sex hormones 5-6 Flashcards
1
Q
What is gynaecology?
A
the study of diseases unique to women especially those of the genital tract and breasts
2
Q
What is obstetrics?
A
branch of health science dealing with pregnancy, labour and puerperium (3rd stage of labour until anovulation of uterus 3-6 weeks)
3
Q
importance of the fornix and contraception
A
where the contraceptive diaphragm rests inside the vagina, covers the cervix
4
Q
What can excessive body hair be due to?
A
polycysitc ovary syndrome
5
Q
reasons for absent periods
A
pregnancy
menopause
PCOS
congenital abnormality
6
Q
reasons for heavy periods
A
dysfunctional uterine bleeding
fibroids
endometrial polyps
7
Q
reasons for vaginal bleeding in pregnancy
A
haemorrhage from the
- placenta
- placental bed (miscarriage)
- decidua (ectopic pregnancy)
8
Q
reason for vaginal bleeding in postmenopause
A
haemorrhage from uterine lesion
- poly/carcinoma
9
Q
types of infections with abnormal vaginal discharge
A
bacterial vaginosis
candida sp
trichomonas vaginalis
10
Q
causes of abnormal vaginal discharge
A
infections
chemical/physical irritants
allergy/contact dermatitis
carvical polyp/neoplasms (rare)
11
Q
What is bacterial vaginosis?
A
caused by loss of normal vaginal flora
lactobacillus replaced by an overgrowth of mixed flora, including gardnerrella species and anaerobes
thin discharge with fishy odour
complication in pregnancy
12
Q
What is volvo-vaginal candida (thrush) caused by?
A
usually candida albicans
13
Q
symptoms of candida
A
vulvovaginal itching and burning
dysparenuia (painful intercourse)
dysuria
thick, white discharge
14
Q
risk factors for candida
A
pregnancy
diabetes
steroid therapy
antibiotic therapy
15
Q
What is trichomonas vaginalis?
A
STD of flagellated protozoan acquired from sexual contact
causes epithelial damage leading to vaginal and vulvar inflammation
16
Q
symptoms of trichomonas vaginalis
A
vulvular itching
discharge if profuse (a lot), frothy, yellow/green in colour with unplesant odour
17
Q
only condition that can be treated OTC
A
thrush
18
Q
Why is thrush rare in under 16 or over 60?
A
lack of vaginal oestrogen
-> refer to GP
19
Q
treatment for trichomonas and bacterial vaginosis
A
metronidazole
20
Q
pH of trichomonas discharge
A
> 5
21
Q
pH of bactreial vaginosos discharge
A
> 4.5
22
Q
treatment of candida
A
topical/systemic azoles
23
Q
How do azoles work to treat vaginal thrush?
A
synthetic antimycotic agents that inhibit replication of yeast cells by interfering with the synthesis of ergosterol (main sterol in yeast cell membrane)
24
Q
examples of azoles
A
fluconazole
clotrimazole
25
fluconazole
single dose 150mg capsule for vaginal thrush
symptoms improve 12-24hrs after administration
side effects - abdominal pain, diarrhoes, vomiting, nausea, flatulence
26
clotrimazole
topically for vaginal thrush
available as a single 500mg pessary/5g prefilled single application of 10% cream/2% cream applied 2/3 times daily to external genitalia
symptoms improve more quickly than with oral fluconazole
27
bases used in some preparations of clotrimazole
the bases of some preparations might damage latex condoms and diaphragms
28
When should intra-vaginal preparations of clotrimazole be used?
