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Yr3: GP > Men's & Women's Health > Flashcards

Men's & Women's Health Flashcards

1
Q

***GO OVER SEM 3: REPRO menstrual cycle notes!

A
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2
Q

Remind yourself of the definitions of the following terms:

  • Menarche
  • Menopause
  • Dysmenorrhoea
  • Menorrhagia
  • Metrorrhagia**
  • Oligomenorrhoea**
  • Primary amenorrhoea
  • Secondary amenorrhoea

**FIGO argues these terms should perhaps not be used

A
  • Menarche: onset of periods
  • Menopause: ceasing of periods
  • Dysmenorrhoea: painful periods
  • Menorrhagia: heavy periods
  • Metrorrhagia: irregular periods
  • Oligomenorrhoea: infrequent periods
  • Primary amenorrhoea: absence of periods- never had/started periods
  • Secondary amenorrhoea: absence of periods but have had periods in past
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3
Q

State some red flag for endometrial cancer in women

A
  • Visible haematuria in women age 55yrs and over accompanied by any of following:
    • ​Hyperglycaemia
    • Low haemoglobin
    • Thrombocytosis
    • Unexplained vaginal discharge
  • Post menopausal bleeding
  • Cervix
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4
Q

State some red flags for ovarian cancer

A
  • Loss of appetite or early satiety
  • Abodminal distension
  • Pelvic or abdominal mass identified on examination
  • Ascites
  • Abdo or pelvic pain
  • IBS symptoms
  • Change in bowel habit
  • Fatigue
  • Urinary urgency and/or frequency
  • Weight loss
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5
Q

State some red flags for vulval cancer

A
  • Vulval bleeding
  • Vulval lump or ucleration
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6
Q

State some red flags for cervical cancer

A

*Cervix may or may not look abnormal: may be altered colouring/pigmentation, ulceration, mass

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7
Q

Define the following terms:

  • Inter-menstrual bleeding
  • Post-coital bleeding
  • Breakthrough bleeding
A
  • Inter-menstrual bleeding: bleeding between periods
  • Post-coital bleeding: bleeding after sex
  • Breakthrough bleeding: irregular bleeding between periods using hormonal contraception
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8
Q

State some potential causes of inter-menstrual bleeding

*List is long, just know a few

A
  • Pregnancy related (including ectopic pregnancy & gestation trophoblastic disease)
  • Physiological:
    • Vaginal spotting around time of ovulation
    • Hormonal fluctuations during perimenopause
  • Vaginal causes:
    • Adenosis
    • Vaginitis
    • Tumours
  • Cervical causes:
    • Infection e.g. chlamydia, gonorrhoea
    • Cancer (more commonly post-coital)
    • Cervical polyps
    • Cervical ectropion
  • Uterine:
    • Fibroids
    • Endometrial polyps
    • Cancer
    • Endometritis
    • Adenomyosis
  • Oestrogen secreting ovarian cancers
  • Iatrogenic:
    • Tamoxifen
    • Following smear or treatment of cervix
    • Missed oral contraceptives
    • Drugs that alter clotting e.g. anticoagulants, SSRIs, corticosteroids
    • Alternative remedies when taken with hormonal contraceptives e.g. St John’s Wort
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9
Q

State some potential causes of post-coital bleeding

A
  • Infection
  • Vaginal cnacer
  • Cervical cancer
  • Trauma or sexual abuse
  • Cervical ectropion (eversion of endocervix)
  • Vaginal atrophic change
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10
Q

When is breakthrough bleeding commong?

