Week 8 - Disorders of the Female Reproductive System

Question 1

Define the term menopause. Provide examples of symptoms associated with menopause.

Answer 1

• Menopause refers to the cessation of menses for 12 consecutive months
• Symptoms include:
  
  • non-specific features
    
    • hot flushes
    • night sweats
    • fatigue
    • lethargy
  • reproductive system
    
    • genital tract atrophy, reduction in breast size
    • vaginal dryness, dyspareunia (difficult or painful intercouse)
    • urinary tract infections
  • neurological
    
    • changes in mood, memory
    • headache, dizziness, paraesthesia
  • musculoskeletal
    
    • osteoporosis
    • athralgia, myalgia
  • cardiovascular
    
    • hypertension, risk for AMI

Question 2

Compare the advantages to the disadvantages of menopause hormone therapy

Answer 2

• Advantages:
  
  • relieves symptoms of menopause
  • prevents early menopausal bone loss (reduce risk of fracture)
• Disadvantages:
  
  • ‘pre-menstrual-like symptoms’ e.g. bloating and fluid retention, breast tenderness, irritability
  • increased risk for:
    
    • thromboembolic disease
    • cardiovascular disease (stroke)
    • cancer: breast, endometrial (oestrogen-only HT)
    • gall bladder disease

Question 3

Your patient asks you about the evidence related to the use of hormone therapy for the prevention of cardiovascular disease and dementia. What is your response?

Answer 3

• Current evidence suggests that HT is NOT recommended for prevention of CVD, dementia or cognitive decline

Question 4

List the diagnostic criteria for polycystic ovary syndrome

Answer 4

• Menstrual irregularity (anovulatory cyles or oligomenorrhoea = no period)
• clinical hyperandrogenism (acne, hirsutism = exessive facial hair, male pattern baldness, Clevated serum androgens)
• Ultrasonic evidence of polycystic ovaries (>12 enlarged follicles in each ovary)

MARVEL CINEMATIC UNIVERSE - unrealistic = polycystic ovarian syndrome

Question 5

What hormonal factors have been linked to polycystic ovary syndrome?

Answer 5

• Inappropriate gonadotrophin secretion is present in PCOS
  
  • typically, LH is elevated and FSH is low
  • persistent LH elevation causes an increase in androgens from thecal cells
• Excessive androgens lead to clinical features associated with ‘undesireable male traits’

Question 6

Summarise the clinical features associated with polycystic ovaries

Answer 6

• Relate to anovulation and elevated androgen levels:
  
  • menstrual disturbance: oligomenorrhoea (reduced period), amenorrhoea (no period at all)
  • infertility (in severe cases, begins as subfertility)
  • hyperandrogenism (acne, hirsutism, male pattern baldness)
  • obesity (38% of cases)
  • asymptomatic (20% of cases)
  • increased risk for:
    
    • type 2 diabetes
    • CVD
    • endometrial cancer (due to hormonal imbalances)

Question 7

Describe two classes of medication that can be used to manage polycystic ovarian syndrome

Answer 7

Any two of:

• Combined oral contraceptive pill
  
  • supresses androgen production
  • reduces endometrial hyperplasia (induces a withdrawal bleed)
• Anti-androgen agents
  
  • decreases the effect of androgens
  • often used in combination with COCP
• Insulin-sensitisers (for hyperinsulinaemia)
  
  • decreases risk for type 2 diabetes
  • can help restore ovulation and regular menstrual cycles

Question 8

Define the term pelvic inflammatory disease. What factors have been associated with this disorder?

Answer 8

• Definition - PID is not one specific disease, but the outcome of any infection in the genitourinary tract which has not been adequately treated
• Associated with:
  
  • sexually-active women who have more than one partner
  • women who have had adequately or untreated chlamydia or gonorrhoea
  • some surgical procedures
    
    • abortion, dilation and curettage (scooping of uteral lining), IUD insertion

Question 9

Summarise the clinical features of pelvic inflammatory disease

Answer 9

• Vary considerably - in some women, it is asymptomatic
• there may be a combination of:
  
  • lower abdominal pain
    
    • worse with movement, palpation, intercourse or urination
  • irregular bleeding
  • mucopurulent discharge

Question 10

List the complications of pelvic inflammatory disease

Answer 10

• Infertility
• Pelvic adhesions (formation of scar tissue = inappropriate anchoring of organs to abdominal wall)
• Abscess formation (pus)
• Ectopic pregnancy

Question 11

Explain how the diagnosis of pelvic inflammatory disease is made

Answer 11

PID is a diagnosis of exclusion - it is necessary to rule out other DDx first

• So NOT:
  
  • endometriosis
  • ectopic pregnancy
  • rupture of an ovarian cyst
  • appendicitis or bowel disorders
  • gall or renal stones

Question 12

Define the term endometriosis.

