obs/ gynae vol 2 Flashcards
what are fibroids
most common benign uterine tumour and most common pelvic tumour in women.
affects around 50% of women
composed of smooth muscle and fibrous tissue.
generally found under the uterine serose, within the myometrium or just below the endometrium
signs and symptoms of fibroids + risk factors
many are asymptomatic, strong genetic link.
pelvic pain, pressure, bloating, dysmenorrhoea, fatigue, heavy menstrual bleeding, irregular firm pelvic mass.
not often a cause of infertililty.
RF: increaced weight, 40s, black, low vit D. (lifetime oestrogen exposure)
investigations and management of fibroids
Ix: Transvag ultrasound, biopsy
Mx:
COCP- to reduce bleeding.
GnRH- shrink them but when stop they grow back to prev size.
antiprogesterones (mifepristone)
IUD
NSAIDS
tranexamic acid.
Surgical: myomectomy (preserves fertililty) - but significant burden of disease needed
hysterectomy
uterine artery embolisation.
complications of fibroids
recurrent growth
labour/ delivery comlications
acute torsion
hemorhage
you can get some that are cancerous- leiomyomas. these do not come from benign fibroids, instead they grow from the outset as cancerous.
poly cystic ovary syndrome summmary
the most common endocrine disorder of women.
unknwon aetiology- proposed some part of the HPA (possibly varying all parts)
a leading cause of infertility
risk factors for PCOS + signs and symptoms
familial history, premature adrenarche
obesity
low birth weight
S+S:
missed, irregular or light periods. excess body hair, in androgen dependent areas.
acne/ oily skin.
male pattern baldness/ thinning hair, infertility, skin tags
weight gain
investigations of PCOS
serum 17-hydroxyprogesterone (exclude 21 deficiency adrenal hyperplasia)
serum prolactin (exclude hyperprolacinaemia)
TSH
glucose tolerance test
fasting lipid panel.
consider USS pelvis.
management of PCOS
focuses on either imprvement of fertility OR Rx of symptoms of hyperandrogenism
IF obese weight loss. +/- metformin.
letrozole- (aromatase inhibitor)
COCP
consider anti-androgens
anovulatory women have estrogen without progesterone- expose to progesterone (IUD, COCP)
complications of PCOS
infertility is the big one (80% of infertile women have PCOS)
T2DM
CVD
Nonalcoholic fatty liver disease-
metabolic syndrome
HTN
Dyslipidaemia
discuss anovulary cycles
periods where there is no ovulation or leuteal phase. usually varies in duration from from a normal cycle
can be less than 21 days, or more than 180.
bleeding is due to insufficient estrogen to continue to support the endometrium, rather than a withdrawal of progesterone.
investigation of anovulatory cycles + Rx
pregnancy testing
rule out anaemia
then rule out thyroid issues, prolactin issues, PCOS, coagulopathy.
Rx:
if wants to be pregnant
letrozole OR Clomiphene
if not COCP to restore normal hormonal cycles without pregnancy.
aetiology + epidaemiology of anovulatory bleeding
part of a disturbance in the HPA.
physiologic anovulation normal at extremes of fertility ages.
causes also can be:
annorexia, excessive stress/ exercise, hyper androgenism, premature ovarian faliure.
53 per 1000
discuss combines oral contraceptive pill
Progest + estrogen
both do -ve feedback on HPA axis. - keep FSH and LH low.
estrogen causes endometrium to prolif, progesterone suppresses this.
ADV- reliable, safe, woman in control, taken away from sex.
reversable - 10days after your last pill your next cycle kicks in.
decs rate of ovarian and endometrial ca.
Disadv- HTN, Clotting, insulin resistance, appetite, chrons, gallstones, mood sings, lower libido.
can either take a pill for 21 days (on first day of bleed) then 7 day break. or have 7 placebo pills in pack. or take continually and not have periods.
discuss progsterone only implants.
the IUD, the arm implant. release a continuous amount of progesterone, can take a pill also.
increace vol and viscosity of cervical mucous- barrier to sperm.
assists in preventation of implantation.
prevents ovulations (variable) by suppressing mid cycle peaks of LH and FSH.
effective, less side effects, reversable, can eliminate dysmenorhea and mid cycle pain,
complications with insertion and removal are main issues.
discuss emergency contraception
- up to 72 hrs after sex.
essentially large doses of progesterone.
suppress ovulation ( no Lh)
prevent implantation.
various pills available, some contraindications (TB meds, acute migrane)
can also get copper IUD- spermicidic and prevents implantation.
discuss termination of pregnancy
if done electivally all parts of treatment must be completed within 23 weeks and 6 days of last menstrual period.
2 syles- medical-
mifeprisone tablet (swallow) + misoprostol tablet(s- more needed if after 10 weeks) (dissolve) - done at home or in clinic.
pregnancy is passed 4-6 hours after taking. - bleed for a few days. no f/u needed. -
some need surgical removal of pregnancy (72/1000 before 13 weeks, 130/1000 after)
Surgical termination- using a suction tube or instruments inserted into the vagina.
unser sedation/ anaesthetic. - wont see the pregnancy.
if before 14 weeks then medication used to dilate vagina. if after osmotic dilators are used.
no f/u needed.
36/1000 need further surgery.
what is infertility in women
faliure to become pregnant after 12 months of regular and unprotected sexual intercourse.
Globally main reason is tubal disease due to infection. (ghon, chlaymidia), but PCOS, endometriosis, age, unexpected, extremes of weight etc can all be causes.
12% americal women have used fert clinic.
1 in 3 women in central/ southern africa infertile.
Ix: - assess mens sperm first- usually the cause
thourough history, inc infection.
physical exam, ax of ovulation, reserve testing.
Rx: correct any causes found, induce ovulation- clomifene -
or aromatase inhibitors- letrozole.
OR
IVF- collect egg that have been stimulated. combine with sperm and transfer back.
54% success in under 35. declines- 26.6% 38-40
infertility in men- go
either abnora semen/ sperm production or the inability to deliver effectively.
30% of cases of difficulty in concieving.
need two semen analysis 1 month apart to be diagnosed.
RF:
varicocele, crypotchidism, chameo/ radio, steds/ TRT, CF,
Ix: sperm conc, motility, morphology, seminal fluid parameters. hormonal assessment.
Rx: if cause found- treat this
clomifene- inhibits -ve feedback. aromatase inhibitors-
steriods if auto immune.
discuss cervical screening program
25-64 every 3 years up to 50, then 5 years.
looks for HPV- change in cell type in the cervix
if abnormal cells found- reffered for colposcopy.
sensitivity- 94.6%
specificity 94.1%
HPV and cervical cancer
14 types are high risk for ca
HPV 16 and HPV 18 cause 70% of all cervical cancer cases.
6 times more likely to develop cervical cancer if HIV+ve.
