Gynae Flashcards
(65 cards)
1
Q
What are some causes of HMB?
A
PALM COIEIN
PALM: Structural causes
- Polyp
- Adenymyosis
- Leimyosis (fibroid)
- Malignancy + hyperplasia
COEIN
- Coagulatopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classifed
2
Q
What are some of the causes of HMB/ AUB?
A
- Pathology: Fibroids, Adenomyosis / endometriosis, IUCD, PID, Polyps
- Medical disorders: Hypothyroidism, Liver disease
- Abnormal clotting: von Willebrand’s, thrombocytopenia, platelet disorders, coagulation disorders, leukaemia.
- Other: Cancer/hyperplasia
3
Q
How can HMB be managed?
A
- Medical
- Symptomatic: tranexamic acid, mefanamic acid
- Fibroids: GnRH analogues e.g. goserelin, ulipristal acetate
- Hormonal: POP, LARC: mirena IUS, implant, depo provera, COCP
- Surgical
- Polyps: hysterocopic removal of polyps (myosure), myomectomy, uterine a. embolisation, endometrial ablation, hysterectomy
- short term control: norethisterone, GnRH analogues
4
Q
What are some of the causes of 1o +2o amenorrhoea?
A
Primary: delayed puberty, obstructive issues: imperforate hymen, transverse septum, Müllerian a genesis (no uterus), Turner syndrome (gonadal dysgenesis), PCOS (less common in primary)
Secondary: Prolactinoma, Thyroid disease Cushing’s, Eating disorder, Exercise induced, Asherman Syndrome, Sheehan Syndrome
- Physiological: prepubertal, pregnancy, menopause
-
Cryptomenorrhea:
- Haematocolpos: vagina is pooled with menstrual blood due to multiple factors
- Haematometra: retention of blood in the uterus. Causes: imperforate hymen or transverse vaginal septum
- Uterine, ovarian failure, hypothalmic
5
Q
What ix are used for 1o + 2o amenorrhea?
A
+ USS FOR PCOS
6
Q
How do tranexemic acid + mefanamic acid work?
A
Tranexamic Acid: Antifibrinolytic
- Inhibit plasminogen activation (inhibit tPA, and uPA), thus reduce fibrinoysis
- Reduces MBL by 50%
- Side effects: Nausea, dizziness, tinnitus, rash, abdominal cramp
- Low incidence of thrombotic disorders
Mefanamic: NSAID
- Inhibit the production of PG and inhibit the binding of PGE2 to its receptor
- Reduces MBL by 20-44.5%
- Side effects: gastrointestinal (50%) usually mild. Dizziness and headaches 20%, deranged liver function, asthma, renal disease.
7
Q
How would u clinically examine/ investigate someone with HMB?
A
- Examination: abdominal palpation, speculum and bimanual examination
- Assess for: pallor, palpable uterus/ pelvic mass
- Smooth or irregular uterus (fibroids)
- Tender uterus/ cervical excitation – adenomyosis/ endometriosis
- Inflamed cervix/ cervical polyp/ tumour
- Vag tumour
- Ix: FBC, coagulation disorders (vWB)
- Hysteroscopy may be needed + biopsy (endometrial - >45 and failure of treatment)
- Imaging: pelvic US, If a woman declines transvaginal US, consider transabdominal ultrasound or MRI
- Other not routine: TFTs (hypothyroidism); hormones (PCOS)
8
Q
What is 1o + 2o amenorrhoea?
A
- Primary: No menarche by age 16
- Secondary: absent period for 3/12 cycles if cycles previously regular. Absent periods for at least 6/12 if previously had oligomenrrhoa
9
Q
What is oligomenorrhea + some of its causes?
A
10
Q
What are the features of male vs female anovulation in terms of history, examination, investigations and mx?
A
11
Q
What is PCOS?
A
- Heterogenous endocrine disorder with unknown aetiology
- Familial clustering
12
Q
What are the features and sx of PCOS?
A
- Features: hyperandrogenism: acne, hirsutism, obesity, chronic pelvic pain, depression, oligo/amenorrhoea
-
On examination: hirtuism, acne, acne, acanthosis nigricans (darkened skin, which occurs secondary to insulin resistance), male pattern hair-loss, obesity and/or hypertension.
