Repro Revision Prt 2 Flashcards
Symptoms of endometrial cancer
Post menopausal bleeding ⭐️
Irregular heavy menstrual bleed ⭐️
Post-coital bleed Pelvic pain Loss of appetite/weight Tiredness Constipation
Risk factors for endometrial cancer
Overweight Nullparity Early menarche/late menopause (Tamoxifen/unopposed oestrogen therapy) ➡️➡️lots of oestrogen
PCOS
Family hx
HNPCC
DM, HT
What can protect you from endometrial cancer
Oral contraceptive pill
Aspirin
Increased physical activity
Treatment of endometrial cancer
Hysterectomy and remove tubes and ovaries
Pelvic lymph node dissection
Chemo, radio
Prognosis of ovarian cancer
Poor because most present at advanced stage
Symptoms of ovarian cancer
VAGUE Indigestion Early satiety Poor appetite Altered bowel habit Pain Pelvic mass --> no symptoms or asymptomatic (1% of women with these symptoms will have ovarian cancer)
CA125
???
Which genes put you in high risk of ovarian cancer
HPCC
BRCA1
BRCA2
Presentation of cervical cancer
Assymptomatic - picked up on cervical smear Intermenstrual bleeding Postcoital bleeding Pelvic pain Persistent offensive discharge
Treatment of cervical cancer
Chemo/radio therapy in early stage
Surgical - excision biopsy, radical hysterectomy, trachelectomy (to spare fertility)
Factors predisposing to cervical cancer
HPV - 16+18
Multiple partners
Early age of first intercourse
Smoking
Presentation of vulval cancer
Vulval lump or mass
Long standing pruritis
Postmenopausal bleed
Discharge or dysuria
Majority of vulval cancer are
Squamous cell carcinoma
Epidemiology of vulval cancer
Rare 80% >60yrs Vulval skin conditions & vulval Intraepithelial neoplasia HPV -- high risk Smoking
Factors that increase risk of urinary incontinence
Age Parity ⭐️ Menopause Increased intra-abdominal pressure - chronic coughing condition Connective tissue disease
Assessment of urinary incontinence
3 day urinary diary - fluid intake/output; frequency, nocturia…
Urine dipstick
Examination
Investigations for urinary incontinence
(Urinary diary, urine dipstick, exam)
MSSU and multistick
Bladder scanning
Urodynamics
Management of urinary incontinence (stress)
Lifestyle - stop smoking, lose weight, avoid constipation, avoid alcohol and caffeine
Pelvic floor muscle training
Duloxetine with muscle training
Symptoms of overactive bladder syndrome
Urgency
Urge UI
Frequency
Nocturia
What bowel problems may cause urinary incontinence
IBS
Constipation
Anal incontinence
Risk factors for overactive bladder syndrome
Increasing age
Diabetes
Recurrent UTI
Smoking
Pharmacological management of overactive bladder syndrome
Tri-cyclic antidepressants - imipramine
Anti-muscarinic - oxybutinin
Most common age of last period
51
When would menopause be considered premature
Symptoms of menopause
Vasomotor symptoms - “hot flushes”
Vaginal dryness/soreness
(Mood change, memory loss)
Benefits of HRT
Treat vasomotor symptoms, local genital symptoms
Helps osteoporosis (not first line),
Less colon cancer risk
Risks of HRT
Breast cancer Ovarian cancer Endometrial cancer Venous thrombosis Myocardial infarct CVA
How does mortality in HRT compare to non-users
No overall increase in mortality in HRT
XS risk of cancers (etc.) as for never users after 5 yrs off of treatment
Causes of premature menopause
Idiopathic - radio, chemo, surgery Infection - TB, mumps Chromosome abnormalities Autoimmune endocrine disease FSH receptor abnormalities
Complications of menopause
Lose the protective effect of oestrogen on bones so accelerates osteoporosis
Greater risk of ischaemic heart disease
Absolute contraindications for HRT
Severe hepatic impairment Recurrent idiopathic thrombosis History of recent breast cancer Irregular vaginal bleeding of unknown origin Myocardial infarction and stroke
Choice of HRT preparation
Oestrogen only for those without uterus
Need progesterone for those with uterus to prevent endometrial proliferation
Treatment alternative to HRT for menopause
Tibolone - selective oestrogen receptor modulator
SSRI/SNRI for hot flushes
Natural methods such as exercise, red clover..