A
  • Common when new contraceptive method is started and often settles without intervention but important to exclude other causes such as pregnancy and any underlying infection
  • Bleeding problems more common with progesterone only methods
  • Smokers have increased risk of breakthrough bleeding
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11
Q

State some potential causes of breakthrough bleeding

A
  • Infection
  • Pregnancy, including ectopic
  • Endometrial or cervical polyps
  • Endometrial cancer
  • Cervical cancer

THEREFORE MUST INVESTIGATE if continues/you don’t suspect its the normal breakthrough bleeding which can happen when first start new contraception

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12
Q

Dicuss how you would approach a patient presenting with inter-menstrual bleeding, post-coital bleeding or breakthrough bleeding

A
  • History:
    • Rule out red flags
    • Menstrual history
    • Sexual history
    • Obstetric history
    • Gynaecological history: contraception, smears, STIs
  • Examination:
    • Abdo examination
    • PV examinaion
  • Investigations
    • Pregnancy test (if child bearing age)
    • Infection screen
    • Blood tests: FBC, clotting, TFTs, FSH/LH
    • Transvaginal ultrasound (immediately post-menstrually as endometrium is at it’s thinnest)
    • Refer if suspect cancer
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13
Q

State some potential causes of mennorrhagia, consider:

  • Uterine & ovarian pathologies
  • Systemic pathologies
  • Iatrogenic causes
A
  • Idiopathic (50%)
  • Uterine & ovarian pathologies:
    • Uterine fibroids
    • Endometriosis
    • Adenomyosis
    • PID
    • Infection
    • Endometrial polyps
    • Cancer
    • PCOS
  • Systemic pathologies:
    • Coagulation disorders
    • Hypothyroidism
    • DM
    • Hyperprolactinaemia
    • Liver or renal disease
  • Iatrogenic
    • Anticoagulation treatment
    • Chemotherapy
    • Intrauterine contraceptive devices
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14
Q

Discuss how you would approach a patient with menorrhagia

A
  • History
    • Nature of bleeding
    • Menstrual cycle history e.g. normal for her, menarche, perimenopause, IMB etc..
    • Cervical screening
    • Sexual history
    • Medical history & FH e.g. thyroid, coagulation disorders, endometriosis
    • Related symptoms
    • Drug history
  • Examination (only need to do if history of menorrhagia with other related symptoms)
    • ​Abdo exam
    • Signs of systemic disease e.g. hypothyroid, coag disorders etc…
    • Pelvic examination
  • Investigations:
    • Bloods: FBC (rule of Fe deficiency anaemia as strong indicator of menorrhagia), TFTs, clotting
    • Transvaginal or pelvic ultrasound
    • Vaginal or cervical swab for infection
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15
Q

Discuss the management of menorrhagia in primary care

A
  • Provide information & reassuance on menorrhagia
  • Dicuss risk and benefits of treatment options (if woman wants treatment):
    • First line= LNG-IUS (levonergesrel intrauterine system)
    • If not consider:
      • Non-hormonal: tranexamic acis, NSAIDs
      • Hormonal: CHC, cyclical oral progestogen
  • Refer if any cause for concern e.g. mass, ascties, suspected cancer, large fibroids causing complications
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16
Q

Explain how a LNG-IUS helps menorrhagia

A
  • a T-shaped plastic device placed in the uterus that steadily releases small amounts of levonorgestrel each day.
  • Levonorgestrel is a form of progesterone and remember progesterone thins lining of endometrium.
    *

*Just an IUS that releases levonorgestrel as its form of progesterone

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17
Q

In around 50% of cases there is no clear cause of menorrhagia; what do we call this?

A

Dysfunctional uterine bleeding

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18
Q

Remind yourself of the difference between primary and secondary dysmenorrhoea

A
  • Primary: from start of periods (usually starts 6-12 months after the menarche once cycles are regular). Pain starts shortly before onset of menstruation and may last up to 72 hrs improving as menses progresses. Occurs in young females in absence of any underlying pelvic pathology.
  • Secondary: develops after several years of painless periods. Pain is not consistenlty related to menstruation alone and may persist after menstruation finishes or may be present throughout cycle but be exacerbated by meses. Caused by an underlying pelvic pathology
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19
Q

