Women's health - gynaecology Flashcards
What is considered in the field of gynaecology?
- Female organ problems
- Pregnancy before 13 weeks
How long is a normal menstrual cycle?
21-35 days
What are the stages of the ovarian menstrual cycle and how long do they last?
- Follicular (d1-13)
- Ovulation (d14)
- Luteal (d14-28)
What are the stages of the uterine menstrual cycle and how long do they last?
- Menses (d1-5)
- Proliferative (d6-14)
- Secretory (d15-28)
What is considered the first day of the menstrual cycle?
The first day of the menstruation
When is the fertile window in the menstrual cycle?
5 days before ovulation until the day after ovulation (so d9-15)
Draw out the menstrual cycle - phases of cycle, thickness of the endometrium and levels of oestrogen and progesterone.
Follow link, scroll to bottom of page
https://zerotofinals.com/obgyn/reproductivesystem/menstrualcycle/
What stimulates LH and FSH production?
Gonadotrophin releasing hormone
Where are LH and FSH released from?
Anterior pituitary
Where is oestrogen released from?
Theca granulose cells in ovaries
What causes the release of oestrogen?
LH + FSH
What are the effects of oestrogen (4)?
- Growth + development of breast + female reproductive organs
- Increase BMD
- Growth of endometrium
- Development of blood vessels in uterus
Where is progesterone released from?
Corpus luteum
What are the functions of progesterone (3)?
- Maintain endometrial thickness
- Thicken cervical mucous
- Increase body temp
What does FSH act on and what does it do?
Granulose cells –> stimulates folliculogenesis
What effect does oestrogen alone have on LH and FSH?
Increases LH levels and FSH
What effect does high oestrogen and progesterone have on LH and FSH?
Negative feedback
What are the main presenting complaints in gynaecology (9)?
- Amenorrhoea (no periods)
- Irregular menstruation
- Intermenstrual bleeding
- Dysmenorrhoea (painful periods)
- Menorrhagia (heavy periods)
- Postcoital bleeding
- Pelvic pain
- Vaginal discharge
- Pruitis vulvae (itchy vagina)
When does puberty in girls typically begin?
8 to 13 years
menarche 2 years after this
What are the two types of amenorrhoea?
- Primary - never started periods
- Secondary - > 3 months no period (in normally regularly menstruating woman)
What is primary amenorrhoea defined as (2)?
- No periods + no evidence of puberty at 13 years
- All 15 year olds without periods
or 3 years after starting breast development
What is the first sign and stages of puberty in females (3)?
- 1st = breast buds
- 2nd = pubic hair
- 3rd = menstruation
What are the two fundamental causes of primary amenorrhoea?
- Hypogonadotrophic hypogonadism
- Hypergonadotrophic hypogonadism
What are some causes of hypogonadotrophic hypogonadism (5)?
- Hypopituitarism
- Delayed growth + development (but otherwise normal)
- Excessive exercise/ dieting/ failure to thrive
- Endocrine disorders e.g. hypothyroidism/ growth hormone deficiency
- Kallman syndrome
What are some causes of hypergonadotrophic hypogonadism (relating to primary amenorrhoea) (4)?
- Turners syndrome
- Damage to ovaries e.g. cancer, torsion, infection
- Absence of ovaries
- Androgen insensitivity syndrome (although high levels of sex hormones this is still hypogonadism as the function is decreased)
What other condition may cause primary amenorrhoea?
Congenital adrenal hyperplasia (this often causes high levels of androgens, but lack of periods)
How is primary amenorrhoea typically investigated (6)?
- Standard bloods - coeliac screen, U&E for CKD, anaemia
- FSH, LH levels
- TFTs
- ILGF-1
- Genetic testing
- USS + other imaging
What are some causes of secondary amenorrhoea (8)?