Answer 12

• Deposits of endometrial tissue found anywhere other than the uterine mucosa
  
  • the deposits behave like normal endometrium (they proliferate, break down and bleed in response to fluctuations in ovarian hormones)

Question 13

What is meant by the term vicarious bleeding? Name the most common sites involved

Answer 13

• Vicarious bleeding refers to cyclical bleeding from a surface other than uterine mucosa
• Possible sites include:
  
  • most common - surface of the uterine tubes, uterus, bowel, bladder and ureters
  • post-surgery - vagina, perineum
  • rarely - umbilicus, inguinal canal
  • extremely rare - pleura, diaphragm, nose

Question 14

Briefly discuss the theories related to the development of endometriosis

Answer 14

• Retrograde menstruation
  
  • retrograde flow of endometrial tissue during menstruation
  • flow into the uterine tubes and pelvic cavity
• Embryonic cells
  
  • which have potentially remained scattered throughout the body
  • triggered by hormonal stimuli to differentiate into secretory tissue
• Endometrial emboli
  
  • travel via blood or lymphatics
  • new sites seeded with endometrial tissue

Question 15

Summarise the clinical features of endometriosis

Answer 15

• Depends on the site and extent of the endometrial tissue deposits
• Bleeding causes pain and inflammation in surrounding tissues
  
  • Pain: pelvic pain, dysmenorrhoea, dyspareunia
  • Bleeding: menorrhagia, irregular periods, spotting
  • Bowel or bladder symptoms: dysuria, dyschezia (painful defacation), ‘cyclic’ IBS symptoms
  • Reduced fertility
  • Systemic: fatigue, lethargy, depression

Question 16

Define the term uterine fibroid

Answer 16

• A common, benign tumour arising from the smooth muscle cells of myometrium

Question 17

What factors have been associated with the development of uterine fibroids?

Answer 17

• Familial pattern
• More common in nulliparous women (those women who have not given birth)
• Age - prevalence increases in women aged 30-35 years
  
  • Incidence decreases with menopause

Question 18

Summarise the clinical features of uterine fibroids

Answer 18

• Usually asymptomatic, but occassionally cause cramping, excessive bleeding or pressure on nearby structures
• bloating, palpable mass, protruding belly, sensation of abdominal heaviness
• dysmenorrhoea or menorrhagia (can lead to iron deficiency anaemia)
• pressure on surrounding organs:
  
  • urinary frequency
  • urgency
  • dysuria
  • compromising venous drainage of lower limb (leading to leg oedema or variscosities)
  • compromising rectum (constipation)

Question 19

Compare uterine, ovarian and cervical cancer. Suggested headings to include in your table:

Answer 19

Question 20

Discuss strategies that can help prevent or reduce the mortality associated with cervical cancer.

Answer 20

• HPV Vaccination Program
  
  • Gardasil introduced in 2006
  • Covers HPV phenotypes that cause 70% of cervical cancers
  • In 2013, the program was expanded to include boys
• National Screening Program
  
  • from 1991-2017, a free pap smear test (cytology) was offered every two years to women aged between 18-70
  • recently changed (december, 2017) to better complement the HPV vaccination program
    
    • HPV test for women aged 25-74, every five years
    • detects the HPV inside cervical cells and identifies the phenotype
    • if HPV is found, cytology is also performed on the same sample of cells
• Papanicolaou Smear
  
  • cytology-based screening for dysplastic changes of the cervix
  • cells collected from the transformation zone and classified based on the extent of cellular dysplasia

Question 21

Define the term sexually transmitted infection (STIs)

Answer 21

• Diseases which are spread predominantly, but not exclusively, by sexual intercourse

Question 22

Name some common STIs that are (i) bacterial (ii) viral (iii) protozoal and (iv) parasitic in nature