State some risk factors for dysmenorrhoea

A
  • Earlier age at menarche
  • Heavy menstrual flow
  • Multiparity
  • FH of dysmenorrhoea
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20
Q

State some potential causes of secondary dysmenorrhoea

A
  • Endometriosis
  • Adenomyosis
  • Fibroids
  • Endometrial polyps
  • PID
  • IUD insertion
  • Ovarian cancer
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21
Q

Discuss how you would approach a patient with dysmenorrhoea

A
  • History
    • When symptoms started
    • Characteristics of pain
    • Associated symptoms
    • Menstrual history
    • Medical history
    • Obstetric history
  • Examanation
    • Abdo exam to feel for any masses
    • Pelvic examination
  • Investigations
    • Ultrasound: rule out fibroids, endometriosis, assess IUD
    • Vaginal & endocervical swabs for STIs
    • Pregnancy test
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22
Q

Discuss the management of dysmenorrhoea, include management for:

  • Primary dysmenorrhoea
  • Secondary dysmenorrhoea
A

Primary

  1. NSAIDs
  2. Paracetamol is NSAIDs are contraindicated, not tolerated or not sufficient
  3. If woman does not want to concieve, consider hormonal contraception trial as an alternative first line treatment
  4. Combine all of above

Secondary

  • Main idea is to manage underlying cause such as fibroids, PID etc…
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23
Q

State some symptoms of menopause

A
  • Hot flushes
  • Night sweats
  • Vaginal dryness
  • Lack of sex drive
  • Mood changes/swings
  • Difficulty sleeping
  • Decreased muscle & bone mass
  • Increased CVD risk
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24
Q

Discuss how we diagnose the menopause

A

Diagnosis is mainly clinical:

  • Age
  • Change to menstrual cycle: may initially shorten to 2-3 weeks or lengthen to many months. Amount of blood my change. Absence of periods.
  • Symptoms of menopause (see other slide)
  • FSH is not routinely done
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25
Q

State some circumstances in which you may consider using FSH to diagnose menopause

A
  • >45 and atypical symptoms
  • 40-45 with menopausal symptoms, including a change in their menstrual cycle
  • <40 with diagnosis of suspected POI
  • Over 50yrs using progesteron only contraception
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26
Q

Diagnosis of menopause can be complicated in women using oral contraceptives; true or false?

A

True

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27
Q

State some storage, voiding and post-micturition symptoms

A

Storage

  • Urgency
  • Frequency
  • Nocturia
  • Urinary incontinence

Voiding

  • Hesitancy
  • Weak or intermittne stream (splitting or spraying)
  • Straining
  • Intermittency

Post-micturition

  • Post-micturition dribble
  • Sensation of incomplete emptying
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28
Q

Dicuss how you would approach/assess a male presenting with lower urinary tract symptoms

A
  • History
    • ​Establish symptoms
    • Ask about possible underlying causes e.g. diabetes, MS, current drug treatments
    • Establish main concerns
  • Examine
    • Abdo exam for distended abod, dull to percussion etc…
    • DRE
    • External genitalia exam
  • Investigations
    • Urinary frequency volume chart
    • IPSS
    • PSA
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29
Q

Remind yourself of the main types of incontinence

A
  • Stress
  • Mixed
  • Urgency
  • Overflow
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30
Q

What questions do you need to ask to determine the type of incontinence?

A
  • Does it occur during coughing, sneezing, exertion etc…
  • Is there sudden urgency
  • Increased frequency
  • Nocturia
  • Voiding difficulty (suggest chronic urinary retention
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31
Q

Discuss what you must include in your examination when examining a lady with incontinence

A
  • Abdo examination
  • Pelvic examination
    • During this ask to cough with comfortably full bladder and observe external urethral meatus for leakage
    • Assess pelvic muscle tone and contraction during bimanual examination
    • Look for evidence of pelvic organ prolapse
32
Q

If a pt presents with urinary symptoms, what chart may you ask them to complete? What info can this tell you?

