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Phase 3a > Gynae > Flashcards

Gynae Flashcards

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1
Q

What is menarche?

+ when is normal

A

Onset of menstruation

Around 13 usually

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2
Q

At what age would you class puberty as being early in females / males?

A

Females <8

Males <9

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3
Q

At what age would you class puberty as being late in females / males?

A

Females >13

Males >14

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4
Q

What is the first sign of puberty in females?

A

Breast budding

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5
Q

What is the first sign of puberty in males?

A

Testicular enlargement

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6
Q

What stimulates the production of secondary sexual characteristics in females?

A

FSH + LH –> oestrogen

This is thelarce

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7
Q

What is menorrhagia?

A

Heavy menstrual bleeding
Over 80ml loss in one cycle
Affecting quality of life - physical, emotional, social

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8
Q

What would be classed as irregular periods?

A

Period outside of 23-35 day cycle with variability of more than 7 days between shortest and longest cycle

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9
Q

What is primary amenorrhoea?

A

Never had a period by 16

Or by 14 if no development of secondary sexual characteristics either

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10
Q

What is secondary amenorrhoea?

A

Previously had periods but no period for 6 months or more

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11
Q

What is oligomenorrhoea?

A

Infrequent periods - between 35 and 6 months between periods

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12
Q

What is post-menopausal bleeding?

A

Bleeding more than 1 year after menopause

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13
Q

What is dysmenorrhoea?

A

Painful periods

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14
Q

What are the causes of menorrhagia?

A 
primary - unknown
secondary;
- uterine fibroids
- polyps
Less common:
- PID
- endometrial / cervical cancers
- coagulopathies - very rare
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15
Q

What would you ask for in the history of a patient with menorrhagia (to establish its existence)?

A

flooding - flooding sanitary towels / having to change tampons excessively / using both
passing clots bigger than a 10p piece

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16
Q

How would you investigate a patient with menorrhagia?

A

Look for signs of anaemia
Masses - uterine (fibroids), ovarian (cancer)
Tenderness on examination - adnomyosis
Bloods - anaemia, coag screen, TFTs
TVUS (endometrial thickness / fibroids / ovarian mass) - biopsy if indicated

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17
Q

When would you biopsy a patient with menorrhagia who has had a TVUS?

A

POST MENOPAUSAL
Endometrial thickening of more than 4mm if symptomatic
More than 11mm if asymptomatic

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18
Q

How would you treat a patient presenting with menorrhagia?

A

First line = IUS
Second line = Tranexamic acid / Mefanamic acid
Third line = progestogens or GnRH agonists
Last resort = surgery

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19
Q

What are the differentials for dysmenorrhoea?

A 
Primary - at the start of menstruation = common
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumours
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20
Q

How would you treat primary dysmenorrhoea?

A

NSAIDs, COCP

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21
Q

What are the causes of IMB?

A

Non-malignant:

  • Fibroids
  • Polyps
  • Adenomyosis
  • Ovarian cyst
  • PID

Malignant - endometrial cancer

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22
Q

How would you investigate a patient with IMB?

A

Assess blood loss
FBC, coag screen, TFTs
TVUS - endometrial thickness - biopsy if needed

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23
Q

How would you manage a patient with IMB?

A

IUS or COCP
High dose progesterone to cause amenorrhoea - but withdrawal bleed occurs
HRT in perimenopause

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24
Q

CASE

A patient with pain that starts a few days before menstruation and ends 1-2 days after bleeding starts
+ pain during sex

