Obstetrics and Gynaecology Flashcards
Outline the Hypothalamic-Pituitary-Gonadal Axis (HPGA)
Hypothalamus releases gonadotrophin-releasing hormone (GnRH)
GnRH stimulates anterior pituitary to produce LH and FSH
LH and FSH stimulate development of follicles in ovaries
Theca granulosa cells around follicles secrete oestrogen
Oestrogen has negative feedback effect on hypothalamus and anterior pituitary to suppress release of GnRH, LH and FSH
What is produced by the anterior pituitary?
LH and FSH
Outline oestrogen
Steroid sex hormone produced by ovaries in response to LH and FSH
17-beta oestradiol- Acts on tissues with oestrogen receptors to promote female secondary sexual characteristics
What does oestrogen stimulate?
Breast tissue development
Growth and development of female sex organs (vulva, vagina and uterus) at puberty
Blood vessel development in uterus
Development of endometrium
Outline progesterone
Steroid sex hormone produced by corpus luteum after ovulation
In pregnancy- Progesterone produced mainly by placenta from 10wks
Acts on tissues previously stimulated by oestrogen
Outline role of progesterone
Thicken and maintain endometrium
Thicken cervical mucus
Increase body temperature
Outline hormonal changes during pregnancy
GH increases initially- Growth spurt
Hypothalamus starts to secrete GnRH- Initially during sleep
GnRH stimulates release of FSH and LH from pituitary gland
FSH and LH stimulate ovaries to produce oestrogen and progesterone
FSH levels plateau a yr before menarche
LH levels continue to rise and spike just before induce menarche
What age do boys and girls start puberty?
Girls- 8-14y
Boys- 9-15y
Overweight children tend to enter puberty earlier- Aromatase is enzyme in adipose tissue- Important in creation of oestrogen
Before puberty girls have little GnRH/LH/FSH/oestrogen/progesterone
List causes of delayed puberty in girls
Low birth weight
Chronic disease
Eating disorders
Athletes
Outline Tanner staging
Stage I- <10y- No pubic hair- No breast development
Stage II- 10-11y- Light and thin PH- Breast buds from behind areola
Stage III- 11-13y- Course and curly PH- Breast begins to elevate beyond areola
Stage IV- 13-14y- Adult-like PH but not reaching thigh- Areolar mound forms and projects from surrounding breast
Stage V- >14y- PH extending to medial thigh- Areolar mounds reduce and adult breasts form
Outline the follicular phase of menstruation
Start of menstruation to moment of ovulation (0-14d of cycle)
Outline luteal phase of menstrual cycle
Moment of ovulation to start of menstruation (14-28d)
After ovulation, follicle that released ovum collapses and becomes corpus luteum
Corpus luteum secretes progesterone and maintains endometrial lining- Becomes thick and no longer penetrable- Also secretes small amount of oestrogen
In fertilisation- Syncytiotrophoblast of embryo secretes hCG- Maintains corpus luteum
No fertilisation- No hCG- Corpus luteum degenerates and stops producing oestrogen and progesterone- Fall in oestrogen and progesterone causes endometrium to breakdown and menstruation
Stromal cells of endometrium release prostaglandins- Encourage endometrium to breakdown and uterus to contract
Negative feedback from oestrogen and progesterone on hypothalamus and pituitary gland ceases- Allows level of LH and FSH to begin to rise and cycle restart
Outline formation of follicles
Oocytes surrounded by granulosa cells, forming follicles
1. Primordial follicles
2. Primary follicles
3. Secondary follicles- Requires FSH stimulation to develop into antral follicle
4. Antral follicles (Graafian follicles)
As follicles grow- Granulosa cells secrete increasing amounts of oestradiol- Negative feedback effect on pituitary gland, reducing quantity of LH and FSH
Rising oestrogen causes cervical mucus to become more permeable- Allows sperm to penetrate cervix around time of ovulation
One follicle develops more than other and becomes dominant
LH spikes just before ovulation, causing dominant follicle to release ovum from ovary
What is menstruation?
Superficial and middle layers of endometrium separating from basal layer
Tissue broken down inside uterus, and released via cervix and vagina
Release of fluid containing blood from vagina lasts 1-8d
Outline development of primary follicle
Primordial follicles grow and become primary follicles
Primary follicles have 3 layers:
1. Primary oocyte in centre
2. Zona pellucida
3. Cuboidal shaped granulosa cells
Granulosa cells secrete material that become zona pellucida- Secrete oestrogen
Follicles grow larger and develop surrounding layer called theca folliculi
- Inner layer- Theca interna- Secretes androgen hormones
- Outer layer- Theca externa- Made of connective tissue containing smooth muscle and collagen
Outline development of secondary follicle
Primary follicle grows larger and develop small fluid-filled gaps between granulosa cells
Develop receptors for FSH
Further development after secondary follicle stage requires stimulation from FSH
At start of menstrual cycle, FSH stimulates further development of secondary follicles
Outline development of antral follicles
Secondary follicle develops single large fluid-filled area within granulosa cells- Antrum- Antral follicle stage
Antrum fills with increasing fluid- Follicle expands rapidly
Corona radiata- Made of granulosa cells- Surrounds zona pellucida and oocyte
One of the follicles becomes dominant follicle and matures, bulging through wall of the ovary- Others degrade
Outline ovulation
Surge of LH from pituitary
Causes smooth muscle of theca externa to squeeze and follicle bursts
Follicular cells release digestive enzymes that puncture hole in wall of ovary- Ovum passes and escapes
Oocyte released into surrounding area and swept up by fimbriae of fallopian tubes
Outline corpus luteum
Leftover parts of follicle collapse and turn yellow
Collapsed follicle becomes corpus luteum
Cells of granulosa and theca interna become luteal cells
Luteal cells secrete steroid hormones- Progesterone
Corpus luteum persists in response to hCG from a fertilised blastocyst when pregnant
If fertilisation doesn’t occur- Corpus luteum degenerates after 10-14d
Outline fertilisation
Just before time of ovulation- Primary oocyte undergoes meiosis- Splits 46 chromosomes in oocyte in 2
Secondary oocyte has 23 chromosomes
Oocyte surrounded by zona pellucida surrounded by corona radiata (granulosa cells)
Sperm enters fallopian tube and attempts to penetrate corona radiata and zona pellucida to fertilise egg
Outline development of blastocyst
Combination of chromosomes from egg and sperm- Zygote
Cell divides rapidly to create mass of cells- Morula- Mass of cells travels along fallopian tube toward uterus
Fluid-filled cavity gathers within group of cells- Blastocyst
Blastocyst contains embryoblast and blastocele surrounded by trophoblast
Gradually loses corona radiata and zona pellucida
Enters uterus
Outline implantation of blastocyst
Arrives at uterus 8-10d after ovulation and reaches endometrium
Cells of trophoblast undergo adhesion to stroma of endometrium
Outer layer of trophoblast= Syncytiotrophoblast- Produces hCG
Cells of stroma convert into decidua- Provides nutrients to trophoblast
hCG maintains corpus luteum and produces progesterone and oestrogen
Outline development of embryo
Week after fertilisation- Implanted blastocyst differentiates
Cells of embryoblast splits in 2- Yolk sac and amniotic cavity
Cells of embryonic disc develop into fetal pole, then fetus
Chorion surrounds complex- 2 layers- Cytotrophoblast and syncytiotrophoblast
Chorionic cavity forms around yolk sac, embryonic disc and amniotic sac
Suspended from chorion by connecting stalk- Eventually becomes umbilical cord
What occurs in the fetus at 5wks?