A

Flow-volume chart; these detect:

  • Frequency (high frequency with normal volume)
  • Polyuria (up to 3L in 24hr is normal)
  • Nocturia
  • Nocturnal polyuria (passing more than 35% of 24hr urine production at night)
33
Q

What is functional incontinence?

A

Urinary tract is functioning properly however other illnesses or disabilities are preventing a person from being continent. For example, if pt has dementia and is consequently unaware about needing the toilet, if you have arthritis so struggle to get up in time to go to the toilet etc…

Common in elderly

34
Q

State some potential causes of lower urinary tract symptoms in females; for each of the causes, state some specific LUT symptoms they may experience

A
  • UTI: abdo pain/discomfort, soreness/burning when wee, increased frequency, urgency, cloudy urine, haematuria
  • Menopause: stress, urgency, overactive bladder
  • Vaginal delivery: as above
  • Neurological conditions: e.g. MS
35
Q

State some potential causes of lower urinary tract symptoms in men

A
  • BPH
  • Urethral strictures
  • Neurolgoical disroders
  • Drugs with antimuscuranic actions
  • Lower urinary tract infection
  • STI
  • Cancer of bladder and/or prostrate
36
Q

State some potential causes of nocturnal polyuria

A
  • Medical conditions:
    • Diabetes mellitus
    • Diabetes insipidus
    • Liver failure
    • CHF
  • Drugs:
    • Diuretics
    • CCBs
    • SSRIs
37
Q

Discuss the management of stress incontinence in primary care

A
  • Manage any reversible causes or contributing factors e.g. constipation, obesity, smoking, certian drugs such as ACE inhibitors (cause cough)
  • Lifestyle advice:
    • Reduce caffeine
    • Avoid excessive fluid intake
    • Weight loss
    • Smoking
  • Provide info about self help resources- NHS website
  • Refer for at least 3 months of supervised pelvic floor muscle training

… If require further management refer to secondary care e.g. urogynaecologist, gynaecologist, urologist etc..

38
Q

Discuss the management of urgency incontinence in primary care

A
  • Exclude or manage any treatable causes of overactive bladder syndrome if possible
  • Lifestyle advice:
    • Reduce cafeeine
    • Fluid intake
    • Weight loss
    • Smoking
  • Offer self-help resources- NHS website
  • Refer for bladder training (for at least 6 weeks)
  • If symptoms persist, despite bladder training encourage to continue bladder training and add in an antimuscuranic e.g. oxybutynin
  • If woman is post-menopausal and has vaginal atrophy consider intravaginal oestrogen therapy
39
Q

Discuss the management of mixed incontinence in primary care

A

Mixed incontinence is a combination of stress and urgency incontinence; therefore, you should manage the woman according to the most predominant type of urinary incontinence: stress or urgency.

40
Q

Discuss the management of voiding symptoms in men in primary care

A
  • Exclude or manage causes of voiding symptoms if possible e.g. BPH, antimuscuranic drugs…
  • Offer:
    • Active surveillance:reassurance and lifestyle advice with a follow up to see how getting on
    • Conservative management: pelvic floor & bladder training
  • If active surveillance not appropriate and/or conservative fails:
    • Use IPSS to calculate score; if score >8 offer alpha blocker e.g. doxasozin, tamsulosin & review in 4-6 weeks
  • If has prostatic enlargement and is considered high risk can also offer 5-alpha reductase inhibitor e.g. finaseride, dutasteride
  • If also has storage symptoms can consider adding antimuscuranic e.g. oxybutynin
  • Referral to urologist if all above fails
41
Q

Discuss the management of overactive bladder symptoms in men

*Overactive bladder syndrome: urgency with or without urgency incontinence and the sensation of need to pass urine again just after urinating

