PBL ILO’s Flashcards
Weight-loss related amenorrhoea
Weight-loss related amenorrhoea = the cessation of menstrual periods for >6months following a short-term weight loss >10-15% of the standard body mass
• Low energy availability can disturb GnRH release .: low levels of FSH and LH .: ovulation cannot be maintained
Weight gain related oligomenorrhoea
Weight-gain related oligomenorrhoea = excess adipose tissue associated with obesity can lead to a hormonal imbalance and stop ovulation causing missed periods
Common causes of infertility
Causes
• Sperm problems (30%)
• Ovulation problems (25%)
• Tubal problems (15%)
• Uterine problems (10%)
• Unexplained (20%)
• 40% of infertile couples have a mix of male and female causes.
General advice for couples trying to get pregnant
General Advice
There is some general lifestyle advice for couples trying to get pregnant:
• The woman should be taking 400mcg folic acid daily
• Aim for a healthy BMI
• Avoid smoking and drinking excessive alcohol
• Reduce stress as this may negatively affect libido and the relationship
• Aim for intercourse every 2 – 3 days
• Avoid timing intercourse
Timed intercourse to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship.
Management of anovulation
Management of Anovulation
The options when anovulation is the cause of infertility include:
• Weight loss for overweight patients with PCOS can restore ovulation
• Clomifene may be used to stimulate ovulation
• Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
• Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
• Ovarian drilling may be used in polycystic ovarian syndrome
• Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Management of tubal factors causing infertility
Management of Tubal Factors
The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include:
• Tubal cannulation during a hysterosalpingogram
• Laparoscopy to remove adhesions or endometriosis
• In vitro fertilisation (IVF)
Management of uterine factors causing infertility
Management of Uterine Factors
Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility.
Management of sperm problems causing infertility
Management of Sperm Problems
Surgical sperm retrieval is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen. A needle and syringe is used to collect sperm directly from the epididymis through the scrotum.
Surgical correction of an obstruction in the vas deferens may restore male fertility.
Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. It is unclear whether this is any better than normal intercourse.
Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm.
Donor insemination with sperm from a donor is another option for male factor infertility.
Physiological changes during the menopause and the symptoms these cause
Hormonal Changes – Increase in anovulatory cycles
Reduction of circulating oestrogen, significant increase of FSH and LH
Irregular vaginal bleeding
Pulsatile LH release - Hot flushes - Peripheral vasodilation and transient rise in body temperature
Vaginal atrophy and thinning of the myometrium - Urinary incontinence - The bladder and urethra share embryological derivation with the uterus and vagina and so these tissues also atrophy with the decrease in circulating oestrogen. - Increased risk of UTIs
Post menopausal bleeding differentials
Post-menopausal Bleeding (Differential)
– Endometrial cancer
– Endometrial or cervical polyps
– Endometrial hyperplasia
– Atrophic vaginitis
– Iatrogenic (anti-coagulants, HRT, intra-uterine devices)
– Infection e.g. vaginal candida
Post menopausal bleeding investigations
Investigations
– Spec and bimanual exam
– Trans-vaginal USS
– Endometrial sampling- method will depend on symptoms and patient preference (pipelle biopsy,
hysteroscopy + biopsy, D+C etc.)
How can psychogenic symptoms of menopause be medically managed?
SSRIs, SNRIs
- Fluoxetine 20 mg daily
- Citalopram 20 mg daily
- Paroxetine 10 mg daily
CBT
Vasomotor symptoms of menopause and how these are managed?
Vasomotor symptoms:
- Hot flushes
- Night sweats
- Palpitations
- Migraines
1st line:
HRT (tablets, sprays, gels, vaginal rings or patches)
- Available as oestrogen only, oestrogen- progestin combination, oestrogen-bazedoxifene and progestin only
- Significantly decreases severity and frequency of vasomotor symptoms
2nd line:
SSRIs, SNRIs
- Fluoxetine 20 mg daily
- Citalopram 20 mg daily
- Paroxetine 10 mg daily
- Venlafaxine modified release 37.5 mg daily for 1 week, increase 75 mg daily
Gabapentin
- Up to 300 mg three times daily, titrate up over three days
Benefits of HRT
Benefits of HRT
In women under 60 years, the benefits of HRT generally outweigh the risks.
The key benefits to inform women of include:
• Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
• Improved quality of life
• Reduced the risk of osteoporosis and fractures
Benefits of HRT
In women under 60 years, the benefits of HRT generally outweigh the risks.
