Repro wk 4 Flashcards
What is the important gynae history of an adolescent?
Age of menarche
Cycle
Pain
Sexual (absence of parents) - activity/contraception
Abuse
Weight loss/gain
Exercise
When do you investigate primary ammenorrhoea?
If normal secondary secondary characteristics for age - 16
If absent secondary sexual characteristics - age 14
What investigations should be done before gynae referral?
FSH, LH, PRL, TSH, testosterone/oestrogen
Pelvic USG
Progesterone withdrawal bleed - pregnancy vs not enough oestrogen
How do you induce puverty?
Gradual build up with oestrogen
Check its effect on breast development
Add progesterone once maximum height potenital is reached
Once on at least 20mg of oestrogen
What can cause secondary amenorrhoea?
Weight
PCOS
Pregnancy
Fluctuating LH/oestrogens
What can cause bleeding disorders in the young?
Anovulation (najority - normal up to 2-4 years post menarche)
Sexual abuse/trauma
Pregnancy complications
PLatlet defects/other blood disorders
How do you treat menorrhagia?
Reassure + talk to girl directly Progesterone only pill/combined Mefenamic acid Tranexamic acid Mirena
What are the possible adverse outcomes with ovarian cysts?
They can turn gangrenous
Tort
Or rupture
What are the symptoms of ovarian cysts?
Subacute history
Usually tender on one side of pelvis or behind uterus
May feel mass
What is prolapse?
50% of parous
Only 10-20% seek medical help
How many women have prolapse?
A protrusion of an organ/structure beyond its normal anatomical confines
What are the three layers of the pelvic floor?
Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the endopelvic fascia?
Network of fibro-muscular connective tissue
Fibromuscular allows it to stretch
What is pelvic diaphragm?
Layer of striated muscle with fascial coverings
Consists of levator ani + coccygeus
What is the urogenital diaphragm?
Superficial + deep transverse perinela muscles with fascial coverings
Normally weakest part
What are the parts of the endopelvic fascia?
Uterosacral/cardinal complex
Pubocervical fascia
Rectovaginal fascia
Where does the uterosacral c/cardinal complex extend to/from?
Medially from uterus, cervix
Laternal vaginal fornices
Pubocervical/rectovaginal fascia
Laterally to sacrum + fascial overlying piriformis muscle
How do you palapate the uterosacral complex?
Down traction on cervix
See if there is any side-side movement of cervix
Where does the uterosacral complex tend to break?
Medially
What is the pubocervical fascia?
A trapezoid fibromuscular tissue
Which provides the main support of the anterior vaginal wall
Often leads to bladder prolapse
What structures are found on the central surface of the pubocervical fascia?
Base of cardinal ligmanets (where it merges)
Cervix
What are found at the lateral boundaries of the pubocervical fascia?
Arcus tendineis fascia pelvis (a white line)
What is found at the distal boundary of the pubocervical fascia?
Urogenital diaphragm
Where does the pubocervical fascia tend to break?
At lateral attachments
Or immediately in front of cervix
What is the rectovaginal fascia?
Fibro-muscular elastic tissue
Holds rectum in place and leads to rectal prolapse
What does the rectovaginal fascia fuse with centrally?
Mereges with base of cardinal/uterosacral ligaments and perineum
What does the rectovaginal fascia fuse with laterally?
Fuses with fascia over levator ani
What is the attachment of the rectovaginal fascia distally?
Perineal body
Where does the rectovaginal fascia tend to brreak?
Centrally
How many levels of endopelvi support are there?
3 levels
What are the risk factors for pelvic organ prolapse?
Forceps delivery Large baby Prolonged second stage of labour Child birth in general Advancing age Obesity Previous pelvic floor surgery Other - syndromes, hormonal, constipation, heavy lifting
What is a safe answer for all pelvic floor disorders?
Forceps delivery
What types of exercise can cause pelvic prolapse?
High impact aerobics
Weight lifting
What are the typical vaginal pelvic organ prolpase symptoms?
Sensation of buldge/protrusion "heaviness" Seeing or feeling buldge/protrusion Pressure Difficulty inserting tampons Splinting
What investigations are there for prolapse?
