Week 7 - Paediatrics (B) and Men & Women's health Flashcards
Outline the range of days for a complete menstrual cycle that is considered normal
21-35 days
Outline the difference between central precocious puberty and peripheral precocious puberty
Central precocious puberty is due to increased GnRH production
Peripheral precocious puberty is due to increased oestrogen or testosterone production (normal GnRH levels)
List a few causes of central precocious puberty
- Idiopathic or constitutional
- Obesity related (levels of leptin)
- CNS lesions
- Gonadotropin-secreting tumours
- Systemic conditions e.g. neurofibromatosis
List a few causes of peripheral precocious puberty
- Ovarian cysts
- Congenital adrenal hyperplasia
- Primary hypothyroidism
- Obesity related (compensatory hyperinsulin-aemia)
- Tumours e.g. ovarian, adrenocortical, leydig-cell
List some causes of delayed onset puberty
- Constitutional delay (most commonly)
- Malnutrition or chronic disease e.g. IBD
- Hypogonadism
Outline the definition of primary amenorrhoea
Absence of menarche either by the age of:
14 if there is the absence of secondary sexual characteristics
16 if there is the presence of secondary sexual characteristics
Outline the definition of secondary amenorrhoea
Cessation of periods for:
6 months if periods previous regular
12 months if periods previous irregular
List some causes of primary amenorrhoea
Anatomical:
- Imperforate hymen
- Vaginal septum (vertical or horizontal)
- No vagina
- No uterus
Genetic:
- Turner’s syndrome (XO)
- Complete androgen insufficiency syndrome (XY)
- GnRH deficiency
Other:
- Constitutional delay
- Pregnancy!
- Hypothalamic failure e.g. malnutrition or weight loss
List some causes of secondary amenorrhoea
Anatomical:
- Cervical stenosis
- Asherman syndrome (intrauterine adhesions)
- Early menopause
- PCOS (main reason)
Endocrine:
- Thyroid disease (both hyper and hypo)
- Pituitary disorders e.g. prolactinoma, pituitary necrosis, drugs affecting pituitary gland
- Functional hypothalamic amenorrhoea (weight loss or excessive exercise)
PLUS physiological:
- Pregnancy!! Or lactational amenorrhoea
- Menopause!!
- Contraception
Outline causes of abnormal intrauterine bleeding (PALM-COEIN)
Structural:
- Polyps
- Adenomyosis
- Leiofibroma (fibroids)
- Malignancy / hyperplasia
Non-structural:
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial issues
- Iatrogenic
- Not yet classified
State the definition of menopause and what it’s caused by
Menopause is the absence of periods for 12 months, in the absence of any other biological or physiological cause
Cause:
- Failure of follicle development and oestrogen production
Outline the age of which menopause is considered early menopause
Under age of 45
Outline the age of which menopause is considered premature menopause (also called premature ovarian failure)
Under age of 40
Outline the age range of which menopause normally happens
Between ages of 45 and 55 (average 50 years)
State the 4 menopausal stages
- Pre-menopausal - slightly changes to FSH/LH levels
- Peri-menopausal
- Menopausal - ovulation actually stops
- Post-menopausal
Outline what happens during the pre-menopause period, with regards to FSH / LH levels, oestrogen levels and fertility
- Less oestrogen secreted
- FSH / LH levels may rise (due to less oestrogen)
- Reduced fertility, but periods remain similar
Outline what happens during the peri-menopause period
Transition phase
- Follicular phase shortens
- Ovulation early / absent
Outline what happens during the menopause period
Permanent cessation of menstruation - lack of ovulation and follicular development failure
Outline what is meant by the post-menopause period
Period of time after 12 consecutive months of no periods
What hormone do you measure to confirm the menopause
FSH - rises (not oestrogen as that is decreasing)
List some physiological symptoms of the menopause
- Hot flushes / sweating
- Sleep changes / tiredness
- Itching
- Restless limbs
- Mood changes
- Forgetfulness
- Vaginal dryness
- Urinary incontinence (increased risk UTIs)
- Constipation and bloating
Appearance:
- Hair thinning
- Thin / fine skin
- Increased weight
- Voice deepening (thickening vocal cords)
- Breast changes
- Sparse pubic hair and reduced fat of labia