- Pregnancy
- Menopause
- PCOS
- Hyperprolactinaemia
- Psychological/ physiological stress (weight loss/ extreme exercise)
- Ashermans syndrome
- Sheehans syndrome (damage to pituitary gland - typically after birth due to shock)
- Hyperthyroidism
Why does hyperprolactinaemia cause amenorrhoea?
Prolactin acts on hypothalamus to prevent GnRH release –> low LH + FSH –> no periods
How is secondary amenorrhoea investigated (3)?
- Hormone bloods
- USS pelvis
- Urine bHCG
What is included in the hormone blood tests for secondary amenorrhoea?
- FSH +LH
- Prolactin
- TSH
- Testosterone
What are some congenital structural abnormalities that occur in females (4)?
- Bicornuate uterus
- Imperforate hymen
- Transverse vaginal septum
- Vaginal hypoplasia and agenesis
What is a bicornuate uterus?
Uterus with two horns (heart shaped appearance)
What are some complications of bicornuate uterus (3)?
- Miscarriage
- Premature birth
- Malpresentation
How does an imperforate hymen present?
When girls start to menstruate they will get ‘period cramps’ but without any bleeding
What is a transverse vaginal septum?
Septum forms transversely across the vagina - can be imperforate or perforate (with a hole)
presents similarly to imperforate hymen
What is vaginal hypoplasia and agenesis?
Abnormally small or non-existent vagina
What causes vaginal hypoplasia and agenesis?
Failure of mullerian ducts to properly develop
What is the typical amount of blood lost during menstruation?
40 ml
What is considered menorrhagia in terms of blood loss?
> 80ml
rarely measured in practice - rely on history
What causes menorrhagia (2 big ones, 6 others)?
- Dysfunctional uterine bleeding
- Fibroids
- IUD
- Hypothyroidism
- Bleeding disorders
- Endometriosis + adenomyosis
- PCOS
- Cancers
How is menorrhagia investigated (3)?
- FBC, clotting, ferritin, TFTs
- USS
- Hysteroscopy
What is dysfunctional uterine bleeding?
No identifiable cause for the menorrhagia
How is dysfunctional uterine bleeding managed symptomatically (2)?
- Transexamic acid (reduces bleeding)
- Mefanamic acid (when there is associated pain - reduces bleeding and pain, type of NSAID)
How is dysfunctional uterine bleeding typically treated (3)?
- Mirena coil
- COCP
- Cyclical oral progesterones
What is a fibroid also known as and what are they?
Uterine leiomyomas - benign tumours of the smooth muscle
What age are fibroids most common?
Child bearing age 30-50 years old
What percent of females have fibroids of child bearing age?
1/3rd
What tends to happen to fibroids after menopause?
Shrink as oestrogen sensitive
What are the types of fibroids (4)?
- Subserosal = just below the outer layer of uterus - can grow to fill abdomen
- Intramural = within the myometrium
- Submucosal = just below the lining of uterus (endometrium)
- Pedunculated = on a stalk
What are some risk factors for fibroids (4)?
- Nulliparous
- Black
- Early menarche/ late menopause
- Obesity
What are the signs/ symptoms of fibroids?
- Menorrhagia
- Prolonged periods (> 7 days)
- Abdo pain
- Deep dyspareunia
- Reduced fertility
- Bowel/ urinary Sx/ bloating
How are fibroids investigated (3)?
- Bimanual exam = large, irregular, non tender uterus
- TV USS
- Hysteroscopy
How are fibroids managed medically (3)?
Same as dysfunctional endometrial bleeding:
* Mirena coil
* COCP
* Symptomatic management = transexamic acid
How can fibroids be managed surgically (4)?
- Uterine artery embolisation
- Hysteroscopic endometrial ablation/ resection
- Myomectomy
- Hysterectomy
What size should fibroids be referred?
Larger than 3 cm
What is uterine artery embolisation?
Radiologically guided catheter insertion –> particles injected to block artery to fibroid
What is myomectomy?
Laparoscopic procedure to remove fibroid
What is a big advantage of myomectomy?