Embryonic disc develops into fetal pole
Contains 3 layers- Ectoderm, mesoderm and endoderm
What occurs in the fetus at 6wks gestation?
Fetal heart forms and starts to beat
Spinal cord and muscles develop
Embryo (fetal pole) is about 4mm length
What does the endoderm become?
GI tract
Lungs
Liver
Pancreas
Thyroid
Reproductive system
What does the mesoderm become?
Heart
Muscle
Bone
Connective tissue
Blood
Kidneys
What does the ectoderm become?
Skin
Hair
Nails
Teeth
CNS
Outline development of the placenta
In follicular phase, endometrium thickens
Myometrium sends off artery branches into endometrium- Spiral arteries
Syncytiotrophoblast grows into endometrium and forms finger-like projections- Chorionic villi (contain fetal blood vessels)
Complete by 10wks gestation
Outline development of lacunae
Trophoblast invasion of endometrium sends signals to spiral arteries, reducing their vascular resistance- More fragile
Breakdown into lacunae (lakes)
Maternal blood flows from uterine arteries into lacunae and back out through uterine veins
Lacunae form at 20wks gestation
Lacunae surround chorionic villi, separated by placental membrane- Oxygen, CO2 and other substances diffuse across between mother and fetal blood
Outline the association between lacunae formation and pre-eclampsia
If process of forming lacunae inadequate- Can develop pre-eclampsia
Pre-eclampsia caused by high vascular resistance in spiral arteries
Sharp rise in maternal BP
Outline the role of the placenta in respiration
Source of oxygen for fetus
Fetal Hb has higher affinity for oxygen than adult Hb
Oxygen drawn off maternal Hb to fetal Hb
CO2, H+, HCO3-, and lactic acid also exchanged across placenta- Maintains acid-base balance
Outline role of placenta in nutrition
All nutrition comes from mother
Mostly in form of glucose- Energy and growth
Transfers vitamins and minerals to fetus
Outline role of placenta in excretion
Performs similar function to kidneys- Filters waste products from fetus
Eg: Urea and creatinine
Outline the endocrine function of the placenta
hCG- Levels increase in early pregnancy, plateau at 10wks gestation, then start to fall- Maintains corpus luteum until placenta takes over production of oestrogen and progesterone- Can cause nausea and vomiting
Oestrogen- Placenta produces oestrogen- Softens tissue and makes them more flexible- Allows muscles and ligaments of uterus and pelvis to expand- Cervix becomes soft and ready for birth- Enlarges and prepares breasts and nipples for breastfeeding
Progesterone- Placenta mostly takes over production by 5wks gestation- Maintains pregnancy- Causes relaxation of uterine muscles (prevents contraction and labour) and maintains endometrium
List some side effects of increased progesterone in pregnancy
Relaxes muscles:
- Lower oesophageal sphincter (heartburn)
- Bowel (constipation
- Blood vessels (hypotension, headaches and skin flushing)
Raises body temperature by 0.5-1 degrees C
What can cause increased levels of hCG, above that of normal pregnancy?
Multiple pregnancy (twins)
Molar pregnancy
Outline the role of the placenta in immunity
Mother’s antibodies transfer across placenta to fetus during pregnancy
What hormonal changes occur in pregnancy?
Raised:
Steroid hormones (cortisol and aldosterone)- Improves AI conditions but increases susceptibility to diabetes and infections
T3/T4 (TSH normal)
Prolactin- Suppresses FSH and LH
Melanocyte S.H.
Oestrogen- Rises throughout pregnncy, produced by placenta
Progesterone- Rise throughout pregnancy- Maintains pregnancy/prevents contractions/suppresses mother’s immune reaction to fetal antigen- Corpus luteum till 10wks, then placenta
hCG
Anterior pituitary produces more ACTH, prolactin and melanocyte stimulating hormone
What cardiovascular changes occur in pregnancy?
Raised:
Blood volume
Plasma volume
Cardiac output
Decreased:
Peripheral vascular resistance
BP (returns to normal by term)
Vasodilation- Causes flushing and hot sweats
Varicose veins
What respiratory changes occur in pregnancy?
Raised:
Tidal volume
RR
What renal changes occur in pregnancy?
Raised:
Blood flow
GFR
Sodium reabsorption
Water reabsorption
Protein excretion
Aldosterone- Increased salt/water reabsorption and retention
Physiological hydronephrosis
What changes occur in the blood in pregnancy?
Raised:
RBC production (higher iron, folate and B12 requirements)
Plasma volume increases more than RBC volume- Lower conc. RBCs
WBC
Clotting factor- Hypercoagulable- Increased risk VTE
ALP (placenta)
ESR and D-dimer
ALP- Due to secretion by placenta
Decreased:
Platelets
Albumin
Hb conc. and red cell conc.- Anaemia (due to high plasma volume)
Calcium requirements increase, but so does gut absorption of calcium- Stable
What changes can occur to the skin in pregnancy?
Linea nigra (increased melanocyte stimulating hormone)
Melasma
Striae gravidarum
Spider naevi
Palmar erythema
Pruritis- Can be normal or can indicate obstetric cholestasis
Postpartum hair loss- Normal, usually improves within 6mths
What changes occur in the female reproductive system during pregnancy?
Uterus- 100g increased to 1.1kg
Myometrium- Hypertrophy
Cervix- Increased discharge, ectropion
Vagina- Hypertrophy, increased discharge, candida, bacteria
What are the 3 stages of labour?
1st stage- Onset of labour (true contractions) until 10cm dilation
2nd stage- 10cm cervical dilation to delivery of baby
3rd stage- Delivery of baby to delivery of placenta
Outline the role of prostaglandins in pregnancy
Act like hormones
Stimulate contraction of uterine muscles
Ripen cervix before delivery
Pessaries containing prostaglandin E2 can be used to induce labour
What are Braxton-Hicks Contractions?
Occasional irregular contractions of uterus
Usually felt during second and third trimester
Can experience temporary and irregular tightening or mild cramping in abdomen
not true contractions- Don’t indicate onset of labour
Management- Stay hydrated and relax
Outline the 1st stage of labour
Onset of labour until cervix fully dilated (10cm)
Involves cervical dilation and effacement
Show- Mucus plug in cervix- Falls out
Latent phase
Active phase
Transition phase
What is the mucus plug?
The ‘show’
Prevents bacteria from entering uterus during pregnancy
Falls out during first stage of labour
What is the latent phase?
In first stage of labour
0-3cm dilation of cervix
Progresses at 0.5cm/h
Irregular contractions
What is the active phase?
3-7cm dilation of cervix
Progresses at 1cm/h
Regular contractions
What is the transition phase?
