Obstetrics and Gynaecology Flashcards

1
Q

Outline the Hypothalamic-Pituitary-Gonadal Axis (HPGA)

A

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

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2
Q

What is produced by the anterior pituitary?

A

LH and FSH

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3
Q

Outline oestrogen

A

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

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4
Q

What does oestrogen stimulate?

A

Breast tissue development
Growth and development of female sex organs (vulva, vagina and uterus) at puberty
Blood vessel development in uterus
Development of endometrium

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5
Q

Outline progesterone

A

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

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6
Q

Outline role of progesterone

A

Thicken and maintain endometrium
Thicken cervical mucus
Increase body temperature

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7
Q

Outline hormonal changes during pregnancy

A

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

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8
Q

What age do boys and girls start puberty?

A

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

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9
Q

List causes of delayed puberty in girls

A

Low birth weight
Chronic disease
Eating disorders
Athletes

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10
Q

Outline Tanner staging

A

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

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11
Q

Outline the follicular phase of menstruation

A

Start of menstruation to moment of ovulation (0-14d of cycle)

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12
Q

Outline luteal phase of menstrual cycle

A

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

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13
Q

Outline formation of follicles

A

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

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14
Q

What is menstruation?

A

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

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15
Q

Outline development of primary follicle

A

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

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16
Q

Outline development of secondary follicle

A

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

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17
Q

Outline development of antral follicles

A

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

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18
Q

Outline ovulation

A

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

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19
Q

Outline corpus luteum

A

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

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20
Q

Outline fertilisation

A

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

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21
Q

Outline development of blastocyst

A

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

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22
Q

Outline implantation of blastocyst

A

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

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23
Q

Outline development of embryo

A

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

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24
Q

What occurs in the fetus at 5wks?

A

Embryonic disc develops into fetal pole
Contains 3 layers- Ectoderm, mesoderm and endoderm