- Multiple ovarian follicles on USS (12 or more in one or both ovaries)
- Increased ovarian volume > 10cm3
13
Q
How is PCOS diagnosed (criteria)?
A
Diagnosis: Rotterdam criteria:two out of three features must be present
- Clinical or biochemical signs of hyperandrogenism
- Oligo amenorrhoea
- USS features of polycystic ovaries
14
Q
What are the Ix for PCOS?
A
- Ix: sex binding globulin (↓), total testosterone (↑), free androgen Index (FAI), FSH (normal), LH (↑), TFT prolactin, progesterone (↓),
- Other: glucose tolerance test
- Imaging: USS - peripheral ovarian follicles and ovarian volume >10cm
15
Q
How is PCOS managed?
A
- Conservative: weight loss, encourage healthy lifestyle; assess mental wellbeing and refer appropriately, fertility assessment and referrals
- Medical – depends on needs
- Wants regular periods: COCP + Cyclical progestogens (dydrogesterone)
- Obesity: orlistat - (pancreatic lipase inhibitor)
-
Infertility: reduce BMI, folic acid, baseline fertility assessment and referral to fertility services, possible ovarian induction
- 1st line: Clomifene +/- metformin – controversial – SE: increased risk of multiple pregnancies, ovarian hyperstimulation syndrome and ovarian cancer (so it is limited to use in 6 cycles).
- Laparoscopic ovarian drilling: if BMI normal
-
Acne and Hirsutism: COCP
- Anti-androgen medication such as cyproterone, spironolactone or finasteride.
- Eflornithine is a topical cream that can also be used to help reduce the growth rate of facial hair.
- Treatment for acne - retinoids, antibiotics etc as per dermatology
16
Q
What are the complications of PCOS?
A
- Metabolic disorders – impaired glucose tolerance and T2DM, CVS, obstructive sleep apnoea
- Gynae: infertility, recurrent miscarriage, pregnancy complications (pre eclampsia and gestational diabetes
- Endometrial cancer
- Psychological disorders: anxiety + depression
17
Q
What is the definition of oligomenorrhoea and its causes?
A
- Infrequent periods
-
Cycle > 35 days but <6 months in length
- Causes: constitutional, anovolution: PCOS, thyroid disease, prolactinoma,
18
Q
What is the definition of secondary and primary amenorrhoea and its causes?
A
-
Primary: No menarche by age 16
- Causes: delayed puberty, obstructive issues: imperforate hymen, transverse septum, Müllerian a genesis (no uterus), Turner syndrome (gonadal dysgenesis), PCOS (less common in primary)
-
Secondary: absent period for 3/12 cycles if cycles previously regular.
- Absent periods for at least 6/12 if previously had oligomenrrhoa
- Causes: Prolactinoma, Thyroid disease Cushing’s, Eating disorder, Exercise induced, Asherman Syndrome, Sheehan Syndrome
Causes
- Physiological: prepubertal, pregnancy, menopause
-
Cryptomenorrhea: menstruation occurs but is not visible due to obstruction of the outflow tract.
- Haematocolpos: vagina is pooled with menstrual blood due to multiple factors
- Haematometra: retention of blood in the uterus. Causes: imperforate hymen or transverse vaginal septum
- Uterine, ovarian failure, hypothalmic
19
Q
What is chronic pelvic pain?
A
- Intermittent or constant pain in the lower abdomen or pelvis (sx and not a diagnosis)
- At least 6 months in duration
- Not occurring exclusively with menstruation or intercourse and not associated with pregnancy
20
Q
What are some of the cause of Chronic Pelvic Pain
A
- Causes: PID, adenomyosis, endometriosis, adhesions (residual ovary syndrome and trapped ovarian syndrome), IBS, interstitial cystitis
21
Q
What is the pathophysiology of chronic pelvic pain?
A
- Acute pain - resolve when tissue heals
-
Chronic pain - additional factors contribute hence pain persist longer
- Local factors at the site of pain - chemokines and TNF ⍺ affect peripheral nerves
- Central nervous system response - persistent pain lead to changes within the central nervous system which eventually magnify the original signal.
- Visceral hyperalgesia - Alteration in visceral sensation and function
-
Pelvic pain can be multifactorial
- IBS or endometriosis, adenomyosis MSK, PID, Interstitial cystitis, adhesions (intraabdo), social and psychological factors
22
Q
What investigations are important for chronic pelvic pain?