Can improve fertility in women of child bearing age
What are some complications of fibroids (6)?
- Red degeneration
- Reduced fertility
- Pregnancy complications
- Malignant change (very rare)
- IDA
- Torsion (usually affecting pedunculated fibroids)
What is red degeneration?
Ischemia, infarction, necrosis of fibroid due to interruption of blood supply
When does red degeneration often present?
During pregnancy - often in 2nd + 3rd trimester due to changing shape of uterus interrupting the blood supply
How does red degeneration present (4)?
- Mild fever
- Tachycardia
- Vomiting
- Pain
How is red degeneration managed?
Supportive
What is a differential for a fibroid (2)?
- Endometrial polyps
- Malignant tumours
What is dysmenorrhoea?
Painful periods
What are some causes of painful periods (6)?
- Primary dysmenorrhoea (no underlying cause)
- Endometriosis
- Adenomyosis
- Fibroids
- PID
- IUD
What are the features of primary dysmenorrhoea (2)?
- Present from menarche (or within 1-2 years)
- Just before or after start of period (not days before)
How is primary dysmenorrhoea managed (2)?
- NSAIDs e.g. mefenamic acid
- COCP
What is endometriosis?
Ectopic endometrial tissue (outside the uterus)
What age does endometriosis most commonly occur?
20-40 year old
What percentage of females have endometriosis in uk?
10%
Where does endometrial tissue sometimes form (4)?
- Urinary tract
- Bowel
- Abdomen (especially ovaries)
- Thorax (may present with cyclical haemoptysis)
What are some theories for the cause of endometriosis (4)?
- Retrograde menstruation
- Embryonic cells destined to become endometrial tissue remained outside uterus during development
- Spread via lymphatic system
- Cells change via metaplasia
What are some risk factors for endometriosis (5)?
- Nulliparous
- Early menarche/ late menopause
- Vaginal outflow obstruction
- Autoimmune disease
- Family history
What are the signs/ symptoms of endometriosis (5)?
- Cyclical abdo/ pelvic pain
- Dysmenorrhoea
- Deep dyspareunia
- Infertility
- Cyclical bleeding (in GI or uriniary or resp tract)
How is endometriosis investigated (3)?
- Bimanual vaginal exam + abdo exam (adnexal motion tenderness + fixed retroverted uterus)
- TV USS = first line
- Laparoscopic surgery = gold standard
What is a staging system that can be used for endometriosis?
ASRM (stages 1-4)
american society of reproductive medicine
How is endometriosis managed (5)?
- NSAIDs
- COCP
- GnRH analogue
- Laparoscopic ablation/ excision
- Hysterectomy
What does a GnRH analogue do?
Prevents the anterior pituitary producing LH and FSH
What is an example of a GnRH analogue?
Goserelin
What is endometrial tissue in the ovaries known as?
Chocolate cyst
What is a side effect of GnRH analogues?
OSTEOPOROSIS (no oestrogen)
What are the different types of hysterectomy (4)?
- Partial hysterectomy = ONLY uterus
- Total hysterectomy = uterus + cervix
- Radical hysterectomy = uterus + cervix + part of vagina/ soft tissues
- Hysterectomy with bilateral salpingo-oophrectomy = uterus + cervix + fallopian tubes + ovaries
What is a major differential/ sister condition of endometriosis?
Adenomyosis
What is adenomyosis?
Endometrial tissue in myometrium
What are some risk factors for adenomyosis?
- Multiparous
- Uterine surgery/ trauma
*
What age does adenomyosis typically occur?
Later in reproductive age (35-45)
resolves with menopause
What percentage of women are affected by adenomyosis?
10%
What are the signs/ symptoms of adenomyosis (4)?
- Dysmenorrhoea/ cyclical pain
- Menorrhagia
- Deep dyspareunia
- Subfertile
How is adenomyosis investigated (3)?