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25
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
26
What does the endoderm become?
GI tract Lungs Liver Pancreas Thyroid Reproductive system
27
What does the mesoderm become?
Heart Muscle Bone Connective tissue Blood Kidneys
28
What does the ectoderm become?
Skin Hair Nails Teeth CNS
29
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
30
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
31
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
32
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
33
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
34
Outline role of placenta in excretion
Performs similar function to kidneys- Filters waste products from fetus Eg: Urea and creatinine
35
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
36
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
37
What can cause increased levels of hCG, above that of normal pregnancy?
Multiple pregnancy (twins) Molar pregnancy
38
Outline the role of the placenta in immunity
Mother's antibodies transfer across placenta to fetus during pregnancy
39
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
40
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
41
What respiratory changes occur in pregnancy?
Raised: Tidal volume RR
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
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
50
What is the mucus plug?
The 'show' Prevents bacteria from entering uterus during pregnancy Falls out during first stage of labour
51
What is the latent phase?
In first stage of labour 0-3cm dilation of cervix Progresses at 0.5cm/h Irregular contractions
52
What is the active phase?
3-7cm dilation of cervix Progresses at 1cm/h Regular contractions
53
What is the transition phase?
7-10cm dilation of cervix Progresses at 1cm/h Strong, regular contractions
54
Outline the 2nd stage of labour
10cm dilation to delivery of baby - Power- Strength of uterine contractions - Passenger- Size/attitude/lie/presentation - Passage
55
What does attitude of the fetus mean?
Posture of fetus Eg: How the back is rounded and how head and limbs are flexed
56
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
57
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)
58
What are the cardinal movements of labour?
Engagement Descent Flexion Internal rotation Extension Restitution and external rotation Expulsion
59
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
60
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
61
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
62
What is amenorrhoea?
Lack of menstrual periods
63
What is primary amenorrhoea?
Patient never develops periods
64
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
65
What is secondary amenorrhoea?
Patient previously had periods that subsequently stopped
66
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
67
What is anovulation?
Lack of ovulation
68
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
69
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
70
What is dysmenorrhoea?
Painful periods
71
What are the causes of dysmenorrhoea?
Primary dysmenorrhoea Endometriosis or adenomyosis Fibroids PID Copper coil Cervical or ovarian cancer
72
What is menorrhagia?
Heavy menstrual bleeding
73
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
74
What are the causes of postcoital bleeding?
RED FLAG Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
75
What are the causes of pelvic pain?
UTI Dysmenorrhoea IBS Ovarian cysts Endometriosis PID Ectopic pregnancy Appendicitis Mittelschmerz Pelvic adhesions Ovarian torsion IBD
76
What is Mittelschmerz?
Cyclical pain during ovulation
77
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
78
What is pruritis vulvae?
Itching of vulva and vagina
79
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
80
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
81
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
82
What is hypogonadotropic hypogonadism?
Deficiency of LH and FSH leading to deficiency of sex hormones Result of abnormal functioning of hypothalamus or pituitary gland
83
What are LH and FSH?
Gonadotrophins produced by anterior pituitary gland in response to gonadotropin releasing hormone (GnRH)
84
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
85
What is Hypergonadotropic hypogonadism?
Gonads fail to respond to LH and FSH Anterior produces high levels of LH and FSH and low sex hormones
86
What can cause hypergonadotropic hypogonadism?
Previous damage to gonads (torsion, cancer, infections (mumps)) Congenital absence of ovaries Turner's syndrome
87
What is Kallman syndrome?
Genetic condition Causes hypogonadotrophic hypogonadism Failure to start puberty Associated with anosmia (absent sense of smell)
88
What is congenital adrenal hyperplasia?
Congenital deficiency of 21-hydroxylase enzyme Underproduction of cortisol and aldosterone and overproduction of androgens from birth Autosomal recessive
89
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
90
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
91
List structural pathology causes of primary amenorrhoea
Imperforate hymen Transverse vaginal septae Vaginal agenesis Absent uterus Female genital mutilation