A
- History and examination
- Bloods, CA125; STI screening: Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of pelvic inflammatory disease (PID).
- Imaging: TVS, MRI. Gold standard: Diagnostic laparoscopy
23
Q
What is endometriosis?
A
- Presence of endometrial glands and stroma like lesions outside of the uterus
- Predominantly found in the pelvis: can occur in the ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs.
- Peritoneal lesions, superficial implants or cysts (chocolate cysts) on the ovary, or deep infiltrating
- Responds to cyclical hormonal changes and bleeds at menstruation
24
Q
What are some of the RFs for endometriosis?
A
- Early menarche
- FH of endometriosis
- Short menstrual cycles
- Long duration of menstrual bleeding
- Heavy menstrual bleeding
- Defects in the uterus or fallopian tubes
25
How does endometriosis present?
* Painful periods (**dysmenorrhea**),
* Painful intercourse (**dyspareunia**),
* Painful defecation (**dyschezia**) and
* Painful urination (**dysuria**)
* HMB
* Lower abdominal pain persistent
* IMB and PCB
* Epistaxes , rectal bleeding
* Little correlation between symptom severity and disease severity
26
What are some of the clinical fx found on examination for endometriosis?
* NAD
* Thickened uterosacral ligaments
* Adnexal masses
* Fixed retroverted uterus
* Uterine/ovarian enlargement
* Forniceal tenderness
* Uterine tenderness
* **Speculum:** may show visible lesions in vagina or cervix (rare)
27
* What are some of the visible features of endometriosis on laparoscopy?
* Powder burn depsoits
* Red flame hamorrhaghes
* Scarring
* Peritoneal defects
28
What are some of the Ix used for endometriosis?
* **TVS** – for ovarian cysts but useless for identifying other parameters of disease
* Bowel involvement: MRI, CA125 (raised but not used as a screening tool)
* **Gold standard: laparoscopy with biopsy –** important for diagnosis of infiltrating lesions and should be avoided within 3 months of hormonal therapy due to under diagnosis
29
How is endometriosis managed?
* **Management**: cure after treatment not guaranteed,
* Treatment depends on: fertility issues, type and severity of symptoms, therapies tried and failed
* 1st: NSAIDs + paracetemol
* Medical: **Hormonal medical therapies that suppress ovulation:**
* COCP, continuous progrestogen therapy MPA.
* 3rd: GnRH analogues (nasal spray, implants) +/- HRT
* **Danazol, mefenamic acid/ tranexamic acid**
* **4th: Surgical**: laparoscopic – diathermy, laser ablation, excision
* **TAH + BSO**: risk of bladder, ureteric bowel injury, subtotal hysterectomy, role of HRT – either open or lap
30
What is adenomyosis?
* Presence of **endometrial tissue** within the **myometrium** of the uterus
* Thought to occur when the **endometrial stroma** (connective/supporting tissue) is allowed to communicate with the underlying myometrium after uterine damage. Can occur in:
* Pregnancy and childbirth, previous C section
* Uterine surgery (e.g endometrial curettage)
* Surgical management of miscarriage or termination of pregnancy
31
What is the aetiology of adenomyosis?
1. Retrograde menstruation (Sampson’s theory)
2. Coelomic metaplasia (Meyer’s theory)
3. Müllerian remnants
32
What are some of the RFs for adenomyosis?
* High parity
* Uterine surgery
* Previous C-section caesarean section
* Hereditary
33
What are the investigations for adenomyosis and what can be seen on examination?
* S**ymmetrically** **enlarged tender uterus** may be palpable.
* Ix:
* TVS:
* Globular uterine configuration
* Poor definition of the endometrial-myometrial interface
* Myometrial anterior-posterior asymmetry
* Intramyometrial cysts and a heterogeneous myometrial echo texture.
* **MRI** – shows an ‘endo–myometrial junctional zone’
34
By what aetiology are adenomyosis and endometriosis thought to arise?
1. Mullerian remnants
2. Retrograde menstruation - Sampson theory
3. Coloemic metaplasia - Meyers theory
35
What are some of the causes of pelvic pain adhesions?
