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Year 3 - GP > SLA 11 - Male and Female Health > Flashcards

SLA 11 - Male and Female Health Flashcards

1
Q

Outline the steps of the HPG axis that result in the release of FSH and LH by the anterior pituitary gland.

A
  1. Hypothalamus releases GnRH, stimulating anterior pituitary gland
  2. Anterior pituitary gland releases LH and FSH, which go on to act upon the ovaries in the female reproductive tract
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2
Q

Describe the effect of FSH on the female reproductive tract.

A

FSH binds to granulosa cells to stimulate follicle growth, permit the conversion of androgens to oestrogens, and stimulate inhibin secretion.

LH binds to theca cells to stimulate the production and secretion of androgens.

The HPG Axis
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3
Q

Outline the effects of the following hormones upon the HPG axis:

a) moderate oestrogen levels

b) high oestrogen levels

c) oestrogen in the presence of progesterone

d) inhibin

A

a) negative feedback exerted on HPG axis

b) positive feedback exerted on HPG axis

c) negative feedback on the HPG axis

d) selectively inhibits FSH at the anterior pituitary

The HPG Axis
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4
Q

Name the 3 phases of the ovarian cycle.

A
  1. Follicular phase
  2. Ovulation
  3. Luteal phase
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5
Q

Describe the changes that occur in the follicular phase of the ovarian cycle.

A

At the beginning of the follicular phase, there are low androgen and inhibin levels, resulting in an increase of FSH and LH levels. These stimulate follicle growth and oestrogen production.

As oestrogen levels rise, negative feedback reduces FSH levels, allowing the survival of a single follicle.

Follicular oestrogen eventually becomes high enough to exert positive feedback onto the HPG axis, increasing levels of GnRH. This results in the LH surge, which stimulate LH receptors on granulosa cells.

Note FSH levels do not rise alongisde LH, as there is increased follicular inhibin to inhibit FSH production at the anterior pituitary.

The Ovarian Cycle
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6
Q

Describe the changes that occur at ovulation in the ovarian cycle.

A

In response to the LH surge, the follicle ruptures and the mature oocycte is assisted to the fallopian tube by fimbria.

Following ovulation the follicle secretes oestrogen and progesterone, reverting to negative on the HPG axis. This, together with inhibin, stalls the cycle in anticipation of fertilisation.

The Ovarian Cycle
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7
Q

Following ovulation, for approximately how long does the oocyte remain viable for fertilisation?

A

Approximately 24 hours.

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8
Q

Describe the changes that occur in the luteal phase of the ovarian cycle if the oocyte is unfertilised.

A

The corpus luteum forms at the site of the ovary where the follicle ruptured, producing oestrogens, progesterone and inhibin to maintain conditions for fertilsation and implantation.

After approximately 14 days, the corpus luteum spontaneously regresses. This causes a significant fall in hormones, relieving negative feedback, and resetting the HPG axis ready to begin the cycle again.

The Ovarian Cycle
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9
Q

Describe the changes that occur in the luteal phase of the ovarian cycle if the oocyte is fertilised.

A

The corpus luteum forms at the site of the ovary where the follicle ruptured, producing oestrogens, progesterone and inhibin to maintain conditions for fertilsation and implantation.

If fertilisation occurs, the syncytiotrophoblast of the embryo produces HcG, maintaining the corpus luteum. The corpus luteum continues to maintain hormones that support the pregnancy until around 4 months gestation, where the placenta is capable of production of sufficient steroid hormone to control the HPG axis.

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10
Q

Name the 3 phases of the uterine cycle.

A
  1. Proliferative phase
  2. Secretory phase
  3. Menses
The Uterine Cycle
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11
Q

Describe the changes that occur in the proliferative phase of the uterine cycle.

A

The proliferative phase runs alongside the follicular phase, preparing the reproductive tract for fertilisation and implantation.

Oestrogen initiates fallopain tube formation, thickening of the endometrium, increased growth and motility of the myometrium and production of a thin alkaline cervical mucus (to facilitate sperm transport).

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12
Q

Describe the changes that occur in the secretory phase of the uterine cycle.

A

The secretory phase runs alongside the luteal phase.

Progesterone stimulates further thickening of the endometrium into a glandular secretory form, thickening of the myometrium, reduction of motility of the myometrium, thick acidic cervical mucus production (a hostile environment to prevent polyspermy), changes in mammary tissue and other metabolic changes.

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13
Q

Describe the changes that occur at menses of the uterine cycle.

A

Menses marks the beginning of a new menstrual cycle, occuring in the absence of fertilisation as the corpus luteum regresses and the internal lining of the uterus is shed.