7-10cm dilation of cervix
Progresses at 1cm/h
Strong, regular contractions
Outline the 2nd stage of labour
10cm dilation to delivery of baby
- Power- Strength of uterine contractions
- Passenger- Size/attitude/lie/presentation
- Passage
What does attitude of the fetus mean?
Posture of fetus
Eg: How the back is rounded and how head and limbs are flexed
What does lie of the fetus mean?
Position of fetus in relation to mother’s body:
Longitudinal lie- Fetus straight up and down
Transverse lie- Fetus is straight side to side
Oblique lie- Fetus is at an angle
What does presentation of the fetus mean?
Part of fetus closest to cervix
Cephalic- head first
Shoulder- Shoulder first
Breech- Legs first- Complete (hips and knees flexed), Frank (hips flexed, knees extended, bottom first), Footling (foot hanging through cervix)
What are the cardinal movements of labour?
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution and external rotation
Expulsion
Outline descent of the baby in labour
Position of baby’s head in relation to mother’s ischial spines during descent phase
-5 When baby is high up at pelvic inlet
0 Head is at ischial spines (head engaged)
+5 Fetal head has descended further out
Outline 3rd stage of labour
Completed birth of baby to delivery of placenta
Physiological management- Placenta delivered by maternal effort w/o meds or cord traction
Active management- Assisted delivery of placenta- Shortens 3rd stage and reduces risk of bleeding
Haemorrhage/>60min delay should prompt active management
Can be associated with nausea and vomiting
What is active management of third stage of labour?
Dose of IM oxytocin helps uterus contract and expel placenta
Careful traction applied to umbilical cord
What is amenorrhoea?
Lack of menstrual periods
What is primary amenorrhoea?
Patient never develops periods
List causes of primary amenorrhoea
Hypogonadotropic hypogonadism- Abnormal functioning of hypothalamus or pituitary gland
Hypergonadotropic hypogonadism- Abnormal functioning of gonads
Imperforate hymen or other structural pathology
What is secondary amenorrhoea?
Patient previously had periods that subsequently stopped
What are the causes of secondary amenorrhoea?
Pregnancy
Menopause
Physiological stress- Excessive exercise/low body weight/chronic disease/psychosocial factors
PCOS
Meds- Hormonal contraceptives
Premature ovarian insufficiency (menopause <40y)
Thyroid hormone abnormalities
Excessive prolactin (prolactinoma)
Cushing’s syndrome
What is anovulation?
Lack of ovulation
List the causes of irregular menstruation
Extremes of reproductive age (early periods or perimenopause)
PCOS
Physiological stress (excessive exercise/low body weight/chronic disease/psychosocial factors
Meds- Progesterone only contraception/antidepressants/antipsychotics
Hormonal imbalances- Thyroid abnormalities/Cushing’s syndrome/high prolactin
What are the causes of intermenstrual bleeding?
RED FLAG
Hormonal contraception
Cervical ectropion, polyps, cancer
STI
Endometrial polyps or cancer
Vaginal pathology- Including cancer
Pregnancy
Ovulation
Medications- SSRIs and anticoagulants
What is dysmenorrhoea?
Painful periods
What are the causes of dysmenorrhoea?
Primary dysmenorrhoea
Endometriosis or adenomyosis
Fibroids
PID
Copper coil
Cervical or ovarian cancer
What is menorrhagia?
Heavy menstrual bleeding
What are the causes of menorrhagia?
Dysfunctional uterine bleeding
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
PID
Contraceptives- Copper coil
Anticoagulant meds
Bleeding disorders- VWD
Endocrine disorders- Diabetes and hypothyroidism
Connective tissue disorders
Endometrial hyperplasia or cancer
PCOS
What are the causes of postcoital bleeding?
RED FLAG
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
What are the causes of pelvic pain?
UTI
Dysmenorrhoea
IBS
Ovarian cysts
Endometriosis
PID
Ectopic pregnancy
Appendicitis
Mittelschmerz
Pelvic adhesions
Ovarian torsion
IBD
What is Mittelschmerz?
Cyclical pain during ovulation
What are the causes of abnormal vaginal discharge?
Bacterial vaginosis
Candidiasis
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
What is pruritis vulvae?
Itching of vulva and vagina
What are the causes of pruritis vulvae?
Irritants (soaps, detergents, barrier contraception)
Atrophic vaginitis
Infection- Candidiasis/pubic lice
Eczema
Vulval malignancy
Pregnancy-related
Urinary or fecal incontinence
Stress
What are the definitions of primary amenorrhoea?
Not starting menstruation:
By 13y if no other signs of pubertal development
By 15y if other signs of puberty
What is hypogonadism?
Lack of sex hormones/oestrogen/testosterone
Hypogonadotropic hypogonadism- LH and FSH deficiency
Hypergonadotropic hypogonadism- Lack of response to LH and FSH by gonads
What is hypogonadotropic hypogonadism?
Deficiency of LH and FSH leading to deficiency of sex hormones
Result of abnormal functioning of hypothalamus or pituitary gland
What are LH and FSH?
Gonadotrophins produced by anterior pituitary gland in response to gonadotropin releasing hormone (GnRH)
What can cause hypogonadotropic hypogonadism?
Hypopituitarism
Damage to hypothalamus or pituitary
Sig. chronic conditions- CF or IBD
Excessive dieting or exercise
Constitutional delay in growth and development
Endocrine disorders- GH deficiency, hypothyroidism, Cushing’s, hyperprolactinaemia
Kallman syndrome
What is Hypergonadotropic hypogonadism?
Gonads fail to respond to LH and FSH
Anterior produces high levels of LH and FSH and low sex hormones
What can cause hypergonadotropic hypogonadism?
Previous damage to gonads (torsion, cancer, infections (mumps))
Congenital absence of ovaries
Turner’s syndrome
What is Kallman syndrome?
Genetic condition
Causes hypogonadotrophic hypogonadism
Failure to start puberty
Associated with anosmia (absent sense of smell)
What is congenital adrenal hyperplasia?
Congenital deficiency of 21-hydroxylase enzyme
Underproduction of cortisol and aldosterone and overproduction of androgens from birth
Autosomal recessive
How does congenital adrenal hyperplasia present?
Severe- Neonate unwell shortly after birth- Electrolyte disturbances and hypoglycaemia
Females:
Tall for age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
What is androgen insensitivity syndrome?
Tissues unable to respond to androgen hormones (testosterone)
Typical male sexual characteristics don’t develop
Results in female phenotype- Other than internal pelvic organs
Normal external genitalia and breast tissue
Internally- Testes, absent uterus/upper vagina/fallopian tubes/ovaries
List structural pathology causes of primary amenorrhoea
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation
Outline investigations of primary amenorrhoea
Anaemia- FBC, ferritin
CKD- U&Es
Coeliac disease- Anti-TTG, anti-EMA antibodies
Hormonal bloods:
FSH and LH
TFTs
GH deficiency screening- ILGF-1
Hyperprolactinaemia- Prolactin raised
Raised testosterone- PCOS, androgen insensitivity syndrome, congenital adrenal hyperplasia
Genetic testing with microarray- Turner’s syndrome
Imaging:
Xray wrist- Constitutional delay
Pelvic US- Ovaries and pelvic organs
MRI brain- Assess olfactory bulbs in possible Kallman syndrome
How is hypogonadotrophic hypogonadism managed?