How can these be managed
* Vascular adhesions
* Residual ovary syndrome – ovary or component of ovary which cannot be removed. E.g. hysterectomy but the ovary was left
* Trapped ovary syndrome
Management
* Medical: GnRH agonists
* Surgery: division of vascular adhesions, removal of residual ovaries
36
Another cause of chronic pelvic pain is IBS. What diagnostic criterias are required for IBS to be diagnosed?
* **ROME III CRITERIA-THE DIAGNOSIS OF IBS**
* Continuous or recurrent abdominal pain or discomfort on at **least 3 days a month** in the last **3 months**
* Onset at least **6 months** previously
* Associated with at least **two** of the following:
* ***Improvement** with **defecation***
* *Onset associated with a change in **frequency** of stool*
* *Onset associated with a change in the **form** of stool.*
37
What is PID? How is it caused?
* Infection of the upper genital tract. Many cases go undetected due to lack of symptoms so difficult to ascertain
* Causes: ascending **infection** from endocervix: STI: *chlamydia* and *gonorrhoea*
* **Uterine instrumentation** (e.g. hysteroscopy), IUCD insertion, TOP
* **Post partum**
38
What organisms commonly cause PID?
* ***Chlamdydia***: 14-35% of causes. 10-20% untreated infections -\> PID
* 10% of women with untreated chlamydia may develop PID within 12 months of infection
* Risk increases with subsequent infections – hypersensitivity response
* *Gonorrhoea*
* 10-19% of infections -\> PID
* *Gardnerella vaginalis/ anaerobes* (prevotella, atopobium, leptotrichia) – more common in older women
* *Mycoplama genitalium/ mycoplasma hominis*
39
What are some of the long term complications of PID?
* Ectopic pregnancy
* Chronic pelvic pain (due to adhesions)
* Tubo ovarian abscess (more common with NG)
* **Fitz hugh Curtis syndrome**: RUQ, perihepatitis, more commonly associated with chlamydia PID
* Violin string adhesions in peritoneal cavity and attach themselves to liver capsule inflammation with perihepatic adhesions
* Subfertility from tubal blockage
40
What are the RFs for PID?
* young age \<25
* Previous PID
* TOP/ miscarriage
* STI: chlamydia, gonorrhoea
* Coil insertion
* Douching (increased risk of BV)
* New sexual partner
* Instrumentation of uterus
* Hx of multiple partners
41
What are some of the symptoms of PID?
* Lower abdo pain (bilateral)
* Deep dyspareunia
* Abnormal PV discharge (purulent)
* Abnormal vaginal bleeding: **IMB** or PCB**.**
* Fever + chills – **gonococcal**
* ASSYMPTOMATIC
42
What are some of the signs of PID?
* Lower abdo tenderness (bilateral)
* Speculum: abnormal/ purulent vaginal disrhcage,
* **Cervical motion tenderness**
* **Bilateral adnexal tenderness + mass** (if tubo ovarian abscess)
* **F**ever 38
* When taking swabs: Contact bleeding from cervix (**cervicitis**)
43
What are some of the differentials for PID and what is most important to rule out?
What Ix would you use to do this?
* Ectopic pregnancy: pregnancy test
* GI: IBD, IBS, appendicits
* Endometriosis
* UTI: cystitis
44
How would you investigate PID?
* Bloods: elevated WCC, CRP, ESR
* STI screening: NG, CT, MG, BV
* Gram stain microscopy
* Imaging (limited use):
* USS:hydrosalpinx/ free fluid/ abscess
* MRI/ CT
* Laparoscopy
45
How is PID managed?
* C: rest, analgesia
* Admit if: if temp \>38), admit + observe I severe disease, pregnant or suspected tubo ovarian abscess.
* M: **Broad spectrum abx**: (OP regimen)
* **500mg IM Ceftriaxone**
* **100mg Doxycyline BD PO 14 days**
* **400mg Metranidazole BD PO 14 days**
* IP regimen - cont'd till 24h post improvement then switch to oral
* IV **Ceftriazone** 2g OD
* IV **doxycycline** 100mg BD
* Surg: lap draiange +/- division of adhesions
46
What are **fibroids**?
* **Benign smooth muscle tumours** arising from the uterus Their production is oestrogen dependent
* They are the most common **benign** tumour in women of **reproductive age** (20-40%)
* Risk of malignancy is v. **low** (\<0.1%)
47
What are the different types of fibroids?