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14
Q

Approximately how much blood loss is typical in menses?

A

Between 10-80ml across 2-7 days.

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15
Q

Define ‘menarche’.

A

The first occurence of menstruation, normally occuring between the ages of 11 and 15 years.

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16
Q

Define ‘dysmenorrhoea’.

A

Pain upon menses, which is the most common gynaecological symptom.

Patients may describe it as a cramping lower abdominal pain, which starts with menstruation. It may also be associated with other symptoms (e.g. malaise, nausea, vomiting, dizziness).

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17
Q

What is the pathogenesis of dysmenorrhoea?

A

The excessive release of prostaglandins from endometrial cells leads to spiral artery vasospasm and increased myometrial contractions.

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18
Q

Define ‘menorrhagia’.

A

Menstruation with abnormally heavy or prologned bleeding.

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19
Q

Define ‘metrorrhagia’.

A

Abnormal bleeding between regular menstrual periods.

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20
Q

Define ‘oligomenorrhoea’.

A

Infrequent mestrual periods.

Defined as fewer than 9 menses per annum.

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21
Q

Define ‘primary amenorrhoea’.

A

The failure of menstruation by age 16 years in the presence of normal secondary sexual characteristics.

The failure of menstruation by age 14 years in the absence of normal secondary sexual characteristics.

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22
Q

Define ‘secondary amenorrhoea’.

A

Absent periods for at least six months in a women who has previously had regular periods.

Absent periods for at least twelve months in a woman who has previously had oligomenorrhoea.

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23
Q

Consider why a urine pregnancy test is an important investigation in the following scenarios:

a) missed menstrual period

b) painful menstrual period

c) heavy menstrual period

A

a) ?pregnancy

b) ?miscarriage / ?ectopic pregnancy

c) ?miscarriage

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24
Q

Give some red flag symptoms of endometrial cancer.

What is the management?

A
  • visible haematuria
  • post-menopausal bleeding
  • unexplained vaginal discharge

If presenting with red-flag symptoms of endometrial cancer, refer via a suspected cancer pathway (for appt within 2/52).

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25
Q

Give some red flag symptoms of ovarian cancer.

What is the management?

A
  • bloating
  • early satiety / appetite loss
  • abdominal / pelvic pain
  • change in bowel habit
  • weight loss (unexplained)
  • fatigue
  • abdominal or pelvic mass (identified by abdominal examination)

Measure serum CA125 and refer urgently via a suspected cancer pathway (for appt within 2/52).

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26
Q

Give some red flag symptoms of vaginal cancer.

What is the management?

A
  • unexplained vaginal mass
  • visible or palpable at the entrance to the vagina

If presenting with red-flag symptoms of vaginal cancer, refer via a suspected cancer pathway (for appt within 2/52).

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27
Q

Give some red flag symptoms of vulval cancer.

What is the management?

A
  • unexplained vulval bleeding
  • vulval lump
  • vulval ulceration

If presenting with red-flag symptoms of vaginal cancer, refer via a suspected cancer pathway (for appt within 2/52).

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28
Q

Give some causes of post-coital bleeding.

A
  • infection (e.g. STI)
  • cervical ectropion (esp. if taking COCP)
  • cervical / endometrial polyps
  • vaginal cancer
  • cervical cancer
  • trauma or sexual abuse
  • vaginal atrophy

Note no specific cause for bleeding is found in approx. 50% of women.

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29
Q

Give some causes of inter-menstrual bleeding.

A

PALM COEIN:

Polyps
Adenomyosis
Leiomyoma
Malignancy

Coagulopathy
Ovulatory disorder
Endometrial
Iatrogenic
Not otherwise classified

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30
Q

What is breakthrough bleeding?

A

The unscheduled vaginal bleeding that occurs when a new contraceptive method is started, often settling without intervention.

Breakthrough bleeding is common in the following contraceptive methods:
- COCP
- POP
- IUS / implant
- emergency hormonal contraception

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31
Q

Give some causes of menorrhagia.

A
  • uterine fibroids
  • endometriosis
  • pelvic inflammatory disease
  • polycycstic ovary syndrome (PCOS)
  • endometrial carcinoma

Note no cause is identified in around 50% of cases.

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32
Q

How can primary dysmenorrhoea be managed?

A
  • offer NSAIDs
  • if woman does not wish to conceive, 6/12 trial of homronal contraceptives can be prescribed
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33
Q

How can secondary dysmenorrhoea be managed?