- Bimanual exam
- TV USS
- Excision + biopsy (post hysterectomy)
What is the classic finding on a bimanual exam for adenomyosis?
BOGGY uterus
How is adenomyosis managed (6)?
- Symptomatic = transexamic/ mefenamic acid
- Mirena coil = first
- COCP
- Cyclical oral progesterones
- GnRH analogues
- Surgery (hysterectomy, myomectomy, uterine artery embolisation)
+ REFER
What are some complications on pregnancy of adenomyosis (7)?
- Miscarriage
- Infertility
- Preterm
- Small for gestational age
- Malpresentation
- PPH
- C-section (increased likelihood)
What is polycystic ovarian syndrome?
A metabolic and reproductive condition causing multiple cysts (immature follicles) on the ovaries
What criteria are used to diagnose PCOS?
Rotterdam criteria
What are the Rotterdam criteria to diagnose PCOS (3)?
- Oligo/anovulation (irregular/ absent periods)
- Hyperandrogenism (hirtuism + acne)
- Polycystic ovaries/ ovaries over 10cm^3 on USS
How many Rotterdam criteria are needed for a diagnosis of PCOS?
2 out of 3
What are the signs/ symptoms of PCOS (8)?
- Oligo/anovulation (or oligo/amenorrhoea)
- Infertility
- Obesity (up to 70% of people with PCOS)
- Hirsutism
- Acne
- Male pattern hair loss
- Mood swings
- Acanthosis nigricans
What are some complications of PCOS (5)?
- Insulin resistance/ diabetes
- Infertility
- Endometrial hyperplasia + cancer
- OSA
- Metabolic syndrome
What is metabolic syndrome?
At least 3 of the 5 medical conditions:
* Abdo obesity
* High blood pressure
* High blood sugar
* High serum triglycerides
* Low HDL
What are the effects of insulin resistance on PCOS (3)?
- Insulin increases production of androgens (e.g. testosterone)
- Insulin surpreses sex hormone binding globulin (SHBG) –> more testosterone free in blood –> hirsutism
- Insulin further halts the development of follicles in ovaries –> anovulation
Other than PCOS what are some other causes of hirsutism (3)?
- Medications (e.g. steroids, phenytoin - anticonvulsant)
- Cushings
- Congenital adrenal hyperplasia
How is PCOS investigated (3)?
- Bloods
- TV USS
- OGTT (check for diabetes - not HbA1C)
What blood are done on those with PCOS (5)?
- Testosterone
- LH + FSH
- SHBG
- Prolactin
- TSH
What would the blood test results typically show for those with PCOS?
- Raised LH
- Raised LH:FSH ratio
- Raised testosterone
What finding on ultrasound would satisfy one of the Rotterdam criteria (2)?
either:
* Ovary more than 10cm^3
* 12 or more developing follicles in one ovary
“beads on string” appearance
How is PCOS managed?
- Lifestyle advice
What are some examples of lifestyle advice for those with PCOS?
- Weight loss
- Stop smoking
- Exercise
How can increased risk of endometrial cancer be managed for those with PCOS?
Mirena coil
How can reduced fertility be managed in those with PCOS (3)?
- Clomifene (induces OVULATION)
- Metformin
- IVF
How can hirsutism be managed in those with PCOS (4)?
- COCP
- Topical eflornifine
- Spironolactone (reduces androgens)
- Laser hair removal
How is acne managed in those with PCOS?
COCP
What are the important gynaecological cancers to know about (4)?
- Endometrial cancer
- Cervical
- Ovarian cancer
- Vulval cancer
How are all gynaecological cancers staged?
Using FIGO staging criteria
International Federation of Gynaecology and Obstetrics
What is the most common gynaecological cancer worldwide?
Cervical
endometrial in UK - due to HPV vaccine
When should endometrial and cervical cancer be suspected?
- Endometrial = post menopausal bleeding (until proven otherwise)
- Cervical = intermenstrual