Pelvic organ prolapse, PMS, Menopause, causes of bleeding/dyspareunia

Question 1

What is a pelvic organ prolapse due to?

Answer 1

weak pelvic vaginal wall muscle = collapse
defective fascia, pelvic floor and uterine vault (post hysterectomy)

Question 2

what are the 2 types of prolapse?

Answer 2

cystocele
rectocele

Question 3

what is a cystocele?
type of defect?

Answer 3

Anterior (+ lateral) prolapse
Bladder prolapses into vagina

Question 4

What is a urethrocele?

Answer 4

When the urethra pushes into the vaginal canal

Question 5

what is a rectocele?
type of defect?

Answer 5

When the rectum pushes into the vagina
Posterior defect

Question 6

what is an apical pelvic organ prolapse?

Answer 6

Enterocele

Question 7

what is an enterocoele?

Answer 7

small bowel descends into the lower pelvic cavity (pouch of Douglas) and pushes at the top part of the vagina, creating a bulge

Question 8

RF for prolapse?

Answer 8

multiparty
uterine surgery
increased age
obese

Question 9

Sx of a prolapse?

Answer 9

Urinary Sx = cystocele
Fecal Sx = Rectocele
Palpable/visible bulge, pressure, sexual anxiety

Question 10

Dx of a prolapse?

Answer 10

Exam (speculum) + bimanual
Grades 1- 4
POP-Q system (pelvic organ prolapse quantification system)
+/- Urine Dip (UTI)

Question 11

what are the grades 1-4?

Answer 11

1. 1+cm from hymen
2. less than 1 cm from hymen
3. 1+cm outside hymen
4. total uterus prolapse

Question 12

Tx for prolapse : conservative?

Answer 12

weight loss, avoid constipation and lifting heavy
PT (Kegel 3-6 months) - pelvic floor exercises

Question 13

Tx for prolapse: medical?

Answer 13

Ring pessary (re inserted 4-6 months by Dr)

Question 14

Tx for prolapse: surgical?

Answer 14

many, last line eg. pelvic floor repair or hysterectomy
egs. colposuspension, sacrohysteropexy, colporrhapy

Question 15

What is pre menstrual syndrome?

Answer 15

behaviour and psychological changes associated with luteal phase
(1 week pre menses until the start of next)

Question 16

what is PMS due to?

Answer 16

hormonal changes (oestrogen + progesterone) and low serotonin in luteal phase

Question 17

what are the RF for PMS?
typical age it affects?
% Menstruating females it affects?

Answer 17

Fix depression + pHx post partem depression
20-45 y/o
(other: smoking, stress, alcohol, mood disorders)
<40% menstruating females

Question 18

Sx of PMS?
Hormone and serotonin

Answer 18

hormone = bloating, tired, hot flushes

serotonin = depressed, anxious, irritable, fatigue, constipation

Question 19

Dx of PMS?

Answer 19

2+ cycles like this (must be assoc with luteal phase) with Sx diary

Question 20

What is the GS Tx for PMS?

Answer 20

Give GnRH 3 months (1 month to work, 2 months in effect) = +ve complete resolution

Question 21

Conservative Tx for PMS?

Answer 21

Regular sleep, stop alcohol and smoking

Question 22

Medical and behaviour Tx for PMS?

Answer 22

pain = NSAID
Physical = COCP
LL = GnRH
Behaviour (depression/anx) = CBT + SSRI (Sertraline)

Question 23

What is a complication of PMS?

Answer 23

PMDD (pre menstrual Dysphoric disorder)
3-8% PMS

Question 24

Sx of PMDD?

Answer 24

severe mood swings, agitation +/- psychosis
high risk self harm/suicide

Question 25

what is Mittelschmerz?

Answer 25

Mid cycle pre ovulatory low abdo pain
day 7-24 in 40% F

Question 26

What is the definition of menopause?

Answer 26

Cessation of menstrual cycle 12+ months in 45-55y F (median 51) or post hysterectomy

Question 27

What is perimenopause?

Answer 27

1-11 months amenorrhoea in 45-55 with vasomotor Sx

Question 28

What age is early menopause?

Answer 28

40-44

Question 29

What is premature Ovarian insufficiency?

Answer 29

The ovary does not release an egg each month as it should, early menopause
<40y
(>25 FSH IU/L levels)

Question 30

RF and Tx for premature ovarian insufficiency?

Answer 30

RF = Cancer, infection, chemo, PCOS, High T4, Fhx, Fragile X carrier

Tx = HRT at least till age 51

Question 31

Causes of menopause?

Answer 31

idiopathic
PCOS
Eating disorders
hysterectomy
Sheehan and asherman

Question 32

Sx of menopause
vasomotor and general?

Answer 32

Vasomotor = flushing + night sweats

General = mood swings, brain fog, low libido, high urination, bloating, atrophic vaginitis

Question 33

Sx of atrophic vaginitis?
Tx?

Answer 33

dry secretions
superficial dyspareunia
pale mucosa
sparse hair
thin skin

Topical oestrogen

Question 34

Dx of menopause?
clinical? Uncertainty?

Answer 34

clinical (12+ months amenorrhoea)
Uncertainty = Do FSH (>30 IU/L on 2 samples 4-6 weeks apart)

Question 35

What medication and class is good as a Tx for vasomotor Sx?

Answer 35

Venlafaxine (SNRI)

Question 36

Tx for unproblematic menopause?

Answer 36

no treatment

Question 37

Tx for problematic menopause?

Answer 37

Oestrogen and progesterone transdermal continuous combined HRT

Question 38

Why is transdermal HRT better?

Answer 38

reduces VTE risk

Question 39

when would you only give oestrogen? and why?

Answer 39

post hysterectomy (decreases endometrial cancer risk)

Question 40

What are the benefits of HRT?

Answer 40

Lower bowel, endometrial, ovarian cancer risk
Decrease osteoporosis

Question 41

What are the cons of HRT?

Answer 41

Increase breast cancer risk (5+ y)
increase VTE and stroke risk

Question 42

Continuous amenorrhoea?
+/- cyclical amenorrhoea?

Answer 42

menopause
perimenopause

Question 43

Post menstrual bleeding
MC cause?
Most serious cause?
Other causes?

Answer 43

MC - atrophic vaginitis
Most serious - endometrial cancer
Other - endometrial polyps, endometrial atrophy

Question 44

Post coital bleeding
Young person cause?
Older person cause?

Answer 44

Young - cervical ectropion, cervicitis

older - atrophic vaginitis

Question 45

Causes of superficial dyspareunia (on contact)

Answer 45

vulvodynia, vulval ca, lichen sclerosis, atrophic vaginitis

Question 46

Causes of deep dyspareunia (penetration)

Answer 46

Endometriosis, adenomyosis, PID, cervical cancer