Pulsatile GnRH to induce ovulation and menstruation
Or can replace sex hormones- COCP
What is the definition of secondary amenorrhoea?
No menstruation >3mths after regular periods
Investigate after 3-6mths
What are the causes of secondary amenorrhoea?
Pregnancy
Menopause and premature ovarian failure
Hormonal contraception (IUS or POP)
PCOS
Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
Pituitary tumours- Prolactin-secreting prolactinoma
Pituitary failure- Trauma/radiotherapy/surgery/Sheehan syndrome
Excessive exercise/low body weight/ED/chronic disease/psychological stress
What is hyperprolactinaemia?
High prolactin levels act on hypothalamus to prevent release of GnRH
No GnRH= No LH and FSH- Hypogonadotrophic hypogonadism
What is galactorrhoea associated with?
Is breast milk production and secretion
Hyperprolactinaemia
High prolactin level
What is the most common cause of hyperprolactinaemia?
Pituitary adenoma secreting prolactin
How is hyperprolactinaemia managed?
Often no treatment
Dopamine agonists- Bromocriptine or cabergoline- Can reduce prolactin production
What can bromocriptine and cabergoline be used to treat?
(Dopamine agonists)
Hyperprolactinaemia
Parkinson’s disease
Acromegaly
Outline investigations of secondary amenorrhoea
Hormonal blood tests
US pelvis to diagnose PCOS
Which hormone tests are done in secondary amenorrhoea?
bHCG- Pregnancy
LH and FSH:
High FSH- Primary ovarian failure
High LH, or LH:FSH ratio- PCOS
Prolactin- Hyperprolactinaemia
Follow with MRI- Pituitary tumour
TSH
Follow with T3 and T4 if abnormal
High TSH, low T3 and T4- Hypothyroidism
Low TSH, high T3 and T4- Hyperthyroidism
Raised testosterone- PCOS, androgen insensitivity syndrome or congenital adrenal hyperplasia
Why does PCOS require a withdrawal bleed every 3-4mths when managing and why?
Reduce risk endometrial hyperplasia/cancer
Medroxyprogesterone for 14d, or regular use of COCP- Stimulate withdrawal bleed
Outline association between secondary amenorrhoea and osteoporosis
Amenorrhoea associated with low oestrogen- Increased risk osteoporosis
Treat if amenorrhoea >12mths
How is risk of osteoporosis managed in secondary amenorrhoea?
Vit D and calcium
HRT or COCP
What is premenstrual syndrome?
Psychological/emotional/physical symptoms during luteal phase of menstrual cycle
Resolve once menstruation begins
Not present before menarche/during pregnancy/after menopause
Outline presentation of PMS
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
When can PMS continue in absence of periods?
Hysterectomy
Endometrial ablation
Mirena
Ovaries continue to function and hormonal cycle continues
What is progesterone-induced premenstrual disorder?
Symptoms of PMS occurring in response to taking meds containing progesterone
COCP or cyclical-HRT
How is PMS diagnosed?
Symptoms diary spanning 2 menstrual cycles
Definitive- Administer GnRH analogues and temporarily induce menopause to see if symptoms resolve
Outline management of PMS
Lifestyle- Diet/exercise/alcohol/smoking/stress/sleep
COCP- Drospirenone
SSRI antidepressants
CBT
Continuous transdermal oestrogen (patch)- Requires progesterone endometrial protection alongside (norethisterone/mirena coil) to trigger withdrawal bleed
GnRH analogues- Induce menopausal state
Hysterectomy and bilateral oopherectomy- HRT will be required
Danazole and tamoxifen- Cyclical breast pain
Spironolactone- Breast swelling, water retention, bloating
What are the potential SEs of GnRH analogues?
Osteoporosis
Add HRT to mitigate effects
What investigations should be done in menorrhagia?
Pelvic exam with speculum and bimanual
FBC- Iron deficiency anaemia
Outpatient hysteroscopy- If suspected submucosal fibroids/suspected endometrial pathology/persistent intermenstrual bleeding
Pelvic and transvaginal US- If possible large fibroid/adenomyosis/exam difficult to interpret (obesity)/hysteroscopy declined
Swabs- If evidence infection
Coagulation screen- FH clotting disorders
Ferritin- Clinically anaemic
TFTs- Features of hypothyroidism
Outline management of menorrhagia
No contraception:
TXA (if no pain)
Mefenamic acid (if associated pain)
Contraception:
1. Mirena coil
2. COCP
3. Cyclical oral progestogens- Norethisterone
Refer to secondary care
Surgical:
Endometrial ablation
Hysterectomy
What are fibroids?
Benign tumours of smooth muscle of uterus
Oestrogen sensitive- Grow in response to oestrogen
List the types of fibroids in the uterus
Intramural- Within myometrium- Can change shape and distort uterus
Subserosal- Just below outer layer of uterus- Grow out, can be very large filling abdomen
Submucosal- Just below endometrium
Pedunculated- Stalk
Outline symptoms of Fibroids
Often asymptomatic
Heavy menstrual bleeding most common
Prolonged menstruation (>7d)
Abdominal pain- Worse during menstruation
Bloating/feeling full in abdo
Urinary/bowel symptoms due to pelvic pressure/fullness
Deep dyspareunia
Reduced fertility
Outline investigations of PCOS
Hysteroscopy- Initial investigation
Pelvic US
MRI scanning
Outline management of fibroids <3cm
1st line- Mirena coil
NSAIDs and TXA
COCP
Cyclical oral progestogens
Surgical:
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
Outline management of fibroids >3cm
NSAIDs and TXA
Mirena coil
COCP
Cyclical oral progestogens
Surgical:
Uterine artery embolisation
Myomectomy
Hysterectomy
What can be used to reduce size of fibroids before surgery?
GnRH agonists- Goserelin or leuprorelin
What are the complications of fibroids?
Heavy menstrual bleeding- Iron deficiency anaemia
Reduced fertility
Pregnancy complications- Miscarriages, premature labour, obstructive delivery
Constipation
Urinary outflow tract obstruction and UTI
Red degeneration of fibroid
Torsion of fibroid (pedunculated)
Malignant change to leiomyosarcoma (rare)
What is red degeneration of fibroid?
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply
More likely to occur in large fibroids during 2nd/3rd trimester pregnancy
How does red degeneration of fibroid present?
Severe abdo pain
Low grade fever
Tachycardia
Vomiting
How is red degeneration of fibroid managed?
Supportive
Rest
Fluids
Analgesia
What is endometriosis?
Ectopic endometrial tissue outside uterus
What is adenomyosis?
Endometrial tissue within myometrium of uterus
More common in later reproductive years and in multiparous women
What is the main symptom of endometriosis?
Pelvic pain
Endometrial cells outside uterus also shed lining and bleed
Deposits in bladder/bowel- Blood in urine/stools
Localised bleeding and inflammation lead to adhesions- Fixes structures together
What are the key symptoms of adhesions in endometriosis?