A

Suspect a serious secondary cause of dysmenorrhoea and refer urgently if:
- ascites or pelvic / abdominal mass
- abnormal cervix upon examination
- persistent intermentrual or postcoital bleeding

Must identify and treat the underlying cause of secondary dysmenorrhoea.

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34
Q

Give some causes of primary amenorrhoea when secondary sexual characteristics are present.

A
  • constitutional delay
  • genitourinary malformation (e.g. imperforate hymen)
  • androgen insensitivity syndrome
  • hyperprolactinaemia
  • pregnancy
35
Q

Give some causes of primary amenorrhoea when secondary sexual characteristics are absent.

A
  • ovarian failure
  • hypothalamic failure
  • tumours
  • congenital adrenal hyperplasia
36
Q

Give some causes of secondary amenorrhoea.

A
  • premature ovarian failure
  • pregnancy
  • menopause
  • female athlete triad (eating disorder, amenorrhoea and osteoporosis)
  • thyroid disease
  • PCOS
  • Cushing’s syndrome
  • adrenal or ovarian carcinoma
37
Q

Outline the management of amenorrhoea.

A

Amenorrhoea treatment is directed by the diagnosis, with underlying conditions treated where possible.

Referral to fertility clinic if fertility is a concern of a woman.

Hormone replacement therapy.

Assess for risk of osteoporosis.

38
Q

What is menopause?

A

The permanent cessation of menstruation, indicating the end of female reproductive life.

It is defined when a woman has had amenorrhoea for 12 consecutive months.

39
Q

Describe the hormonal changes that occur during menopause.

A

Menopause is characterised by a reduction of circulating oestrogen.

Due to low levels of oestrogen and inhibin, levels of FSH and LH increase significantly during the menopause (loss of negative feedback).

40
Q

Describe the vasomotor changes that occur during menopause.

A

Pulsatile LH release results in peripheral vasodilation and a transient rise in body temperature.

In menopause, these are often known as hot flushes - a red flush starting on the face and spreading down the neck and chest.

41
Q

Describe the urogenital changes that occur during menopause.

A

Low levels of oestrogen results in atrophy of the vagina and thinning of the myometrium. There is also thinning of the vaginal walls and dryness, resulting in dyspareunia.

The tissues of the uterus and bladder can also atrophy under low levels of oestrogen, leading to symptoms of urinary incontinence and an increase in urinary tract infections.

42
Q

Describe the bone density changes that occur during menopause.

A

Oestrogen usually acts to protect bone mass and density via reducing the activity of osteoclasts.

Under low levels of oestrogen, oesteoclastic activity is poorly controlled leading to an increase in bone reabsorption. This results in an acceleration of age-related loss of bone density and an increased frequency of fractures (ie. osteoporosis).

43
Q

Outline why CVD incidence increases in post-menopausal women as opposed to pre-menopausal women.

A

Oestrogen reduces levels of LDL cholesterol and increases HDL cholesterol, so has protective effects against heart disease.

After the menopause, women experience the same frequency of cardiovascular disease as men.

44
Q

Presentation of menopause.

A

Alongside the absence of menstrual periods, see the image attached for common symptoms of menopause.

Symptoms of Menopause
45
Q

What is premature ovarian insufficiency?

What is the treatment?

A

A reversible cause of amenorrhoea, occuring in women aged <40years.

It is characterised by low oestrogen, high gonadotropins and amenorrhoea.

Treatment often involved MDT to manage the psychological impact of the condition alongside the physical symptoms. HRT is the main treatment, alongside monitoring for cardiovascular disease and osteoporosis.

46
Q

What are the benefits of prescribing HRT for menopause?

A

HRT acts to replenish oestrogen levels within the body that are usually lost during menopause.

  • menopausal symptoms usually ease
  • reduced risk of osteoporosis
47
Q

What lifestyle advice can be offered to a woman with menopausal symptoms?

A
  • smoking cessation
  • avoid exercise late in the day
  • adequate sleep
  • regular physical activity
48
Q

What are the risks of HRT?

A
  • increased risk of breast, endometrial and ovarian cancers
  • increased risk of blood clots (note mitigated if using HRT patches or gels)
49
Q

a) Name the class of medication prescribed to mitigate post-menopausal osteoporosis.

b) Give an example of the above medication class.

c) Give the menchanism of action of the above medication.

A

a) bisphosphonates

b) alendronic acid

c) reduces osteoclastic bone resorption

50
Q

Give the storage urinary symptoms.

A
  • urgency
  • daytime urinary frequency
  • nocturia
  • urinary incontinence
  • feeling need to urinate again just after passing urine
51
Q

Give the voiding urinary symptoms.

