Prolapse,Incontinence and Infertility Flashcards
What is the term used to describe prolapse of upper posterior wall of vagina? What structures does it contain?
Enterocoele.
Prolapse of the upper posterior wall of vagina. This may contain loops of small bowel.
What is the term used to describe prolapse of the lower posterior wall of the vagina? Which structures does it contain?
Rectocoele.
Prolapse of the lower posterior wall of the vagina. Contains the anterior wall of the rectum.
What is urethrocoele?
Prolapse of the anterior vaginal wall involving the urethra and the bladder
Describe what vault prolapse is and what usually precedes/cause it?
Vault prolapse is prolapse of the top of the vagina, and is usually seen in those who have undergone hysterectomy
What are the causes of prolapse?
Mechanical injury after vaginal child-birth.
Large babies
Instrumental deliveries
Prolonged 2nd stage
Menopause (from deterioration of connective tissue due to lack of oestrogen from ageing)
Congenital (eg. Ehlers Danlos)
Iatrogenic
What are the signs and symptoms of prolapse?
Sensation of a lump, dragging sensation, discomfort down below, Urinary or Bowel issues, Difficulties with intercourse
Why is abdominal examination done on those who complains of prolapse?
This is to rule out masses in the abdomen
What managements are there for prolapse?
Weight loss, Physiotherapy,
Ring or shelf pessaries,
Vaginal hysterectomy, sacrospinous fixation
After how long of usage must pessaries be changed?
After 6 months.
What is infertility?
Infertility is defined as when a woman of reproductive age has not conceived after 1 year of unprotected sexual intercourse.
What is a polycystic ovary?
A polycystic ovary is a characteristic transvaginal ultrasound appearance of multiple small (2-8mm) follicles in an enlarged (>10mL) ovary
What are the investigations done to determine if there is PCOS?
Bloods: Hormones such as LH, FSH, androgens and testosterone levels
TFT: TRO Hypothyroidism (weight gain and hair loss)
Glucose level and HbA1c
Cholesterol
USS (to detect cysts in ovaries)
What are the 3 significant features of PCOS?
- Polycystic ovaries seen in USS
- Irregular periods (Oligo/Amenorrhoea)
- Hirsutism or raised serum testosterone
What is the FSH level in PCOS?
How about in ovarian failure or in hypothalamic disease?
FSH level in PCOS is normal.
FSH Is increased in ovarian failure and decreased in hypothalamic disease.
What is the LH level in PCOS? Is this diagnostic of PCOS?
LH levels are raised in PCOS. This is not diagnostic of PCOS.
What causes Hirsutism?
Increased peripheral androgens cause hirsutism
What type of cancer is more common in women with PCOS?
Endometrial cancer
What is a complication of PCOS?
Type 2 Diabetes is commonly developed later in life for 50% of women with PCOS.
Gestational diabetes is also common.
What are the management steps for PCOS?
To encourage weight loss and exercise (increase insulin sensitivity).
Advise smoking cessation.
To treat hirsutism and regulate bleeds so as to prevent endometrial cancer: COCP or Mirena coil if fertility is not required. Eflornithine for facial hirsutism.
If fertility is to be maintained, Clomifene can induce ovulation.
To decrease insulin levels and prevent/treat diabetes: Metformin (can help improve menstrual disturbances too)
What are the other causes of anovulation?
Hypotgonadotropic hypogonadism: results in a reduction in hypothalamic GnRH release. Example is Kallmann’s syndrome: a condition where the GnRH releasing neurones fail to develop. Characterised by delayed or absent menstruation and a loss in the sense of smell.
Hyperprolactinaemia: (from prolactinoma): increased prolactin secretion leading to inhibition of GnRH production
What are the possible causes of hypothalamic hypogonadism?
Anorexia Nervosa, Stress, Excessive exercise or dieting
Give a first line treatment of anovulation: an ovulation induction drug.
What is the mechanism of action of this drug?
Clomifene.
Clomifene is an anti-oestrogen which blocks the oestrogen receptors in the hypothalamus and pituitary. As gonadotrophin release is inhibited by oestrogen, it increases the release of FSH and LH, initiating the process of follicular maturation.
What is the surgical treatment of PCOS?
Laparoscopic ovarian diathermy
What is a side effect of ovulation induction caused by Clomifene but not Metformin?
Multiple pregnancy and ovarian cancer
What is Intrauterine Insemination?
Intrauterine Insemination is a procedure where washed sperm are injected directly into the cavity of the the uterus
During IVF, what is the maximum number of embryo transferred?
2
What is ICSI?
Intracytoplasmic sperm injection. This is an injection of one sperm directly into the oocyte cytoplasm with the use of a very fine needle.
When is ICSI offered?
Intracytoplasmic sperm injection is offered to couple with male factor infertility: when there is not enough motile sperm available to incubate a sufficiently high concentration with each oocyte for standard IVF.
What is done in testing for ovarian reserve?
Traditionally, ovarian reserve is assessed using FSH levels, but using serum levels of anti-Mullerian hormone is proven to be better
Which hormone is used to reflect the “ovarian reserve”?
What produces this hormone?
Anti-Mullerian Hormone (AMH) is thought to reflect the ovarian reserve.
It is produced by granulosa cells in ovarian follicles of less than 8mm.
What is the AMH levels in women with PCOS?
Women with PCOS often have high AMH levels.