A
  • Exclude or manage treatable causes of overactive bladder e.g. BPH, neurological conditions, STIs, urinary tract infection
  • Lifestyle advice:
    • Reduce caffeine
    • Fluid intake
    • Weight loss
    • Smoking
    • Avoiding constipation
  • Self help resources- bladder&bowel foundation
  • If necessary offer a choice of temporary containment products to achieve social continecne whilst waiting for referral to continence service
  • Offer referral to supervised bladder training
  • If symptoms persist, consider adding in antimuscuranic e.g. oxybutynin
42
Q

Discuss how you should approach/clinically assess a male with lower urinary tract symptoms

A
  • History
    • Storage, voiding etc..
    • Comorbidities that might be a cause e.g. diabetes, MS
    • Current drug treatments
    • ICE
  • Examination
    • Abdo
    • External genitalia e.g. for phimosis, penile cancer
    • DRE to assess prostrate for size, consistency, nodules and tenderness
    • Examine lower limbs for motor & sensory function
  • Further investigations:
    • Frequency volume chart
    • Dipsick
    • PSA testing
43
Q

State some questions in the IPSS (international prostrate symptom score)

A
44
Q

State some red flag symptoms, in males with lower urinary tract symptoms, that would prompt urgent investigation and/or referral

A

Urological Cancer Red Flags

  • Prostrate that is hard and irregular
  • Unexplained haematuria
  • Lower back pain
  • Bone pain
  • Weight loss

Urological Infection Red Flags

  • Pain on urination
  • Pelvic and/or loin pain
  • Fever
  • Abnormal dipstick

Sciatica (NOTE: can cause or aggrave LUTs)

  • Weakness, numbness or tingling in leg
45
Q

What is meant by erectile dysfunction?

A

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.

46
Q

Causes of erectile dysfunction can be split into biological, psychological and drug related; state some biological causes (includes vascular, anatomical, hormonal, neurological)

A

Biological

  • Cardiovascular disease
  • Hypertension
  • Hyperlipidaemia
  • DM
  • Smoking
  • Major pelvic surgery
  • Degenerative disorders e.g. MS, Parkinson’s
  • Stroke
  • Spinal cord trauma or diseases
  • CKD
  • Penile cancer
  • Prostrate cancer
  • Hypsopadias
  • Hypogonadism
  • Hyper/hypothyroid
  • Cushing’s disease
  • Hyperprolactinaemia
47
Q

Causes of erectile dysfunction can be split into biological, psychological and drug related; state some psychological causes

A
  • Generalised e.g. lack of arousability & sexual intimacy
  • Situational e.g. stress, partner or performance related issues, psychiatric illnes (e.g. anxiety, depression)
48
Q

Causes of erectile dysfunction can be split into biological, psychological and drug related; state some drug related causes

A
  • Antihypertensives
    • Beta blcokers
    • Verapamil
  • Diuretics
    • Spironolactone
    • Thiazides
  • Antidepressants
    • Tricyclics
    • Monoamine oxidase inhibitors
    • SSRIs
  • Antiarrhythmics
    • Digoxin
    • Amiodarone
  • Hormone & hormone modifying drugs
    • 5 alpha reductase inhibitors
    • Corticosteroids
  • Antipsychotics
    • Haloperidol
    • Chlorpromazine
  • Histamine (H2) antagonists
    • ​Ranitidine
  • Recreational drugs
    • Alcohol
    • Cocaine
    • Marijuana
    • Anabolic steroids
49
Q

Discuss how you should approach the clinical assessment of a man with erectile dysfunction

A
  • ***If possible, good to involve man’s partner.*
  • ***Idea is to try and find underlying cause whilst also assessing for risk factors.*
  • History
    • Psychosexual history e.g. sexual orientation, current emotional status, sexaul function
    • Issues with sexual aversion or pain
    • Medical history
    • Current medications
    • Lifestyle questions e.g. alcohol
    • How they feel generally
  • Examination
    • _​_BP
    • HR
    • Waist circumference
    • BMI
    • Genital examination
    • Check for gyanecomastia, hair loss
    • DRE (if symptoms of enlarged prostrate or relevant history or >50)
  • Investigations
    • Screen diabetes: fasting glucose or HbA1c
    • Lipid profile
    • Calculate Q risk
    • Morning sample of total testosterone
    • Arrrange other investigations guided by history and examination e.g. PSA

