Reproductive Flashcards
Clinical presentation of PCOS?
Infertility, oligomenorrhoea, amenorrhoea.
Hirsutism, acne occuring after adolescence.
Obesity & acanthosis nigrans (insulin resistance).
Investigations for PCOS?
Total testosterone- normal to moderately elevated.
Sex hormone-binding globulin (SHBG)- normal to low.
Free androgen index- normal to elevated.
Ultrasound: >12 follicles in at least one ovary = polycystic overies..
Polycystic overaies dont need to be present to make diagnosis.
Rule out other causes: LH, prolactin, TFTs
Differentials for PCOS?
Obesity.
Hypothyroidism.
Premature ovarian failure.
Cushing’s syndrome
Possible long term complications of PCOS?
T2DM.
Cardiovascular disease.
Obstructive sleep apnoea
Management of PCOS in adults?
If pregnant/considering;
Offer 75-g oral glucose tolerance test.
Refer to specialist- do no initiate metformin.
Cyclical progestogen for 14 days to induce withdrawal bleed then transvaginal USS to assess endometrial thickening.
If endometrial thickening refer for sampling if not then prescribe: Cyclical progestogen (medroxyprogesterone every 1-3mo) Low dose COC Levonorgestrel releasing IUD
If no hormonee tx then regular ultrasonography every 6-12mp
How to manage PCOS in adolescents?
COC for clinical hyperandrogenism/irregular menses
Advise on long term complications:
Healthy lifestyle, smoking cessation, referral screening for diabetes and CVS risk
Contraindications to oral contraceptive pill/
Known or suspected pregnancy. Smoker over 35 age of >15 cigs a day. Obesity. Breast feeding <6 weeks post partum. Fx of thrombosis before 45yrs old. Breast cancer, BRCA genes, cancer within last few years.
Consider:
Migraines with aura, active liver or gallbladder disease
Causes of dysmenorrhoea?
Endometriosis/adenomyosis. Fibroids. PID. Ovarian cancer. Cervical cancer IUD insertion
What is primary dysmenorrhoea and how does it present?
Occurs in absence of any identifiable underlying pelvic pathology. Thought to be caused by production of uterine prostaglandins during mestruation which causes contractions and pain.
Presents:
Pain improves as menses progresses. Pain is lower abdo but may radiate to back and thighs and may be accompanied by nausea, vomiting, fatigue etc.
Pelvic exam will be normal.
How does secondary dysmenorrhoea present?
Often starts after several years of painless periods.
Pain not consistently related to menstruation cycle alone.
Other gynae symptoms like dyspareunia often present.
Pelvis examination may be abnormal.
How to manage primary dysmenorrhoea?
NSAIDs
Paracetamol if NSAIDs contraindicated/inefficient.
Consider contraception:
Combined = 30-35mg ethinylestradiol and norethisterone.
Oral, parenteral or IUD may be considered.
Consider transcutaenous electrical nerve stsimulation.
If pain still persist after 6/53 refer to gynae
Red flag symptoms for dysmenorrhea?
Ascites
Pelvic/abdo mass
Abnormal cervix OE.
Peristent intermenstrual or postcoital bleeding without assoc features of PID (pain, deep dyspareunia, abnormal discharge)
Causes of primary amonorrhoea (failure to establish menstruation by 15yrs with normal secondary sexual characteristics)?
Genito-urinary malformations (imperforate hymen, transverse septum, absent vagina or uterus).
Endocrine: hypothyroid, hyperthyroid, hyperprolactinaemia, Cushing’s
Primary ovarian insufficiency
Causes of secondary amenorrhoea?
If no features of androgen excess:
Pregnancy, lactation, menopause, chronic stress/illness, POI (chemo, autoimmune disease).
Features of androgen excess:
PCOS, Cushing’s, tumours of ovary and adrenal gland.
Investigations to identify causes of amenorrhoea in primary care and when to refer to gynae?
USS Serum prolactin TSH FSH, LH Total testosterone
Ask about: sexual hx and contraception, stress, weightloss, headaches, visual disturbances, age of menarche of family
Refer to gynae/endo:
Elevated FHS and LH in <40
Hx of uterine/cervical surgery or severe pelvic infection
Hyperprolactinaemia