A
  • hesitancy
  • weak or intermittent urinary stream
  • terminal dribbling
52
Q

Give the post-micturition urinary symptoms.

A
  • post-micturition dribble
  • sensation of incomplete emptying
53
Q

What is stress urinary incontinence?

A

The involuntary loss of urine during moments of physical activity that increases abdominal pressure (e.g. sneezing, coughing, laughing, exercising).

54
Q

What is urge urinary incontinence?

A

The involuntary loss of urine immediately preceeded by a sudden an intence need to pass urine, unable to delay going to the toilet.

Note there are only a few seconds between the need to urinate and the release of urine, so may not make it to the toilet in time.

55
Q

What is functional urinary incontinence?

A

The involuntary loss of urine occuring when the patient can control the bladder, but is unable to reach the toilet in time.

Can be due to disability, immobility etc. Common in the elderly.

56
Q

What is mixed urinary incontinence?

A

The involuntary loss of urine associated with urgency, and also with exertion, effort, sneezing or coughing.

57
Q

According to NICE, flow-volume charts can detect:

A
  • frequency (high frequency with normal 24 hour volume)
  • polyuria (passing more urine than usual >3L/day)
  • nocturia (waking at night to urinate)
  • nocturnal polyuria (passing urine at night, >35% of the 24 hour urine production)
58
Q

Give some risk factors for urinary incontinence in females.

A
  • increasing age
  • postmenopausal urogenital changes
  • obesity
  • number of children
  • poor obstetric care
  • pelvic organ prolapse
59
Q

What LUTS present in women?

A
  • urgency
  • frequency
  • nocturia
  • incontinence (urge, stress, mixed)
  • dysuria
  • retention
  • hesitancy
  • terminal dribble
  • dyspareunia
  • vaginal dryness
60
Q

Give some common causes of LUTS in women.

A
  • UTIs
  • pregnancy
  • anxiety
  • OAB
  • genital prolapse
  • obstruction
  • age-related detrusor muscle weakness
  • diabetes mellitus
  • CKD
61
Q

How can stress urinary incontinence be managed?

A

Lifestyle advice:
- reduce caffeine intake
- avoid drinking excessive amounts of fluid
- weight loss if obese
- smoking cessation

Offer referral for a trial of 3/12 pelvic floor muscle training (PFMT) to an appropriate practitioner (e.g. physiotherapy, urogynaecologist).

If the above conservative treatments fail, referral to urology can be considered. Duloxetine can also be prescribed.

62
Q

Describe the menchansim of action of duloxetine in treating stress urinary incontinence.

A

Noradrenaline reuptake inhibitor, meaning there is a stronger agonising effect upon A1 receptors at IUS. This allows for increased and stronger contractions of the IUS.

63
Q

How can urge urinary incontinence be managed?

A

Lifestyle advice:
- reduce caffeine intake
- avoid drinking excessive amounts of fluid
- weight loss if obese
- smoking cessation

Offer referral for bladder training for 6/52 by a continence physiotherapist or urology.

If symptoms persist despite bladder training, encourage the woman to continue bladder training and consider prescribing an antimuscarinic drug.

64
Q

Describe the menchansim of action of an antimuscarinic in treating urge urinary incontinence.

A

Antimuscarinic will antagonise M3 receptors on detrusor muscle, meaning parasympathetic input fails to cause contraction of the detrusor muscle.

Note dosage of medication should be titrated to lowest possible dose to manage symptoms.

65
Q

What questionnaire can be used to assess severity of LUTS in males?

66
Q

Presentation of benign prostatic hyperplasia (BPH).

A
  • urinary frequency
  • urinary urgency
  • hesitancy
  • incomplete bladder emptying
67
Q

Investigations for BPH presentation.

A

A DRE should be performed, which will reveal a firm, smooth and rubbery prostate (enlarged >2 finger breadth).

Routine blood tests (U&E, creatinine, FBC, LFTs). Note abnormal LFTs may indicate other disease; isolated elevation of ALP can occur if the prostate is malignant and has metastasised to the bone.

PSA may be raised.

68
Q

An increased serum PSA can be present with:

A
  • prostate enlargement (e.g. BPH)
  • older age
  • infection (e.g. prostatitis / UTI)
  • DRE
  • prostate cancer
  • a normal prostate

Note a normal serum PSA level can be present with prostate enlargement, prostate cancer and infection.

69
Q

What is the management of BPH?

A

If symptoms are minimal, watchful waiting is the first-line option provided malignancy has been excluded. Lifestyle advice can be given.

Medications include alpha-blockers (e.g. tamsulosin) or 5-alpha reductase inhibitors (e.g. finasteride).