List some long term consequences of low oestrogen (post-menopausal)
- Osteoporosis
- Increased cardiovascular risk
- Alzheimer’s disease
Reduced quality of life
List the different methods of administration of HRT and an advantage and disadvantage for each
Oral
+ cheap and effective
- higher doses required
Patch/transdermally
+ reduces risk of VTE
- more expensive / skin reactions
Vaginal
+ minimal systemic absorption
- only treats vaginal symptoms
Mirena coil
+ provides progesterone aspect
- still need oestrogen aspect
State some conservative and non-hormonal pharmacological measures for women with menopause symptoms
Conservative:
- Wear loose/light clothing
- Regular exercise
- Weight loss
- Reduce stress
- Sleep hygiene measures
- CBT
- Vaginal lubricants / moisturisers
Non-hormonal:
- Clonidine (lowers BP and reduces hot flushes)
- Gabapentin
- SSRIs e.g. Fluoxetine
Outline the order of puberty / secondary sexual characteristics in females
- Breast development
- Pubic hair
- Growth spurt
- Menarche
Outline the order of puberty / secondary sexual characteristics in males
- Testes enlargement
- Pubic hair
- Spermatogenesis
- Growth spurt
Outline the meaning of menarche
First menstrual period
Outline the meaning of dysmenorrhoea
Painful periods
Outline the meaning of menorrhagia
Heavy periods, defined either by:
- > 80ml loss of blood per cycle
- Having an impact on the quality of life of the woman
Outline the meaning of oligomenorrhoea
Infrequent periods, defined by: > 35 days long (4-9 cycles per year)
Outline the red flags for endometrial cancer
Visible haematuria AND hyperglycaemia (older than 55)
Visible haematuria AND Low haemoglobin (older than 55)
Unexplained vaginal discharge (older than 55)
Post-menopausal bleeding, more than 12 months after menopause
Outline some red flag symptoms for ovarian cancer
- Abdominal distension (> 12 times per month)
- Abdominal or pelvic pain (> 12 times per month)
- Appetite loss or early satiety
- Abdominal mass or ascites (not fibroids)
- Change in bowel habit / IBS symptoms within last 12 months (older than 50)
- Urinary urgency or frequency
- Unexplained weight loss
- Fatigue
Outline the meaning of breakthrough bleeding
Irregular bleeding that occurs associated with hormonal contraception
List some causes of post-coital bleeding
- Cervical ectropion
- Cervical / endometrial polyps
- Infection
- Malignancy (vaginal or cervical)
- Trauma/abuse
- Vaginal atrophic change
List some causes of intermenstrual bleeding
- Pregnancy including ectopic
- In association with ovulation
Vaginal:
- Adenosis (glandular epithelium in vagina)
Cervical:
- Infection
- Cancer
- Cervical polyps
- Cervical ectropion
Uterine:
- Polyps
- Fibroids
- Cancer
- Adenomyosis
- Endometriosis
Oestrogen secreting ovarian cancers
Other:
- Tamoxifen
- Smear or cervix treatment
- Missed COCP/POP
- Coagulant-interfering drugs
List some investigations to consider for intermenstrual bleeding or post-coital bleeding
- Pregnancy test
- Infection screen
- Cervical smear only if overdue
- Blood tests: FBC, clotting profile, TFT, FSH/LH
- Transvaginal ultrasound
- May need hysteroscopy +/- endometrial biopsy
List some causes of menorrhagia (local and systemic pathology)
Local pathology:
- Endometriosis
- Adenomyosis
- Cancer of the ovary, uterus, cervix, or endometrium
- Endometrial fibroids
- Endometrial polyps
- PCOS
- PID
- Intrauterine contraception / COCP / POP
Systemic:
- Coagulation disorders e.g. Von Willebrand disease
- Hypothyroidism
- Diabetes
- Hyperprolactinaemia
- Liver or renal disease
- Medications e.g. anticoagulants
Outline the difference between primary and secondary dysmenorrhoea and when they start
Primary dysmenorrhoea:
- Occurs in the absence of any identifiable underlying pelvic pathology
- Caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain
- Usually starts 6–12 months after the menarche, once cycles are regular
Secondary dysmenorrhoea:
- Caused by an underlying pelvic pathology e.g. endometriosis, fibroids, or pelvic inflammatory disease [PID] or by intrauterine device (IUD) insertion
- Starts after several years of painless periods
- Pain is not consistently related to menstruation alone +/- other gynaecological symptoms
When do you decide that following conditions are present?
