Women's Health - Gynae Flashcards

Question

Differential diagnosis for PCOS

Answer 1

Differential Diagnoses There are a number of differential diagnoses to consider in cases of suspected polycystic ovary syndrome. The alternative endocrine diagnoses include: Hypothyroidism – obesity, hair loss and insulin resistance. Hyperprolactinaemia – oligomenorhoea/amenorrhoea, acne and hirsutism. Cushing’s disease – obesity, acne, hypertension, insulin resistance and depression.

Answer 2

1. LH + FSH - calculate ratio 2. TV USS 3. OGTT Hormonal blood tests typically show: - LH- Raised luteinising hormone - FSH -Raised LH to FSH ratio (high LH compared with FSH) - testerone - raised - also check prolactin, SHBG and TSH **TOM TIP: The key thing to remember for your exams is the raised LH, and the raised LH:FSH ratio.** Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either: - 12 or more developing follicles in one ovary - Ovarian volume of more than 10cm3 (even without visualisation of follicles) OGTT for diagnosis of diabetes- the results are: Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink) Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

Answer 3

****Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Steps: **1. lifestyle modification around weight loss (?consider orlistat BMI 30+) ** 2. **Everyone - COCP - Offer a combined oral contraceptive pill** - helps regulate periods, endometrial hyperplasia prevention, opposes androgens causing acne and hirsutism Additional steps: 3. **Prolongued ammenorrhea** - to prevent endometrial hyperplasia - mirena or induce a withdrawal bleed with cyclical progesterone or COCP every 3 months 4. **Acne** - (COCP above) topical retonids or topical antibiotics 5. **Hirsuitism** (COCP avoice) managment - waxing and shaving 6. **Manage CVD risk facotrs**- check lipids, blood pressure (antihypertensive medicaitons), glycemic control and smoking status. //// Background: Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer. Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.

Answer 4

Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. A diagnosis of PCOS requires at least two of: Anovulation Hyperandrogenism Polycystic ovaries on ultrasound

Answer 5

A cyst is a fluid-filled sac. Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women: The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.

Answer 6

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, ovarian cysts can cause vague symptoms of: Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

Answer 7

Functional Cysts Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound. (I think this is because multiple follicles develop each cycle) Corpus luteum cysts occur when the corpus luteum fails to break down (i think after releaing the egg) and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy. Other Types of Ovarian Cysts: Cystadenoma - These are benign tumours of the epithelial cells. Endometrioma These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation. Dermoid Cysts / Germ Cell Tumours These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Sex Cord-Stromal Tumours These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

Answer 8

USS is the Ix of choice Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations. ONLY DONE IF POST MENAUPAUSAL, CYST APPEARS ABNORMAL OR IS ABOVE 5CM: CA125 is the tumour marker to remember for ovarian cancer. It contributes to the overall impression of whether an ovarian cyst is related to cancer and forms part of the risk of malignancy index (remember it is non specific and rises in endometriosis, adenomyosis, fibroids....) Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour: Lactate dehydrogenase (LDH) Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 9

- Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist. - Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery. Simple ovarian cysts in premenopausal women can be managed based on their size: - Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. - 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. - More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. **Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.** Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Answer 10

Meig’s syndrome involves a triad of: Ovarian fibroma (a type of benign ovarian tumour) Pleural effusion Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites. TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.

Answer 11

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status Ultrasound findings CA125 level

Answer 12

Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas. They are very common, affecting 40-60% of women in later reproductive years. They are oestrogen sensitive, meaning they grow in response to oestrogen. As such they usually shrink with menopause.

Answer 13

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. Submucosal means just below the lining of the uterus (the endometrium). Pedunculated means on a stalk.

Answer 14

Fibroids are often asymptomatic. They can present in several ways, Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom Other Sx: Prolonged menstruation, lasting more than 7 days Abdominal pain, worse during menstruation Bloating or feeling full in the abdomen Urinary or bowel symptoms due to pelvic pressure or fullness Deep dyspareunia (pain during intercourse) Reduced fertility Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

Answer 15

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. (basically I think the submucosal ones are the main ones that cause menorrhagia) Pelvic ultrasound is the investigation of choice for larger fibroids - I think TA> TV MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 16

Management can be medical or surgical For fibroids less than 3 cm: the medical management is the same as with heavy menstrual bleeding: - Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus - Symptomatic management with NSAIDs and tranexamic acid - Combined oral contraceptive - Cyclical oral progestogens Surgical options for managing smaller fibroids with heavy menstrual bleeding are: - Endometrial ablation - Resection of submucosal fibroids during hysteroscopy - Hysterectomy Medical management for larger fibroids - the same as for smaller basically. Surgical options for Larger fibroids - Uterine artery embolisation (interventional radiologists, blocks arterial supply to the fibroid) - myomectomy - hysterectomy

Answer 17

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy. Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia. TOM TIP: Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.