A

Endometriosis

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25
What is endometriosis?
Presence / growth of endometrial tissue outside the uterus
26
Where are the common sites of endometriosis?
``` Uterosacral ligaments Ovaries Vagina Rectum Bladder ```
27
What are the complications of endometriosis?
Chocolate cysts | Fibrosis and adhesions
28
What are the typical features of endometriosis?
Cyclical pain with menstruation (starts a few days before) Deep dyspareunia Subfertility Acute pain if rupture of chocolate cyst Can be haematuria or rectal bleeding if tissue on bladder or rectum
29
How would you investigate a patient with suspected endometriosis?
O/E - tender and thickened adnexa TVUS to exclude ovarian endometrioma (remove in case ovarian malignancy) Gold standard = laparoscopy to see the lesions
30
How would you treat a patient with endometriosis?
NSAID - ibuprofen, naproxen, mefanamic acid If don't want to get preggo: - Tricyclic COCP - Oral progesterone pill / depot / IUS NSAID + analgesia GnRH analogue Surgical - diathermy, dissection of adhesions, removing endometriomas, hysterectomy
31
What might you find on examination of a patient with endometriosis?
Tenderness and thickening in the adnexae Adnexal masses - endometriomas Retroverted / immobile uterus - adhesions Rectovaginal nodule on digital exam
32
What are the risk factors for endometriosis?
Nulliparous | Family history?
33
What are the complications of endometriosis?
Subfertility | Frozen pelvis
34
What are fibroids?
Benign growths of the endometrium
35
What are the risk factors for fibroids?
Afro-Caribbean | Family history
36
What are the protective factors for fibroids?
COCP Parity + are oestrogen dependent so regress after menopause
37
What are the possible locations for fibroids?
``` Subserous polyp Subserous Intracavity polyp Intramural Submucosal Cervical ```
38
What are the complications of fibroids in pregnancy?
``` Can grow (1/3) Premature labour Malpresentation (transverse lie) Obstructed labour PPH Red degeneration Torsion of pedunculated fibroid after birth - pain ```
39
What are the complications of fibroids?
``` Pregnancy stuff Torsion Calcification after menopause Red degeneration Malignancy (0.1%) ```
40
What symptoms can fibroids cause?
Menorrhagia Dysmenorrhoea Depending on location - urinary frequency, infertility
41
How would you investigate a patient with suspected fibroids?
``` Abdo / bimanual exam for masses TVUS MRI Laparoscopy Hysteroscopy or hysterosalpingogram ```
42
How would you manage a woman with fibroids?
If asymptomatic - just annual check up to see size and growth If menorrhagia + less than 3cm with no distortion of the uterine cavity: - 1st line IUS - 2nd line tranexamic acid (anti-fibrinolytic) - 3rd line norethisterone from day 5-26 Surgical - resection, ablation, myomectomy, uterine artery ablation
43
What are the differentials for cervical excitation?
PID | Ectopic pregnancy
44
CASE Obese lady who has always had irregular periods, bad acne, issues with facial hair and is now trying to get pregnant with difficulty. Differential?
PCOS | Polycystic ovary syndrome
45
What are the pathophysiological features of PCOS?
Disordered LH production Peripheral insulin resistance (so raised insulin levels) Increased androgens
46
What are the clinical features of PCOS?
Oligo/amenorrhoea Obesity Acne Hirsutism
47
What would you see on examination of a patient with PCOS?
``` High BMI Hirsutism Acne Alopecia Acanthosis nigrans ```
48
How would you investigate a patient with suspected PCOS?
Day 2-5 LH and FSH for ovulation TFTs - exclude hyper/hypothyroidism Prolactin - exclude hyperprolactinaemia Testosterone If hyperandrogenism - DHEAS (dihydroepiandosterone sulfate), SHBG (sex hormone binding globulin) Exclude other causes of primary oligo/amenorrhoea Pelvic USS
49
How would you make a diagnosis of PCOS?
Rotterdam criteria 2 of: - Oligo/anovulation - Hyperandrogenism - hirsutism, acne, alopecia, or biochemical - Polycystic ovaries on USS - >12 antral follicles on one ovary, 2-8mm in size, in enlarged ovary >10mm
