WH Flashcards
Define primary amenorrhoea
Primary amenorrhoea = when menstruation has not started by 16 years old
Define secondary amenorrhoea
Secondary amenorrhoea = when menstruation stops for >6 months
Define oligomenorrhoea
Oligomenorrhoea = irregular periods - a cycle of 35d to 6m
A 17 year old presents to you complaining that her periods haven’t started when all of her friends have. What causes are you going to investigate?
Non path - constitutional delay? Drugs? Head to toe - anorexia nervosa/athletism/hyperprolactinaemia - Hyper/hypothyroidism - adrenal tumours/ hyperplasia -PCOS/POF -Turners syndrome
A 35yr old female complains of not having a period for 7 months. What could be the cause of this?
Non-path = pregnancy/lactation/early menopause/drugs
Head to toe
-Anorexia nervosa/athletism/hyperprolactinaemia
-Hyper/hypothyroidism
-Adrenal tumours
-PCOS/POF
-Ashermans syndrome
What is dysmenorrhoea?
Dysmenorrhoea is painful menstruation. It is associated with prostaglandin levels in the endometrium and is due to contraction and uterine ishaemia
A 18 year old f comes to you complaining of painful periods. She has a regular cycle of 28 days but the pain can be so bad that she has to miss college every month for 2 days. What advice would you give her and what treatment options would you suggest?
Dysmenorrhoea is very common and occurs in 50% of women especially adolescents. Most of the time there is no cause.
She could use NSAIDs for pain suppression or she could use the COCP to suppress her ovaries.
A 33 year old f comes to you complaining of very heavy periods. What investigations would you request?
FBC
Coag screen and thyroid function
Transvaginal USS (Polyps/fibroids/endometrial thickening)
Endometrial biopsy - >45 do they have endometrial hyperplasia?
Hysteroscopy
What are some of the causes of menorrhagia?
Uterine fibroids
Polyps
silent changes in endometrial haemostasis/uterine prostaglandin levels
Rare: thyroid disease, von-willebrand’s disease + anti coag therapy
A 26 yr old complains of very heavy periods. However she wants to conceive. What is the first line treatment?
Menorrhagia and wanting to get pregnant
Antifibrinolytics = tranexamic acid
NSAID = Mefenamic acid
A 38 yr old f comes wanting treatment for her menorrhagia. She has 5 children already and doesn’t want any more. What is the first line treatment for her?
Intra-uterine device - mirena coil
What treatment options can a hysteoscopy offer for a lady wishing to treat her heavy periods?
Polyp removal
Transcervical resection of fibroid
Endometrial ablation - reduces fertility
What are the treatment options for menorrhagia?
IUD Traexamic acid (anti fibrinolytic) Mefenamic acid (NSAID) Progestagens Histeroscopy (polyp/fibroid removal if small or endometrial ablation) Myomectomy Hysterectomy
What pelvic pathology can cause IMB?
Non-malignant = fibroids, uterine + cervical polyps, ovarian cysts and chronic pelvic infection
Malignant (older w/ recent change) = ovarian, cervical + endometrial
What are the treatment options for IMB?
IUD or COCP
HRT if perimenopausal
What are the 3 pregnancy hormones?
hCG
Progesterone
Oestrogen
What is the role of hCG in pregnancy?
It maintains the corpus luteum which secretes progesterone and oestrogen to maintain the pregnancy initially
What are the roles of progesterone during pregnancy?
1) Vascularization and proliferation of endometrial storma
2) Myometrium quiescence (SM of myometrium relaxation)
3) Increased maternal ventilation
4) Increased glucose stores in fat
5) Suppression of maternal immune system to foetal antigens
What are the roles of oestrogen during pregnancy?
Increased BF to uterus due to vasodilation
Changes in sensitivity to CO2
Breast ductal development for lactation
Cervical softening, myometrial excitation + initiating uterine activity + maintaining labour
Relaxation of pelvic ligaments in mother
At what week range would you offer fetal anomaly scan?