night time
29
advice for vaginal thrush treatment
- complete course of treatment
- topical treatment can damage latex (condoms)
- avoid perfumed tolietries/baths/douched/deodrants, they can strip away the protective liing of the vagina
- candida can be transferred to the bowel, wipe anus from front to back to prevent transfer
- wear cotton underwear, avoid tights, cool, loose fitting clothes
- dry vagina after washing, infection thrives in warm/moist environment
- avoid sexual intercourse until treatment is over
30
metronidazole dose for treatment for bacterial trichomonas and bacterial vaginosis
400mg BD for 5-7 days
OR
2g as a single dose
31
MOA of metronidazole
anaerobic, protozoal parasites have electron transport component (such as ferrodoxins), small Fe-S proteins that have sufficiently negative redox potential to donate e- to metronidazole
this single transfer froms a highly reactive nitro radical-mediated mechanism that target the DNA and other biomolecules
-> results in cell death
32
PCOS
polycystic ovarian syndrome
33
What is PCOS associated with?dyslipidaemia
insulin resistance
obesity
hirsutisn
dysfunctional bleeding
34
hormones in PCOS
- high LH (low FSH:LH ratio)
- elevated orstrogen and androgen
- low progesterone
35
diagnosis of PCOS
at least 2 of:
- ovulatory failure -> oligomenorrhoea/amenorrhoea
- androgen excess -> elevated circulating androgens in the blood or clinical manifestations of excess andeogen (hirsutism/acne)
- polycyctic ovary seen on ultrasound
36
What is increased in PCOS?
inc free oestradiol
37
What does incresed free oestradiol lead to?
- dysfunctional uterine bleeding (heavy bleeding)
- dec FSH
- inc LH (no LH surge, no ovuation, theca call hyperplasia)
38
What does theca call hyperplasia in PCOS lead to?
increased androgens
- > inc DHT (dihydrotestosterone)
- > hirsutism and virilisation
39
treatment of amenorrhoea/oligomenorrhoea in PCOS
progesterone
40
treatment to induce ovulation and fertility in PCOS
```
clomifene
OR
gonadotropin preparations
OR
pulsatile GnRH analogues
```
41
How does clomifene work?
antagonises the normal negative feedback of endogenous oestrogen on the hypothalamus and the pituitary
resulting in increased FSH release which induces folicular growth
42
side effects of clomifene
ovarian enlargement
palpitations
flushing
43
How is clomifene used in breast cancer?
anti-oestrogen
44
What is danazol and MOA?
weak androgen
inhibits gonadotropin secretion resulting in reduction in oestrogen levels
minics feedback of endogenous androgens and reduces gonadotropin secretion
45
examples of gonadotropin receptor agonists used in PCOS
leuprolide
| nafarelin
46
How do gonadotropin receptor agonists work?
stimulate GnRH receptors
after brief stimulation they cause desensitisation of the GnRH receptor
this results in reduced concentrations of LH and FSH
47
How are gonadotropin receptor agonists administered?
parenteral
48
side effects with gonadotropin receptor agonists
bone loss
vasomotor symptoms
genitourinary atrophy
49
examples of steroidal anti-androgens used in PCOS
spironolactone
| cyproterone
50
MOA of spironolactone
inhibits cytochrome P450 mono-oxygenases and alters steroidogenesis
reduces testosterone synthesis and increases its metabolism
causes K retention
-> need to monitor K
51
monitoring for spironolactone
potassium
| -> can cause potassium retention
52
cyproterone for PCOS
progesteronic actions
requires periodic interruption of therapy to allow breakthrough menstrual bleeding
can be given with EE to give contraceptive cover
53
What is used for PCOS androgen excess when infertility is not an issue?
COC
54
What is endometriosis?
presence of endometrial glands and stroma outside the uterus, anywhere in the pelvis
55
What does endometroisis cause?
dysmenorrhoea
pelvic pain
subfertility
56
What causes subfertility with endometriosis?
distortion of pevlic anatomy by adhesions/cysts or disturbance of reproductive processes
57
age where endometroisis is more commonly diagnosedq
between 30-40yrs
| uncommon under 20
58
pathogenesis of endometroisis (3)
1. retrograde/implantation theory - menstrual blood containing fragments of endometrium forced upwards through the fallopian tubes into the peritoneal cavity
2. metaplasia/metastatic theory - dormant immature cellular elements spread over wide area during embryonic development persist into adult life and differentiate into endometrial tissue
3. vascular/lymphatic theory - endometrial tissue may metastasise through the lymphatics or vascular system
59
diagnosis of endometriosois
needs 2/3 findings:
endometrial glands
endometrial strome
hemosiderin
60
signs/symptoms of endometriosis
secondary dysmenorrhoea (before/during menstruation)
deep dyspareunia
chronic pelvic pain
ovulation related pain
cyclical or peri-menstrual bowel or bladder symptoms
subfertility
pain on defecation/micturition
61
mamanement of endometriosis
COC (continuous)
progesterones (medroxyprogesterone/norethisterone)
POP
IUS
implant
androgens and GnRH analogues
surgery (excision/albation) - can improve symptoms and sub fertility
62
What are fibroids?