Chronic, non-cyclical pain
May be sharp/stabbing/pulling and associated with nausea
Outline presentation of endometriosis
Cyclical abdo/pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclical haematuria/blood in stools
Urinary/bowel symptoms
Outline potential signs on examination in endometriosis
Endometrial tissue visible in vagina on speculum (posterior fornix)
Fixed cervix on bimanual
Tenderness in vagina/cervix/adnexa
Outline diagnosis of endometriosis
Pelvic US
Laparoscopic surgery- Gold standard
Outline staging of endometriosis
Stage 1: Small superficial lesions
Stage 2: Mild, deeper lesions
Stage 3: Deeper lesions, lesions on ovaries and mild adhesions
Stage 4: Deep and large lesions affecting ovaries with extensive adhesions
Outline management of endometriosis
Analgesia as required
COCP- Can be used back to back
POP
Depo injection
Nexplanon implant
Mirena coil
GnRH agonists
Surgical:
Laparoscopic surgery- Excise or ablate
Hysterectomy
Which management of endometriosis may improve fertility?
Laparoscopic treatment
Outline presentation of adenomyosis
Dysmenorrhoea
Menorrhagia
Dyspareunia
Infertility
Enlarged tender uterus- Softer than in fibroids
Outline diagnosis of adenomyosis
Transvaginal US
MRI and transabdominal US
Gold standard- Histological exam of uterus after hysterectomy
Outline management of adenomyosis
No contraception:
TXA (antifibrinolytic)- If no associated pain
Mefenamic acid- Pain
Contraception:
1. Mirena coil
2. COCP
3. Cyclical oral progestogens
Others:
GnRH analogue
Endometrial ablation
Uterine artery embolisation
Hysterectomy
Outline the link between pregnancy and adenomyosis
Infertility
Miscarriage
Preterm birth
SGA
Preterm PROM
Malpresentation
Need for CS
PPH
What is menopause?
Permanent end to menstruation
No periods for 12mths
When is someone described as postmenopausal?
12mths after final menstrual period onwards
When is someone described as perimenopausal?
Time leading up to last period and the 12mths after
May experience vasomotor symptoms and irregular periods
Typically >45y
What happens to levels of sex hormones during meopause?
Oestrogen and progesterone- Low
LH and FSH- High (due to absence negative feedback from oestrogen)
Outline physiology of menopause
Decline in development of ovarian follicles- Reduced production oestrogen
Low oestrogen- High LH and FSH, endometrium doesn’t develop (amenorrhoea)
Ovulation doesn’t occur- Irregular menstruation
What causes perimenopausal symptoms?
Low oestrogen
List some perimenopausal symptoms
Hot flushes
Emotional lability/low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier/lighter periods
Vaginal dryness and atrophy
Reduced libido
What does low oestrogen increase risk of?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Outline diagnosis of menopause
> 45y with typical symptoms
FSH blood test:
Women <40y with suspected premature menopause
Women 40-45y menopausal symptoms/change in menstrual cycle
Outline contraception around menopause
Need contraception for:
2y after last period <50y
1y after last period >50y
Which contraceptive methods are recommended for women approaching menopause?
UKMEC1:
Barrier
Mirena/copper coil
POP
Progesterone implant
Progesterone depot injection (<45y)
Sterilisation
COCP- UKMEC2- Use COCP containing norethisterone or levonorgestrel >40y (lower risk VTE)
What are the SEs of depo-provera injection?
Weight gain
Reduced bone mineral density (osteoporosis)
How are perimenopausal symptoms managed?
Vasomotor symptoms likely to resolve after 2-5y
No treatment
HRT
Tibolone- Synthetic steroid hormone- Continuous combined HRT- Only after 12mths amenorrhoea
Clonidine
SSRI- Fluoxetine or citalopram
Testosterone- Treat reduced libido
Vaginal oestrogen cream/tablet- Helps vaginal dryness and atrophy
Vaginal moisturisers
What is premature ovarian insufficiency?
Menopause <40y
How is premature ovarian insufficiency characterised?
Hypergonadotropic hypogonadism
Raised LH and FSH
Low oestradiol
What are the causes of premature ovarian syndrome?
Idiopathic
Iatrogenic- Chemo/radiotherapy/surgery
AI- Coeliac disease, adrenal insufficiency, T1D, thyroid disease
Genetic- FH, Turners
Infections- Mumps, TB, CMV
Outline presentation of premature ovarian syndrome
Irregular/lack of periods <40y
Symptoms of low oestrogen- Hot flushes, night sweats, vaginal dryness
How is premature ovarian syndrome diagnosed?
<40y
Typical menopausal symptoms
Elevated FSH (raised on 2 tests 4wks apart)
Outline management of premature ovarian syndrome
HRT until age of menopause:
Traditional HRT- Lowers BP
COCP
What are the risks associated with premature ovarian syndrome?
CVD
Osteoporosis
Cognitive and psychological risks
What is the risk of taking HRT >50y?
Breast cancer
What is the risk of taking HRT <50y?
VTE
Reduce risk with transdermal patch
Outline HRT
Used in perimenopausal/postmenopausal symptoms associated with low oestrogen
Progesterone needs to be given to women with a uterus- Prevents endometrial hyperplasia/cancer
Which women need continuous combined HRT?
Postmenopausal with uterus and >12mths no periods- Requires progesterone protection
Which women can take oestrogen-only HRT?
Without uterus
Which women should take cyclical HRT?
Still having periods
Should also have cyclical progesterone and regular breakthrough bleeds
Outline non-hormonal treatments for menopausal symptoms
Improve diet, exercise, weight loss, smoking cessation, reduce alcohol, reduce caffeine, reduce stress
CBT
Clonidine
SSRI- Fluoxetine
SNRI- Venlafaxine
Gabapentin
How does clonidine work?
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in brain
Lowers BP and HR
Reduces vasomotor symptoms and hot flushes
What are the SEs of clonidine?
Dry mouth
Headaches
Dizziness
Fatigue
Sudden withdrawal- Raises BP, agitation
List alternative remedies for menopausal symptoms
Black cohosh
Dong quai
Red clover
Evening primrose oil
Ginseng
What are the SEs of black cohosh?
Liver damage
What are the SEs of Dong quai?
Cause bleeding disorders
What are the SEs of Red Clover?
Oestrogenic effects- Concerning in oestrogen sensitive cancers
What are the SEs of Evening Primrose Oil?
Significant drug interactions
Linked with clotting disorders and seizures
What are the SEs of Ginseng?
Mood and sleep benefits
What are the indications for HRT?
Replacing hormones in premature ovarian insufficiency
Reduce vasomotor symptoms
Improve low mood/decreased libido/poor sleep/joint pain
Reduce risk osteoporosis <60y
What are the benefits of HRT in <60y?
Improved vasomotor and symptoms of menopause
Improved QoL
Reduce risk osteoporosis and fractures
What are the risks of taking HRT?
Older women with increased duration:
Breast cancer
Endometrial cancer
VTE
Stroke and coronary artery disease
No increased risk <50y
No risk endometrial cancer if no uterus
No increased risk CAD in oestrogen-only HRT
Can have unscheduled bleeding in first 3-6mths- Investigate after this (endometrial cancer)
What are the CIs to HRT?
