Gynae Passmed 2 Flashcards
What are the 3 main categories of anovulation?
Class 1 : hypogonadotropic hypogonadal anovulation
- notably hypothalamic amenorrhoea
Class 2 : normogonadotropic normoestrogenic anovulation
- PCOS
Class 3 : hypergonadotropic hypoestrogenic anovulation
- premature ovarian insufficiency
- In this class, IVF with donor oocytes is usually required to conceive
What is the main goal of ovulation induction?
to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development
What is the first line mx for patients with PCOS struggling with infertility?
Exercise and weight loss
What is the second-line medical therapy for patients with PCOS? What is it’s MOA? ADRs?
Letrozole
Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of FSH production
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene
Side effects: fatigue, dizziness
What is the first line medical therapy for PCOS? MOA?
Clomiphene citrate
MOA: selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens.
What tx can be used for class 1 ovulatory dysfunction ? MOA?
Gonadotropin therapy
Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
Pelvic inflammatory disease (PID) is infection and inflammation of the female pelvic organs, usually as a result of ascending infection from the endocervix.
What are the most common causative organisms?
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
How should PID be investigated?
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab (often negative)
screen for Chlamydia and Gonorrhoea
How should PID be managed?
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Low threshold for tx due to risks incl infertility, chronic pelvic pain and ectopic pregnancy
Give some chronic causes of pelvic pain?
Endometriosis
IBS
abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ovarian cyst
Unilateral dull ache which may be intermittent or only occur during intercourse
Large cysts may cause abdominal swelling or pressure effects on the bladder
Urogenital prolapse
Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction. What features may it present with?
subfertility and infertility
menstrual disturbances: oligomenorrhoea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
How should PCOS be investigated?
pelvic ultrasound: multiple cysts on the ovaries
LH, FSH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
raised LH:FSH ratio is a ‘classical’ feature
prolactin may be normal or mildly elevated
testosterone may be normal or mildly elevated - if markedly raised consider other causes
SHBG is normal to low in women with PCOS
check for impaired glucose tolerance
the Rotterdam criteria state that a diagnosis of PCOS can be made if 2 of the following 3 are present:
infrequent or no ovulation (usually manifested as infrequent or no menstruation)
clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of testosterone)
polycystic ovaries on ultrasound scan (≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
How can hirsutism and acne be managed in PCOS?
COCP
if doesn’t respond to COCP then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
Postcoital bleeding describes vaginal bleeding after sexual intercourse. What can cause this?
no identifiable pathology is found in around 50% of cases
cervical ectropion
cervicitis e.g. secondary to Chlamydia
cervical cancer
polyps
trauma
Postmenopausal bleeding is defined as vaginal bleeding occurring after 12 months of amenorrhoea. What can cause it?
vaginal atrophy
the most common cause of postmenopausal bleeding
HRT (hormone replacement therapy)
with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy
endometrial hyperplasia
endometrial cancer
although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
cervical cancer
ovarian cancer
other uncommon causes include:
trauma
vulval / Vaginal cancer
bleeding disorders
Premature ovarian insufficiency is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
What can cause it?
idiopathic ( most common)
bilateral oophorectomy
radiotherapy / chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
How can POI be diagnosed?
elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
How should POI be managed?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
How can it be managed?
specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
e.g Yasmin
severe symptoms may benefit from an SSRI
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions.
What can cause it?
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders, PCOS
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
What are the key points of the Abortion Act?
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
What should be done for women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation?
anti-D prophylaxis should be given
What surgical options are available for termination of pregnancy?
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
What medical and surgical management is available for miscarriage?
Medical:
Vaginal misoprostol alone
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
Surgical :
vacuum aspiration (suction curettage) or surgical management in theatre
How does overactive bladder (OAB)/urge incontinence present? How should it be managed?
due to detrusor overactivity
the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
Mx:
bladder retraining (lasts for a minimum of 6 weeks)
bladder stabilising drugs (antimuscarinics)
oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
oxybutynin should be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
surgery: sacral nerve augmentation, botox injections
How should any urinary incontinence be investigated?
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
What are the different types of incontinence?
Urge
Stress
Mixed
Overflow
Functional
How should stress incontinence be managed?
pelvic floor muscle training
NICE recommend at least 8 contractions 3 x / day for a minimum of 3 months
duloxetine : noradrenaline and serotonin reuptake inhibitor
increased conc of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter
surgical procedures: e.g. retropubic mid-urethral tape procedures, rectus fascial sling, bulking agent injection (Bulkamid)