When is never having had a period a concern
> 14 with no secondary sexual characteristics
> 16 with secondary sexual characteristics
Define primary amenorrhoea
Never having had a period
Define secondary amenorrhoea
Has had periods in the past but none for 6 months
Causes of primary amenorrhoea
Constitutional delay
Illness affecting the hypothalamopituitary axis - thyroid, coeliac, anorexia, renal failure
Chromosomal - turner’s
Endocrine - congenital adrenal hyperplasia
Infection - TB, mumps
Anatomical
Illnesses which can affect the hypothalamopituitary axis
Renal failure Coeliac Anorexia Thyroid Cushing's Galactosaemia
Chromosomal causes of primary amenorrhoea
Turners XO
XY androgen insensitivity
Fragile X
Noonans
Endocrine causes of primary amenorrhoea
Congenital adrenal hyperplasia
Pregnancy
What causes hypogonadotropic hypogonadism
Low levels of LH and FSH
Constitutional delay (short for the family but appropriate for the stage of puberty and bone age
Chronic medical condition (hypothyroid or malabsorption)
Anorexia nervosa
Causes of secondary amenorrhoea
Pregnancy or lactation
Polycystic ovaries
Stress/weight change
BMI >30 or
Causes of increased prolactin
Phenothiazine
Prolactinoma/pituitary adenoma
Treatment of premature menopause
Offer HRT until aged 50
Tests for secondary amenorrhoea
PREGNANCY TEST
Dipstick for glucose
Blood - LH, FSH, oestradiol, prolactin, thyroid function, testosterone
Pelvic ultrasound
What triggers menstruation
A decrease in progesterone 2 weeks after ovulation if not pregnant
Term for heavy periods
Menorrhagia
Term for painful periods
Dysmenorrhoea
Term for infrequent periods
Oligomenorrhoea
Term for lack of period
Amenorrhoea
Causes of menstrual problems in early teens
Anovulatory cycles ⭐️
Congenital abnormalities
Coagulation problems
Treatment of dysfunctional uterine bleeding
Non-hormonal or hormonal tablets or IUD to preserve fertility
If family complete consider endometrial ablation or hysterectomy
Likely cause of menstrual problems in the 40-menopausal age group
Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction
Presentation of polycystic ovarian syndrome
Oligo/amenorrhoea
Androgenic sx - hair/acne
Anovulatory infertility
Diabetes, cardiovascular disease
Management of PCOS
Encourage weight loss
Antiandrogens - combined OCP
Spironolactione
Endometrial protection - progestogens, mirena IUD, CHC
Fertility treatment with clomiphene or metformin (have underlying insulin resistance)
What is endometriosis characterised by
Endometrial type tissue outside the uterine cavity
–> pouch of douglas, ovary, pelvic peritoneum
Symptoms of endometriosis
Perimenstrual pain
Dysmenorrhoea
Deep dyspareunia
Sub fertility
Medical treatment of endometriosus
PSEUDOPREGNANCY
Progesterone - oral, injection, mirena
Combined oral contraceptive pill for 3 months at a time
GnRH analogues
Surgical management of endometriosus
Excision of deposits from peritoneum/ovary
Diathermy/laser ablation of deposits
Hysterectomy AND oophorectomy
In someone with amenorrhoea what do low LH and FSH levels imply; what do high levels imply
Low: no stimulation from hypothalamus
High: PCOS or ovarian failure (if very high)
Describe the progesterone challenge test
Test for amenorrhoea
Administer a progestogen for 5 days and within 3 days of stopping there will be a withdrawal bleed. This implies that the endometrium has been primed with oestrogen, the uterus is present and there is no outflow tract obstruction
How does prolactin affect menstruation
High prolactin levels inhibit pulsatile release of GnRH from the hypothalamus
Diagnosis of endometriosis
Diagnostic laparoscopy show powder burns and chocolate cysts
MRI
USS of endometrioma
Which race has the highest incidence of fibroids
Afro-caribbean women
Name the types of fibroids
Submucus (protrude into uterine cavity)
Intramural (within uterine wall)
Subserous (project out of uterus into peritoneal cavity
Symptoms of fibroids
Pressure sx if large
If enlarge uterine cavity surface area may cause menorrhagia
If submucous or polyp may cause intermenstrual bleeding
May grow fast in pregnancy –> pain, malpresentation, obstruction
Treatment of fibroids
Nothing!