Undiagnosed abnormal bleeding
Endometrial hyperplasia/cancer
Breast cancer
Uncontrolled HTN
VTE
Liver disease
Active angina/MI
Pregnancy
What are the options for delivering progesterone with HRT?
Oral tablets
Transdermal patches
IUS (Mirena)
What is Tibolone?
Helps patients with reduced libido
Used as form of continuous combined HRT- Must be postmenopausal
Synthetic steroid that stimulates oestrogen and progesterone receptors
What is the role of testosterone transdermal patches in menopause?
Improves energy levels and sex drive
What should patients taking oestrogen-containing contraceptives or HRT do before major surgery?
Stop 4wks before
What are the oestrogenic SEs of HRT?
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
What are the progestogenic SEs HRT?
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
How should HRT be stopped?
No specific regime
Can reduce slowly if prefer to reduce risk of symptoms suddenly recurring
Outline Rotterdam criteria
Diagnosing PCOS
Oligoovulation/anovulation- Irregular/absent periods
Hyperandrogenism- Hirsutism and acne
Polycystic ovaries on US (or ovarian volume >10cm3)
Outline presentation of PCOS
Oligomenorrhoea or amenorrhoea
Infertility
Obesity
Hirsutism
Acne
Hair loss in male pattern
Outline additional features of PCOS
Insulin resistance and diabetes
Acanthosis nigricans
CVD
Hypercholesterolaemia
Endometrial hyperplasia and cancer
OSA
Depression and anxiety
Sexual problems
What is acanthosis nigricans?
Thickened, rough skin
In axilla and on elbows
Velvety texture
Occurs with insulin resistance
List causes of Hirsuitism
Meds- Phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids
Ovarian/adrenal tumours that secrete androgens
Cushing’s syndrome
PCOS
Congenital adrenal hyperplasia
Outline insulin resistance and PCOS
Resistance to insulin- Produce more insulin
Insulin promotes release of androgens from ovaries and adrenal glands
Insulin supresses sex hormone-binding globulin (SHBG) produced by liver- Normally suppresses androgens function- Low SHBG promotes hyperandrogenism
High insulin- Halts follicle development in ovaries- Anovulation and multiple partially developed follicles on scan
Outline investigations of PCOS
Bloods:
Testosterone- Raised
Sex hormone-binding globulin (SHBG)- Low
LH- High
FSH
LH:FSH- High LH compared to FSH
Raised insulin
Mildly elevated prolactin
TSH
Normal/raised oestrogen
Pelvic US- Transvaginal- String of pearls
OGTT
What is the characteristic description of PCOS on TV US?
String of pearls around periphery of ovary
Outline how to interpret OGTT
Impaired fasting glucose: Fasting glucose 6.1-6.9 mmol/l (before glucose drink)
Impaired glucose tolerance: Plasma glucose at 2h 7.8-11.1mmol/l
Diabetes: Plasma glucose at 2h >11.1mmol/l
Outline general management of PCOS
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive meds if required
Statins if indicated (QRISK >10%)
Outline orlistat
Can help weight loss in women BMI >30
Lipase inhibitor that stops absorption of fat in intestines
How is the risk of endometrial cancer managed in PCOS?
Less frequent menstruation- Don’t produce enough progesterone- Endometrial lining proliferates
If extended gap between periods (>3mths) or abnormal bleeding- Pelvic US and assess endometrial thickness- Use cyclical progestogens prior to scan
Endometrial thickness >10mm- Biopsy
What are the risk factors for endometrial cancer in PCOS?
Obesity
Diabetes
Insulin resistance
Amenorrhoea
What are the options for reducing risk of endometrial cancer in PCOS?
Mirena coil- Continuous endometrial protection
Induce withdrawal bleed at least every 3-4mths:
Cyclical progestogens
COCP
How is infertility managed in PCOS?
Weight loss
Clomifene
Laparoscopic ovarian drilling
IVF
Metformin and letrozole
Ovarian drilling- Laparoscopic surgery
If become pregnant- Screen for gestational diabetes (OGTT)
How is hirsutism managed in PCOS?
Weight loss
Co-cyprindiol (Dianette)- For acne also- 3x increased risk VTE
Topical eflornithine (facial)- Takes 6wks to improve- Once stopped hirsutism recurs
Electrolysis
Laser hair removal
Spironolactone
Finasteride
Flutamide
Cyproterone acetate
How is acne managed in PCOS?
COCP- 1st line
Topical adapalene
Topical ABs (clindamycin and benzoyl peroxide)
Topical azelaic acid
Oral tetracyclines (eg: Lymecycline)
Outline ovarian cysts
Fluid filled sac
Functional ovarian cyst- Related to fluctuating hormones in menstrual cycle- Common premenopausal
Postmenopausal cysts- More concerning for malignancy
Outline presentation of ovarian cysts
Mostly asymptomatic
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
Acute pelvic pain- Torsion, haemorrhage or rupture
What are the types of functional ovarian cysts?
Follicular- On developing follicle- If don’t rupture and release egg, can persist- Harmless and disappear after a few menstrual cycles
Corpus luteum- Occur when corpus luteum fails to breakdown- Often seen in early pregnancy
What are serous cystadenomas?
Ovarian cyst
Benign tumour of epithelial cells
What are mucinous cystadenomas?
Ovarian cyst
Benign tumour of epithelial cells
Can become huge- Take up lots of space in pelvis and abdomen
What are endometriomas?
‘Chocolate cyst’
Sign of endometriosis
What are dermoid cysts/Germ cell tumours?
Benign ovarian tumour
Teratomas
Contain various tissue types- Skin/teeth/hair
Particularly associated with ovarian torsion
What are sex cord-stromal tumours?
Rare ovarian cyst
Can be malignant or benign
Arise from stroma or sex cords
What are the symptoms associated with ovarian cysts that may suggest malignancy?
Abdominal bloating
Reduced appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
List the risk factors of ovarian cancer
Reduced number of ovulations:
Later onset of periods
Early menopause
Any pregnancy
COCP
What are the causes of raised CA125?
Ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Outline blood tests to be done to investigate ovarian cysts
Premenopausal with simple ovarian cysts <5cm on US don’t require further investigations
CA125- Tumour marker for ovarian cancer
Women <45y complex ovarian mass (tumour markers for possible germ cell tumour):
Lactate dehydrogenase
Alpha-fetoprotein
HCG
What is the Risk of Malignancy Index (RMI)?
Estimates risk of ovarian mass being malignant
Menopausal status
US findings
CA125 level
What is Meig’s syndrome?
Triad:
Ovarian fibroma
Pleural effusion
Ascites
Older women
Remove tumour- Complete resolution of effusion and ascites
What are the complications of ovarian cysts?
Torsion
Haemorrhage
Rupture
Outline management of ovarian cysts
Possible ovarian cancer- 2wk wait
Dermoid cyst- Refer and consider surgery
Persistent/enlarging- Surgical intervention
Simple in premenopause:
<5cm discharge
5-7cm- Refer and yrly US monitoring
>7cm- Consider MRI/surgery
What is ovarian torsion?