*NOTE: in a man with pre-existing cardiovascular disease assess the cardiovascular risk of sexual activity

50
Q

Discuss the treatment options for men with erectile dysfunction

A
  • Lifestyle advice
    • Lose weight
    • Stop smoking
    • Reduce alcohol
    • Increase exercise
    • If men cycle >3hr per week, trial period without cycling or try to make adjustments to cycling position
  • Pharmacological
    • Prescribe PDE-5 inhibitor regardless of cause PROVIDED there are no contraindications e.g. sildenafil (viagra), tadafil (cialis)
  • Other
    • Provide additional information- NHS, BAUS, sexual dysfuntion association page
    • Arrange follow up 6-8 weeks after initiation of treatmen tto assess efficacy
    • Approrpriate referral if required e.g. urology, endocrinology, cardiology, mental health services etc..
51
Q

There are validated psychometric questionnaires you an use to assess erectile dysfunction; true or false?

A

True e.g. IIEF (international index for erectile dysfunction) or SHIM (sexual health inventory for men [shorter version of IIEF)

52
Q

For endometriosis, state:

  • What it is
  • Risk factors
  • Symptoms
  • Investigations
  • Management
  • Complications
A
  • Growth of endometrium outside of the uterus
  • Risk factors: family history, early age of menarche, autoimmune disease, low BMI, smoking
  • Symptoms:
    • Chronic pelvic pain
    • Dysmenorrhea
    • Dyspareunia or post-coital pain
    • Period related or cyclic urinary symptoms
    • Reduced fertility
    • GI symtpoms (particularly during periods)
  • Investigations:
    • Refer for USS (transvaginal better than transabdominal). May also do laparoscopy as this is gold standard/definitive daignosis. Would be arrranged by specialist.
  • Managment:
    • Analgesia: paracetamol and/or ibruprofen
    • Hormonal treatment: COCP, implant, POP etc..
    • Surgery: hysterectomy, bilateral salpingo-opherectomy, excision or ablation of endometriosis
  • Complications:
    • Fertility problems
    • Chronic pain
    • Bowel obstruction (due to adhesion or circumferential endometriotic deposition)
    • Decreased quality of life
53
Q

For adenomyosis, state:

  • What it is
  • Risk factors
  • Symptoms
  • Investigations
  • Management
  • Complications
A
  • Endometrial tissue extends into myometrium
  • Risk factors:
    • Prior uterine surgery e.g. caesarean, fibroid removal etc..
    • Childbirth
  • Symptoms:
    • Menorrhagia
    • Dysmenorrhea
    • Dyspareunia
    • Chronic pelvic pain
    • May feel bilaterally enlarged palapate uterus
  • Investigations:
    • MRI
  • Management:
    • NSAIDS to control pain
    • Hormonal treatments (may lessen heavy bleeding & pain) e.g. COCP, implant, GnRH agonists
    • Hysterectomy
    • Uterine artery embolisation (block blood supply to adenomyosis so shrinks)
  • Complications:
    • Infertility
    • Anaemia
    • Pre-term births
54
Q

For fibroids, state:

