Gynae Flashcards
Summary of premenstrual syndrome?
Emotional + physical Sx women experience in luteal phase of normal menstrual cycles
Only in ovulatory cycles, not prior to puberty, in pregnancy, or after menopause.
Emotional: anxiety, stress, fatigue, mood swings.
Physical: bloating, breast pain.
Tx:
Mild: lifestyle, sleep, exercise, smoking, alcohol reg 2-3hrly small balanced meals, complex carbs
Mod: new gen COCP eg Yasmin
Severe: SSRI, continuously or just in luteal phase.
What is primary amenorrhoea?
defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
Causes of primary amenorrhoea?
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Mullerian agenesis (congen absence of part of uterus/ vagina),
5α reductase def (lack enzyme to form DHT, undergo virilisation in puberty),
constitutional delay
Kallman’
What is secondary amenorrhoea?
cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Causes of secondary amenorrhoea?
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis* / hypothyroidism
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Cervical stenosis, prev biopsy, curettage, infection. Absence of external OS + bulky uterus on exam
Pit tumours: compressive, ↑PRL
Depo = takes while to recover
Investigations for amenorrhoea?
exclude pregnancy with urinary or serum bHCG
full blood count, urea & electrolytes, coeliac screen, thyroid function tests
gonadotrophins
- low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels
- raised levels may be seen in PCOS
USS: outflow obstruction, Mullerian agenesis, androgen insensitivity
oestradiol
Management of primary amenorrhoea?
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
IVF
Management of secondary amenorrhoea?
exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
HPG disorder: exogenous gonadotropins
treat the underlying cause
IVF
What is cervical ectropion?
Eversion of endocervix, exposing columnar epithelium. Induced by high levels of oestrogen.
Normal physiological condition, adolescents, pregnancy + oestrogen contraceptives.
Features of cervical ectropion?
Vaginal discharge, non-purulent.
Post-coital bleeding, fine BVs in epithelium easily broken intercourse
Asymptomatic
Intermenstrual bleeding
Investigations for cervical ectropion?
Speculum: reddish appearance, ring around external OS.
Pregnancy
Triple swabs: any infection.
Cervical swab: rule out IEN.
Treatment of cervical ectropion?
Doesn’t require Tx unless symptomatic
1st: stop any oest containing meds, effective in majority.
Can be ablated, sig vaginal discharge until healing completed.
What is lichen sclerosus?
Inflammatory condition that usually affects the genitalia and is more common in elderly females.
Lichen sclerosus leads to atrophy of the epidermis with white plaques forming
AI disease
Can be precancerous
Features of lichen sclerosus?
white patches that may scar
itch is prominent
may result in pain during intercourse or urination
Diagnosis of lichen sclerosus?
usually made on clinical grounds but a biopsy may be performed if atypical features are present (woman fails to respond to treatment or there is clinical suspicion of VIN or cancer or pigmented areas)
Management of lichen sclerosus?
topical steroids and emollients
Follow-up: (6m)
increased risk of vulval cancer
What is pelvic organ prolapse?
Descent of pelvic organs into vagina due to weakness + lengthening of ligaments + muscles surrounding uterus, rectum, bladder.
It probably affects around 40% of postmenopausal women
Types of pelvic organ prolapse?
Uterine
Vault: hysterectomy, vault top of vagina.
Rectocele: post vaginal wall, rectum prolapse into vagina.
Cystocele: ant wall, bladder prolapse into vagina. Urethrocele cytourethrocele.
Enterocele: herniation of pouch of Douglas incl small intestine into vagina
RF’s for pelvic organ prolapse?
multiple vaginal deliveries
instrumental, prolonged or traumatic delivery
↑age
postmenopausal
obesity
chronic resp disease (coughing)
chronic constipation (straining)
spina bifida.
Features of pelvic organ prolapse?
Feeling of something coming down in vagina
Dragging or heavy sensation in pelvis
Urinary: incontinence, urgency, freq, weak stream, retention.