Ovary twists in relation to surrounding connective tissue, fallopian tube and blood supply (adnexa)
Usually due to ovarian mass >5cm (cyst/tumour)
More likely to occur with benign tumours and in pregnancy
What is the risk of ovarian torsion?
Ischaemia and necrosis if persists
Function of ovary lost- EMERGENCY
Outline presentation of ovarian torsion
Sudden onset severe unilateral pelvic pain
Constant, gets progressively worse
Nausea and vomiting
Can potentially twist and untwist- Fluctuating symptoms
Localised tenderness on examination and possibly palpable mass
Outline diagnosis of ovarian torsion
Pelvic US- Whirlpool sign, free fluid in pelvis and oedema of ovary
Definitive- Laparoscopic surgery
Outline management of ovarian torsion
Emergency admission
Laparoscopic surgery- To untwist or remove ovary
What are the complications of ovarian torsion?
Ovary becomes necrotic and not removed- Infection- Abscess- Sepsis
At rupture- Peritonitis and adhesions
What is Asherman’s syndrome?
Adhesions within uterus following damage to uterus
What are the risk factors for Asherman’s syndrome?
Pregnancy-related dilatation and curretage
Treatment of retained products of conception
Uterine surgery
Pelvic infection
Endometrial curretage
Outline presentation of Asherman’s syndrome
Presents following exposure to RFs
Secondary Amenorrhoea
Sig. lighter periods
Dysmenorrhoea
Infertility
Outline diagnosis of Asherman’s syndrome
Hysteroscopy- Gold standard
Hysterosalpingography
Sonohysterography
MRI
Outline management of Asherman’s syndrome
Dissection of adhesions during hysteroscopy
Reoccurrence common
What is cervical ectropion?
Columnar epithelium of endocervix extends into stratified squamous epithelium of ectocervix
Lining of endocervix becomes becomes visible on examination
Cells of endocervix more fragile and prone to trauma (postcoital bleeding)
What are the risk factors for developing cervical ectropion?
Associated with higher oestrogen levels:
Younger women
COCP
Pregnancy
What is the transformation zone in cervical ectropion?
Border between columnar epithelium of endocervix and stratified squamous epithelium of ectocervix
Outline presentation of cervical ectropion
Often asymptomatic
Increased vaginal discharge
Vaginal bleeding
Dyspareunia
Postcoital bleeding
Exam- Well demarcated border between redder velvety columnar epithelium extending from os, and pale pink squamous epithelium of ectocervix
What is the association between cervical ectropion and cervical cancer?
No association
Always ask about smears
Outline management of cervical ectropion
Asymptomatic- No treatment, resolves as get older/stop pill/not pregnant
Not a CI to COCP
Problematic bleeding- Cauterise with silver nitrate or cold coagulation during colposcopy
What are Nabothian cysts?
Fluid filled cysts on surface of cervix
Up to 1cm size
What is the association between Nabothian cysts and cervical cancer?
No association
What are the risk factors for developing Nabothian cysts?
Childbirth
Minor trauma to cervix
Cervicitis
Outline presentation of Nabothian cysts
Often found incidentally on speculum exam
Don’t typically cause symptoms
If very large, may cause feeling of fullness in pelvis
Have whitish/yellow appearance
Outline management of Nabothian cysts
Diagnosis clear- Reassure, no treatment, often resolve
Uncertain- Refer for colposcopy, may excise or biopsy
What is a uterine prolapse?
Uterus descends in to vagina
What is a vault prolapse?
Occurs if had hysterectomy
Top of vagina descends into vagina
What is a rectocele?
Defect in posterior vaginal wall
Rectum prolapses forward into vagina
Associated with constipation
What are the symptoms of faecal loading in a rectocele?
Significant constipation
Urinary retention (compression on urethra)
Palpable lump in vagina
Women may use fingers to press lump back in to open bowels
What is a cystocele?
Defect in anterior vaginal wall
Bladder prolapses back into vagina
What are the risk factors for prolapse?
Multiple vaginal deliveries
Instrumental/prolonged/traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
Outline presentation of prolapse
Feeling of something coming down in vagina
Dragging/heavy sensation in pelvis
Urine- Urinary incontinence, urgency, frequency, weak stream, retention
Bowel- Constipation, incontinence and urgency
Sexual dysfunction- Pain, altered sensation, reduced enjoyment
Outline examination of prolapse
Empty bladder and bowel before examination
Sim’s speculum
Ask to cough or bear down
Outline grades of uterine prolapse
Grade 0: Normal
Grade 1: Lowest part >1cm above introitus
Grade 2: Lowest part within 1cm of introitus
Grade 3: Lowest part >1cm below introitus but not fully descended
Grade 4: Full descent with eversion of vagina
Uterus descending beyond introitus- Uterine procidentia
Outline conservative management of uterine prolapse
Pelvic floor exercises
Weight loss
Associated stress incontinence- Reduce caffeine intake and incontinence pads
Vaginal oestrogen cream
Outline use of vaginal pessaries in managing uterine prolapse
Insert into vagina and change every 4mths
Ring
Shelf and Gellhorn- Flat disc with stem
Cube
Donut
Hodge- Rectangular
Outline surgical options for uterine prolapse
What are the possible complications of uterine prolapse surgery?
Pain, bleeding, infection, DVT, risk of anaesthetic
Damage to bladder/bowel
Recurrence of prolapse
Altered experience of sex
What are the potential complications of mesh repairs in uterine prolapse?
No longer used
Chronic pain
Altered sensation
Dyspareunia
Abnormal bleeding
Urinary/bowel problems
Outline urge incontinence
Overactivity of detrusor muscle of bladder
Feel sudden urge to pass urine
Outline stress incontinence
Weakness of pelvic floor
Urine leaks when increased pressure- Coughing/laughing/surprised
Outline mixed incontinence
Combination of urge and stress incontinence
Outline overflow incontinence
Chronic urinary retention due to obstruction to outflow of urine
What are the causes of overflow incontinence?
Anticholinergic meds
Fibroids
Pelvic tumours
Neuro- MS, diabetic neuropathy, spinal cord injury
More common in men (rare in women)
How is overflow incontinence diagnosed?
Urodynamic testing
What are the risk factors for urinary incontinence?
Increased age
Postmenopausal status
High BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
MS
Cognitive impairment and dementia
How is strength of pelvic muscle contractions assessed?
Bimanual exam
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, firm squeeze and drawing inwards
Outline investigations of urinary incontinence
Bladder diary over at least 3d
Urine dipstick testing
Post-voidal residual bladder volume
Urodynamic testing- Investigate urge incontinence not responding to 1st line meds/difficulty urinating/urinary retention/previous surgery/unclear diagnosis
Outline urodynamic tests
Stop taking anticholinergic meds 5d before test
Thin catheter in bladder and rectum- Measure pressures in bladder and rectum
Cystometry- Measures detrusor muscle contraction and pressure
Uroflowmetry- Measures flow rate
Leak point pressure- Point at which urine leaks
Post-void residual bladder volume- Incomplete emptying
Video urodynamic testing- Fill bladder with contrast and take xray
Outline management of stress incontinence
Avoid caffeine/diuretics/overfilling bladder
Avoid excessive/restricted fluid intake
Weight loss
Supervised pelvic floor exercises- 3mths
Surgery
Duloxetine- SNRI (2nd line if surgery less preferred)
Outline surgical options for managing stress incontinence
Tension-free vaginal tape
Autologous sling procedures
Colposuspension
Intramural urethral bulking
Outline management of urge incontinence
Bladder retraining- 6wks
Anticholinergic meds- Oxybutynin/tolterodine/solifenacin
Mirabegron
Botulinum toxin type A- Inject in bladder wall
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
What are the anticholinergic SEs?