18+0 –> 20+6
What is the combined test in relation to fetal screening?
Its the screening test for Down’s syndrome that occurs at 10-14 weeks.
Contains:
1) USS - nuchal translucency
2) Bld serum levels - PAPP-A + hCG
What is the quadruple test in the relation to fetal screening?
Quadruple test is the screening for down syndrome done in the 2nd trimester
Looks at 4 specific proteins;
1) Alpha-fetoprotien (AFP)
2) hCG
3) Oestriol (form of oestrogen produced in placenta)
4) Inhibin A
Define the 1st and second stages of labour
1st = start of contractions –> 10cm/fully dilated
2nd = 10cm/fully dilated –> delivery
What does the 1st stage of labour contain?
Latent phase + active phase
Latent phase = dilation –> 4cm
Cervical effacement, mucus show + strom
Active phase = 3/4cm –> 10cm
Stronger contractions 2-5 mins apart, intense peaks, pressure in the back of the rectum
What does the 2nd stage of delivery contain?
Passive stage + active stage + delivery
Passive stage = flexion of the head + internal rotation @ level of ischial spines
Active stage = Crowning + expulsive contractions (prinip 40m, multi 20m)
Delivery = extension (stretching of the perineum) + external rotation (restitution)
Describe the descent of the baby’s head before delivery (order of the words)
Engagement (OT) Descent Flexion Internal rotation (ROT --> ROA) Extension External rotation (restitution) (back to OT) Expulsion
What is effacement of the cervix?
Effacement is the thinning of the cervix as it is drawn up into the lower segment of the uterus.
Throughout pregnancy the cervix is tightly closed and is protected by a mucus plug (mucus show in 1st stage of labour)
What is cervical ripening?
The softening of the cervix + it becoming more distensible in preparation for labour and delivery
Due to the effects of prostaglandins, estrogen + pregesterone
Define a fibroid
A benign tumour of muscle and fibrous tissue
What are the RF for fibroids?
Oestrogen!!!
- Long menarche (early periods/late menopause)
- Age
- Obesity
- Nuliparous
Black> Caucasian
FHx
How can fibroids present?
Menstural problems = menorrhagia/IMB
Pain = dysmenorrhia/dyspareunia
Compression = urinary symptoms/consipation
Sub fertility
A 55 year old complains of very painful periods. After questioning she reveals that she has been experiencing pain during intercourse. She has no other symptoms. O/E you feel a pelvic mass. You order a USS and a she has a uterine fibroid.
What treatment would you give her?
Menorrhagia Rx:
Levonorgestel intra uterine system LNG-IUS
But if she was wanting to conceive - would give Tranexamic acid
What are the treatment options for fibroids?
Levonorgestel intra uterine system LNG-IUS (X wanting to conceive)
Tranexamic acid (If wanting to conceive)
Ibuprofen
COCP
Progesterone Pill
GnHR analogues +/- HRT (this shrinks the fibroids)
Surgical options:
Hysteroscopy
Myomectomy
Hysterectomy
What is adenomyosis?
Adenomyosis = endometrial tissue that grows in the myometrium and causes enlargement.
It can cause heavy/long menstrual bleeding, severe cramping and pain during inter course
What is the definition of polycystic ovaries?
PCO:
1) PCO on USS (proven that they have cysts)
2) Irregular periods >35 days apart (cysts interfering with regular ovulatory function - symptoms
3) Hirtuism = acne/increased body hair due to increased testosterone and increased unopposed oestrogen
Explain the pathophysiology of PCOS and how it leads to its symptoms
Genetics + Obesity + sedentary life style
1) Increased GnRH, Increased LH:FSH
2) Insulin resistance, hyperinsulinemia
1 + 2 = androgen excess
Androgen (testosteron) excess –>Hirsutism + acne + alopecia
And… androgen causes an arrest in follicle development causing cysts (…PCO)
Corpus luteum produces progesterone - less progesterone and more unopposed oestrogen causes anovulatory bleeds and irregular periods.