Answer 18

Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation. On average, women experience the menopause around the age of 51 years, although this can vary significantly. Menopause is a normal process affecting all women reaching a suitable age. A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations. NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in: Women under 40 years with suspected premature menopause Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle - in GP you saw FSH used in women who were on hormonal contraception to help diagnose menopause NOTE DONT GET THIS CONFUSED WITH CONTRACEPTION ADVICE. DIAGNOSIS IS ALWAYS 12 MONTHS OF NO MENSTRUATION - REGARDLESS OF AGE, CONTRACEPTION IS 2 YEARS BELOW 50. Women need to use effective contraception for: Two years after the last menstrual period in women under 50 One year after the last menstrual period in women over 50

Answer 19

Perimenopause refers to the time around the menopause,** where the woman may be experiencing vasomotor symptoms and irregular periods.** Perimenopause **includes the time leading up to the last menstrual period, and the 12 months afterwards. **This is typically in women older than 45 years.

Answer 20

Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle: - Oestrogen and progesterone levels are low - LH and FSH levels are high, in response to an absence of negative feedback from oestrogen Background ME - remember that it is the theca and granulosa cells that make produce oestrogen and the corpus luteum that produces progesterone. Without follicles there is no production of these hormones The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH. The symptoms: The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.

Answer 21

A lack of oestrogen in the perimenopausal period leads to symptoms of: - Hot flushes - Emotional lability or low mood - Premenstrual syndrome - Irregular periods - Joint pains - Heavier or lighter periods - Vaginal dryness and atrophy - Reduced libido - Me - Diffculty concentrating and Sleep Disturbance

Answer 22

Women need to use effective contraception for: - Two years after the last menstrual period in women under 50 - One year after the last menstrual period in women over 50 Good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause are: - Barrier methods - Mirena or copper coil - Progesterone only pill - Progesterone implant - Progesterone depot injection (under 45 years) - Sterilisation COCP is UKMEC 2 so still an option.

Answer 23

DONT HAVE TO LEARN WROTE, BUT HAVE AN IDEA Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include: - No treatment - Hormone replacement therapy (HRT) - Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) - Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors - good for hot flushes - Cognitive behavioural therapy (CBT) - SSRI antidepressants, such as fluoxetine or citalopram - Testosterone can be used to treat reduced libido (usually as a gel or cream) - Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) - Vaginal moisturisers, such as Sylk, Replens and YES

Answer 24

A condition where there is ectopic (abnormal position) endometrial tissue outside of the uterus - endometriomas. ***Adenomyosis*** refers to endometrial tissue within the ***myometrium*** (muscle layer) of the uterus. Background - not known what causes endometriosis but retrograde menstruation (through fallopian tubes into pelvis) is one notable theory

Answer 25

Endometriosis can be asymptomatic in some cases, or present with a number of symptoms: - Cyclical abdominal or pelvic pain - Deep dyspareunia (pain on deep sexual intercourse) - Dysmenorrhoea (painful periods) - Infertility - Cyclical bleeding from other sites, such as haematuria BACKGROUND PATHOPHYSIOLOGY Dont have to learn this for answering exams but good to have an this for understanding this presentation. The main symptom of endometriosis is ***pelvic pain***. Cyclical pain: The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis. This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis. Deposits of endometriosis in the bladder or bowel can lead to blood in the urine or stools. Non-cyclical pain: (non relating to the menstrual cycle) Localised bleeding and inflammation can lead to ***adhesions***. Inflammation causes damage and development of scar tissue that binds the organs together. For example, the ovaries may be fixed to the peritoneum, or the uterus may be fixed to the bowel. Adhesions can also occur after abdominal surgery. Adhesions lead to a ***chronic***, ***non-cyclical*** ***pain*** that can be sharp, stabbing or pulling and associated with nausea. Endometriosis can lead to ***reduced*** ***fertility***. Often it is not clear why women with endometriosis struggle to get pregnant. It may be due to adhesions around the ovaries and fallopian tubes, blocking the release of eggs or kinking the fallopian tubes and obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.

Answer 26

Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms. Background Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.

Answer 27

- analgesia - NSAIDs and paracetamol first line - **Hormonal management** options can be tried before establishing a definitive diagnosis with laparoscopy: - COCP - Progesterone only pill - Depot progesterone injection - progesterone implant - Mirena coil - GnRH agonists - goserilin shut down the ovaries temporary and induce a menopause like state - **Surgical management** options: - Laparoscopic surgery to ***excise*** or ***ablate*** the endometrial tissue and remove adhesions (***adhesiolysis***) - Hysterectomy - final option, induce menopause but still isnt a definitive cure. Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.

Answer 28

Adenomyosis typically presents with: Painful periods (dysmenorrhoea) Heavy periods (menorrhagia) Pain during intercourse (dyspareunia)

Answer 29

Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). Extra: It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall. It may occur alone, or alongside endometriosis or fibroids. The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.

Answer 30

**TV USS - first line **Can also use TA USS or MRI Gold Standard- histological examination of uterus following hysterectomy - not approapriate usually.

Answer 31

NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding. When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding) Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain) Management when contraception is wanted or acceptable: Mirena coil (first line) Combined oral contraceptive pill Cyclical oral progestogens Progesterone only medications such as the pill, implant or depot injection may also be helpful. Other options are that may be considered by a specialist include: GnRH analogues to induce a menopause-like state Endometrial ablation Uterine artery embolisation Hysterectomy

Answer 32

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen/perimenaupause Oestrogen maintains thickness, estalasticity and secretions in the epithelial lining of the genitourinary tract. It also maintians the connective tissue around pelvic organs hence why menopause causes pelvicu organ prolapse and stress incontinence Atrophic vaginitis presents in postmenopausal women with symptoms of: Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation You should also consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse.