Answer 22

• bacterial - chlamydia, gonorrhoea, syphillis
• viral - herpes simplex virus (HSV), human papilloma virus (HPV), HIV, viral hepatitis (HBV, HCV)
• protozoal - trichomoniasis
• parasitic - scabies, pubic lice

Question 23

List some serious pathological outcomes of STIs

Answer 23

• malignancy
• infertility
• ectopic pregnancy
• PID
• neonatal morbidity and mortality

Question 24

Comment on factors that have potentially contributed to the alarming increase in STIs

Answer 24

• greater sexual freedom
• chances in perceived sexual risk
• increased travel
• increased use of recreational drugs
• less use of barrier contraception

Question 25

What role can an osteopath play in the prevention or early detection of STIs?

Answer 25

• refer to GP or sexual health clinic (Melbourne Sexual Health Clinic - no appointment is required)

Question 26

What pathogens are responsible for chlamydia and gonorrhoea?

Answer 26

• Chlamydia - chlamydia trachomatis
• Gonorrhoea - neisseria gonorrhoeae

Question 27

Compare the clinical features of chlamydia and gonorrhoea.

Answer 27

• Chlamydia
  
  • women:
    
    • vaginal discharge*
    • bleeding*
    • abdominal pain
    • bloating
    • dyspareunia
  • men:
    
    • dysuria*
    • some, penile discharge
• Gonorrhoea
  
  • affects the lower genital tract, rectum, pharynx and eyes
  • women:
    
    • 60% are asymptomatic
    • vaginal discharge*
    • dysuria
    • spotting*
  • men:
    
    • dysuria* and purulent discharge
    • urinary frequency and urgency
  • rectal infection
    
    • rectal pail, tenesmus and discharge
    • + cervical lymphadenopathy
  • pharyngeal gonorrhoea
    
    • often asymptomatic
    • + cervical lymphadenopathy
  • conjunctivitis
    
    • copious amounts of exudate, bright red or ‘beefy’ conjunctivae
    • can occur during vaginal delivery of child

Question 28

Can these diseases masquerade as a musculoskeletal complaint? (Refer to slide on reactive arthritis)

Answer 28

• YES !
• reactive arthritis can be a complication of chlamydial and gonorrhoeal infection
  
  • ? cross-reaction between antibodies produced in the infection and the body’s own tissues
  • characteristics
    
    • assymetrical oligoarthritis (affects < 6 joints)
    • joints affected: (on examination, joints are red, swollen and tender)
      
      • knees
      • SIJs
      • interphalangeal joints
      • LBP
    • entheses (where tendons attach to bone): heel pain (achilles tendon, plantar fascia)

Question 29

What pathogen is responsible for syphilis?

Answer 29

• treponema pallidum (spirochaete bacterium)

Question 30

Explain the three stages of syphilis

Answer 30

• Primary syphillis
  
  • symptoms appear after 2-4 weeks
  • development of a chancre (small, solitary lesion that is firm, non-tender, raised and red… it can later ulcerate)
  • site of chancre
    
    • penis
    • cervix
    • vagina
    • anus
  • may be localised lymphadenopathy
  • chancre can spread readily, but may heal without treatment
• Secondary syphillis
  
  • typically appear after 6-8 weeks after the change
  • skin and mucous membrane lesions:
    
    • rash
    • wart-like lesions (condylamata lata)
    • silvery-grey lesions
• Late tertiary syphillis
  
  • rare in developed countries
  • clinical features re-appear and mostly relate to the formation of granulomas (gummas)
  • gummas commonly affect the skin, mucous membranes and bone (but can affect any organ including the nervous system and cardiovascular system)

Question 31

Suggest why early syphilis may remain undetected in women and MSM?

Answer 31

• A chancre may go unnoticed, depending on the site
• Also, they have the ability to heal without treatment

Question 32

Which diseases have been associated with human papilloma virus (HPV) infection?

Answer 32

• Associated with reproductive cancers
  
  • cervical
  • vulval
  • anorectal and penile

Question 33

In 2013, the HPV Vaccination program was expanded to include boys. Explain the potential health benefits of this change.

Answer 33

• warts fell in heterosexual men (<21 y/o)
• this may reduce spread to women and spread amongst MSM