92
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
93
How is hypogonadotrophic hypogonadism managed?
Pulsatile GnRH to induce ovulation and menstruation Or can replace sex hormones- COCP
94
What is the definition of secondary amenorrhoea?
No menstruation >3mths after regular periods Investigate after 3-6mths
95
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
96
What is hyperprolactinaemia?
High prolactin levels act on hypothalamus to prevent release of GnRH No GnRH= No LH and FSH- Hypogonadotrophic hypogonadism
97
What is galactorrhoea associated with?
Is breast milk production and secretion Hyperprolactinaemia High prolactin level
98
What is the most common cause of hyperprolactinaemia?
Pituitary adenoma secreting prolactin
99
How is hyperprolactinaemia managed?
Often no treatment Dopamine agonists- Bromocriptine or cabergoline- Can reduce prolactin production
100
What can bromocriptine and cabergoline be used to treat?
(Dopamine agonists) Hyperprolactinaemia Parkinson's disease Acromegaly
101
Outline investigations of secondary amenorrhoea
Hormonal blood tests US pelvis to diagnose PCOS
102
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
103
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
104
Outline association between secondary amenorrhoea and osteoporosis
Amenorrhoea associated with low oestrogen- Increased risk osteoporosis Treat if amenorrhoea >12mths
105
How is risk of osteoporosis managed in secondary amenorrhoea?
Vit D and calcium HRT or COCP
106
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
107
Outline presentation of PMS
Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido
108
When can PMS continue in absence of periods?
Hysterectomy Endometrial ablation Mirena Ovaries continue to function and hormonal cycle continues
109
What is progesterone-induced premenstrual disorder?
Symptoms of PMS occurring in response to taking meds containing progesterone COCP or cyclical-HRT
110
How is PMS diagnosed?
Symptoms diary spanning 2 menstrual cycles Definitive- Administer GnRH analogues and temporarily induce menopause to see if symptoms resolve
111
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
112
What are the potential SEs of GnRH analogues?
Osteoporosis Add HRT to mitigate effects
113
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
114
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
115
What are fibroids?
Benign tumours of smooth muscle of uterus Oestrogen sensitive- Grow in response to oestrogen
116
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
117
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
118
Outline investigations of PCOS
Hysteroscopy- Initial investigation Pelvic US MRI scanning
119
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
120
Outline management of fibroids >3cm
NSAIDs and TXA Mirena coil COCP Cyclical oral progestogens Surgical: Uterine artery embolisation Myomectomy Hysterectomy
121
What can be used to reduce size of fibroids before surgery?
GnRH agonists- Goserelin or leuprorelin
122
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)
123
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
124
How does red degeneration of fibroid present?
Severe abdo pain Low grade fever Tachycardia Vomiting
125
How is red degeneration of fibroid managed?
Supportive Rest Fluids Analgesia
126
What is endometriosis?
Ectopic endometrial tissue outside uterus
127
What is adenomyosis?
Endometrial tissue within myometrium of uterus More common in later reproductive years and in multiparous women
128
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
129
What are the key symptoms of adhesions in endometriosis?
Chronic, non-cyclical pain May be sharp/stabbing/pulling and associated with nausea
130
Outline presentation of endometriosis
Cyclical abdo/pelvic pain Deep dyspareunia Dysmenorrhoea Infertility Cyclical haematuria/blood in stools Urinary/bowel symptoms
131
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
132
Outline diagnosis of endometriosis
Pelvic US Laparoscopic surgery- Gold standard
133
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
134
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
135
Which management of endometriosis may improve fertility?
Laparoscopic treatment
136
Outline presentation of adenomyosis
Dysmenorrhoea Menorrhagia Dyspareunia Infertility Enlarged tender uterus- Softer than in fibroids
137
Outline diagnosis of adenomyosis
Transvaginal US MRI and transabdominal US Gold standard- Histological exam of uterus after hysterectomy
138
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
139
Outline the link between pregnancy and adenomyosis
Infertility Miscarriage Preterm birth SGA Preterm PROM Malpresentation Need for CS PPH
140
What is menopause?
Permanent end to menstruation No periods for 12mths
141
When is someone described as postmenopausal?
12mths after final menstrual period onwards
142
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
143
What happens to levels of sex hormones during meopause?
Oestrogen and progesterone- Low LH and FSH- High (due to absence negative feedback from oestrogen)
144
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
145
What causes perimenopausal symptoms?
Low oestrogen
146