Answer 33

Management Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES. Topical oestrogen can make a big difference in symptoms. Options include: Estriol cream (syringe), Estriol pessaries, Estradiol tablets (Vagifem), Estradiol ring (Estring) Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible. Me - If you still have a uterus, progesterone is generally needed with local estrogen therapy.

Answer 34

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis. Presentation -The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. Cause - Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo. Diagnosis - The diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis. Don't confuse with lichen simplex (caused by stratching) or lichen planus (purplish with white lines, not ususally on vulva)

Answer 35

Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Emollients should be used regularly, both with steroids initially and then as part of maintenance. Lichen sclerosis cannot be cured, but the symptoms can be effectively controlled.

Answer 36

The decent of pelvic organs (uterus, rectum or bladder) into the vagina Just think about that for one second - the vaginal canal/space, interally is filled by these tissues (only grade 3 and 4 are when it decends passed the introitus) Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder. The factors that can contribute to this include: Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and postmenopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining

Answer 37

Uterine prolapse is where the uterus itself descends into the vagina. Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina (where the cervix was). Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels. Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

Answer 38

Typical presenting symptoms are: A feeling of “something coming down” in the vagina A dragging or heavy sensation in the pelvis cystocele - Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention rectocele- Bowel symptoms, such as constipation, incontinence and urgency Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Answer 39

There are three options for management: **1. conservative management - supervised (physio) pelvic floor exercises, also:** - weightloss - caffeine reduction - smoking cessation - medical treatment for stress incontinence - vaginal oestrogen if susepected atrophic vaginitis **2.Vaginal pessary (ring, shelf or gellhorn)** **3.Surgery (definative management, highly effective):** - Anterioir (cystocele) or posterioir (rectocele) vaginal wall repair - hysterectomy or sacrohysteropexy (attach uterus to sacrum)

Answer 40

Androgen insensitivity syndrome is a condition where cells are unable to respond to androgen hormones due to a **lack of androgen receptors**. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. Patients with androgen insensitivity syndrome are genetically male, with XY sex chromosome. However, the absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue. Patients have** testes in the abdomen** or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. **The female internal organs do not develop because the testes produce anti-Müllerian** hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.

Answer 41

At puberty: - lack of pubic or axillary hair - slightly taller than female on average - Primary ammenorrhea - no menarche by age 15/16 (absence of a uterus) Androgen insensitivity syndrome often presents in **infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.** The results of hormone tests are: - Testosterone: Normal or elevated (because testes produce testosterone, but the body cannot use it). - LH elevated, FSH normal or elevatedLdue to lack of androgen response and feedback. - Oestrogen: Normal or elevated (testosterone is aromatized to estrogen in peripheral tissues).

Answer 42

Medical input involves: - Bilateral orchidectomy (removal of the testes) to avoid testicular tumours - Oestrogen therapy - Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.

Answer 43

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus. Damage usually occours due to endometrial curretage (for RPOC), myomectomy or endometritis. These adhesions form physical obstructions and distort the pelvic organs. Presentation Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with: Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods) It may also present with infertility. //// Diagnosis There are several options for establishing a diagnosis of intrauterine adhesions: Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan Management Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common.

Answer 44

- tends to affect younger women - peaking in the reproductive years - second most common type of gynaecological cancer after endometrial - 80% of cervical cancers are squamous cell carcinoma. Adenocarcinoma (glandular epithelium) is the next most common type. - Cervical cancer is strongly associated with human papillomavirus. Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer. - Cervical screening with smear tests is used to screen for precancerous and cancerous changes to the cells of the cervix. Early detection of precancerous changes enables prompt treatment to prevent the development of cervical cancer.

Answer 45

The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18: **Strains 6 and 11 cause genital warts** **Strains 16 and 18 cause cervical cancer** HPV is primarily a sexually transmitted infection. There are over 100 strains of HPV. The important ones to remember are type 16 and 18, as they are responsible for around 70% of cervical cancers. There is no treatment for infection with HPV. Most cases resolve spontaneously within two years, while some will persist. HPV produces two proteins that inhibit tumour supressor genes - E6 inhibits p53 and E7 inhibits pRb

Answer 46

Cervical cancer may be detected during cervical smears in otherwise asymptomatic women. The presenting symptoms that should make you consider cervical cancer as a differential are: Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) Vaginal discharge Pelvic pain Dyspareunia (pain or discomfort with sex) These symptoms are non-specific, and in most cases, not caused by cervical cancer. The next step is to examine the cervix with a speculum. During examination, swabs can be taken to exclude infection. Where there is an abnormal appearance of the cervix suggestive of cancer, an urgent cancer referral for colposcopy should be made to assess further. Appearances that may suggest cervical cancer are: Ulceration Inflammation Bleeding Visible tumour The NICE Clinical Knowledge Summaries (2017) recommend against unscheduled cervical screening with a smear test. They also advise against using the result of cervical screening to exclude cervical cancer where it is suspected for another reason, even if the smear result was normal.

Answer 47

Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are: CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, **likely to return to normal without treatment** - I think 12 month repeat smear, if still dyskaryosis repeat colposcopy. CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated CIN III: severe dysplasia, very likely to progress to cancer if untreated TOM TIP: Try not to get mixed up between dysplasia found during colposcopy and dyskaryosis on smear results.

