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Gynaecology > Menses > Flashcards

Menses Flashcards

1
Q

What is PMB?

A

Vaginal bleeding after established menopause (12m of amenorrhea)

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2
Q

What is recurrent PMB?

A

Another episode of bleeding 6m apart from last PMB assessment

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3
Q

What are the DDx of PMB?

A 
GYNE
Uterus: CA, polyp, iatrogenic (post-HRT endometrial gland act)
Cervix: CA, polyp, inf
Vagina/vulva: CA, inf
PID

NON-GYNE
Other holes: PRB, hematuria
Anticoagulants, coagulopathy

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4
Q

How to Ix PMB?

A

Hx & PE, pap smear (>65yo + x recent smear)
TVS: endometrial thickness (>5mm), smoothness
Hysteroscopy (high risk) or endometrial sampling (low risk)

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5
Q

What are the indications of hysteroscopy?

A

Endometrial thickness >5mm
Recurrent PMB
Hx of CA breast on tamoxifen (risk of CA endometirum)

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6
Q

What are the contraindications of hysteroscopy?

A

Inf: uterine collection, genital tract inf

CA cervix

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7
Q

What is menopause?

A

Amenorrhea for 12m since LMP

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8
Q

When is menopause?

A

45-55yo

Mean 51y

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9
Q

What is premature menopause?

A

<40yo

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10
Q

What is surgical menopause?

A

After bilateral oophorectomy

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11
Q

What are the causes of menopause?

A

Physiological: natural, premature
Iatrogenic: surg, post chemo/RT
Inf: post-mumps, TB
AI: SLE, thyroiditis, oophoritis

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12
Q

What are the effects of menopause?

A

Acute

  • Vasomotor: hot flushes, night sweats
  • Psycho: labile mood, sleep disturbance
  • Arthralgia, dry & itchy skin
  • Decreased libido

Intermediate (genital atrophy): vaginal dryness & soreness, dyspareunia, UG prolapse, recurrent UTI / freq & urg

Long term: CV disease, osteoporosis, dementia

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13
Q

How to Ix menopause?

A

High FSH

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14
Q

How to Mx menopause?

A 
Non-pharm
- stop smoking, healthy diet
- wt-bearing ex, vit D, sunshine, 
- self-breast awareness
- avoid hot flush triggers (spicy food, caffeine, alcohol), dress in light layers
Pharm: HRT
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15
Q

What are the indications of HRT?

A

Replacement: hypogonadotrophic amenorrhea, surg <40yo, premature
Tx: climacteric symptoms, osteoporosis
Prev: RF for osteoporosis
- PMH: Cushing, hypothyroid, hyperPTH, RA
- Iatrogenic: steroid, thyroxine, anticonvulsant, gastrectomy

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16
Q

What are the contraindications of HRT?

A 
CA endometrium, breast, ovary
Recent ATE (stroke, MI, angina), RF for VTE
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17
Q

How long should HRT be prescribed?

A

For climacteric symptoms: 2-3y
For premature menopause: until avg age of natural menopause
For osteoporosis: until 60yo

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18
Q

What are the first line regimens of HRT?

A 
ORAL
Estrogen-only: x uterus
Combined
- Menopause <2y or premature: cyclical
- Menopause >2y: continuous

TOPICAL
Estrogen-only: local vaginal pathology, HT, hyperthyroid, gallstone & metabolic risk

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19
Q

What is the second line regimen of HRT?

A

SERM: Raloxifene

  • Intact uterus: combine w/ cyclical progesterone
  • x uterus: raloxifene only
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20
Q

What is dysmenorrhea?

A

Cyclical pain during menstruation

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21
Q

What are the RF of dysmenorrhea?

A

Early menarche, long menstrual period, G0
Smoking
FH

22
Q

What is primary dysmenorrhea?

A

Onset: 6-12m after menarche
Starts before onset of menstruation in each cycle -> resolves as period starts
Nature: spasmodic over lower abdomen, radiates over ant thigh

23
Q

What is secondary dysmenorrhea?

A

Onset: years after menarche
Starts before menstruation -> worsens as period starts (crescendo)
Nature: congestive

24
Q

What are the causes of primary dysmenorrhea?

A

x organic causes

Uterine contraction & vasoconstriction -> stimulates pain fibres

25
Q

What are the causes of secondary dysmenorrhea?

A 
Pelvis
- MC endometriosis
- Mass: adenomyosis, fibroid, polyp
- Adhesion: chronic PID, Asherman
Vascular: pelvic congestion syndrome
Iatrogenic: IUCD
26
Q

How to Ix dysmenorrhea?

A

Primary: x
Secondary: USG, diagnostic laparoscopy

27
Q

How to Mx dysmenorrhea?

A

Primary: NSAID, COCP
Secondary: tx underlying cause

28
Q

What is pelvic congestion syndrome?

A

Varicose vs near ovary
Aggravated by: prolonged standing/sitting, coitus
Relived by: sitting down
MC on the left (R to IVC, L to renal v at sharp angle)

29
Q

What is the inheritance of PCOS?

