premenstrual disorders + infertility

Question 1

management of heavy menstrual bleeding

Answer 1

1st = IUS - slow release local progesterone + prevents proliferation of endometrium

2nd = COCP or tranxemic acid (if still want babies)

3rd = DMOA - long acting progesterone

norethisterone - shortterm option to rapidly stop

Question 2

causes of heavy menstrual bleeding

Answer 2

fibroids
polyps
adenomyosis(Hx of csection, uterine curettage, STOP)

coagulopathy - commonest = von willebrand
malignancy

Question 3

define infertility

Answer 3

inability to conceive after 12months of regular intercourse without contraception
- affects 1 in 6 couples

ooligomenorrhea >35day cycle
amenorrhea - primary or secondary

Question 4

ovulation predictor test

Answer 4

detects LH surge (24-36hr before ovulation)

LH surge triggers ovulation, progesterone peaks after

Question 5

infertility investigations

Answer 5

day 21 progesterone
TSH
rubella immunity
chlamydia screen
up to date smeer
tubal patency testing - hysterosalpingogram, hydrotubation
hysteroscopy - is specific cases

semen analysis

consultation - seen together, length of relationship, time trying, examinations of both

Question 6

abnormal semen parameters

Answer 6

check LH, FH, testosterone, prolactin
karyotype, CF mutation, Y microdeletions

> 50% unexplained

Question 7

Assisted reproductive technolgy (ART)

Answer 7

intrauterine insemination
in vitro fertilisation (IVF)

intracytoplasmic sperm injection (ICSI)

Question 8

lifestyle advice for infertility

Answer 8

stop smoking
good BMI
reduce/stop alcohol
moderate caffeine
folic acid

Question 9

criteria for polycystic ovarian syndrome (PCOS)

Answer 9

Rotterdam, 2 of -

• oligo/amenorrhoea
• polycystic ovaries - 12 or more 2-9mm follicles
• signs of hyperandrogenism - acne, hirsutism

Question 10

management of polycycstic ovarian syndrome

Answer 10

COCP - for symptoms
clomifene citrate - for fertility
- alternatively letrozole (tamoxifen)
- if resistant add metformin (improves sensitivity to clomifene citrate)

gonadotrophin injections - risk of multiple pregnancy, overstimulation

laparoscopic ovarian diathermy - risk ovarian destruction

Question 11

assisted reproduction technology (ART)

Answer 11

intrauterine insemination (IUI) +/- superovulation

IVF - 2 embryos can be transferred in IVF

ICSI (intracytoplasmic sperm injections)

Question 12

eligibility for assisted reproduction technology (ART)

Answer 12

stable relationships - 2yrs, cohabiting
femakes age <40yrs or 42 if never had before
female BMI 18.5-30
non-smokers - at least 3 months pre treatment
no biological child
no illegal/abusive substances - incl methadone
neither partner to have been sterilised
duration unexplained infertility 2 yrs

up to 3 cycles treatment

Question 13

miscarriage presentation

Answer 13

cervical shock
- clinical emergency
- cramps, N+V, sweating, faint
- resolves quickly if products removed from cervix
- resis with IV infusion + uterotonics

bleeding primary symptom (>cramps

Question 14

causes of miscarriage

Answer 14

chromosomal abnormality
antiphopholipid
infections - CMV, rubella, toxoplasmosis, listeria
severe emotional upsets, stress
heavinf smoking, cocaine, alcohol misuse
uncontrolled diabetes
cervical incompetence + shortening

Question 15

non-continuing pregnancy (NCP)

Answer 15

(Early fetal demise)
- pregnancy in situ, no heartbeat
- mean sac diameter >25mm
- fetal pole >7mm

Question 16

speculum exam to assess stage of miscarriage

Answer 16

os closed = threatened

products at the open os = inevitable

in vagina + os is closed = complete

Question 17

how soon to try again after miscarriage

Answer 17

physically/emotionally healed - counsel
usually prefer to try after at least a normal menstrual cycle + periods

physiologically - allowing slightly longer interval allows regeneration of endometrial lining + reduce inflammation by improved stem cell population

Question 18

recurrent miscarriage classification + causes

Answer 18

referred if 3 or more pregnancy losses
- or if 2 losses + age >35yrs

causes
- antiphospholipid
- thrombophilia
- uterine abnormality - late 1st trimester losses
- age + previous miscarriages

Question 19

management of viable pregnancy in someone with antiphospholipid syndromes

Answer 19

use of low dose aspirin + fragmin injections after confirmation

Question 20

adenomyosis

Answer 20

endometrial glands + stroma within the myometrium
causes menorrhagia/dysmenorrhoea

cause of AUB

Question 21

leiomyoma

Answer 21

(fibroid)
benign tumour of smooth muscle, may be found in locations othr than uterus

growth is oestrogen dependent
–> growth during post menopausal state would be more concerning

microscopic = interlacing smooth muscle cells