Answer 48

Dyskaryosis - pre-cancerous changes (not the same as displasia from colposcopy) initially cells are tested for high-risk HPV: - If negative, the cells are not examined. - If positive -> cytology for dyskaryosis HPV positive with normal cytology – repeat the HPV test after 12 months HPV positive with abnormal cytology – refer for colposcopy Background: - dyskaryosis - looks at the nucleus of the cells - dysplasia looks at the tissue architecture of biopsied tissue REMEMBER THIS - COLPOSCOPE IS FOR ABNORMAL SMEAR RESULTS - HPV **AND DYSKARYOSIS** POSITIVE.

Answer 49

Colposcopy involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas. acetic acid - acetowhite - cells with increased nuclear to cytoplasmic ratio (CI neoplasia) appear white Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain. A punch biopsy or large loop excision of the transformation zone can be performed during the colposcopy procedure under local anastetic to get a tissue sample/remove abnormal tissue This is different to a cone bopsy - using a scalpel under general anastetic - very early stage cervical cancer treatment

Answer 50

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer: Stage 1: Confined to the cervix Stage 2: Invades the uterus or upper 2/3 of the vagina Stage 3: Invades the pelvic wall or lower 1/3 of the vagina Stage 4: Invades the bladder, rectum or beyond the pelvis //// Management of cervical cancer depends on the stage and the individual situation. The usual treatments are: Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy Stage 2B – 4A: Chemotherapy and radiotherapy Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care The 5-year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4. Early detection makes a significant difference, which is one reason the screening program is so valuable and important. Bevacizumab (Avastin) is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer.

Answer 51

Endometrial cancer is cancer of the endometrium, the lining of the uterus. Around 80% of cases are adenocarcinoma. It is an oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells. The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding - any woman presenting with postmenopausal bleeding has endometrial cancer until proven otherwise. The key risk factors to remember are obesity and diabetes.

Answer 52

Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time. Less than 5% go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of: Hyperplasia without atypia Atypical hyperplasia Endometrial hyperplasia may be treated by a specialist using progestogens, with either: Intrauterine system (e.g. Mirena coil) Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

Answer 53

You can think of the risk factors for endometrial cancer in relation to the patient’s exposure to unopposed oestrogen. Unopposed oestrogen refers to oestrogen without progesterone. Unopposed oestrogen stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer. Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Polycystic ovarian syndrome - lack of ovulation (LH surge lost) so no corpus luterum to produce progesterne in the luteal phase of the menstral cycle -> need COCP, Mirena, or cyclical progesterone for endometrial protection Obesity - adipose tissue contains aromtase which converts testosterone from the adrenal glands into oestrogen. If a woman is post-menopausal then there is no corpus leuteum to produce progesterone Tamoxifen - has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer. T2D - increased production on insulin stimualtes endetrial hyperplasia

Answer 54

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than 12 months after the last menstrual period). Note perimenopausal bleedig still needs TVUSS and endometrial biopsy. NOTE NICE also recommends referral for a transvaginal ultrasound in women over 55 years with: Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Answer 55

There are three investigations to remember for diagnosing and excluding endometrial cancer: - Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause) - Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer - Hysteroscopy with endometrial biopsy NOTES Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women. Depending on local guidelines, a normal transvaginal ultrasound (endometrial thickness < 4mm) and normal pipelle biopsy are sufficient to demonstrate a very low risk of endometrial cancer and discharge the patient.

Answer 56

The usual treatment for **stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy**, also known as a TAH and BSO (removal of uterus, cervix and adnexa (ovaries and tubes)). Other treatment options depending on the individual presentation include: A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina Radiotherapy Chemotherapy Progesterone may be used as a hormonal treatment to slow the progression of the cancer /// NOT TO LEARN PERSAE Stages The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer: Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 57

Follicular phase - At the start of the menstrual cycle, FSH stimulates further development of the secondary follicles. As the follicles grow, the granulosa cells that surround them secrete increasing amounts of oestradiol (oestrogen). The oestradiol has a negative feedback effect on the pituitary gland, reducing the quantity of LH and FSH produced. LH spike just before ovulation causing the dominant follicle to release the ovum. After ovulation, the follicle that released the ovum collapses and becomes the corpus luteum. The corpus luteum secretes high levels of progesterone, which maintains the endometrial lining. When no fertilisation of the ovum occours there is no production of hCG and the corpus luterum degenerates - fall in oestrogen and progesterone and the endometrial breaks down- the point in the cycle they are low is just before mentstruation.

Answer 58

Ovarian cancer often presents late due to the non-specific symptoms, resulting in a worse prognosis. More than 70% of patients with ovarian cancer present after it has spread beyond the pelvis. Symptoms that may indicate ovarian cancer include: Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain - due to obturator nerve compression Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites

Answer 59

Epithelial Cell Tumours - tumours arising from the epithelial cells of the ovary are the most common type. Subtypes of epithelial cell tumours include: Serous tumours (the most common) Endometrioid carcinomas Clear cell tumours Mucinous tumours Undifferentiated tumours Dermoid Cysts / Germ Cell Tumours - These are benign ovarian tumours. - They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone. - They are particularly associated with ovarian torsion. - Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG). Sex Cord-Stromal Tumours These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours. Metastasis Ovarian tumours may be due to metastasis from a cancer elsewhere. A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.

