Week 6: Womens' health (1) (menstrual cycle and micturition) Flashcards
1
Q
Menstrual bleeding history
A
Menstrual history
Menarche: How old were you when you started your period?
LMP: When was the first day of your last period?
Cycle: Are your cycles regular? How often do you get your period? How long does the bleeding last?
Other problems: Other than your periods being heavy, do you have any problems with them?
- Painful periods (dysmenorrhoea can suggest endometriosis/fibroids)
- Bleeding between cycles (intermenstrual bleeding can suggest STI/contraception problems/malignancy)
- Bleeding after sex (post-coital bleeding can suggest ectropion/malignancy)
- Long breaks between periods (amenorrhoea can be a feature of anorexia/hormonal problems such as hypothyroidism)
How heavy are your periods (e.g. how many times do you change you tampon/pad)
Complete a full gynaecological history
Sexual and contraception history:
- Are you sexually active at the moment? Do you have a regular partner? How many partners have you had in the past 6 months?
- Have you had a sexual health screen in the past? When? Have you ever been treated for an STI?
- Have you noticed any changes to your vaginal discharge?
- Have you noticed any rashes or itching around your vulva?
- Do you have pain when you’re having sex (dyspareunia)?
- Are you using contraception at the moment? Have you used anything in the past?
- Is there any chance you could be pregnant (e.g missed pills)?
Cervical smears:
- When was your last cervical smear? Are you up to date with your smears?
- Have you been vaccinated against HPV?
- Any abnormal smears?
- Any treatment required?
Urinary questions:
- Any problems with going to the toilet?
- Are you passing urine more often (frequency)?
- Do you have any burning or stinging on passing urine (dysuria)?
- Do you have any problems with incontinence?
- So you have the sensation of “dragging” in your vagina (prolapse)?
Brief obstetric history:
- Have you ever been pregnant? Any miscarriages or terminations?
- Do you have any children? How old are they? Were they vaginal deliveries or c-sections? Any complications?
- Are you currently trying to to get pregnant or have plans for a baby soon? (this will have an impact on management)
PMH
Family history e.g. of heavy bleeding
Allergies
Drugs
e.g. contraception
Social history
- effect on personal life, inc time off work or school
- smoking
- alcohol
2
Q
gynecological examination
A
Clinical examination should be undertaken to assess for any anaemia and also to rule out potential organic causes of menorrhagia.
- Note general appearance and BMI. Body fat is very important in relation to metabolism of steroid hormones.
- Note any signs suggestive of endocrine abnormality (hirsutism, acne) or bruising.
- Look at the tongue for pallor and the nails for koilonychia.
- Examination of the abdomen always precedes pelvic examination; otherwise, large pelvic masses can be missed.
- Pelvic examination may not always be appropriate (for example, in adolescents) but should be considered:
- Where underlying pathology seems likely from the history.
- When the levonorgestrel-releasing intrauterine system (LNG-IUS) is being considered as treatment.
- Where initial treatment has not been effective.
- Where relevant, ascertain that the cervical smear is up to date.
- Inspect the cervix and take swabs if clinically indicated.
- Where indicated, perform a bimanual examination. Abnormalities may include a bulky or grossly enlarged uterus, fixation of the uterus or tenderness.
3
Q
urological history taking
A
History of presenting complaint
Key urological symptoms
Symptoms that are typically associated with urological disease include:
- Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
- Urinary frequency: commonly associated with UTIs.
- Urinary urgency: may be associated with UTIs or detrusor instability.
- Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hyperplasia).
- Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
- Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hyperplasia).
- Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
- Fevers and rigors: typically associated with pyelonephritis.
- Nausea and vomiting: typically associated with pyelonephritis.
- Weight loss: associated with malignancy and uraemia.
- Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.
SOCRATES
Associated symptoms
- red flags
- fever
- weight loss
- night sweats
- systemic enquiry
- palpitations or chest pain
- SoB
- abdominal pain
- confusion
- muscle wasting
- uraemic frost
PMH
Allergies
Drug history (some relevant examples)
- Diuretics (e.g. furosemide): a common cause of nocturia and can cause acute kidney injury.
- Alpha-blockers: commonly used to treat prostatic enlargement
- Nephrotoxic medications (e.g. ACE inhibitors, NSAIDs): may cause acute or chronic kidney injury.
- Antibiotics: commonly required for recurrent UTIs and may be prescribed as prophylaxis.
Family hisotry
Social history
- type of accom
- who they live with
- ADL
- carer input
- smoking
- alcohol
- recreational drug use
- diets and fluids
- occupation
Closing
- summarise key points
- make sure to have included ICDE
4
Q
urinary examination
A
- General - look for fever and signs of infection and systemic illness.