50
How would you treat a patient with PCOS (not wanting to get pregnant)?
Weight loss + exercise COCP Antiandrogens
51
How would you treat a patient with PCOS (wanting to get pregnant)?
Metformin | Clomiphene
52
How would you treat a patient with severe PCOS not responding to treatment?
Laparoscopic ovarian drilling
53
CASE A 29 year old presents having collapsed at home following severe abdominal pain and bleeding. Diagnosis?
Ectopic pregnancy until proven otherwise
54
What is ectopic pregnancy?
Implantation of the embryo outside the uterine cavity
55
What are the risk factors for ectopic pregnancy?
``` PID Previous pelvic / tubal surgery Assisted conception Previous ectopic Smoking ``` + rule out in a woman with an IUD - prevents intrauterine pregnancies but not tubal ones
56
What are the clinical features of ectopic pregnancy?
Abnormal vaginal bleeding - dark Abdominal pain ± collapse Amenorrhoea of 4-10 weeks Shoulder tip pain
57
What would you see on examination of a woman with ectopic pregnancy?
``` Tachycardia (blood loss) Abdominal / rebound tenderness Cervical excitation Adnexal tenderness Closed os ```
58
How wold you investigate a woman with a suspected ectopic pregnancy?
Pregnancy test - urine bhCG TVUS Serum hCG >1000IU/ml (declining / slow rising levels) Diagnostic laparoscopy
59
What would you see on a TVUS in an ectopic pregnancy?
Empty uterus Free fluid Mass - tubal / elsewhere
60
From beta hCG levels, how would you distinguish between a viable uterine pregnancy and an ectopic pregnancy?
Raising = viable uterine | Declining / slow rising = ectopic or non-viable intrauterine
61
What is incontinence?
Involuntary leakage of urine
62
What can cause incontinence?
``` Stress incontinence Detrusor overactivity Fistula Neurological Overflow Functional Mixed Incontinence ```
63
What are the symptoms associated with detrusor overactivity?
Urge incontinence ``` Frequency Nocturia Nocturnal enuresis ‘Key in the door’ ‘Handwash’ Intercourse ```
64
What are the symptoms associated with stress incontinence?
``` Involuntary leakage with increased intra-abdominal pressure Cough Laugh Lifting Exercise Movement ```
65
How would you investigate a patient with urinary incontinence?
Bladder diary - frequency volume chart Urinalysis Residual urine measurement Questionnaire - ePAQ + assess pelvic floor muscles, prolapse + residual urine volume (post-void volume) - cystometry + urodynamic testing after conservative management
66
How would you manage stress incontinence?
Conservative = Kegel exercises SNRI - duloxetine - enhances the urethral sphincter Surgery = sling / suspension
67
How would you manage overactive bladder (detrusor overactivity)?
``` Bladder drills Anticholinergic drugs - oxybutynin Botox Augmentation Bypass ```
68
What lifestyle measures would you give to someone with urinary incontinence?
``` Avoid caffeine Modify fluid intake Weight loss Avoid straining Stop smoking ```
69
What medication would you use to treat detrusor overactivity? + side effects
Anti-cholinergic eg Oxybutynin, Tolterodine SE = dry mouth, constipation, drowsiness, blurred vision
70
What are the options for incontinence before surgery?
``` Lifestyle Containment options: - Catheters - Leakage barriers - pads and pants - Vaginal support devices - Skin care - Odour control ```
71
What are the symptoms of utero-vaginal prolapse?
Feeling like something is coming down / dragging sensation Lump Discomfort Pelvic floor + sexual symptoms
72
How would you investigate a patient with suspected prolapse?
Sims speculum examination
73
What are the treatment options for uterovaginal prolapse?
Lifestyle - lose weight etc Conservative = pessaries Surgical (eg hysteroplexy, sacroplexy, anterior or posterior wall repair) Oestrogen replacement - adds turgor to the vagina
74
What are the types of prolapse?
``` Frontal = urethrocoele or cystocoele Apical = uterine prolapse Back = enterocoele (small bowel) or rectocoele (rectum) ```

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