- Perimenopause
- Menopause
Generally clinical diagnoses based on age and symptoms
Perimenopause:
- If the woman has vasomotor symptoms and irregular periods.
Menopause:
- If the woman has not had a period for at least 12 months (and is not using hormonal contraception)
Outline specific conditions where you might test FSH levels to diagnose menopause
- Aged < 40 (premature menopause
- Aged 40-45 (early menopause)
- Over 45 but with atypical symptoms
Can be complicated in women using COCP!
Outline polyuria
- Passage of large volumes of urine with an increase in urinary frequency
- Daily urine output of more than three litres
However it is different to increased urinary frequency, which is a much more common presenting complaint
Outline nocturia
- The need to wake and pass urine at night
It is different to enuresis, where urine is passed unintentionally during sleep (wetting the bed)
Outline the 3 main categories of lower urinary tract symptoms and list some examples of symptoms from each category
Voiding/obstructive symptoms:
- Terminal dribbling
- Spraying
- Hesitancy
- Poor / intermittent stream
- Straining to wee
- Prolonged micturition
Storage symptoms:
- Increased frequency
- Nocturia
- Urgency / urge incontinence
- Bedwetting (chronic urinary retention)
Post-micturition symptoms:
- Post-micturition dribble
- Feeling of incomplete bladder emptying
Explain the difference between terminal dribble and post-micturition dribble
Terminal dribble: where the flow slows and reduces at the end of voiding
Post-micturition dribble: involuntary loss of urine immediately after urination
List some common types of incontinence
Stress incontinence
Urge incontinence (+/- OAB)
Mixed incontinence
OAB
Also:
Urogenital fistula
Urethral diverticulum
Outline the aspects that are recorded in a frequency volume chart for bladder monitoring
Fluids:
- Volume of fluid intake
- Fluid type e.g. water or coffee
Urination:
- Volume of urination
- Any urgency to urination
- Any accidental leaks
Outline what flow-volume charts can detect
Increased frequency
Polyuria (high amount)
Nocturia
Nocturnal polyuria
List some lower urinary tract symptoms in women
- Dysuria
- Abdominal pain / suprapubic pain
- Increased urinary frequency
- Nocturia
- Urinary urgency
- Incontinence
- Slow stream
- Difficult initiating urinary
- Feeling of incomplete bladder emptying
- Dribble of urine once finished
- Haematuria
List some causes of urinary tract symptoms in women
- UTI
- Menopause
- Detrusor instability
- Diabetes
- Renal colic
- Bladder cancer
- Neurological conditions
- Diuretics and other medications
Outline the management for stress incontinence
- Lifestyle advice e.g. reducing caffeine intake, weight loss, fluid intake etc.
- Pelvic floor training (trial of at least 3 months)
- Bladder diary
Consider referral - offer slings and Duloxetine
Outline the management for urge incontinence
- Lifestyle advice e.g. reducing caffeine intake, weight loss, fluid intake etc.
- Bladder training (at least 6 weeks)
- Consider Oxybutynin (antimuscarinic)
- Mirabegron as an alternative
Consider referral - botulinum toxin injection into bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty, and urinary diversion
Suggest how mixed urinary incontinence is managed
Managed according to the most prevalent type of incontinence - stress or urge
Outline red flag signs/symptoms for males presenting with LUTS
- DRE revealing hard /craggy prostate
- Unexplained haematuria
- Weight loss
- Lower back pain
- Bone pain
- Any symptoms of cauda equina / neurological symptoms
- Feeling generally unwell
- Fever
- Loin pain
Outline some management options for males presenting with predominantly voiding LUTS (e.g. terminal dribbling, spraying, hesitancy)
- Lifestyle measures e.g. avoiding constipation, smoking cessation, limit caffeine intake
- Pelvic floor or bladder training
- Alpha blocker e.g. Tamsulosin
- If enlarged prostate 5 alpha reductase inhibitor e.g. Finasteride
Consider referral - TURP or long-term urethral catheterisation
Outline some management options for males presenting with predominantly overactive bladder LUTS
- Lifestyle measures e.g. avoiding constipation, smoking cessation, limit caffeine intake
- Don’t reduce fluid intake to avoid symptoms
- Supervised bladder training
