sex hormones 5-6 Flashcards
What is gynaecology?
the study of diseases unique to women especially those of the genital tract and breasts
What is obstetrics?
branch of health science dealing with pregnancy, labour and puerperium (3rd stage of labour until anovulation of uterus 3-6 weeks)
importance of the fornix and contraception
where the contraceptive diaphragm rests inside the vagina, covers the cervix
What can excessive body hair be due to?
polycysitc ovary syndrome
reasons for absent periods
pregnancy
menopause
PCOS
congenital abnormality
reasons for heavy periods
dysfunctional uterine bleeding
fibroids
endometrial polyps
reasons for vaginal bleeding in pregnancy
haemorrhage from the
- placenta
- placental bed (miscarriage)
- decidua (ectopic pregnancy)
reason for vaginal bleeding in postmenopause
haemorrhage from uterine lesion
- poly/carcinoma
types of infections with abnormal vaginal discharge
bacterial vaginosis
candida sp
trichomonas vaginalis
causes of abnormal vaginal discharge
infections
chemical/physical irritants
allergy/contact dermatitis
carvical polyp/neoplasms (rare)
What is bacterial vaginosis?
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
What is volvo-vaginal candida (thrush) caused by?
usually candida albicans
symptoms of candida
vulvovaginal itching and burning
dysparenuia (painful intercourse)
dysuria
thick, white discharge
risk factors for candida
pregnancy
diabetes
steroid therapy
antibiotic therapy
What is trichomonas vaginalis?
STD of flagellated protozoan acquired from sexual contact
causes epithelial damage leading to vaginal and vulvar inflammation
symptoms of trichomonas vaginalis
vulvular itching
discharge if profuse (a lot), frothy, yellow/green in colour with unplesant odour
only condition that can be treated OTC
thrush
Why is thrush rare in under 16 or over 60?
lack of vaginal oestrogen
-> refer to GP
treatment for trichomonas and bacterial vaginosis
metronidazole
pH of trichomonas discharge
> 5
pH of bactreial vaginosos discharge
> 4.5
treatment of candida
topical/systemic azoles
How do azoles work to treat vaginal thrush?
synthetic antimycotic agents that inhibit replication of yeast cells by interfering with the synthesis of ergosterol (main sterol in yeast cell membrane)
examples of azoles
fluconazole
clotrimazole
fluconazole
single dose 150mg capsule for vaginal thrush
symptoms improve 12-24hrs after administration
side effects - abdominal pain, diarrhoes, vomiting, nausea, flatulence
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
bases used in some preparations of clotrimazole
the bases of some preparations might damage latex condoms and diaphragms
When should intra-vaginal preparations of clotrimazole be used?
night time
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
metronidazole dose for treatment for bacterial trichomonas and bacterial vaginosis
400mg BD for 5-7 days
OR
2g as a single dose
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
PCOS
polycystic ovarian syndrome
What is PCOS associated with?dyslipidaemia
insulin resistance
obesity
hirsutisn
dysfunctional bleeding
hormones in PCOS
- high LH (low FSH:LH ratio)
- elevated orstrogen and androgen
- low progesterone
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
What is increased in PCOS?
inc free oestradiol
What does incresed free oestradiol lead to?
- dysfunctional uterine bleeding (heavy bleeding)
- dec FSH
- inc LH (no LH surge, no ovuation, theca call hyperplasia)
What does theca call hyperplasia in PCOS lead to?
increased androgens
- > inc DHT (dihydrotestosterone)
- > hirsutism and virilisation
treatment of amenorrhoea/oligomenorrhoea in PCOS
progesterone
treatment to induce ovulation and fertility in PCOS
clomifene OR gonadotropin preparations OR pulsatile GnRH analogues
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
side effects of clomifene
ovarian enlargement
palpitations
flushing
How is clomifene used in breast cancer?
anti-oestrogen
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
examples of gonadotropin receptor agonists used in PCOS
leuprolide
nafarelin
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
How are gonadotropin receptor agonists administered?
parenteral
side effects with gonadotropin receptor agonists
bone loss
vasomotor symptoms
genitourinary atrophy
examples of steroidal anti-androgens used in PCOS
spironolactone
cyproterone
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
monitoring for spironolactone
potassium
-> can cause potassium retention
cyproterone for PCOS
progesteronic actions
requires periodic interruption of therapy to allow breakthrough menstrual bleeding
can be given with EE to give contraceptive cover
What is used for PCOS androgen excess when infertility is not an issue?
