Obs & Gyn Flashcards
Differential diagnosis for intermenstrual bleeding
- Cervical malignancy
- Cervical ectropion
- Endocervical polyp
- Atrophic vaginitis
- Pregnancy
- Irregular bleeding related to the contraceptive pill
Drugs associated with hyperprolactinaemia (due to dopamine antagonist effects)
- Metoclopramide
- Phenothiazines (e.g. chlorpromazine, prochlorperazine, thioridazine)
- Reserpine
- Methyldopa
- Omeprazole, ranitidine, bendrofluazide (rare associations)
If the woman fails to conceive after correction of hyperprolactinaemia, then a full fertility
investigation should be planned with what investigations?
- semen analysis
- tubal patency testing (laparoscopy
and dye test, hysterosalpingogram or hysterosalpingoconstrastsonography (hyCoSy))
Effects of premature menopause
Hypo-oestrogenic effects:
* vaginal dryness
* vasomotor symptoms (hot flushes, night sweats)
* osteoporosis
* increased cardiovascular risk
Psychological and social effects:
* infertility
* feeling of inadequacy as a woman
* feelings of premature ageing and need to take HRT
* impact on relationships
Causes
of oligospermia
pretesticular:
- pituitary tumours,
- smoking or
- medication
Testicular
- varicocoele,
- trauma,
- mumps or
- Y chromosome deletions
posttesticular
- prostatitis or cystic fibrosis causing vas deferens obstruction
Investigations for infertility
Woman:
* Day 3 FSH
* Day 3 LH
* Prolactin
* Testosterone
* Day 21 Progesterone
* Hysterosalpingogram report: the uterine cavity is of normal shape with a smooth regular outline. Contrast medium is seen to fill both uterine tubes symmetrically and free spill of dye is confirmed bilaterally.
* Transvaginal ultrasound scan report: the uterus is anteverted with no congenital abnormalities, uterine fibroids or polyps visualized. Both ovaries are of normal morphology, volume and mobility. No follicles are noted.
Men:
Semen analysis report: normal volume, count, normal forms and motility
Confirmation of the diagnosis and management of ovarian cancer
The surgical aphorism ‘there is no diagnosis without a surgical diagnosis’ means that tissue
needs to be obtained to confirm the diagnosis. Laparotomy should be performed with three objectives:
1. obtaining tissue for diagnosis
2. staging the disease according to the extent of tissue involvement
3. primary debulking – to perform a total abdominal hysterectomy and bilateral
salping-oophorectomy and to reduce all abdominal tumour deposits to a volume
of less than 2 cm. This allows optimal effect of chemotherapy following surgery.
Lymph node dissection and omental resection are usually part of the procedure.
Typical presentations of fibroids
- Menorrhagia
- Abdominal mass
- Pressure effect from pressure on the bladder, stomach or bowel
- Infertility
Management of fibroids
- Iron and folate for anemia
- conservative tranexamic acid and/or ponstan
- GNRH analogue to shrink fibroid
- Uterine artery embolisim
- Myemectomy
- Hysterectomy
Treatment and advice for cervical intraepithelial neoplasia
- The commonest treatment is large-loop excision of the transformation zone (LLETZ)
– removal of abnormal cervical tissue with a diathermy loop - Assuming that all of the abnormal cells are excised, with clear margins, at the time of LLETZ treatment, then six-month follow-up should be arranged where she should have a repeat smear and human papilloma virus (HPV) screening.
Advice after LLETZ procedure
- The patient may have light bleeding for several days.
* If heavy bleeding occurs she should return as secondary infection may occur and
need treatment.
* She should avoid sexual intercourse and tampon use for 4 weeks, to allow healing
of the cervix.
* Fertility is generally unaffected by the procedure, though cervical stenosis leading
to infertility has been reported, and midtrimester loss from cervical weakness is
rare.
Management of dysfunction uterine bleeding
- The anaemia should be treated with ferrous sulphate 200 mg twice daily until
- Tranexamic acid (an antifibrinolytic) should be given during menstruation to reduce the
amount of bleeding. - The levonorgestrel-releasing intrauterine device is used for its action on the endometrium to reduce menorrhagia,
- The combined oral contraceptive pill is effective for menorrhagia in young women (below 35 years).
If these first-line management options are ineffective then endometrial ablation should be considered, which destroys the endometrium down to the basal layer.
There are several approved minimally invasive endometrial ablation techniques with
broadly similar efficacy: these include use of radiofrequency waves, electrocautery, microwaves, heated saline, or a heated balloon.
Hysterectomy is considered a ‘last resort’ for DUB, due to the associated morbidity
Differential diagnosis of secondary amenorrhoea
Hypothalamic:
* chronic illness
* anorexia
* excessive exercise
* stress
Pituitary:
* hyperprolactinaemia (e.g. drugs, tumour)
* hypothyroidism
* breast-feeding
Ovarian:
* polycystic ovarian syndrome
* premature ovarian failure
* iatrogenic (chemotherapy, radiotherapy, oophorectomy)
* long-acting progesterone contraception
Uterine:
* pregnancy
* Asherman’s syndrome
* cervical stenosis
Causes of postmenopausal bleeding
- Endometrial cancer
- Endometrial/endocervical polyp
- Endometrial hyperplasia
- Atrophic vaginitis
- Iatrogenic (anticoagulants, intrauterine device, hormone-replacement therapy)
- Infective (vaginal candidiasis)
Causes of dysmenorrhoea
- Idiopathic
- Premenstrual syndrome
- Pelvic inflammatory disease
- Endometriosis
- Adenomyosis
- Submucosal pedunculated fibroids
- Iatrogenic (e.g. intrauterine contraceptive device (IUCD) or cervical stenosis after
large-loop excision of the transformation zone (LLETZ))
Differential diagnoses of postcoital bleeding in a young woman
- Cervical ectropion
- Chlamydia or other sexually transmitted infection (STI)
- Cervical malignancy
- Complication of the COCP
- Endocervical polyp