benign smooth muscle tumours of the uterus
leiomyomas
63
Who do fibroids affect?
women of reproductive age
after puberty prevalence of fibroids increases progressively until menopause
64
How do fibroids develop?
promoted and maintained by exposure to oestrogen and progestogen
65
What increases the risk of fibroids?
early puberty
obesity
increasing age
66
What reduces the risk of fibroids?
pregnancy
dec with an increasing number of pregnancies
67
How are fibroids found?
during examniation or investigation for gynaecological problems or during pregnancy assessment
they're usually asymptomatic
67
How are fibroids found?
during examniation or investigation for gynaecological problems or during pregnancy assessment
they're usually asymptomatic
68
symptoms of fibroids
menorrhagia in 30s/40s (heavy bleeding)
```
abdominal swelling
pevlic pain/discomfort
dyspareunia
constipation
urinary symptoms due to compression of adjacent structures
```
69
What can distortion of the endometrial cavity cause in fibroids?
increase the SA and impair haemostasis
-> results in menorrhagia and dysmenorrhoea
abnormality in pregnancy
obstructed labour
impaired haemostasis after separation of the placenta
70
treatment options for fibroids where fertility is desired
primary (medical) - leuprorelin, mifepristone, LNG-IUS
secondary - naproxen
primary (surgical) - myomectomy
71
What does treatment for fibroids dependon?
if fertility is desired or not
72
leuprorelin for fibroids
3.75mg IM once a month for up to 3 months
OR
11.25mg IM as a single dose
73
mifepristone for fibroids
5-50mg orally OD for 3-6mths
74
LNG-IUS for fibroids
insert52mg device into uterine cavity
| remove and replace after 5yrs
75
naproxen for fibroids
500mg orally BD PRN
76
myomectomy for fibroids
surgical removal of uterine fibroids
| or: laparotomy/laparoscopy/hysteroscopy
77
treatment options for fibroids where fertility is NOT desired AND uterine preservation is DESIRED
primary - uterine artery embolisation (UAE)
or
myomectomy
adjunct preoperative therapy - same as primary for desired fertility
78
What does fibroids treatment for when fertility is not desired depend on?
if uterine preservation is desired
79
fibroid treatment when fertility NOT desired AND uterine preservation NOT desired
surgical candidate:
- primary - hysterectomy (vaginal/laparoscopic/abdominal)
- preoperative therapy
non surgical candidate:
- surgery if willing
- preoperative therapy
80
Why would a woman not be a surgical candidate?
```
significant obesity
diabetes
hypertension
serious cardiac/pulmonary dysfunction
-> high risk for major surgery
```
81
How does heavy menstrual bleeding (HMB) affect QoL?
physical
emotionsl
social
material
82
risk factors for HMB
gynaecological conditions:
- uterine fibroids
- adenomyosis/endometriosis
- endometrial cancer
- unopposed oestrogen use
increased age
ethnic group
sociocultural factors
83
investigations for HMB (3)
1. if Hx suggests structural abnormalities and uterus is palpable - ULTRASOUND to ID structural abnormalities
2. HYSTEROSCOPY WITH BIOPSY - ultrasound outcomes are inconclusive to determine location of fibroid/nature of abnormality
3. ENDOMETRIAL BIOPSY if - intermittent bleeding presists, med treatment fails/not effective over age of 45
84
phaemaceutical treatment for HMB (hormonal and non-hormonal treatment acceptable)
LNG-IUS - for LT use (>12mths), 1st line
tranexamic acid/NSAIDs/COC
norethisterone 15mg daily from days 5-26 of cycle/injected long acting progestogens
85
What to do if symptoms of HMB don't improve within 3mths?
