Chronic Gynae Flashcards
(44 cards)
What is menopause, who does it affect and why does it occur?
Absence of menses for >12 months (retrospective diagnosis)
Average age = 51y, but can be 45-55y. If <40 then –> POI
Due to the depletion of oocytes –> reduction in ovarian production of progesterone, oestradiol and testosterone
How may a woman undergoing the menopause present? How many women get Sx?
note: approximately 75% women get symptoms, and these can last for around 7 years
Sx:
- Persistent amenorrhoea (often initial oligomenorrhoea and/or shortened cycles)
- Vasomotor symptoms –> hot flushes, night sweats, palpitations
- Urogenital - vaginal dryness, dyspareunia, frequency, dysuria, recurrent UTI
- Psychological - tiredness/lack of sleep, mood disturbances/swings, reduced libido (these present first)
What investigations would you do in a woman with suspected menopause?
Ix:
- Clinical diagnosis so no further Ix required if symptoms fit the picture
- Pregnancy test as amenorrhoea in sexually active woman
- if under 45 or POI then can do FSH/oestradiol
How would you manage a patient with the menopause? What is important when counselling treatment? What are CI to HRT?
Mx: Firstly do they have a uterus?
- Yes –> Oestrogen+Progesterone treatment to protect against endometrial carcinoma
- No –> systemic oestrogen (oral/implant) but think about CI such as DVT (other options are transdermal/topical)
1st line: LIFESTYLE CHANGES
- weight loss (for flushes)
- exercise (light = yoga, aerobic = running, swimming, walking) but NOT late at night
- alcohol, caffeine (vasomotor) and stress reduction
- sleep hygiene - reducing blue light exposure before bed, good wind down routine, relaxation techniques
2nd line: HRT
Oestrogen alone (Elleste Solo) - only in post-hysterectomy 1
- Oral Oestrogen (standard tx)
- Transdermal patch (if BMI>30 due to lower VTE risk)
- Can also get oestrogen only combined with a Mirena coil
O+P (Elleste Duet)
- Oral, Implant, Transdermal, vaginal creams/gel (last 2 have reduced clot risk)
CYCLICAL pattern (peri-menopausal) =
- -> Monthly (for those with regular periods and menopause symptoms): oestrogen everyday of the month with progesterone in last 14 days
- -> 3-monthly (for those with IRRegular periods and menopause symptoms): oestrogen everyday for 3 months and progesterone for last 14 days
CONTINUOUS pattern (post-menopausal) ---> Oestrogen + Progesterone everyday
absolute CI:
- Hx of VTE
- undiagnosed vaginal bleeding
- pregnancy
- prev breast cancer
- severe liver disease
- current thrombophillia
OTHER THERAPIES:
- Vasomotor Sx –> SSRIs i.e. fluoxetine (1st line) –> citalopram, venlafaxine –> gabapentin, alpha agonists such as clonidine but many anti-ach side effects
- Vaginal dryness - lubricants/gels
- Oesteoprosis treatments e.g. bisphosphonates
COUNSELLING:
- If <60 then HRT is definitely beneficial i.e. in POI ensure you stress this!
- Acts to improve symptoms (vasomotor, libido) and also protects against CVD and osteoporosis
- HRT best effects when started within 10y
- O+P have small increase in breast cancer, O alone = risk of endometrial
- Transdermal O with micronised P looks to be the optimal treatment especially for CVD patients
What are the benefits of HRT? What are the risks of HRT?
benefits of HRT = improved menopause symptoms (vasomotor, sleep + UG sx), prevention of osteoporosis
risks of HRT = combined–> breast cancer, Oes= breast and endometrial cancer; VTE (2-4x higher - 2/1000 people taking HRT in 7.5y)
What are the SE’s of HRT?
SE =
- breast tenderness
- nausea
- headaches (oestrogenic)
- fluid retention
- mood swings, depression (progestognenic)
- unscheduled vaginal bleeding (common in 1st 3 months of HRT) more so in sequential HRT but Ix if continues after 6mo OR after a spell of amenorrhoea)
What else must women experiencing the menopause also take?
Contraception requirement until 1y amenorrhoeic if 50+, 2y amenorrhoeic if <50.
What is dysfunctional uterine bleeding (DUB)? Who does it affect and what are some RFs? What are the 2 types?
Abnormal uterine bleeding in the absence of organic pathology
- Affects ~10% women
- Res = extremes of reproductive age, obesity
Types:
- Anovulatory (90%) - failure of follicular development –> no increase in progesterone –> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation –> cyclical heavy bleeding
- Ovulatory (10%) - prolonged progesterone secretion –> irregular shedding
How may women with DUB present? What are some causes of DUB?