Dry mouth
Dry eyes
Urinary retention
Constipation
Postural hypotension
Cognitive decline, memory problems, worsening of dementia
What are the CIs of mirabegron?
Uncontrolled HTN
Monitor BP regularly
Can lead to hypertensive crisis and increased risk TIA and stroke
What is atrophic vaginitis?
Dryness and atrophy of vaginal mucosa
Related to lack of oestrogen
Occurs in menopause
Epithelial lining usually thickens/elastic/produces secretions in response to oestrogen
Tissue more prone to inflammation
Changes in vaginal pH and microbial flora- Infections
Low oestrogen can also lead to prolapse and stress incontinence (affects health of CT)
Outline presentation of atrophic vaginitis
Postmenopausal
Itching
Dryness
Dyspareunia
Bleeding due to localised inflammation
Recurrent UTIs
Stress incontinence
Prolapse
Outline findings on examination of atrophic vaginitis
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
Outline management of atrophic vaginitis
Vaginal lubricants
Estriol cream/pessaries
Estradiol tablets/ring
What are the CIs of topical oestrogens?
Breast cancer
Angina
VTE
What are the CIs of HRT?
Breast cancer
Angina
VTE
What is Bartholin’s cyst?
Bartholin’s glands either side of posterior part of vaginal introitus- Usually pea sized and not palpable
Ducts blocked- Glands swell
What is the function of Bartholin’s glands?
Produce mucus to help with vaginal lubrication
Outline presentation of Bartholin’s cysts
Usually unilateral
Swollen, tender
If infected- Bartholin’s abscess- Hot, tender, red, potentially draining pus
Outline management of Bartholin’s cyst
Usually resolve with good hygiene, analgesia and warm compress
Biopsy if vulval malignancy needs excluding
Outline management of Bartholin’s abscess
ABs
Swab
E. coli most common cause
Swab for chlamydia and gonorrhoea
Surgery:
Word catheter- Local anaesthetic
Marsupialisation- General anaesthetic
What are the complications of lichen sclerosus?
5% risk developing SCC of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal or urethral openings
What is Lichen Sclerosus?
Chronic inflammatory skin condition
Patches of shiny ‘porcelain-white’ skin
Commonly affects labia, perineum and perianal skin
Associated with AI diseases- T1D, alopecia, hypothyroid and vitiligo
How is lichen sclerosus diagnosed?
Clinically- History and examination
If doubt- Vulval biopsy
What is lichen simplex?
Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin
Excoriations, plaques, scaling and thickened skin
What is lichen planus?
AI
Localised inflammation with shiny, purplish, flat-topped raised areas with Wickham’s striae
Outline presentation of lichen sclerosus
Woman 45-60y
Vulval itching and skin changes in vulva
Soreness and pain possibly worse at night
Skin tightness
Superficial dyspareunia
Erosions
Fissures
Koebner phenomenon
What is the Koebner phenomenon?
Signs and symptoms made worse by friction to skin
Outline appearance of lichen sclerosus
Fissures, cracks, erosions, or haemorrhages under skin
Porcelain white
Shiny
Tight
Thin
Slightly raised
May be papules or plaques
How is lichen sclerosus managed?
Can’t be cured
Follow up every 3-6mths
Potent topical steroids- Clobetasol propionate 0.05% (dermovate)- Reduce risk of malignancy
Emollients
What is androgen insensitivity syndrome?
Cells unable to respond to androgen hormones due to lack of androgen receptors
X-linked recessive
Extra androgens converted into oestrogen- Female secondary sexual characteristics
Genetically male, female external genitalia
Testes in abdomen, absence of female internal organs
What is the role of anti-Mullerian hormone?
Produced by testes which prevents female internal organs developing
Shrinks Mullerian ducts
Outline presentation of androgen insensitivity syndrome
Inguinal hernia containing testes
Primary amenorrhoea
Lack of pubic hair
Lack of facial hair
Male type muscle development
Taller than female average
Infertile
Increased risk testicular cancer
Outline hormone test results of androgen insufficiency syndrome
Raised LH
Normal/raised FSH
Normal/raised testosterone (for a male)
Raised oestrogen levels (for a male)
Outline management of androgen insensitivity syndrome
Bilateral orchidectomy to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery to create adequate vaginal length
Support and counselling
Outline vaginal hypoplasia and agenesis
Abnormally small vagina/absent vagina
Occur due to failure of Mullerian ducts to develop properly
Ovaries often unaffected- Normal female sex hormones
How are vaginal hypoplasia and agenesis managed?
Vaginal dilator
Vaginal surgery
What is a transverse vaginal septae?
Septum forms transversely across vagina- Can be perforate or imperforate
Perforate- Still menstruate but may have difficulty with intercourse/tampon use
Imperforate- Cyclical pelvic symptoms w/o menstruation
Can lead to infertility
How is transverse vaginal septae diagnosed?
Examination
US
MRI
How is transverse vaginal septae managed?
Surgical correction- Can cause vaginal stenosis and recurrence
What is an imperforate hymen?
Hymen at entrance of vagina fully formed, w/o an opening
How does imperforate hymen present?
Primary amenorrhoea
Cyclical pelvic pain and cramping but no vaginal bleeding
How is an imperforate hymen diagnosed and managed?
Clinical examination
Surgical incision to create opening
What could potentially occur if an imperforate hymen is not treated?
Retrograde menstruation leading to endometriosis
Outline bicornate uterus
2 horns of uterus- Heart shaped
Diagnosed on Pelvis US
Outline complications of bicornate uterus
Miscarriage
Premature birth
Malpresentation
Outline basic embryological development
Female: Paramesonephric ducts (Mullerian ducts)- Upper vagina, cervix, uterus, fallopian tubes
Male: Produce Anti-Mullerian hormone- Suppresses growth of Mullerian ducts
Outline the types of FGM
Type 1: Removal of part or all of clitoris
Type 2: Removal of part or all of clitoris and labia minora, labia majora may also be removed
Type 3: Narrowing or closing of vaginal orifice (infibulation)
Type 4: All other unnecessary procedures to female genitalia
List immediate complications of FGM
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
List long term complications of FGM
Vaginal infections- Bacterial vaginosis
Pelvic infections
UTIs
Dysmenorrhoea
Sexual dysfunction and dyspareunia
Infertility
Sig. psych issues and depression
Reduced engagement with healthcare and screening
Outline management of FGM
Mandatory to report <18y to police
Social services and safeguarding
De-infibulation in cases of type 3
Re-infibulation- Illegal