Bowel: constipation, incontinence, urgency
Sexual dysfunction: pain, altered sensation ↓enjoyment
Rectocele: constipation, faecal loading, women may use their fingers to press lump back allowing them to open bowels.
Investigation/examination for pelvic organ prolapse?
Empty bladder + bowel before exam
Sim’s speculum: U-shaped, single bladed, support ant/post vaginal wall whilst other vaginal walls examined. Woman can be asked to cough or bear down to assess full descent of prolapse
Grades: 0-4 (0 ischial level, 4 past Introitus)
Management of pelvic organ prolapse?
Pelvic floor exercises, WL, ↓caffeine
Vaginal oest cream
Ring pessary: give extra support to pelvic organs, clean + changed every 4 mnths. Shelf + Gellhorn (flat disc, stem sits below uterus, can’t have sex), donut/cube shaped. Hodge (rectangular, 1 side hooked around post cervix, other extends into vagina).
Surgery: mesh repairs, plastic mesh to support organs but not recommended.
Cystocele/ cystourethrocele: ant colporrhaphy, colposuspension
Uterine prolapse: hysterectomy, sacrohysteropexy
Rectocele: post colporrhaphy
What is pelvic inflammatory disease?
term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum.
It is usually the result of ascending infection from the endocervix.
RF’s - UPSI, IUD
Causative organisms of PID?
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Features of PID?
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
Chronic: low grade fever, WL, abdo pain
Investigation for PID?
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab - these are often negative
screen for Chlamydia and Gonorrhoea
Abundant WBC on saline microscopy of vaginal secretions, polymorphonuclear cells.
↑ESR, CRP
Transvaginal USS: tubal wall thickness, incomplete septae within tube, fluid in cul-de-sac, cog-wheel appearance on CS of tubal view tubo-ovarian abscess
Pelvic CT: thickened uterosacral ligaments, inflam changes of tubes + ovaries, abnormal fluid collection, reactive inflam.
Pelvic MRI: thickened, fluid-filled tubes, tubo-ovarian abscess, pyosalpinx.
Management of PID?
due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
oral ofloxacin + oral metronidazole OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole
mild - ntrauterine contraceptive devices may be left in
Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
Complications of PID?
perihepatitis (Fitz-Hugh Curtis Syndrome)
> occurs in around 10% of cases
> it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
Recurrent PID
Hydrosalpinx: fluid filled fallopian tube
Pyosalpinx: infected fallopian tube filled with purulent matter
Ovarian cancer
What is dyspareunia?
Deep or superficial
Deep indicates pathology: scarring, adhesions, endometriosis, masses restricting uterine motility
Acute onset indicates organic cause.
1°: since onset of sexual activity
2°: acquired over pts life
Bartholin’s: non-infectious occlusion of distal Bartholin’s duct, retention of secretions. Mass at inf aspect of labia majora, 5 or 7 o clock position, vulval pressure or fullness, pain during sitting/ walking. Dyspareunia.
Causes of superficial dyspareunia?
Abnormalities at introitus
Inadequate lube
Vaginismus
Overwork/depression
Relationship problems
Drug/alcohol problem
Hormonal changes
Vaginitis/vulvovaginitis - burning sensation with coitus, vulvar/ vaginal oedema, discharge, pruritis, dysuria, PV bleed, abdo pain, vaginal dryness.
Herpes simplex - intense vulvar pain, dysuria, burning, pruritis, fever + general malaise.
Vaginal atrophy - vaginal dryness, feeling of tearing during intercourse, post-coital bleeding, vaginal spotting, vaginal mucosa pale, lacks rugae.
Iatrogenic: meds, radiotherapy, COCP, antidepressant, some antihypertensives
Intersititial cystitis, UTI
Bartholin’s cyst.
What is vaginismus?
voluntary / involuntary contraction of pelvic floor muscles. Failure of penetration, affects gynae exam, tampon insertion, IUDs.