* **Intramural** - most common
* **Submucosal** - develops immediately underneath the endometrium of the uterus, and protrudes into the uterine cavity.
* **Subserosal** - protrudes into and distort the serosal (outer) surface of the uterus. They may be pedunculated (on a stalk).
48
What are some of the RFs of fibroids?
* Increasing age
* Obesity
* Early menarche
* FH
* Ethnicity - more common in african americans
49
What are some of the symptoms of fibroids?
What are the features of examination?
* Menorrhagia (\>7 days) - PMB and IMB is rare
* Dyspareunia
* Lower abdominal pain
* Acute pelvic pain - worse during menstruation
* Feeling of abdominal fullness - distension, pressure sx
* Subfertility
50
What are the features of fibroids on examination and what investigations are used?
* **Examination**: **Non tender solid mass** or enlarged uterus
* Ix: hysteroscopy
* USS
* Pelvic MRI - rare. Usually used pre surgically only
51
How are fibroids managed?
52
What are some of the complications of fibroids?
* HMB, iron deficiency anaemia
* Reduced fertility
* Pregnancy complications: miscarriages, premature labour and obstructive delivery
* Constipation, Urinary outflow obstruction and UTIs
* **Red degeneration of the fibroid** - ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
* **Torsion of the fibroid**, usually affecting pedunculated fibroids
* **Malignant change** to a leiomyosarcoma is very rare (\<1%)
53
What is infertility?
* Defined as the inability to conceive after 12 months of regular unprotected intercourse:
* Prevalence is ~ 14% of couples
54
What are some of the causes of infertility?
* Tubal disease 20%
* Male factors 30%
* Ovulation defects 25%
* Unexplained infertility 25%
* Uterine factors
* Endometriosis
55
What are some of the primary causes of anovulation
* Weight
* PCOS
* Hyperprolactinaemia
* Ovarian failure
56
What Ix are used for measuring incontinence?
Subjective
* Diaries
* Pad tests
Objective
* Urinalysis
* Ultrasound/IVP
* Cystoscopy
* Urodynamics
57
What quantitative questionnaires are used for incontinence?
King’s Health Care
BFLUTs
IIQ & UDI
58
What are some of the causes of incontinencne?
Urodynamic stress incontinence
Detrusor overactivity
Mixed incontinence
Other stuff
59
Define urodynamic stress. incontinence and what is seen?
* Incompetent urethral sphincter: childbirth, menopause, prolapse, chronic cough
* Involuntary leakage of. urine on exertion, sneezing, coughing
* Detrustor pressure \> closing pressure of urethra
* Positional displacement (most)
* Intrinsic weakness (few)
Ix
* Mobile bladder neck
* May be prolapse: cystocoele, urethrocoele
Cystometry
* Normal capacity bladder
* leakage in **absence of detrusor pressure rise**
* provoked by **cough test**
* usually **small to moderate loss**
60
Define what is seen in Detrusor overactivity?
* Uncontrolled and unprovoked detrusor muscle activity - pressure generated exceeds sphincter tone
* Often occurs in patients with a history of childhood UTIs
* May occur as a new problem following incontinence surgery
* Remember **neurological disease**
Findings: **often little**
* may demonstrate leakage on coughing
* Signs of NS involvement eg MS
Cystometry
* reduced capacity bladder
* leakage with detrusor pressure rise
* often large loss
* triggers include running water, washing hands
*
61
How is incontinence mxd?
62
What needs to be offered before a TOP?
* Offer counselling and support
* **Ultrasound** – confirm gestation and identify non viable or ectopic pregnancies
* **Chlamydia + STI screening**
* **Antibiotic prophylaxis**- to reduce post op infection rate
* **Metronidazole 1g PR at TOP + azithromycin**
* **Contraception** – discuss – IUCD, sterilisation, pills
* **Bloods: Hb, ABO, Rh – d – anti D** must be given, **HIV, anti bodies, hep B+C, haemoglobinopathies**
63
What medications are used for TOP
64
How is a TOP carried out?
* \<9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (misoprostol) to stimulate uterine contractions
* \< 13 weeks: surgical dilation + suction of uterine contents
* \>15 weeks: surgical dilation + evacuation of uterine contents or late medical abortion (induces 'mini-labour')
65
What is needed for TOP?
* **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**