Answer 60

The initial investigations in primary or secondary care are: - CA125 blood test (>35 IU/mL is significant) - NON SPECIFIC - Pelvic ultrasound These two findings combined with menopausal status feed in a Risk of malginancy index (RMI). Further investigations in secondary care: - CT scan - establish diagnosis and staging - Histology - Paracentesis - test ascitic fluid for cancer cells Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour: Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 61

CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 62

Usually invovlves a combination of surgery and chemotherapy.

Answer 63

My Summary Stage 1 - confined to that organ - The cervix in cervical, the ovary in ovarian.... Endometrial and Cervical: Stage 2 - they invade each other: Cervical invades uterus (or upper 2/3 vagina) , Endometrial invades the cervix Stage 3 - Invades the rest - the ovaries, the tubes, the pelic wall, the lymph nodes, the lower vagina Stage 4 - invades the bladder, rectum or beyond the pelvis Ovarian staging is weird.... Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 64

Ovarian Rx - involves a combination of surgery and chemotherapy //// Endometrial - Rx Stage 1& 2 - TAH and BSO /// Cervical Management of cervical cancer depends on the stage and the individual situation. The usual treatments are: CIN or Stage 1A (smaller than 5mm): LLETZ or cone biopsy Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy High stage: Chemo and radio Advanced disease - pelvic exenteration - involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. Metastatic - Bevacizumab - Anti- VEGFa

Answer 65

Around 90% are squamous cell carcinomas. Less commonly, they can be malignant melanomas. Vulval cancer most frequently affects the labia majora, it may present with symptoms of: Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin

Answer 66

Around 5% of women with lichen sclerosus get vulval cancer

Answer 67

Endometrial - most common gynae cancer, often presents with post menopausal bleeding, or postcoital, intermenstrual Cervical - next most common, tends to affect younger women (HPV is an STI), also abnormal bleeding Ovarian - peaks around 60, non specific symptoms (appeptide, abdominal bloating, weight loss) Vulval - elderly ladies (75+) bleeding and lumps

Answer 68

Similar to CIN for cervical cancer, VIN is a premalignant condition that can preceed vulval cancer VIN affects the squamous epithilium. High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years. Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years). A biopsy is required to diagnose VIN. A specialist will coordinate management. Treatment options include: Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation

Answer 69

Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral. Establishing the diagnosis and staging involves: Biopsy of the lesion Sentinel node biopsy to demonstrate lymph node spread Further imaging for staging (e.g. CT abdomen and pelvis) The International Federation of Gynaecology and Obstetrics (FIGO) system is used to stage vulval cancer. Management depends on the stage, and may involve: Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy

Answer 70

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments: Mifepristone (anti-progestogen) - halts the pregnancy and relaxes the cervix Misoprostol (prostaglandin analogue) 1 – 2 day later - softens the cervix and stimulates uterine contraction From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion. mnemonic mifepristONE - anti-progesterONE misoPROSTol - PROSTaglandin analog Surgical TOP: - can be performed at any gestational age - can be performed under local anaesthetic (+/- sedation) or general anaesthetic - cervical priming is performed prior with misoprostol, mifepristone, osmotic dilatation - up to 14 weeks - cervical dilatation + suction of the context - 14-24 weeks - cervical dilatation + evacuation using forceps Rhesus negative women with a gestational age of 10 weeks or above having a medical or surgical TOP should have anti-D prophylaxis.

Answer 71

Ectopic vs misscarriage vs viable pregancy This is an ectopic card, but also querring misscarriage and viable pregnancy immediate management - basline HcG - TV USS - to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. 3 Findings on ultrasound scan - Tubal ectopic - adnexal mass moving separately to the ovary, or a gestational sac contianing a yolk sac and fetal pole in one of the tubes - Positive pregnancy test but no sign of pregnancy on ultrasound scan → pregnancy of unknown location (possible ectopic). Track the Serum HcG (interuterine pregnancy should double every 48, a rise of less than 63% indicates an ectopic, a fall indicates miscarriage) - USS shows a possible pregnancy in the uterus - either viable or misscarriage. When a ***fetal heartbeat*** is visible, the pregnancy is considered ***viable***. A ***fetal heartbeat*** is expected once the ***crown-rump length*** is ***7mm*** or more.A ***fetal pole*** is expected once the ***mean gestational sac diameter*** is ***25mm*** or more. But also remeber viability and HcG signs above. I', pretty sure they correlate (you cant get a HB and a HCG that doesnt rise more than 63%)

Answer 72

Abdominal - Rule out any abdominal or pelvic masses that could be responsible for the symptoms Speculum (+cough) Bimanual - pelvic mass, prolapse, assess for pelvic tone (squeeze against fingers)

Answer 73

Simple - A bladder diary - Urine dipstick testing- - Post-void residual bladder volume - incomplete emptying - Specilaist - Urodynamic testing - urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis Lecture- ePAQ - electrionic patient assessment questionaire - effect on QOLA

Answer 74

* Avoid excessive or restricted fluid intake * Weight loss (if appropriate) * smoking cessation * reduced caffeine and alcohol intake * avoidance of straining and constipation * avoid diuretics