Management of dyspareunia?
Rule out organic cause
Relaxation techniques, self-exploration of genitals, insertion of vaginal trainers
Couple programs, CBT, sexual counselling
Lidocaine
HRT
Botox injections
Bartholin’s cyst: sitz bath, warm compress, marsupialisation, catheter drainage, surgical excision silver nitrate cauterisation alcohol sclerotherapy
What is female genital mutilation?
refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
Illegal FGM Act 2003
Cultural practice in girls before puberty. Africa: Somalia, Sudan, Eritrea, Yemen, Kurdistan, Indonesia, south + west Asia.
Classification of FGM?
Type 1 - Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2 - Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3 - Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4 - All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
Features of FGM?
Pain, bleeding, urinary retention, urethral damage
Incontinence
UTI, pelvic/ vaginal infections
Dysmenorrhoea
Sexual dysfunction
Dyspareynia
Infertility, pregnancy complications
Psychosocial issues + depression
↓engagement with healthcare + screening
RF’s for FGM?
From countries that practise FGM, having relatives affected
Pregnant women with FGM + female child.
Siblings/daughters of women affected by FGM
Women who decline exam or cervical screening
Present with complications of FGM
Management of FGM?
Mandatory to report all cases of FGM
Counselling
De-infibulation: T3, correct narrowing of vaginal orifice, improve Sx + try to restore normal function.
Re-infibulation: re-closure of vaginal orifice, requested after childbirth which is illegal.
What is polycystic ovarian syndrome?
complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age.
Ovaries contain large no of harmless follicles. Often unable to release egg, no ovulation.
XS androgen production
The aetiology of PCOS is not fully understood.
Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Hyperinsulinemia: theca cells express insulin receptors, XS insulin, division of theca cells, ↑LH receptors, hypothalamus ↑GnRH > ↑LH
Theca cells produce XS androstenedione, too much for granulosa cells to convert. Some goes into blood, converted to estrone by aromatase in adipose tissue, neg feedback. Block ant pit from releasing FSH/ LH, no LH surge, no dominant follicle, remains in ovary as cyst, or degen with other follicles, no ovulation.
XS adipose tissue, aromatase, converts androgens to oestrogen.
Features of PCOS?
subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
oily skin or sweating
depression + anxiety
sexual problems
Rotterdam criteria - oligoovulation or an ovulation, hyperandrogegism, polycystic ovaries on US (or ovarian volume of more than 10cm3)
Investigations for PCOS?
pelvic ultrasound: multiple cysts on the ovaries (12+ developing follicles in 1 overt or ovarian volume >10cm)
FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
check for impaired glucose tolerance - OGTT
Management of PCOS?
weight reduction if appropriate, stop smoking, orlistat > can restore fertility
if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed
Hirsutism and acne:
> a COC pill may be used help manage hirsutism. Possible options include a third generation (dianette) COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
> if doesn’t respond to COC then topical eflornithine may be tried
> spironolactone, flutamide and finasteride may be used under specialist supervision
> laser hair removal
> topical Tx for acne - retinoid, clindamycin, azelaic acid, tetracyline.
Infertility:
weight reduction if appropriate
supervised by a specialist.
letrozole, clomifene. 2nd line metformin
There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
gonadotrophins - follitropin alfa, follitropin beta, menotrophin.
IVF
Laparoscopic ovarian drilling: puncturing cystic ovary, induces ovulation can damage ovary. Doesn’t resolve overall hormonal imbalance.
RFs for PCOS?
AD
obesity
lack of PE
gestational DM.
Complications of PCOS?
Infertility: ↑testosterone + anovulation
CVD, non-alcoholic fatty liver, hypercholesterolemia, HTN, OSA, endometrial hyperplasia + Ca
Endometrial Ca, unopposed oest causes endometrial hyperplasia.
What is ovarian torsion?
the partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply. If the fallopian tube is also involved then it is referred to as adnexal torsion.