Sx:
- Bleeding - IMB, dysmenorrhoea (painful periods), menorrhagia (as quantified by pt)
- Signs+sx of anaemia
- Signs+sx of cause e.g. relation to menstrual cycle, fertility issues, compression symptoms, cervical screening Hx…
Causes can be remembered by PALM COEINS
- Polyps
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulopathy - vWD
- Ovulation - PCOS, hypothyroid
- Endometriosis
- Iatrogenic
- Not classified
What Ix would you do in a patient with DUB?
Ix:
- Full Hx and exam (anaemia signs or of cause)
- Bimanual examination (e.g. bulky, fibroids)
- Speculum examination (e.g. cervical ectropion) - NOTE if menorrhagia with no other related symptoms e..g persistent IMB, pelvic pain or pressure sx, then consider treatment without examination)
- Bloods - FBC, TFTs, clotting screen if primary menorrhagia or FHx
- 2nd line = TVUSS (PCOS, fibroids, malignancy)
- 3rd line = OPD hysteroscopy or laparoscopy +/- biopsy for endometriosis
How would you manage DUB?
Mx:
- If no identified pathology/ fibroids <3cm/ suspected/diagnosed adenomyosis
1st line
= If contraception required (hormonal) then LNG-IUS Mirena but may not be possible in large fibroids distorting uterus
2nd line
= If fertility required/1st line declined or unsuitable then:
–> BLEED Sx = Tranexamic acid 1g TDS (CI in renal impairment or thrombotic disease)
–> PAIN = Mefenamic acid NSAIDs (CI in IBD)
OR Contraception required
–> COCP
–> Cyclical oral progestogens e.g. Norethisterone 5mg TDS for 10d if bleeding acutely but when you stop taking, it causes a heavy bleed
Surgical
- Endometrial ablation - will require continued contraception
- Hysterectomy
What is endometriosis and who does it affect? What are RFs for it?
Presence and growth of endometrial tissue outside of the uterus
- Affects 1/10 women of reproductive age, mainly ~30-45y
- RFs = early menarche, FHx, nulliparity, prolonged menstruation (>5d), short menstrual cycles
What are some cancer associations with endometriosis? What is Sampson’s theory?
Clear cell ovarian carcinoma»_space;> endometrioid ovarian carcinoma
Sampson’s theory = endometriosis arises due to the retrograde flow of menstruation and implantation, with spill of endometrial cells on to the ovary and other sites in the pelvis
How may women with endometriosis present?
Sx:
- Cyclical or chronic pelvic pain occurring before or during menstruation = dysmenorrhoea (but no menorrhagia as this indicates more -> fibroids)
- [Deep] dyspareunia
- Dyschezia (pain on defecation)
- Subfertility
- Sx of extra-uterine endometriosis i..e rectal pain, bleeding
How would you Ix a woman with suspected endometriosis? What is diagnostic?
Ix:
- Bimanual and speculum examination = reduced mobility, tender nodularity in posterior vagial fornix
- TVUSS = may show endometriomas
- Diagnostic laparoscopy is GOLD STANDARD = red vesicles or punctate marks on peritoneum indicate active lesions, white scars and brown spots show less active endometriosis
How would you manage endometriosis?
Mx - can initiate if clinical examination/TVUSS is normal (no need for laparoscopy) but if no symptomatic relief in 3-6m, then DL should be undertaken
1st line = 3m trial of paracetamol +/- NSAIDs (inhibit PG synthesis which cause pain)
- avoid opiates due to often co-existing constipation
- can add TXA adjunct
2nd line = 3m trial of COCP or progesterone (POP, implant, injectable or LNG-IUS)
- provides cycle control and contraception whilst alleviating symptoms of endometriosis (take for 21d, 7d off OR tricycle)
- progesterone induces amenorrhoea in those where COCP is contraindicated
2nd line (surgical) = laparoscopic ablation (mild endometriosis superficially) or hysterectomy with BSO (radical surgery)
- ablation has a high recurrence rate of 30% so supplement with COCP
- GnRH e.g. leuprorelin can induce a ‘pseudo-menopause’ used to shrink endometriosis in approach to surgery however don’t use for over 6m as inhibits oestrogen release (osteoporosis risk + menopause SEs)
- If presenting with sub fertility = laparoscopic ablation +/- endometrioma cystectomy and no hormonal treatment if trying to conceive
What are complications of endometriosis?