Unopposed oestrogen also increases risk of endometrial Ca
What would you need to see on TVUSS to diagnose PCOS?
> /= 12 small follicles of <5mm
Poly - cystic… lots of small cysts (mosts cysts are from the follicle)
A 33 year old presents to you as her and her partner have been trying unsuccessfully to conceive for the past 3 years. They have regular intercourse. She has a BMI of 31.
After further questioning she reveals she has acne and irregular periods.
What investigations are you going to request?
? PCOS
LH:FSH - is the ratio high? 3:1
Testosterone levels
BM
Prolactin (to exclude prolactinoma)
What medications can you give to treat hirsutism symptoms?
Cyrproate acetate + ethinylestrdiol
Anti androgen + synthetic oestrogen
Anti androgen reduces sebum production in sebaceous glands and reduces amount of androgens produces
OCP + Spirinolactone (also anti-androgen)
Give an example of a medication used to treat an ovulation experienced by a lady with PCOS
Clomiphene Citrate
A selective oestrogen receptor blocker that stimulates ovulation
When is breast screening done in the uk?
47 and 73 years
was 50-70 but in the process of extending it
What is included in the triple assessment?
- Clinical assessment = Hx + Ex
- Imaging = USS, mammogram >35
- Histology = core biopsy or punch biopsy
DD for lump in a 35 yr old
a) fibroadenoma
b) fibrocystic change
c) breast cyst
15-30 = fibroadenoma 30-45 = fibrocystic change 45-55 = breast cyst
DD for lump in a 15 yr old
a) fibroadenoma
b) fibrocystic change
c) breast cyst
15-30 = fibroadenoma 30-45 = fibrocystic change 45-55 = breast cyst
DD for lump in a 85 yr old
a) fibroadenoma
b) fibrocystic change
c) breast cyst
15-30 = fibroadenoma 30-45 = fibrocystic change 45-55 = breast cyst
What type of drug is tamoxifen?
And what are its SE?
Selective estrogen receptor blocker
SE: hot flush, mood swings and sexual dysfunction
What type of drug is Herceptin?
Monoclonal AB that targets HER2 receptors
How long does a woman need to be period free for before no longer needing contraception?
<50 = 24 months >50 = 12 months
Give female and male factors as to why you would refer someone before 1years with fertility issues.
Female >35, menstrual disorder, previous abdo/pelvic surgery, previous STI, PID or abnormal abdo exam
Male previous genital pathology, surgery pr STD, systemic illness or abnormal genital exam
What are the 3 main areas you investigate for infertility?
1) ovulation/ovarian issues
2) Male factors and sperm quality
3) Tubual patency
What hormones do you test for ovulation and ovarian function?
Mid-luteal progesterone
FSH
Antral follicle count AFC
Antimullerian hormone AMH
What medication can you give for ovulation induction?
Clomifene
Give some causes of infertility
Amenorrhoea - PCOS, Sheemans syndrome, kallmans syndrome
Tubual disease - adhesions, PID, STI
Male factor - variocele, low sperm count, hypogonadism,
Uterine abnormality - polyps, fibroids, septum defect
Describe sheemans syndrome
Occurs due to ishaemic damage to the pituitary
A post partum haemorrhage can cause ischaemic necrosis in the pituitary gland due to hypovolaemic shock
Pres: amenorrhoea or reduced lactation or later hypopituitary symptoms
What is included in the combined and the quadruple test and when do you do them?
Combined test at 11-13+6 weeks: NAT GONNA PAPP
Nuchal translucency, hCG and PAPPA (pregnancy associated plasma protein A)
Quadruple test if later 15-20 weeks: BAAE
bhCG, alpha fetoprotein, Estriol, Inhibin A