A

AD

30
Q

How to Dx PCOS?

A

Rosterdam criteria: 2/3

  • Oligomenorrhea / chronic anovulation
  • Hyperandrogenism
  • USG: polycystic kidneys (>20)
31
Q

What are the S/S of PCOS?

A

Oligomenorrhea
Infertility
Metabolic syndrome: obesity, HT, acanthosis nigricans
Hirsutism, acne

32
Q

How to Ix PCOS?

A

Biochemical: high LH, high androgen, mildly high PRL, metabolic syndrome (DM, HL, dLFT)
TVS: multiple small cysts (>10 on each side, necklace appearance), bilateral enlarged ovaries, thickened stroma

33
Q

What are the Cx of PCOS?

A

Reproduction: infertility, recurrent abortion, OHSS during OI
Metabolic: DM, HT
Mal: endometrial hyperplasia / CA

34
Q

How to Mx PCOS?

A

Menses: COCP or cyclical progesterone (norethisterone)
Hyperandrogenism: COCP or anti-androgens (spironolactone)
Infertility: letrozole, laparoscopic ovarian drilling
Metabolic: weight control, metformin

35
Q

What is ovarian drilling?

A

Drill ovary w/ diathermy -> destroy thickened cortex + dcr androgen

36
Q

What is amenorrhea?

A

Absence of menstruation in a woman of reproductive age

37
Q

What is primary amenorrhea?

A

x secondary sexual characteristics: by 14yo

normal secondary sexual characteristics: by 16yo

38
Q

What is secondary amenorrhea?

A

Regular cycles: 3m

Irregular cycles: 6m

39
Q

What is physiological amenorrhea?

A

during preg/lactation

40
Q

What is oligomenorrhea?

A

> 35d cycle

4-9 periods per year

41
Q

What is hypomenorrhea?

A

Low menstrual flow

42
Q

What are the WHO classes of amenorrhea?

A

Class 1: low FSH (gonadotrophin deficiency b/c physio, pit, endocrine, chronic illness)
Class 2: normal FSH (failure of gonadotrophin action b/c PCOS, congenital)
Class 3: high FSH (ovarian failure)
HyperPRL anovulation

43
Q

What are the DDx of normogonadotrophic amenorrhea?

A

Normal uterus: outflow problem e.g. vaginal agenesis, transverse vaginal septum, imperforate hymen
Abn uterus: high androgen (PCOS, CAH), normal androgen (Mullerian agenesis)

44
Q

What are the DDx of hypogonadotrophic amenorrhea?

A 
Physiological: constitutional delay, stress, ex, LOW
Pathological (PECK)
- Kallmann
- Pit: tumour, empty sella, Sheehan
- Endocrine: hypothyroid, DM, Cushing
- Chronic illness: TB, malnutrition
45
Q

What are the DDx of hypergonadotrophic hypoestrogenic amenorrhea?

A

45XO: Turner
46XY: pure gonadal dysgenesis
46XX: idiopathic ovarian failure, AI oophoritis, Fragile X

46
Q

What are the DDx of hyperPRL anovulation?

A 
Physio: preg, lactation, stress, sex
Patho (POSHH)
- Pit: PRLoma
- Stalk: tumor w/ mass effect
- Hypothalamus: prev RT
- Hypothyroid
- Others: PCOS, RF/LF, chest wall lesions
Iatrogenic: dopamine antagonist (anticonvulsant, antidepressant, antiHT, antiemetics, estrogens, cocaine/opiates)
47
Q

How to Mx hyperPRL amenorrhea?

A

Refer: neurosurg (pit macroadenoma), med (asymp)

Dopamine agonist e.g. bromocriptime, cabergoline, quinagolide

48
Q

How to Mx hypogonadotrophic amenorrhea?

A

1) Prev hypoestrogen: COC or combined cyclical HRT
2) Infertility: OI w/ FSH or pulsatile GnRH
3) x secondary sexual characteristics: induce puberty at 12yo
- First 2-3y: unopposed estrogen
- Later: progesterone

49
Q

How to Mx normogonadotrophic amenorrhea?

A

Non-anatomical: mx as PCOS
Anatomical
- Mullerian agenesis: vaginal dilatation, vaginoplasty
- Imperforate hymen: hymenectomy +/- excision of excess hymen tissue

50
Q

How to Mx hypergonadotrophic amenorrhea?

A

Turner: GH, induction of puberty, HRT
Pure gonadal dysgenesis: gonadectomy
Idiopathic ovarian failure: counsel

51
Q

How to Ix amenorrhea?

A 
PE: BMI, secondary sexual characteristics, hyperandrogenism, CNS mass
Pregnancy test
USG pelvis: uterus, morphology of ovaries
Hormone
- Mid-luteal phase prosterone
- Early follicular phase FSH, LH, E2
- PRL, TFT, androgen profile
- Progesterone withdrawal test

Gynaecology (4 decks)

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