Prolapse,Incontinence and Infertility

Question 1

What is the term used to describe prolapse of upper posterior wall of vagina? What structures does it contain?

Answer 1

Enterocoele.

Prolapse of the upper posterior wall of vagina. This may contain loops of small bowel.

Question 2

What is the term used to describe prolapse of the lower posterior wall of the vagina? Which structures does it contain?

Answer 2

Rectocoele.

Prolapse of the lower posterior wall of the vagina. Contains the anterior wall of the rectum.

Question 3

What is urethrocoele?

Answer 3

Prolapse of the anterior vaginal wall involving the urethra and the bladder

Question 4

Describe what vault prolapse is and what usually precedes/cause it?

Answer 4

Vault prolapse is prolapse of the top of the vagina, and is usually seen in those who have undergone hysterectomy

Question 5

What are the causes of prolapse?

Answer 5

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

Question 6

What are the signs and symptoms of prolapse?

Answer 6

Sensation of a lump, dragging sensation, discomfort down below, Urinary or Bowel issues, Difficulties with intercourse

Question 7

Why is abdominal examination done on those who complains of prolapse?

Answer 7

This is to rule out masses in the abdomen

Question 8

What managements are there for prolapse?

Answer 8

Weight loss, Physiotherapy,
Ring or shelf pessaries,
Vaginal hysterectomy, sacrospinous fixation

Question 9

After how long of usage must pessaries be changed?

Answer 9

After 6 months.

Question 10

What is infertility?

Answer 10

Infertility is defined as when a woman of reproductive age has not conceived after 1 year of unprotected sexual intercourse.

Question 11

What is a polycystic ovary?

Answer 11

A polycystic ovary is a characteristic transvaginal ultrasound appearance of multiple small (2-8mm) follicles in an enlarged (>10mL) ovary

Question 12

What are the investigations done to determine if there is PCOS?

Answer 12

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)

Question 13

What are the 3 significant features of PCOS?

Answer 13

1. Polycystic ovaries seen in USS
2. Irregular periods (Oligo/Amenorrhoea)
3. Hirsutism or raised serum testosterone

Question 14

What is the FSH level in PCOS?

How about in ovarian failure or in hypothalamic disease?

Answer 14

FSH level in PCOS is normal.

FSH Is increased in ovarian failure and decreased in hypothalamic disease.

Question 15

What is the LH level in PCOS? Is this diagnostic of PCOS?

Answer 15

LH levels are raised in PCOS. This is not diagnostic of PCOS.

Question 16

What causes Hirsutism?

Answer 16

Increased peripheral androgens cause hirsutism

Question 17

What type of cancer is more common in women with PCOS?

Answer 17

Endometrial cancer

Question 18

What is a complication of PCOS?

Answer 18

Type 2 Diabetes is commonly developed later in life for 50% of women with PCOS.
Gestational diabetes is also common.

Question 19

What are the management steps for PCOS?

Answer 19

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)

Question 20

What are the other causes of anovulation?

Answer 20

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

Question 21

What are the possible causes of hypothalamic hypogonadism?

Answer 21

Anorexia Nervosa, Stress, Excessive exercise or dieting

Question 22

Give a first line treatment of anovulation: an ovulation induction drug.
What is the mechanism of action of this drug?

Answer 22

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.

Question 23

What is the surgical treatment of PCOS?

Answer 23

Laparoscopic ovarian diathermy

Question 24

What is a side effect of ovulation induction caused by Clomifene but not Metformin?

Answer 24

Multiple pregnancy and ovarian cancer

Question 25

What is Intrauterine Insemination?

Answer 25

Intrauterine Insemination is a procedure where washed sperm are injected directly into the cavity of the the uterus

Question 26

During IVF, what is the maximum number of embryo transferred?

Answer 26

2

Question 27

What is ICSI?

Answer 27

Intracytoplasmic sperm injection. This is an injection of one sperm directly into the oocyte cytoplasm with the use of a very fine needle.

Question 28

When is ICSI offered?

Answer 28

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.

Question 29

What is done in testing for ovarian reserve?

Answer 29

Traditionally, ovarian reserve is assessed using FSH levels, but using serum levels of anti-Mullerian hormone is proven to be better

Question 30

Which hormone is used to reflect the “ovarian reserve”?

What produces this hormone?

Answer 30

Anti-Mullerian Hormone (AMH) is thought to reflect the ovarian reserve.
It is produced by granulosa cells in ovarian follicles of less than 8mm.

Question 31

What is the AMH levels in women with PCOS?

Answer 31

Women with PCOS often have high AMH levels.