COC
What is endometriosis?
presence of endometrial glands and stroma outside the uterus, anywhere in the pelvis
What does endometroisis cause?
dysmenorrhoea
pelvic pain
subfertility
What causes subfertility with endometriosis?
distortion of pevlic anatomy by adhesions/cysts or disturbance of reproductive processes
age where endometroisis is more commonly diagnosedq
between 30-40yrs
uncommon under 20
pathogenesis of endometroisis (3)
- retrograde/implantation theory - menstrual blood containing fragments of endometrium forced upwards through the fallopian tubes into the peritoneal cavity
- metaplasia/metastatic theory - dormant immature cellular elements spread over wide area during embryonic development persist into adult life and differentiate into endometrial tissue
- vascular/lymphatic theory - endometrial tissue may metastasise through the lymphatics or vascular system
diagnosis of endometriosois
needs 2/3 findings:
endometrial glands
endometrial strome
hemosiderin
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
mamanement of endometriosis
COC (continuous)
progesterones (medroxyprogesterone/norethisterone)
POP
IUS
implant
androgens and GnRH analogues
surgery (excision/albation) - can improve symptoms and sub fertility
What are fibroids?
benign smooth muscle tumours of the uterus
leiomyomas
Who do fibroids affect?
women of reproductive age
after puberty prevalence of fibroids increases progressively until menopause
How do fibroids develop?
promoted and maintained by exposure to oestrogen and progestogen
What increases the risk of fibroids?
early puberty
obesity
increasing age
What reduces the risk of fibroids?
pregnancy
dec with an increasing number of pregnancies
How are fibroids found?
during examniation or investigation for gynaecological problems or during pregnancy assessment
they’re usually asymptomatic
How are fibroids found?
during examniation or investigation for gynaecological problems or during pregnancy assessment
they’re usually asymptomatic
symptoms of fibroids
menorrhagia in 30s/40s (heavy bleeding)
abdominal swelling pevlic pain/discomfort dyspareunia constipation urinary symptoms due to compression of adjacent structures
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
treatment options for fibroids where fertility is desired
primary (medical) - leuprorelin, mifepristone, LNG-IUS
secondary - naproxen
primary (surgical) - myomectomy
What does treatment for fibroids dependon?
if fertility is desired or not
leuprorelin for fibroids
3.75mg IM once a month for up to 3 months
OR
11.25mg IM as a single dose
mifepristone for fibroids
5-50mg orally OD for 3-6mths
LNG-IUS for fibroids
insert52mg device into uterine cavity
remove and replace after 5yrs
naproxen for fibroids
500mg orally BD PRN
myomectomy for fibroids
surgical removal of uterine fibroids
or: laparotomy/laparoscopy/hysteroscopy
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
What does fibroids treatment for when fertility is not desired depend on?
if uterine preservation is desired
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
Why would a woman not be a surgical candidate?
significant obesity diabetes hypertension serious cardiac/pulmonary dysfunction -> high risk for major surgery
How does heavy menstrual bleeding (HMB) affect QoL?
physical
emotionsl
social
material
risk factors for HMB
gynaecological conditions:
- uterine fibroids
- adenomyosis/endometriosis
- endometrial cancer
- unopposed oestrogen use
increased age
ethnic group
sociocultural factors
investigations for HMB (3)
- if Hx suggests structural abnormalities and uterus is palpable - ULTRASOUND to ID structural abnormalities
- HYSTEROSCOPY WITH BIOPSY - ultrasound outcomes are inconclusive to determine location of fibroid/nature of abnormality
- ENDOMETRIAL BIOPSY if - intermittent bleeding presists, med treatment fails/not effective over age of 45
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
What to do if symptoms of HMB don’t improve within 3mths?
NSAIDs
tranexamic acid
What NOT to use for HMB?
danazol
etamsylate
surgical options for HMB
- endometrial ablation methods - HMB alone with uterus no bigger than 10 week pregnancy
- hysterectomy - not 1st line, route: vaginal first then abdominal
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
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
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
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)
clinical features of pevlvic inflammatory disease
fever
raised WBC
increased ESR
increased CRP
minimum criteria fordiagnosis of pelvic inflammatory disease
- presence of lower back pain
- adnexal tenderness
- cervical motion tenderness on bimanual examination with no apparent cause
differential diagnosis of pelvic inflammatory disease
- ectopic pregnancy
- acute appendicitis
- endometriosos
- ovarian cyst torsion or rupture
- UTI
- functional pain
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
What can delating PID treatment lead to?
increase risk of LT problems
- ectopic pregnancy
- infertility
- pelvic pain
treatment for PID
rest
analgesia
What should be offered after PID diagnosis?
full STI screen including HIV
signs of severe PID (admit for IV treatment)
- temp > 38
- signs of tubo-ovarian abcess
- pelvic peritonitis
- no response to oral treatment
- pregnancy
What needs to be taken into account before treatment for PID?
- age
- contraindications
- cautions
- possible adverse effects
- local antimicrobial sensitivity patterns
first line treatment for PID (3)
- ceftriaxone 500mg single IM dose
followed by oral doxycycline 100mg BD
and metronidazole 400mg BD for 14 days - oral ofloxacin 400mg BD
and metronidazole 400mg BD for 14 days
(levofloxacin 500mg OD 14 days alternative to ofloxacin) - oral moxifloxacin 400mg OD for 14 days
What treatment if positive for Mycoplasma genitalium in initial test?
treatment with moxifloxacin recommended
-> good microbiological activity against M. genitalium
alternative treatments if 1st line not suitable
ceftriaxone 500mg singe IM dose
followed by oral azithromycin 1g per week for 2 weeks
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
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
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
common clinical breast problems
breast lump breast lumpiness breast pain nipple discharge bone pain
