ?
Vasectomy
Tubal occlusion
what does the COCP contain ?
Oestrogen and progestogen
What is the mechanism of action of combined hormonal contraceptives ?
Ovulation is inhibited by the oestrogen and progestogen components. These act on the hypothalamo-pituitary axis to reduce the production of LH and FSH. This means ovulation doesn’t occur.
Why is progestogen given with oestrogen in contraceptions?
The oestrogen component causes the endometrium to proliferate and grow. The progestogen prevents hyperplasia of the endometrium.
What is the normal regime of the COCP ?
21 days of the pill followed by 7 days without