Standard menorrhagia treatment if cavity not too distorted
GnRH analogues to shrink
Antiprogestogen (ella1) over 3 months at low dose
Transcervical resection
Uterine artery embolisation
Investigation of fibroids
Pelvic exam to be confirmed on ultrasound
How does the menopause affect fibroids
They shrink!
Due to oestrogen being removed
Dyskariosis
Low or high grade dyskaryosis reflects cervical intraepithelial neoplasia
Treatment of CIN
LLETZ
Cold coagulation
Laser ablation
What is the cervical transformation zone
The area where endocervical epithelium is pushed out and transformed into squamous cells - occurs during puberty and pregnancy
Most common form of endometrial cancer
Adenocarcinoma
Risk factors for pelvic organ prolapse
Obesity Advancing age Pregnancy and vaginal birth Previous pelvic surgery Large baby Forceps delivery/prolonged second stage
Vaginal symptoms of a pelvic organ prolapse
Sensation of bulge or protrusion Seeing or feeling bulge or protrusion Heaviness Pressure Difficulty inserting tampons
Urinary symptoms of pelvic organ prolapse
Incontinence Frequency/urgency Hesitancy Prolonged or weakened stream Feeling of incomplete emptying
Bowel symptoms of pelvic organ prolapse
Incontinence of flatus or liquid or solid stool
Feeling of incomplete emptying/straining
Urgency
Assessment of pelvic organ prolapse
POPQ (quantification) score
Exam to exclude pelvic mass
Prevention of pelvic organ prolapse
Avoid constipation
Manage respiratory problems
Smaller family size
Management of pelvic organ prolapse
Pelvic floor muscle training
Pessaries
Surgery
What are women offered as a routine screening for down’s syndrome
CUB - combined ultrasound and biochemical screening
Is an oblique lie a contraindiction to induction of labour
Yes!
Which women are recommended to recieve Anti-D in their pregnancy
Rhesus negative women with a rhesus positive partner
Best investigation to confirm endometriosis
Diagnostic laparoscopy
31 year old woman presenting with severe right sided upper abdominal pain at 34 weeks gestation, who has reported normal fetal movements until now; has no vaginal bleeding; a tense and tender abdomen; high blood pressure and a clean urine dipstick is likely to be
Placental abruption!
Best clinical signs to assess if someone is in active labour
Abdominal examination to assess the strength of contractions
Vaginal examination to see if membranes are intact
Best method of pain relief for someone in established labour with no previous analgesia
Morphine
Primary prevention of cervical cancer in the UK is performed by
HPV 16 and 18 immunisation
Why should a pregnant woman always be examined in a left lateral position
In the supine position the pressure of the gravid uterus on the inferior vena cava causes a reduction in venous return to the heart with a possible 25% reduction in cardiac output
Which infections are pregnant women routinely screened for
Hep B
HIV
Rubella
Syphilis