The key benefits to inform women of include:
• Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
• Improved quality of life
• Reduced the risk of osteoporosis and fractures
Risks of HRT
Risks of HRT
Women may be concerned about the risks of HRT. It is crucial to put these into perspective. In women under 60 years, the benefits generally outweigh the risks. Specific treatment regimes significantly reduce the risks associated with HRT.
The risks of HRT are more significant in older women and increase with a longer duration of treatment. The principal risks of HRT are:
• Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
• Increased risk of endometrial cancer
• Increased risk of venous thromboembolism (2 – 3 times the background risk)
• Increased risk of stroke and coronary artery disease with long term use in older women
• The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
These risks do not apply to all women: ○ The risks are not increased in women under 50 years compared with other women their age ○ There is no risk of endometrial cancer in women without a uterus ○ There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)
Ways to reduce the risks:
§ The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
§ The risk of VTE is reduced by using patches rather than pills
Contraindications of HRT
Contraindications to HRT
There are some essential contraindications to consider in patients wanting to start HRT:
• Undiagnosed abnormal bleeding
• Endometrial hyperplasia or cancer
• Breast cancer
• Uncontrolled hypertension
• Venous thromboembolism
• Liver disease
• Active angina or myocardial infarction
• Pregnancy
Contraction of the pelvic floor muscles
When you contract the pelvic floor muscles, they lift the internal organs of the pelvis and tighten the openings of the vagina, anus and urethra. Relaxing the pelvic floor allows passage of urine and faeces.
Two hiatuses of the pelvic floor muscles
The pelvic floor has two hiatuses (gaps): (anteriorly) the urogenital hiatus through which urethra and vagina pass, and (posteriorly) the rectal hiatus through which the anal canal passes.
Urge incontinence
Urge incontinence -
• Overactivity of detrusor muscle of the bladder
• have a sudden, intense urge to urinate followed by an involuntary loss of urine. Causes: infection, diabetes, neurological disorder.
Stress incontinence
Stress incontinence
• Due to weakness of pelvic floor and sphincter muscles.
• Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
Mixed incontinence
Mixed incontinence
• Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.
Overflow incontinence
Overflow incontinence
• Chronic urinary retention due to obstruction to the outflow of urine
• Results in in continence without urge to pass urine
• Can occur with -
○ Anticholinergic medications
○ Fibroids
○ Pelvic tumours
○ Neurological conditions - MS, diabetic neuropathy and spinal cord injuries
• More common in men
• In women should be referred to urodynamic testing and specialist management
Risk factors for urinary incontinence
Risk factors
• Increased age
• Postmenopausal status
• Increased BMI
• Previous pregnancies and vaginal deliveries
• Pelvic organ prolapse
• Pelvic floor surgery
• Neurological conditions - ms
• Cognitive impairment / dementia
Conservative management of urinary incontinence
Conservative:
• Reduce caffeine (OSAB) and alcohol, avoid carbonated drinks
• Stop smoking
• Reduce BMI <30
• Normal fluid intake - some may drink too much and some too little
• Treat chronic constipation or chronic cough
• Bladder training (OAB)
• Continent products e.g. pads
Physio therapy for urinary incontinence
Physiotherapy:
• Supervised pelvic floor muscle training for >3months in stress or mixed UI (1st line)
• Biofeedback devices or pelvic floor stimulation
• Vaginal cones
• Physiotherapy only applicable if SUI or mixed, woman can contract pelvic floor, mild-moderate, instructor guidance
Medication for urinary incontinence
Medications:
• OAB: Anti-muscarinics (Oxybutynin, Solifenacin, Tolterodine)
○ S.E’s of anti-muscarinic: Dry mouth, dry eyes (effect on ANS)
• SUI AND URGENCY: Vaginal oestrogen (all post-menopausal women whom are not on HRT)
○ Duloxetine in SUI
• Desmopressin - unlicensed for nocturia
Types of genitourinary prolapse
Types:
• Anterior wall prolapse (Cystocele [bladder])
• Posterior wall prolapse (Rectocele [rectum])
• Uterine prolapse (uterus)
Causes of genitourinary prolapse
Causes:
• Prolonged labour
• Instrumental delivery
• Complicated delivery
• Trauma
• High parity
• Chronic cough
• Obesity
• Chronic constipation
Symptoms of genitourinary prolapse
Symptoms:
• Dragging sensation
• Feeling of a lump/bulge inside the vagina
• Discomfort
• Pelvic pain/discomfort
• Pelvic pressure/heaviness
• PV bleeding
• Bowel symptoms: constipation, incomplete emptying.
• Urinary symptoms: frequency, urgency, incontinence and incomplete emptying
• Recurrent UTIs