  • What it is
  • Risk factors
  • Symptoms
  • Investigations
  • Management
  • Complications
A
  • (also called leimyomas) benign tumours — they are a mixture of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium. Develop during reproductive age as oestrogen and progesterone control the proliferation and maintenace of fibroids.
  • Risk factors:
    • Age
    • Early puberty
    • Obestiy
    • FH
    • Black ethnicity
  • Symptoms:
    • Commonly asymptomatic and often found when woman seeks help as struggling to concieve. But symptoms may include: menorrhagia, dysmenorrhoea, UTI symptoms, non-specific GI symptoms
  • Investigations:
    • Refer for ultrasound (transabdominal & transvaginal)
  • Management:
    • If no symptoms, arrange annual follow up to review size
    • Refer to specialist if >3cm or having compressive symtpoms e.g. dyspareunia, constipation etc..
    • Analgesia
    • Hormonal e.g. IUS (first line), COCP, POP etc…
    • Tranexamic acid
    • Gonadotropin analogues
    • Surgery to remove fibroids or hysterectomy
55
Q

For PCOS, state:

  • What it is
  • Risk factors
  • Symptoms
  • Investigations
  • Management
  • Complications
A
  • Heterogeneous endocrine disorder that appears to emerge at puberty. The clinical features may include hyperandrogenism (with the clinical manifestations of oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.
  • Risk factors:
    • FH
    • Obesity
  • Symptoms:
    • Oligomenorrhoea or amenorrhoea
    • Hirtuism
    • Acne
    • Infertility
  • Investigations:
    • Use Rotterdam criteria for PCOS. If 2 or more present= diagnose PCOS
    • Blood tests:
      • LH: raised
      • FSH: normal (raised LH:FSH ratio)
      • LH:FSH ratio
      • Total androgens: elevated
      • SHBG:decreased
      • TFT: rule out other causes
      • Prolactin: rule out other causes
      • HbA1c: risk factor
      • Lipids: risk factor
    • Refer for ultrasound (transvaginal best)
  • Management:
    • Lifestyle: weight loss, regular exercise
    • Screen for diabetes, CVD risk factors
    • Oral contraceptives (regulate periods)
    • Clomiphene (if fertility is issue)
    • Co-cyprindiol for hirtuism & acne
    • Consider referral if infertility, poor symptom control, rapid onset etc..
  • Complications:
    • Infertility
    • Increased CVD risk
    • Decreased quality of life/mental health effects
56
Q

Discuss the pathophysiology of PCOS

A

Insulin resistance results in pancreas producing more insulin. Insulin promotes release of androgens from ovaries and adrenal glands therefore there are increased androgen levels. Insulin also suppresses sex hormone binding globulin (SHBG) production by the liver. SHBG usually binds to androgens and suppresses their functions. Reduced SHBG further promotes hyperandrogenism in PCOS women. High insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).

57
Q

What is the Rotterdam criteria for PCOS?

A
58
Q

Describe how PCOS may look on ultrasound

A

“String of pearls” appearnce due to follicles around periphery

ALSO WORTH REMEMBERING: ovarian volume of more than 10cm3 can indicate polycystic ovarian syndrome, even without the presence of cysts.

59
Q

For PCOS, explaint the link with:

  • Secondary amenorrhoea/oligomenorrhoea
  • Androgenism & weight gain
  • Reduced fertility
  • Inreased risk of T2DM
A
  • Amenorrhoea/oligomenorrhoea: large number of fluid filled cysts stop ovulation. No ovulation, no corpus luteum, no period???? CHECK
  • Hyperandrogenism leads to insulin resitance. Hence body tries to compensate and make more insulin. Insulin is anabolic and promotes fat storage- particularly in lower abdomen.
  • PCOS can lead to decreased ovulation/annovulation decreasing fertility
  • Increases risk of T2DM see hyperandrogenism
60
Q

What woudl you expect following levels to be in PCOS:

  • LH
  • LH:FSH ratio
  • Testosterone
  • Prolactin
A
  • LH increased
  • LH:FSH increase
  • Testosterone increaesed
  • Prolactin may be mildly increased
61
Q

State some potential complications of PCOS

A
  • T2DM
  • Increased CVD risk
  • Increased complications in pregnancy e.g. increase risk preeclampsia, gestational diabetes
  • Endometrial hyperplasia and cancer
  • Infertility
  • Hirsutism
  • Acne
  • Obstructive sleep apnoea
  • Depression and anxiety
62
Q

Explain why women with PCOS have increased risk endometrial cancer

A

Women with polycystic ovarian syndrome have several risk factors for endometrial cancer:

  • Obesity
  • Diabetes
  • Insulin resistance
  • Amenorrhoea

Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.

Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.

63
Q

What is HRT?

A

Hormone replacement therapy (HRT) is a treatment to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause

64
Q

State some non-drug options that might be helpful to treat symptoms of menopause

A
65
Q

State some drugs that can be used to treat following symptoms of menopause (not asking about HRT, asking about other medications):

  • Hot flushes
  • Mood changes/swings
  • Decreased muscle & bone mass
A
  • Hot flushes: clonidine (adrenergic/alpha-2 agonist), SSRIs/SNRIs (SSRIs/SNRIs not licensed for treatment of hot flushes but some thoughts they may help)
  • Mood changes/swings: SSRIs, SNRIs
  • Decreased muscle & boone mass: bisphosphonates, vit D, calcium
66
Q

State some indications for HRT

A
  • Premature ovarian insufficiency
  • Reducing vasomotor symptoms (e.g. hot flushes)
  • Reducing risk of osteoporosis
67
Q

Discuss the potential routes of administration for HRT

A
  • First line= oral
  • Second line/alternative= transdermal
    • Patch (combined oestrogen and progesterone or oestrogen only)
    • Gel (oestrogen only)
    • Spray (oestrogen only)
68
Q

Discuss when you would give oestrogen and progesterone as HRT and when you would give oestrogen only as HRT

A
  • Combined oestrogen & progesterone if they have a uterus to decrease risk of endometrial cancer
  • Oestrogen only can be used if they do not have a uterus

*NOTE: vaginal oestrogen has minimal systemic absorption so do not need to prescribe progesterone aswell

69
Q

Discuss which women you would use a cyclical HRT routine in and which you would use a continuous HRT routine in

A
  • Cyclical: if woman is peri-menopausal/still having infrequent perios/not had 12 months of no periods. Can either give monthly or 3 monthly cycle. Take oestrogen every day, then take progesterone for 10-14 days at end of cycle.
  • Continuous: post-menopausal women

*continuous means the woman doesn’t have any bleeding therefore once a woman is post-menopausla consider changing from cyclical to continous

70
Q

Discuss the roel of low dose vaginal oestrogen and vaginal lubricants in menopause

A

Low oestrogen in menopause can lead to vaginal atrophy which can result in pain in intercourse, vaginal discharge, irritation, burning and increased frequency of UTIs.

  • Low dose oestrogen: directly apply to vagina in form of a tablet, cream/gel or ring pessary
  • Lubricant: aids with vaginal dryness
71
Q

Discuss the risk and benefits of HRT

A

Risks: breast cancer, ovarian cancer, endometrial cancer (reduced by progesterone use if necessary), increased risk of thromboembolic disease therefore educate on red flags of this

72
Q

State some potential adverse effects of HRT

A
  • Bloating
  • Water retention
  • Headaches
  • Leg cramps
  • Nausea
  • Abdo pain
  • Acne
  • Indigestion
73
Q

How long does it take, approximately, for a woman to feel the benefits of HRT?

A
  • Start to see improvement in a few weeks
  • Maximal effect may take a few months (and ADRs may take a few months to settle down; hence why we encourage women to try HRT for at least 3 months)
74
Q

State some contraindications to HRT

A
75
Q

What medication can be offered to women with PCOS to help with weight loss?

How does it work?

A

Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.

76
Q

State some causes of hirsutism other than PCOS

A
  • Medications: phenytoin, cliclosporin, corticosteroids, testosterone and anabolic steroids
  • Ovarian or adrenal tumours secreting androgens
  • Cushing syndrome
  • Congenital adrenal hyperplasia

Yr3: GP (21 decks)

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