No investigations to diagnose
MRI/USS - levator ani thickness, fascial defects
How do you prevent vaginal prolapse?
Avoid constipation
Effective management of chronic chest pathology
Smaller family size
Pelvic floor exercises
Improvements in antenatal/intrapartum care
What are management options of vaginal prolapse?
Pessaries
Surgery
What are the aims of pelvic floor surgery?
Relieve symptoms
Restore/maintain bowel/bladder function
Maintain capacity for vaginal sexual function
Tailorto individual needs
What is the benefit of giving methadone via mouth?
Do not get any of the IV side effects
Is methadone safe in pregnancy?
No direct harm, like most opiates
However, if mother stops taking care of self - not eating etc or abuse (as common in opiate drug users) then foetus may be harmed
Why is cocain dangerous in pregnancy?
High chance of miscarriage
Causes vasoconstriction of vessels
Sometimes in heart
How should you care for a neonate with a mother on methadrone?
Monitor and house in neonate unit for 5 days
Risk of epileptic fits or death from withdrawl
How does the umbilical cord look in uterine death?
Dark red
What can cause excess coils in the cord? What is the normal amount?
Exzcessive movement
Normal is 1 coild every 5-6 cm
What can cause placenta abruption?
Hypertension
Trauma
Cocaine
What is the mecahnism behind pre-eclampsia?
Trophoblast problem
Either too many or too active
Tropohoblasts break down smooth muscle around placenta implantation site to prevent vasoconstriction
What is the 5yr (average) survival rate of ovarian cancer after 5yrs?
30%
Who is likely to get ovarian cancer?
Mostly over 30 years
Some genetic cases (5-10%)
Incessant ovulation (no contraception, no pregnancy)
Breast feeding/OCP protective
What are the symptoms of ovarian cancer?
Often vague Indegestion/poor appetiite Altered bowel habit Bloating/discomfort Weight gain Pelvic mass - often asymptomatic and large at presentation
How do you diagnose ovarian cancer?
USS abdo + pelvis
CT to stage
Ca 125 biochem test
What is the Ca 125 test?
A glycoprotein antigen
Caused by inflamation as well as
Malignancy (ovarian, colon/pancreas, breast)
Also in benign conditions - menstration, endometriosis
Liver disease
What are the normal levels of Ca 125?
0-30/35
How do you calculate risk of ovarian cancer?
U x M x Ca125
U being US features, 1 = 1 multiple = 3
M = menopausal, pre = 1, post = 3
What are the US features that contribute to the risk score?
Multi-locular lesion Solida reas Bilateral Ascites Intra-abdominal
How do you treat ovarian cancer?
Surgery (gold standard)
Chemo after has best survival, although sometimes before to reduce
What are the cure rates of the sages of ovarian cancer?
1: 85%
2: 47%
3: 15%
4: 10%
What is the chemo regime for ovarian cacner?
First line being platinum + taxane within 8 wks of surgery
Cure unlikely
Average response being 2 yrs
How do you manage recurrance of ovarian cancer?
Chemo, possibly surgery
If unable to tolerate - tamoxifen or palliation
How thick should the endometrium be in a post menopausal woman?
Less than 4mm
How do you investigate post menopausal bleeding?
Trans-vaginal USS
Endometrial biopsy
How is a hysteroscopy carried out?
Either as out-patient with local anaesthesia
In-patient with general anaesthesia
How do you stage endometiral cancer?
Surgical/pathological
MRI
What is type 1 endometrial cancer?
Endometrioid adenocarcinoma
Caused by unopposed oestrogen
Characterised by hyperplasia with atypia precurosr
By far most common
What is type 2 endometrial cancer?
Uterine serous + clear cell carcinoma
Has higher grade + more aggressive so worse prognosis
Generally in older women
Has serous intraepithelial carcinoma precurose
How do you treat endometrial cancer?
Early stages - surgery
High risk - chemo
Advanced - radio
Surgery preferred if possible
With progesterone for palliation
What is the difference between a total ans subtotal hysteroectomy?
Total includes uterus and cervix
Subtotal only uterus
What are the risk factors for endometrial cancer?