- Subfertility
- Co-existing conditions e.g. IBS and constipation (up to 80%) should also be treated
What is the difference between primary and secondary dysmenorrhoea?
Primary - cramping pain during or just before menstruation, onset in ADOLESCENCE, ~90% incidence
Secondary - painful menstruation due to recognised pathology e.g. endometriosis
What are fibroids and the 3 types? What 3 changes can they undergo? What are some i) RFs? ii) protective factors?
Fibroids are benign tumours arising from the myometrium (leiomyoma). Types:
- Submucosal
- Intramural
- Subsclerosal
Changes they undergo:
- > Hyaline degeneration
- > Calcification (post-menopausal)
- > Red degeneration - coagulative necrosis in pregnancy
RFs = ‘BONE’ = black women (+/- FHx), obesity, nulliparity and expecting (pregnancy)
Protective = smoking, grand multiparity, COCP
How do fibroids grow? How common are they? How may women present with fibroids?
Hormone dependent growth - contain many oestrogen and progesterone receptors and so enlarge during pregnancy (+shrink in menopause)
- Affects 1/3 women of reproductive age
Sx:
- Asymptomatic
- May have palpable pelvic masses, uterine enlargement
- DUB
- Miscarriage, sub-fertility
- Abdominal swelling, pressure symptoms on bowel and bladder
How would you Ix suspected fibroids?
Ix:
- Similar to DUB investigations:
- Full Hx and exam
- Bimanual examination (e.g. bulky, fibroids)
- Speculum examination (e.g. cervical ectropion) - NOTE if menorrhagia with no other related symptoms e..g persistent IMB, pelvic pain or pressure sx, then consider treatment without examination)
- Bloods - FBC, TFTs, clotting screen if primary menorrhagia or FHx
- 1st LINE = TVUSS
- OPD hysteroscopy if >4mm when not expected
How would you manage fibroids?
Mx:
-> TVUSS: No pathology identified/ fibroids <3cm or suspected adenomyosis then DUB Mx
Fibroids >3cm:
- 1st line non-hormonal (not contraceptive)
- -> TXA 1g TDS (CI in renal impairment and thrombotic disease)
- -> Mefenamic acid/NSAIDs (CI in IBD)
- 1st line hormone (contraceptive)
- -> COCP
- -> Cyclical oral progestogens
Other/Surgical/radiological treatment:
- > Injectable GnRH agonists short-term to shrink fibroids but stops oestrogen production (menopause SEs such as vaginal dryness, hot flushes, sweating and osteoporosis). Usually used before surgery
- > Ulipristal acetate OD short-term (6m) to shrink fibroids and reduce bleeding. Not as effective as GnRH agonists but doesn’t induce menopausal state but not widely used clinically and long-term use associated with liver injury
- > Transcervical resection of fibroids - surgery for small submucosal or polypoid
- > Myomectomy - best for improving fertility, may be open or laparoscopic. Power morcellation used to shrink fibroids for removal. More likely to require CS for birth in future due to uterine rupture and small risk of big bleed
- > Hysterectomy
- > Endometrial ablation
- > Radiological uterine artery embolisation - can preserve fertility but risk of ovarian failure, embolises both uterine arteries to infarct fibroids. As effective as myomectomy for alleviating fibroid DUB and pressure Sx
What are the complications of fibroids? What syndrome is associated with leiomyosarcomas?
- > Pregnancy:
- Red degeneration during pregnancy (low fever, vomiting :Mx is conservative and resolves in 4-7d)
- Miscarriage, malpresentation and transverse lie, PTL, PPH
- > 10y recurrence rate after myomectomy is 20%
- > After menopause fibroids regress and calcify
- > Risk of very rare cancer, leiomyosarcoma, is <1/100,000 - associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)
What is a urogenital prolapse and 5 different types? Who does it affect and what are some RF’s?
Descent of the pelvic organs, caused by weakness of pelvic floor muscles
Types:
-> Uterine: prolapse of the uterus into the vagina
-> Cystocele: prolapse of the anterior vaginal wall involving the bladder
-> Rectocele: prolapse of the lower posterior vaginal wall involving the anterior wall of the rectum
-> Enterocele: prolapse of the upper posterior vaginal wall containing loops of small bowel
-> Vault prolapse: prolapse of the vaginal vault after hysterectomy
Affects 30-50% women aged 50+ years
- 9.3% incidence of pelvic organ prolapses
RF’s:
- Increasing age
- Parity
- Menopause
- Pelvic surgery
- Heavy lifting, chronic cough, high impact sports
- Spinal cord injury, muscular atrophy