Answer 75

Treatment: Stress incontinent: - conservative - **physiotherapy (pelvic floor) for 3 months**, lifestyle changes, continence pads Surgery: - Autologous fascial sling (support the urethra) - colposuspension (anteori wall attaches to pubic synthesis to support the urethra) - intramural urethral bulking Vaginal mesh (Tension-free tape) has been baned because of issues with chronic pain, dypareunia, bower and bladder issues. Mesh is still used as part of prolapse repair in sacrohysteroplexy . **Duloxetine** is an SNRI antidepressant used second line where surgery is less preferred Urge Incontinence: **- Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line** - anticholinergic medication - oxybutynin, solifenacine, tolterodine - Mirabegron (Beta 3-agonist) - botulinum toxin type A injecitons into bladder wall - augmentation cystoplasty (enlarge bladder with section of bowel) - bypass/ urinary diversion to a urostomy bag.

Answer 76

Urinary incontinence refers to the loss of control of urination Stress incontinence- the involuntary leakage of urine when there is increased pressure on the bladder from exertion, sneezing or coughing (increased abdominal pressure with a weak pelvic floor). Most often caused by weakness of the pelvic floor. Presents with leakage symptoms. The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis. Urge incontinence - Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Presents with urgency and frequency Also overflow (obstructed outflow or urine -> retention -> incontinent) and mixed incontinence (Stress and Urge) Other causes of urgency and frequency - UTI - dipstick - bladder masses - small capacity bladder - Gynae- fibroids, press onto the bladder - Cystocele - Diabetes

Answer 77

TOM TIP: If you remember one thing about the embryology of the female reproductive system, remember the Mullerian ducts. Medical school exams are unlikely to test your knowledge of the embryology of the female reproductive system in detail (unless the exam is specific to that topic). However, they may refer to a congenital structural abnormality and ask what structure in the fetus this relates to. The answer is the Mullerian ducts. Equally, they may ask why males do not develop a uterus, and the answer is anti-Mullerian hormone, which suppresses the growth of teh paramesonephric ducts. The paramesonephric/mullerian ducts are a pair of passage eways along the outside of teh urogenital region that sure to form the upper third of the vegina, cervix, uterus and fallopian tubes (ovaries develop speerately) ME ADDING THIS AS EXTRA Anti-mullerian hromone produced by testes in Androgen insensitivity syndrome - no uterus. Not an Ix In infertility - female hormone testing - It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve. Completely unrelated to CAH where there is high androgens due to 21 hydrolyase insufficiency (cortisol and aldsoterone converted to testosterone) - ambigious genetialia but not related to worfian ducts, just high testosterone...

Answer 78

1. Bicornuate uterus - two horns (heart-shaoed uterus). Can be diagnosed on pelvic ultrasound scan and leads to complications in pregnancy but usually no complications occour. (miscarraige, prematrue birth and malpresentaiton) No Management 2. Imperforate hymen is where the hymen at the entrance of the vagina is fully formed, without an opening. Imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding. Rx w/ surgical incision. 3. transverse vaginal septae - a septum/wall forms transversely across the vagina. . Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use. Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation. Rx w/ Surgical correction. Infertility and pregnancy related complication me- This is like imperforate hymen but further transverse isn't longitudinal 4. Vaginal hypoplasia (abnormally small vagina) and vaginal agenesis (absent vagina) - failure or mullerian ducts to properly develop. Surgical correction or dilators.

Answer 79

It is an extreme form of macroscopic endometrial hyperplasia (tissue grows so fast that parts of the entrometrium enter the uterine cavity) They present with menorrhagia (heavy periods) and post-menopausal bleeding Diagosis - endometrial biopsy - diagnostic hysteroscopy - TV USS scan may play a role in determinine endometrial thickeness. Management - Polyps should be removed during hysteroscopy because of the risk of endometrial cancer - background endometrial biopsy should also be obtained If asymptomatic they might be left, but for now just learn if symptomatic then remove them...

Answer 80

A vaginal fistula is an abnormal opening between the vagina and other nearby organs in the pelvis, including the bladder or rectum. A fistula can cause many complications, such as urinary and fecal leakage, abnormal vaginal discharge, tissue damage, kidney infections and other irritative type symptoms. Surgical repair is often required.

Answer 81

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), are used to shut down production of male and female sex hormones. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy. They are also used for endometriosis and prostate cancer. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Basic mechanism: GnRH analogues are act just like GnRH and are agonists of GnRH receptors in the anterior pituitary gland. This triggers the release of the gonadotrophins (LH and FSH). GnRH analogues a very powerful stimulation of these receptors leading to a very large (more than normal) release of gonadotrophins (FSH and LH). Intially there is a flare of sex hromones and wprsening of endometriosis or prostate Sx, however, overtime the anterioir pituitary becomes desensitised to the GnRH hormone leading to a reduction in the production in gonadotrophins and thus sex hormones - A HYPOGONATROPHIC HYPOGONADISM ^^^^^^ Learn this, not below... Extra - GnRH antagonists are more complex than agonists, and act through a completely different mechanism but overall both inhibit gonadotropin secretion. GnRH antagonists bind competitively to GnRH receptors, preventing the action of endogenous GnRH pulses on the pituitary. The secretion of gonadotropins is decreased within hours of antagonist administration and no flare-up effect occurs. Background : The Hypothalamic-pituitary-gonadal axis Hypothalamus produces GnRH. In females: GnRH stimulates the pituitary gland to produces LH/FSH LH/FSH stimulate the development of ovarian follicles which secrete oestrogen. Oestrogen has a negative feedback effect on the hypothalamus and pituitary gland. In Males: LH released from the pitary gland stimulates the testicles to produce testosterone, which also has a negative feedback effect on the hypothalamus and pituitary gland.