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
147
What does low oestrogen increase risk of?
CVD and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence
148
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
149
Outline contraception around menopause
Need contraception for: 2y after last period <50y 1y after last period >50y
150
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)
151
What are the SEs of depo-provera injection?
Weight gain Reduced bone mineral density (osteoporosis)
152
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
153
What is premature ovarian insufficiency?
Menopause <40y
154
How is premature ovarian insufficiency characterised?
Hypergonadotropic hypogonadism Raised LH and FSH Low oestradiol
155
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
156
Outline presentation of premature ovarian syndrome
Irregular/lack of periods <40y Symptoms of low oestrogen- Hot flushes, night sweats, vaginal dryness
157
How is premature ovarian syndrome diagnosed?
<40y Typical menopausal symptoms Elevated FSH (raised on 2 tests 4wks apart)
158
Outline management of premature ovarian syndrome
HRT until age of menopause: Traditional HRT- Lowers BP COCP
159
What are the risks associated with premature ovarian syndrome?
CVD Osteoporosis Cognitive and psychological risks
160
What is the risk of taking HRT >50y?
Breast cancer
161
What is the risk of taking HRT <50y?
VTE Reduce risk with transdermal patch
162
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
163
Which women need continuous combined HRT?
Postmenopausal with uterus and >12mths no periods- Requires progesterone protection
164
Which women can take oestrogen-only HRT?
Without uterus
165
Which women should take cyclical HRT?
Still having periods Should also have cyclical progesterone and regular breakthrough bleeds
166
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
167
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
168
What are the SEs of clonidine?
Dry mouth Headaches Dizziness Fatigue Sudden withdrawal- Raises BP, agitation
169
List alternative remedies for menopausal symptoms
Black cohosh Dong quai Red clover Evening primrose oil Ginseng
170
What are the SEs of black cohosh?
Liver damage
171
What are the SEs of Dong quai?
Cause bleeding disorders
172
What are the SEs of Red Clover?
Oestrogenic effects- Concerning in oestrogen sensitive cancers
173
What are the SEs of Evening Primrose Oil?
Significant drug interactions Linked with clotting disorders and seizures
174
What are the SEs of Ginseng?
Mood and sleep benefits
175
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
176
What are the benefits of HRT in <60y?
Improved vasomotor and symptoms of menopause Improved QoL Reduce risk osteoporosis and fractures
177
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)
178
What are the CIs to HRT?
Undiagnosed abnormal bleeding Endometrial hyperplasia/cancer Breast cancer Uncontrolled HTN VTE Liver disease Active angina/MI Pregnancy
179
What are the options for delivering progesterone with HRT?
Oral tablets Transdermal patches IUS (Mirena)
180
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
181
What is the role of testosterone transdermal patches in menopause?
Improves energy levels and sex drive
182
What should patients taking oestrogen-containing contraceptives or HRT do before major surgery?
Stop 4wks before
183
What are the oestrogenic SEs of HRT?
Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps
184
What are the progestogenic SEs HRT?
Mood swings Bloating Fluid retention Weight gain Acne and greasy skin
185
How should HRT be stopped?
No specific regime Can reduce slowly if prefer to reduce risk of symptoms suddenly recurring
186
Outline Rotterdam criteria
Diagnosing PCOS Oligoovulation/anovulation- Irregular/absent periods Hyperandrogenism- Hirsutism and acne Polycystic ovaries on US (or ovarian volume >10cm3)
187
Outline presentation of PCOS
Oligomenorrhoea or amenorrhoea Infertility Obesity Hirsutism Acne Hair loss in male pattern
188
Outline additional features of PCOS
Insulin resistance and diabetes Acanthosis nigricans CVD Hypercholesterolaemia Endometrial hyperplasia and cancer OSA Depression and anxiety Sexual problems
189
What is acanthosis nigricans?
Thickened, rough skin In axilla and on elbows Velvety texture Occurs with insulin resistance
190
List causes of Hirsuitism
Meds- Phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids Ovarian/adrenal tumours that secrete androgens Cushing's syndrome PCOS Congenital adrenal hyperplasia
191
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
192
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
193
What is the characteristic description of PCOS on TV US?
String of pearls around periphery of ovary
194
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
195
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%)
196
Outline orlistat
Can help weight loss in women BMI >30 Lipase inhibitor that stops absorption of fat in intestines
197
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
198
What are the risk factors for endometrial cancer in PCOS?
Obesity Diabetes Insulin resistance Amenorrhoea
199
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
200
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)