Prostatectomy (TURP) is indicated if conservative and pharmacological measures fail to bring symptoms under control.

70
Q

Outline the mechansim of action of:

a) tamsulosin

b) finasteride

in the treatment of BPH.

A

a) tamsulosin is a alpha-blocker, which antagonises A1 receptors in the prostate and bladder neck allowing muscle relaxation.

b) finasteride is a 5-alpha reductase inhibitor (5-ARI), which causes shrinkage of the prostate by means of androgen deprivation.

71
Q

Give some risk factors for prostate cancer.

A
  • increasing age
  • African-Caribbean family origin
  • obesity
  • first-degree relative (+100%)
  • alcohol consumption
72
Q

Presentation of prostate cancer.

A

LUTS plus:
- haematuria
- haematospermia
- perineal / suprapubic pain

Consider metastatic disease when:
- bone pain
- sciatica
- lymph node enlargement
- loin pain
- weight loss
- lethargy

73
Q

Investigations for prostate cancer presentation.

A

A DRE should be performed, which will reveal a hard, irregular prostate gland. Other features on DRE include:
- asymmetry of the gland
- nodule within one lobe
- lack of mobility of the gland

Elevated PSA.

PCA3 urine test (note PCA3 is elevated in 95% prostate cancer cases).

74
Q

NICE recommends performing PSA and DRE to assess for prostate cancer in people with (3):

A
  1. LUTS
  2. erectile dysfunction
  3. visible haematuria
75
Q

Which genetic mutation is commonly associated with prostate cancer?

A

Prostate Cancer gene 3 (PCA3)

PCA3 is highly specific to prostate cancer and this gene is overexpressed in over 95% of prostate cancer cases. This is in
contrast to PSA (prostate specific antigen, the blood test that is most commonly used to look for evidence of prostate cancer) which may be increased by conditions such as benign enlargement of the prostate (BPH or BPE) or inflammation of the prostate (prostatitis). The PCA3 test result is not affected by these conditions.

76
Q

Management of prostate cancer.

A

Treatment for prostate cancer will be initiated and managed in secondary care, so urgent referral necessary (for appt within 2/52).

77
Q

Outline some physical causes of erectile dysfunction.

A
  • reduced blood flow to the penis (commonly due to narrowing of dorsal arteries - risk factors include hypertension, hypercholesterolaemia and smoking)
  • nerve damage (e.g. multiple sclerosis, stroke)
  • diabetes (affecting blood vessels and nerves)
  • anatomical abnormalities (e.g. penile cancer, prostate cancer, congenital curvature of penis, phimosis)
  • hormonal (e.g. Cushing’s disease, hypopituitarism following traumatic brain injury)
78
Q

Outline some psychological causes of erectile dysfunction.

A

Generalised causes include lack of arousability and disorders of sexual intimacy.

Situational causes include partner or performance related issues, stress, and psychiatic illness (e.g. depression, anxiety, schizophrenia)

79
Q

Give drugs drugs that are associated with erectile dysfunction.

A
  • antihypertensives
  • spironolactone
  • antidepressants
  • recreational drugs (e.g. alcohol, heroin, cocaine, marijuana, anabolic steroids)
80
Q

Assessment of erectile dysfunction.

A

Take a detailed psychosexual, medical, and lifestyle history to determine the cause of the dysfunction.

Perform a focused physical examination to identify any genitourinary, endocrine, vascular, or neurological cause of erectile dysfunction.

Measure HbA1c.

Referral may be necessary depending on findings of examination.

81
Q

Outline the mechanism of viagra in the treatment of erectile dysfunction.

A

Viagra inhibits PDE V, preventing the degredation of nitrous oxide.

Increased levels of nitrous oxide have vasodilatory effects on the dorsal arteries of the penis, allowing erection to occur.

Note viagra will only help with an erection if the cause is vascular.

82
Q

Outline the management of priapism in primary care.

A

If there is peristant erection, referral to hospital is necessary.

83
Q

How can a man with erectile dysfunction be managed?

A

Prescribe a PDE-5 inhibitor regardless of suspected cause for erectile dysfunction and give appropriate lifestyle advice:
- lose weight
- smoking cessation
- reduce alcohol consumption
- increase exercise

Note for men who cycle >3hrs/week, encourage a trial period without cycling to see if it improves their erectile function.

Arrange a follow-up 2/12 after treatment. If initial treatment is satisfactory, reinforce lifestyle advice. If initial treatment has not been effective, consider increasing dose of PDE-5 inhibitor and referal to urology.

Year 3 - GP (17 decks)

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