Answer 82

PMS describes a range of psychological and physical symptoms every month during the week or two before your period (the luteal phase). When features are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder. The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history. Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA. Presentation: Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido These symptoms can also be caused by progesterone contraceptives sych as COCP.

Answer 83

Diagnosis: -Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. - A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve. Management in primary care: -General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep - Combined contraceptive pill (COCP) - contianing drospirenone (Yasmin) - SSRI antidepressants Cognitive behavioural therapy (CBT) Severe cases requiring specialist management: - estrogen patches (also requires cyclical progestoerone or mirena to prevent endometrial hyperplasia) - Severe cases GnRH - induce menopausal state and then HRT to mitagate oestoperosis and other adverse effects. - hysterectomy severe and GnRH has not helped. - danazol for cyclic breast pain

Answer 84

In childhood, girls have relatively little GnRH, LH, FSH, oestrogen and progesterone in their system. During puberty, these hormones start to increase sequentially, causing the development of female secondary sexual characteristics, the onset of the menstrual cycle and the ability to conceive children. In girls, puberty starts with the development of breast buds, followed by pubic hair and finally the onset of menstrual periods. The first episode of menstruation is called menarche. Menstrual periods usually begin about two years from the start of puberty. Puberty starts age 8 – 14 in girls and 9 – 15 in boys. It takes about 4 years from start to finish Staging system - the tanner scale (Stage 1-5) is used to stage pubertal development based on the pubic hair and breast development. Hormonal changes in puberty: - Growth Hormonne increases initially which cuases an initial growth spurt - Hypothalamus secretes GnRH - GnRh stimulates the release of FSH and LH which stimulate the ovaries to produce oestrogen and progesterone (causing secondary sexual characteristic development). - FSH levels plateau about a year before menarche, LH continues to rise and has a spike just before menarche.

Answer 85

TOM TIP: Hormone replacement therapy is a massive topic. If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime: - Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. - Women that still have periods (within last 12 months) should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. - Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT. Indications for HRT: The indication for HRT are: - Replacing hormones in premature ovarian insufficiency, even without symptoms - Reducing vasomotor symptoms such as hot flushes and night sweats - Improving symptoms such as low mood, decreased libido, poor sleep and joint pain - Reducing risk of osteoporosis in women under 60 years The risks of HRT are more significant in older women (over 60) and increase with a longer duration of treatment. The principal risks of HRT are increase risk of: - breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk) - endometrial cancer - venous thromboembolism (2 – 3 times the background risk) - stroke and coronary artery disease with long term use in older women The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal

Answer 86

You know it is given for endometrial protection - given in endometrial hyperplasia to induce bleeding. Also already know corpus luteum scretes following ovulation and it is the drop in progesterone that induce a menstrual period. chat GTP: **In one sentence: progesterone stops the proliferation of endometrial cells and induces them to differentiate into a secretory state for prepare and support an embryo**. If progesterone levels drop then menstruation is intiated. In menrrhogia or PCOS giving progesterone is used to oppose the oestrogen and reverses the hyperplasia and prevent progression to cancer.Progesterone causes the abnormal, thickened endometrial cells to undergo apoptosis (cell death) and be replaced with normal tissue, restoring the balance between cell growth and shedding. Role as a contraceptive: 1. if it helps increase secretiosn then hwo does it work as a contraceptive: In progestin-only contraceptive methods, the continuous exposure to synthetic progesterone causes the endometrium to become less receptive to implantation by making the lining thinner and less vascular. This would prevent a fertilized egg from successfully implanting if fertilization occurred. 2. the main way it acts as a contraceptive is through negative feedback - prevents the secreteion of GnRH and without the LH surge ovulation does not occour. The mirena acts locally and mainly works on the endometrium, the progesterone only pill works to inhibit ovulation. Roles of progesterone: secretory ednometrium - Under the influence of progesterone, the proliferative endometrium, which had been thickening under estrogen’s influence before ovulation, undergoes a transformation into the secretory endometrium. The endometrial stroma (the connective tissue of the endometrium) becomes more edematous and vascularized, preparing it to support a potential pregnancy. KEY - these nutrient rich secretion help support a fertilised embryo. inhibit endometrial growth - Progesterone inhibits the proliferative effects of estrogen on the endometrium. This means that, once progesterone levels rise, the thickening and cell division of the endometrial lining, which estrogen promotes, are slowed down. If fertilization occurs and the embryo implants, progesterone continues to be produced, first by the corpus luteum and later by the placenta. This sustained high level of progesterone maintains the endometrium, preventing it from shedding and supporting the growing embryo and placenta. Endometrial Shedding (Menstruation) - If fertilization does not occur, the corpus luteum degenerates, causing progesterone levels to drop.The decline in progesterone leads to vasoconstriction (narrowing of blood vessels) in the endometrium, reducing blood supply and causing the breakdown and shedding of the endometrial lining.