- Oxybutynin (antimuscarinic)
List some causes / risk factors of erectile dysfunction (local, systemic, psychological, medications)
Local:
- Acute reduced blood supply
- Malignancy e.g. penile or prostate
- Congenital curvature
- Hypospadias / epispadias
- Phimosis
Systemic diseases:
Cardiovascular diseases e.g. Diabetes, HTN, metabolic syndrome, smoking
- Neurological conditions e.g. MS, Parkinson’s disease, spinal cord trauma
- Endocrine e.g. Diabetes, hypogonadism, hyperprolactinaemia, Cushing’s disease
- CKD
- Chronic liver disease
Psychological:
- Generalised libido issues
- Depression / anxiety
- PTSD
Medications:
- Prescription medications (see next card)
- Recreational drugs e.g. alcohol, smoking, heroin, cocaine, cannabis
- Anabolic steroids
List some medications that can result in erectile dysfunction (list by category)
BP/CVS drugs:
- Antihypertensives e.g. beta blockers
- Diuretics e.g. Spironolactone
Psychological drugs:
- Opiates e.g. Morphine
- Antidepressants e.g. SSRIs
- Antipsychotics / antiepileptics e.g. Haloperidol or Carbamazepine
- Hormones e.g. anti-androgens
Other drugs:
- Anticholinergics e.g. Duloxetine
- Histamine antagonists e.g. Ranitidine
Outline questions you might ask in the clinical assessment of erectile dysfunction
Psychosexual:
- Sexual orientation / relationships
- Other sexual dysfunction symptoms
- Libido
- Contributing events e.g. recent parents, abuse, sexual trauma
- Mental state e.g. depression or anxiety
Medical history:
- Diabetes / HTN / CVS disease / HF / peripheral arterial disease / stroke
- Surgery on abdomen / pelvis?
- Revascularisation procedures previously
Other symptoms:
- LUTS
- Fatigue
Other:
- Smoking
- Alcohol
- Recreational drugs
Outline the management options for erectile dysfunction
- Address any underlying cause e.g. review medications
- Optimise management of any modifiable risk factors e.g. HTN, diabetes
- Modify any lifestyle factors e.g. limit alcohol intake, smoking cessation
Medical:
- Prescribe Sildenafil (PDE-5 inhibitor), irrespective of underlying cause
Consider referral to urology specialist if above treatment is ineffective
List some common causes of oligomenorrhoea
- PCOS (main)
- Diabetes
- Hyperthyroidism
- Pelvic inflammatory disease (PID)
- Eating disorders / anorexia / malnutrition / weight loss
- Premature menopause / early menopause
- Medications e.g. COCP / POP / antipsychotics / antiepileptics
Hormonal:
- Testosterone secreting tumours from ovaries or adrenal glands
- Cushing’s syndrome
- Prolactinoma
- Congenital adrenal hyperplasia (CAH)
Outline some treatment options for women with menorrhagia
Medical:
- Progesterone intrauterine device
- COCP / POP
- Tranexamic acid
- NSAIDs
Physical pathology - referral to secondary care e.g. fibroids or polyps:
- Second-generation endometrial ablation
- Hysterectomy
Outline initial investigations for patients presenting with urinary symptoms (voiding, storage, incontinence)
- Urine dipstick
- Urine MC&S
- Routine blood tests, including FBC and U&Es (consider PSA)
- Abdominal examination
- DRE examination
- Vaginal examination
Outline management options for BPH
After DRE examination
Conservative:
- Reduce caffeine
- Moderate fluid intake, not late at night
- Symptom diary
- Medication review
- Watch and wait approach
Medical:
- Alpha blocker e.g. Tamsulosin
- Alpha 5 reductase inhibitors e.g. Finasteride
Surgical:
- TURP
Outline some steps that can be taken if you suspect child safeguarding issues / abuse in general practice
- Talk to safeguarding lead at the practice (named GP or nurse)
- Can seek advice at any time from the NSPCC helpline
- Refer to local authority children’s social care
- Police if the child is in immediate danger
By describing the mechanism of action of both GTN spray and Sildenafil, explain why it is important to stop sildenafil when starting GTN
- Sildenafil is a phosphodiesterase inhibitor, allowing cGMP to remain around for longer
- GTN causes vasodilation of peripheral arteries and veins, leading to reduced preload and afterload
- Both of these drugs cause vasodilation therefore there is a risk of significant hypotension which could be fatal
Other than breast cancer, what 3 cancers is the BRCA1 gene mutation shown to increase the risk of?
BOP
- Bowel
- Ovarian
- Prostate