- Abdominal - a tender enlarged bladder with dullness to percussion well above the symphysis pubis, often almost to the level of the umbilicus.
- Genitourinary:
- In men, look for phimosis or meatal stenosis, as well as urethral discharge and genital vesicles.
- In women, look for evidence of:
- Vulval or vaginal inflammation or infection.
- Cystocele, rectocele or uterine prolapse.
- Pelvic mass (eg, retroverted gravid uterus, uterine fibroid, gynaecological malignancy).
- Per rectum (PR) - check anal tone, prostatic size, nodules, tenderness, etc and exclude faecal impaction[6].
- Neurological - look for evidence of prolapsed disc or cord compression by checking lower limb power and reflexes as well as perineal sensation.
5
Q
hormonal production summary (menstrual cycle)
A
- Hypothalamus: GnRH
- Anterior pituitary: FSH and LH (work on the theca and granulosa cells)
- Ovaries- progesterone and oestrogen (theca cells (converted from androgen by the granulosa cells)
6
Q
Cycle length- what is normal
A
- Normal duration 21-35 days (28 day av)
- Day 14 usually ovulation → time for the follicle to mature
- Variation is due to length of follicular phase
7
Q
Disruption to cycle
A
- Physiological factors
- Pregnancy
- Lactation
- Emotional stress
- Body weight
- Infertility
8
Q
2 cycles occurring in paralllel
A
- Ovarian cycle- 2 phases
- Pre- ovulation- follicular phase
- Post ovulation- luteal phase
- Uterine cycle- 2 phases
- Pre-ovulation
- Period
- Proliferative
- Post-ovulation
- Secretory
- Pre-ovulation
9
Q
The Hypothalamic-Pituitary-Gonadal (HPG) Axis
A
The hypothalamus, anterior pituitary gland and gonads (ovaries) work together to regulate the menstrual cycle.
10
Q
summarise how the HPG axis causes ovulation
A
- GnRH from the hypothalamus stimulates luteinising hormone (LH) and follicular stimulating hormone (FSH) release from the anterior pituitary gland.
- LH and FSH are gonadotropins that act primarily on the ovaries in the female reproductive tract
- FSH binds to granulosa cells to stimulate follicle growth and also permits the conversion of androgens produced by the theca cells to oestrogen.
- Also stimulates inhibin à which exerts negative feedback on FSH
- LH binds to theca cells which produces androgens (need converting to oestrogen and progesterone (aromatase produced by granulosa cells)
- FSH binds to granulosa cells to stimulate follicle growth and also permits the conversion of androgens produced by the theca cells to oestrogen.
- Oestrogen and the HPG axis (levels of LH and FSH)
- Moderate levels of oestrogen exerts a negative feedback effect on the HPG axis
- At a high levels of oestrogen, negative feedback is converted to positive feedback to the HPG axis à leads to surge in LH (not FSH due to inhibin) à leading to ovulation
- Oestrogen in the presence of progesterone (i.e. once the follicle is secreting a high level of progesterone in the luteal/ secretory phase) exerts negative feedback on the HPGà preventing the development of another follicle
11
Q
the ovarian cycle isFSH binds to
A
granulosa cells and stimulates follicle growth and also permits the conversation of androgens produced by the theca cells to oestrogen
- Also stimulates inhibin à which exerts negative feedback on FSH
12
Q
LH binds to
A
theca cells
which produces androgens (need converting to oestrogen and progesterone (aromatase produced by granulosa cells)
13
Q
the ovarian cycle is split into
A
follicular phase
(ovulation)
luteal phase
14
Q
Follicular phase
A
- Growth of follicles stimulated by FSH (which is secreted by the AP → stimulated by GnRH release from hypothalamus (stimulated by activin secreted by granulosa cells))
- Primordial follicles → primary follicles à secondary follicles → tertiary follicles
- One of these follicles then becomes the ‘graafian follicle’ or dominant→ oocyte will be released during ovulation
- As time goes by FSH levels reduce due to the release of inhibin
15
Q
dominant follicle
A
graafian follicle
22
Q
the uterine cycle is split into
A
- menstrual phase
- proliferative phase
- secretory phase
27
Q
uterine layer histology
A
-
Endometrium= epithelium and stroma
- Functional layer- responsive to hormone- shed in menstruation
- Basal layer- develops into new functional layer (constant blood supply)
- Myometrium
- Perimetrium
36
Q
summary of micturition nerves
A
