WH- Gynaecology Flashcards
Causes of secondary amenorrhoea
- Post-pill amenorrhoea
- Pregnancy
- PCOS, premature ovarian failure
- Asherman’s syndrome
- Hypothalamic causes: weight loss, exercise, chronic illness, psychological distress
- Hyperprolactinaemia
- Hypopituitarism
- HPG axis damage: tumour, head injury, infiltration
- Thyroid disease
- Cushing’s syndrome
Initial investigations for work up of secondary amenorrhoea
B-HCG, FSH/LH, TSH, prolactin ± pelvic US
What history questions would you ask a woman presenting with infertility (not her partner)?
- Age
- Past reproductive history and outcomes
- Past gynaecological history: menstrual history, sexual history and STIs, contraceptive use, Pap tests, past Ix for infertility
- Development throughout puberty
- Endometriosis: spotting before menses, after sex
- PCOS: weight gain, hirsutism, acne
- Pituitary tumours: visual disturbance
- PMHx
- Previous chemotherapy
- FHx of genetic or autoimmune disease
- Vaccination status
- Alcohol, smoking and drug use
What history questions would you ask a man presenting with infertility (not his partner)?
- Age
- Past reproductive history and outcomes
- Development throughout puberty
- PMHx including of testicular disease or trauma
- Sexual dysfunction, eg/ premature ejaculation, problems with erection or libido
- Previous chemotherapy
- FHx of genetic or autoimmune disease
- Vaccination status
- Steroid use
- Alcohol, smoking and drug use
What investigations are performed initially in infertility?
- Mid-luteal progesterone to confirm ovulation
- Semen analysis
- Screening bloods: FBE and iron studies, blood group, rubella, HIV and HCV status
- Pelvic US
What are the principles of management of azoospermia?
- Ix = serum testosterone and FSH
- If pre-testicular cause = low T and FSH = Mx of pathology
- If testicular cause = normal/high FSH and normal T = ICSI and IVF if sperm can be identified on biopsy
- If post-testicular cause = normal T and FSH = surgery or ICSI/IVF
What are the conservative treatment options for managing prolapse?
- No treatment
- Pelvic floor exercises
- Oestrogen replacement
- Lifestyle changes, eg/ drinking less coffee and alcohol
- Pessary
Reasons for a false negative Pap test
- Sampling error
- Laboratory failure in reading sample
- Infected lesions or smear obscured by blood cells
- Poor fixation of sample
What are the benefits of HRT?
- Most effective Tx of menopausal symptoms
- Improved vaginal dryness
- Maintains or improves bone density, reduces fracture risk
- Improves QoL, sleep and muscle aches and pains
- Reduced DM risk
- Reduced CRC risk
As per current cervical cancer screening protocols, who should be referred to colposcopy?
- 2x LSIL
- HSIL
- Smear reported as: ?carcinoma
- Suspicious symptoms
- Cervix suspicious of invasive disease
What is the management of HSIL of the cervix?
Laser ablation, loop excision or cone biopsy with follow up
What conditions must be excluded in post-menopausal bleeding?
Endometrial hyperplasia and malignancy
What are the symptoms of endometriosis?
- Cyclical pain (dysmenorrhoea, mid-cycle pain, pre-menstrual pain)
- Provoked pain: dyspareunia, on inserting tampon
- Premenstrual spotting
- Infertility
What are the signs of endometriosis?
- Lower abdominal tenderness
- PV tenderness
- Palpable adnexal mass or vaginal nodule or thickening on POD
- Fixed uterus
What are the management options for endometriosis?
- Do nothing
- Analgesia
- OCP is first line for hormonal therapy
- Surgery if 6mo of failure
What are the causes of stress incontinence?
- Increased intra-abdominal pressure: pregnancy, cough, abdominal mass, obesity, constipation
- Failure of intrinsic urethral sphincter: trauma, devascularisation, faulty collagen
- Damage to pelvic floor (ageing, pregnancy, surgery)
What are the disadvantages of HRT?
Oestrogen alone:
- Increased risk of stroke, VTE and PE
- Cholecystitis
- Endometrial hyperplasia and cancer
Combined:
- As above
- Increased breast density and abnormal mammogram
- Increased risk of breast cancer (>5y)
- Increased risk of stroke and CHD (controversial)
- Unscheduled bleeding
What are the management options for fibroids?
- If asymptomatic, do nothing
- Medication: GnRH agonists, mifepristone, mirena IUD, NSAIDs
- Uterine artery embolisation (infertile)
- Ablation (MRgFUS)
- Surgery
What are the disadvantages of a mirena IUD?
- Irregular bleeding and menstrual changes
- Expulsion risk
- Perforation
- Pelvic infection
- Ectopic pregnancy
What are the benefits of COCs?
- Effective, convenient and reliable
- Independent of sex
- Reduced pelvic pain and menstrual flow
- Reduced PID, ovarian cysts, ovarian and endometrial cancer, and benign breast disease
What are the causes of urge incontinence?
Overactive bladder or detrusor instability due to:
- Idiopathic
- Psychosomatic
- Neuropathic, eg/ MS
- Complication of incontinence surgery
- Outflow obstruction
- Bladder pathology causing irritation, eg/ stones, cancerW
What is the management of urge incontinence?
- Conservative: decrease fluid intake to 1.5L/day, physiotherapy for bladder re-training
- Medical: anti-cholinergics or TCAs (especially if nocturia)
- Surgical
How might a uterine fibroid be detected?
- Incidentally on US scan
- Pressure symptoms: urinary frequency, menstrual disturbance (HMB) or pregnancy issues
What are the non-hormonal management options in menopause?
- Gabapentin, SSRI/SNRI and clonidine for hot flushes
- Consider local oestrogen for vaginal dryness
What are the treatment options for stress incontinence?
- Pelvic floor exercises
- Pads
- Pessary
- Surgery: burch colposuspension
What investigations are first line for investigating primary amenorrhoea
FSH/LH, pelvic US
What is the main contraindication to progestin-only pills?
Hormone-dependent cancers
What is the Tx of chlamydia?
Azithromycin
At what age should you Ix primary amenorrhoea?
16yo
Common sites of endometriosis
Uterosacral ligaments, ovaries, POD and anterior vesicle pouch
What features constitute severe endometriosis?
Chocolate cysts and infertility
What hormonal treatment is first line for endometriosis?
Continuous OCP
When is surgery recommended for endometriosis?
After 6months of failed treatment