NSAIDs
tranexamic acid
86
What NOT to use for HMB?
danazol
etamsylate
87
surgical options for HMB
1. endometrial ablation methods - HMB alone with uterus no bigger than 10 week pregnancy
2. hysterectomy - not 1st line, route: vaginal first then abdominal
88
What is pelvic inflammatory disease?
polymicrobial infection of upper reproductive tract
associated with sexually transmitted organisms - Chlamydiatrachomatis, Neisseria gonorrhoeae, Gardnerella vaginalis, anaerobes, other vaginal organisms
89
How does pelvic inflammatory disease occur?
organisms ascent through cervical canal to endometrial cavity and then to tubes and ovaries
bacteria then multiply in the favourable environment and ascend to the fallopian tube
90
risk factors for pevlic inflammatory disease
```
age 16-24
nulliparity (never given birth)
Hx of multiple sexual partners
insertion of IUD
PMH of the disease
```
91
symptoms of pevlic inflammatory disease
```
abdominal pain (bilateral)
dyspareunia
back pain
purulent cervical discharge
presence of adnexal tenderness
painful cervix on bimanual examination
abnormal vaginal bleeding (including post-cotial, inter-menstrual, menorrhagia)
```
92
clinical features of pevlvic inflammatory disease
fever
raised WBC
increased ESR
increased CRP
93
minimum criteria fordiagnosis of pelvic inflammatory disease
- presence of lower back pain
- adnexal tenderness
- cervical motion tenderness on bimanual examination with no apparent cause
94
differential diagnosis of pelvic inflammatory disease
- ectopic pregnancy
- acute appendicitis
- endometriosos
- ovarian cyst torsion or rupture
- UTI
- functional pain
95
investigations for pelvic inflammatory disease
- test for gonorrhoea and chlamydia -> positive supports diagnosos, negative doesn't exclude PID
- elevated CRP/ESR -> support diagnosis, not specific
- absence of endocervical/vaginal pus cell -> PID unlikely but non-specific
96
What can delating PID treatment lead to?
increase risk of LT problems
- ectopic pregnancy
- infertility
- pelvic pain
97
treatment for PID
rest
| analgesia
98
What should be offered after PID diagnosis?
full STI screen including HIV
99
signs of severe PID (admit for IV treatment)
- temp > 38
- signs of tubo-ovarian abcess
- pelvic peritonitis
- no response to oral treatment
- pregnancy
100
What needs to be taken into account before treatment for PID?
- age
- contraindications
- cautions
- possible adverse effects
- local antimicrobial sensitivity patterns
101
first line treatment for PID (3)
1. ceftriaxone 500mg single IM dose
followed by oral doxycycline 100mg BD
and metronidazole 400mg BD for 14 days
2. oral ofloxacin 400mg BD
and metronidazole 400mg BD for 14 days
(levofloxacin 500mg OD 14 days alternative to ofloxacin)
3. oral moxifloxacin 400mg OD for 14 days
102
What treatment if positive for Mycoplasma genitalium in initial test?
treatment with moxifloxacin recommended
-> good microbiological activity against M. genitalium
103
alternative treatments if 1st line not suitable
ceftriaxone 500mg singe IM dose
| followed by oral azithromycin 1g per week for 2 weeks
104
What is there a high risk for in PID and when if infection risk high?
risk of gonococcal infection high
- partner has gonorrhoea
- symptoms are severe
- sexual contact when abroad
105
treatment if risk of gonococcal infection is high
ceftriaxone 500mg single IM dose
followed by oral doxycycline 100mg BD
and oral metronidazole 400mg BD for 14 days
106
after care for PID
- offered to all sexual contacts within 6mths
- chlamydia/gonorrhoea diagnosed partner treated
- both partners avoid SI until completed full treatment course
- reassess at 72hrs to encure responding to treatment
- consider review at 2-4 weeks to ensure completion of antibiotits, pregnancy test if needed and further education
107
common clinical breast problems
```
breast lump
breast lumpiness
breast pain
nipple discharge
bone pain
```