Answer 87

Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location. The **serum hCG** level is repeated after 48 hours, to measure the change from baseline. The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy. A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy.** A repeat ultrasound scan** is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l. A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review. A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete. Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.

Answer 88

Gravidity is defined as the number of times that a woman has been pregnant. Parity is defined as the number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether this resulted in stillbirth or a live birth. 2 Previous misscarriges or terminations.

Answer 89

Primary amenorrhoea is defined as the failure to establish menstruation by the expected age, variably considered to be 15 or 16 years of age in girls with normal secondary sexual characteristics. Secondary amenorrhoea is defined as the cessation of previously established menstruation for 3 cycles.

Answer 90

- The 1990 human fertilisation and embryology act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks. An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the **physical** or **mental** health of: - The woman - Existing children of the family The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners. /// An abortion can be performed at any time during the pregnancy if: - Continuing the pregnancy is likely to risk **the life of the woman** - Terminating the pregnancy will prevent “**grave permanent injury**” to the **physical** or **mental** health of the woman - There is “substantial risk” that the child would suffer **physical or mental abnormalities** making it seriously handicapped /// The legal requirements for an abortion are: 1. Two registered medical practitioners must sign to agree abortion is indicated 2. It must be carried out by a registered medical practitioner in an NHS hospital or approved premises There was a whole lecture on this...

Answer 91

Investigations in Primary Care: - BMI - low could indicate anovulation, high PCOS - STI screen - Semen Anylsis - Female Hormonal testing - see below Female hormone testing involves: - Serum LH and FSH on day 2 to 5 of the cycle - Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle). - Anti-Mullerian hormone - Thyroid function tests when symptoms are suggestive - Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development. High LH may suggest polycystic ovarian syndrome (PCOS). A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone. Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve. Further investigations, often performed in secondary care: - Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus - Hysterosalpingogram to look at the patency of the fallopian tubes (constrat and x-ray), Tubal cannulation can also be performed during the procedure. A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken. - Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

Answer 92

Management of anovulation (PCOS - but for infertility): - weightloss for overweight patients - **clomifene** - anti-oestrogen, prevents negative feedback on GnRH and subsequently hight FSH, LH release. - laproscopic ovarian drilling - improves hormones and ovulations for women with PCOS - metformin for insulin insesitivity Tubal Factors: - tubal cannulation in hysterosalpingogran - laproscopy for adhesions - IVF Uterine issues - Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility. Male factor infertility is also an important cause that is tested elsewhere...

Answer 93

Hyperandrogenism There are several conditions that can lead to increased androgens (hyperandrogenism): 1. Polycystic ovarian syndrome (involving multiple ovarian cysts, lack of ovulation and absent periods) 2. Congenital adrenal hyperplasia (a genetic condition causing deficiency of the 21-hydroxylase enzyme) 3. Androgen-secreting tumours of the ovaries or adrenal glands 4. Anabolic steroid use (exogenous steroids) Symptoms of hyperandrogenism are most notable in women, causing virilisation (male characteristics), facial hair (hirsutism), deepening of the voice, increased muscle mass and changes to the genitals (clitomegaly).

Answer 94

**Semen analysis** is used to examine the quantity and quality of semen and sperm. It assesses for male factor infertility. Normal results indicated by the World Health Organisation are - DONT LEARN Semen volume (more than 1.5ml) Semen pH (greater than 7.2) Concentration of sperm (more than 15 million per ml) Total number of sperm (more than 39 million per sample) Motility of sperm (more than 40% of sperm are mobile) Vitality of sperm (more than 58% of sperm are active) Percentage of normal sperm (more than 4%) /// Causes of MFI - just learn the categoies not the indidual items. Central - Low FSH and LH leading to low testosterone (needed for sperm production): - kallman (hypogonatrophic hypogonadism with agnosia (loss of smell) - pituitary or hypothalamus pathology - hyperprolactinaemia Testicular damage from: - Mumps - Undescended testes - Trauma - Radiotherapy - Chemotherapy - Cancer Genetic or congenital disorders that result in defective or absent sperm production, such as: - Klinefelter syndrome - Y chromosome deletions - Sertoli cell-only syndrome - Anorchia (absent testes) Obstruction preventing sperm being ejaculated can be caused by: - Damage to the testicle or vas deferens from trauma, surgery or cancer - Ejaculatory duct obstruction - Retrograde ejaculation - Scarring from epididymitis, for example, caused by chlamydia - Absence of the vas deferens (may be associated with cystic fibrosis) - Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Answer 95

TESTED IN MOCK 85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally. Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious. /// Causes Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%) 40% of infertile couples have a mix of male and female causes.

Answer 96

/// Ix: Hormonal analysis with LH, FSH and testosterone levels Genetic testing Further imaging, such as transrectal ultrasound or MRI Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction Testicular biopsy //// Management - TEST THIS Management of Sperm Problems - Surgical sperm retrieval- for a blockage along the vas deferens - Surgical correction of an obstruction in the vas deferens may restore male fertility. - Intra-uterine insemination (Syringe sperm into the uterus) - just as good as sex - Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm. Donor insemination with sperm from a donor is another option for male factor infertility.

Women's Health - Gynae Flashcards

(120 cards)