201
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
202
How is acne managed in PCOS?
COCP- 1st line Topical adapalene Topical ABs (clindamycin and benzoyl peroxide) Topical azelaic acid Oral tetracyclines (eg: Lymecycline)
203
Outline ovarian cysts
Fluid filled sac Functional ovarian cyst- Related to fluctuating hormones in menstrual cycle- Common premenopausal Postmenopausal cysts- More concerning for malignancy
204
Outline presentation of ovarian cysts
Mostly asymptomatic Pelvic pain Bloating Fullness in abdomen Palpable pelvic mass Acute pelvic pain- Torsion, haemorrhage or rupture
205
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
206
What are serous cystadenomas?
Ovarian cyst Benign tumour of epithelial cells
207
What are mucinous cystadenomas?
Ovarian cyst Benign tumour of epithelial cells Can become huge- Take up lots of space in pelvis and abdomen
208
What are endometriomas?
'Chocolate cyst' Sign of endometriosis
209
What are dermoid cysts/Germ cell tumours?
Benign ovarian tumour Teratomas Contain various tissue types- Skin/teeth/hair Particularly associated with ovarian torsion
210
What are sex cord-stromal tumours?
Rare ovarian cyst Can be malignant or benign Arise from stroma or sex cords
211
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
212
List the risk factors of ovarian cancer
Reduced number of ovulations: Later onset of periods Early menopause Any pregnancy COCP
213
What are the causes of raised CA125?
Ovarian cancer Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
214
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
215
What is the Risk of Malignancy Index (RMI)?
Estimates risk of ovarian mass being malignant Menopausal status US findings CA125 level
216
What is Meig's syndrome?
Triad: Ovarian fibroma Pleural effusion Ascites Older women Remove tumour- Complete resolution of effusion and ascites
217
What are the complications of ovarian cysts?
Torsion Haemorrhage Rupture
218
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
219
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
220
What is the risk of ovarian torsion?
Ischaemia and necrosis if persists Function of ovary lost- EMERGENCY
221
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
222
Outline diagnosis of ovarian torsion
Pelvic US- Whirlpool sign, free fluid in pelvis and oedema of ovary Definitive- Laparoscopic surgery
223
Outline management of ovarian torsion
Emergency admission Laparoscopic surgery- To untwist or remove ovary
224
What are the complications of ovarian torsion?
Ovary becomes necrotic and not removed- Infection- Abscess- Sepsis At rupture- Peritonitis and adhesions
225
What is Asherman’s syndrome?
Adhesions within uterus following damage to uterus
226
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
227
Outline presentation of Asherman’s syndrome
Presents following exposure to RFs Secondary Amenorrhoea Sig. lighter periods Dysmenorrhoea Infertility
228
Outline diagnosis of Asherman’s syndrome
Hysteroscopy- Gold standard Hysterosalpingography Sonohysterography MRI
229
Outline management of Asherman’s syndrome
Dissection of adhesions during hysteroscopy Reoccurrence common
230
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)
231
What are the risk factors for developing cervical ectropion?
Associated with higher oestrogen levels: Younger women COCP Pregnancy
232
What is the transformation zone in cervical ectropion?
Border between columnar epithelium of endocervix and stratified squamous epithelium of ectocervix
233
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
234
What is the association between cervical ectropion and cervical cancer?
No association Always ask about smears
235
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
236
What are Nabothian cysts?
Fluid filled cysts on surface of cervix Up to 1cm size
237
What is the association between Nabothian cysts and cervical cancer?
No association
238
What are the risk factors for developing Nabothian cysts?
Childbirth Minor trauma to cervix Cervicitis
239
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
240
Outline management of Nabothian cysts
Diagnosis clear- Reassure, no treatment, often resolve Uncertain- Refer for colposcopy, may excise or biopsy
241
What is a uterine prolapse?
Uterus descends in to vagina
242
What is a vault prolapse?
Occurs if had hysterectomy Top of vagina descends into vagina
243
What is a rectocele?
Defect in posterior vaginal wall Rectum prolapses forward into vagina Associated with constipation
244
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
245
What is a cystocele?
Defect in anterior vaginal wall Bladder prolapses back into vagina
246
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
247
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
248
Outline examination of prolapse
Empty bladder and bowel before examination Sim's speculum Ask to cough or bear down
249
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
250
Outline conservative management of uterine prolapse
Pelvic floor exercises Weight loss Associated stress incontinence- Reduce caffeine intake and incontinence pads Vaginal oestrogen cream
251
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
252
Outline surgical options for uterine prolapse
253