Post menopausal High circulating oestrogen >obesity >unopposed oestrogen therapy >PCOS >early menarch/late menopause Atypical endometrail hyperplasia
What are the symptoms of endometrial cancer?
Abnomrla vaginal bleeding
Post menopausal bleesing
What can cause post-menopausal bleeding?
HRT Atrophic chance (vaginitis) Polyps cervical/endometrial Endometrial cancer Other cancer
What is the 5yr survival for endometrial cancer?
78% for all stages
95% stage 1
14 stage 4
What is the average age for menopause?
51
When is premature menopause?
40 years or less
Why does menopause happen?
Due to ovarian insufficnency - not enough viable eggs left
Means that follicle no longer develops to form oestrogen
As a result, oestradiol falls
FSH rises
Results in oestridol from peripheral conversion of androgens in fat
What are the symptoms of menopause?
Vasomotor symptoms "flush" Vaginal dryness/soreness Low libido Muscle/joint aches Mood changes silent - Osteoporosis
What are the modes of treatment for menopause?
HRT either:
local
systemic
What are the local treatments for menopause?
Vaginal oestrogen pessary
Vaginal cream
What are the systemic treatment options for menopause?
Transdermal - reduced risk of VTE as avoids first pass
Oral
Either oestrogen only if no uterus
Progesterone if still has uterus - can be oral
What are the contraindications to HRT?
Current hormone dependant cancer (breast/ endometrium)
Current active liver disease
Uninvestigated abnormal bleeding
Seek advice if previous VTE/blood disorders
Seek advice if previous breast cancer or BRCA carrier
When do you give cyclical vs non-cyclical HRT?
Cyclical (14 days just oestrogen, 14 days with progesterone) - if still ovarian function (perimenopausal)
Still bleeds
Continuous if no ovarian function
Bleed free after 3 months
What are the risks of HRT?
Breast cancer on combined (dependant on BMI) >Returns to normal after 5 yrs off HRT Ovarian cancer VTE (if oral) CVA (oral) (if after 60)
What are the benefits of HRT?
Vasomotor flushes get better
Treats local genital symptoms
Helps prevent osteoporosis
What is secondary amenorrhoea?
Has had periods, none for last 6 months
What are the causes of secondary amenorrhoea?
Pregnancy/breast feeding Contraception Polycystic ovaries Early menopause Thyroid disease/cushings Significant illness Raised prolactin Hypotholamic (stress/weight change (only need 10% weight change) Andorgen secreting tumour
How do you investigate secondary amenorrhoea?
Check androgen features (hirsutism etc) /virilisation
Check pregnancy
Bloods - FSH, LH, oestrogdiol/testosterone
Thyroid function
Pelvic ultrasound
How do you treat secondary amenorrhoea?
Treat specific cause
Assume fertile and give contraception unless after 2yrs post menopause
Check for Fragile X syndrome
How does PCO present?
Oligo/amenorrhoea
Androgenic symptoms
Anovulatory infertility
Does not cause weight gain or pain
How do you manage PCO?
Weight loss/exercise
Anti-androgen
Endometrial protection (progestogens)
How do you manage an ovarian cyst?
Do not touch as may kill eggs
Reassure + USS
What is vulvovaginitis?
Inflammation of the vulva and vagina
Most common condition in young girls (yrs 2-7 most common)
What causes vulvovaginitis?
Most commonly bacteria
What is labial agglutination?
Adhesion of labia minor in midline
Encourages urine retention + vaginal secretions
Can lead to vulvovaginitis
How do you manage labial aggluation?
If symptomatic - improved hygiene may be all that is needed
Treat only if chronic vulvoaginitis or difficulty urinating
Topical oestrogen
Lubrication of labial with bland ointment
Who is likely to get vaginal discharge?
Mucoid discharge common in infants 2 weeks after birth due to maternal oestrogen
Prepubertal girls experiencing increased oestrogen
What can cause pathological vaginal discharge?
Infections by organisms
Haemolytic streptococcal vaginitis
Monial vaginitis
Foreign body
How do you manage vaginal discharge?
Conservatively: Culture to identify organism Urinalysis to rule out cystitis Review hygiene Check for pin worms If persistent, review under anesthesia for foreign body