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
254
What are the potential complications of mesh repairs in uterine prolapse?
No longer used Chronic pain Altered sensation Dyspareunia Abnormal bleeding Urinary/bowel problems
255
Outline urge incontinence
Overactivity of detrusor muscle of bladder Feel sudden urge to pass urine
256
Outline stress incontinence
Weakness of pelvic floor Urine leaks when increased pressure- Coughing/laughing/surprised
257
Outline mixed incontinence
Combination of urge and stress incontinence
258
Outline overflow incontinence
Chronic urinary retention due to obstruction to outflow of urine
259
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)
260
How is overflow incontinence diagnosed?
Urodynamic testing
261
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
262
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
263
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
264
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
265
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)
266
Outline surgical options for managing stress incontinence
Tension-free vaginal tape Autologous sling procedures Colposuspension Intramural urethral bulking
267
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
268
What are the anticholinergic SEs?
Dry mouth Dry eyes Urinary retention Constipation Postural hypotension Cognitive decline, memory problems, worsening of dementia
269
What are the CIs of mirabegron?
Uncontrolled HTN Monitor BP regularly Can lead to hypertensive crisis and increased risk TIA and stroke
270
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)
271
Outline presentation of atrophic vaginitis
Postmenopausal Itching Dryness Dyspareunia Bleeding due to localised inflammation Recurrent UTIs Stress incontinence Prolapse
272
Outline findings on examination of atrophic vaginitis
Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair
273
Outline management of atrophic vaginitis
Vaginal lubricants Estriol cream/pessaries Estradiol tablets/ring
274
What are the CIs of topical oestrogens?
Breast cancer Angina VTE
275
What are the CIs of HRT?
Breast cancer Angina VTE
276
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
277
What is the function of Bartholin's glands?
Produce mucus to help with vaginal lubrication
278
Outline presentation of Bartholin's cysts
Usually unilateral Swollen, tender If infected- Bartholin's abscess- Hot, tender, red, potentially draining pus
279
Outline management of Bartholin's cyst
Usually resolve with good hygiene, analgesia and warm compress Biopsy if vulval malignancy needs excluding
280
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
281
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
282
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
283
How is lichen sclerosus diagnosed?
Clinically- History and examination If doubt- Vulval biopsy
284
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
285
What is lichen planus?
AI Localised inflammation with shiny, purplish, flat-topped raised areas with Wickham's striae
286
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
287
What is the Koebner phenomenon?
Signs and symptoms made worse by friction to skin
288
Outline appearance of lichen sclerosus
Fissures, cracks, erosions, or haemorrhages under skin Porcelain white Shiny Tight Thin Slightly raised May be papules or plaques
289
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
290
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
291
What is the role of anti-Mullerian hormone?
Produced by testes which prevents female internal organs developing Shrinks Mullerian ducts
292
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
293
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)
294
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
295
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
296
How are vaginal hypoplasia and agenesis managed?
Vaginal dilator Vaginal surgery
297
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
298
How is transverse vaginal septae diagnosed?
Examination US MRI
299
How is transverse vaginal septae managed?
Surgical correction- Can cause vaginal stenosis and recurrence
300
What is an imperforate hymen?
Hymen at entrance of vagina fully formed, w/o an opening
301
How does imperforate hymen present?
Primary amenorrhoea Cyclical pelvic pain and cramping but no vaginal bleeding
302
How is an imperforate hymen diagnosed and managed?
Clinical examination Surgical incision to create opening
303
What could potentially occur if an imperforate hymen is not treated?
Retrograde menstruation leading to endometriosis
304
Outline bicornate uterus
2 horns of uterus- Heart shaped Diagnosed on Pelvis US
305
Outline complications of bicornate uterus
Miscarriage Premature birth Malpresentation
306
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
307
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
308
List immediate complications of FGM
Pain Bleeding Infection Swelling Urinary retention Urethral damage and incontinence
309
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
310
Outline management of FGM
Mandatory to report <18y to police Social services and safeguarding De-infibulation in cases of type 3 Re-infibulation- Illegal
311