Gynae

Question 1

what are the 2 most common causes of menorrhagia and 2 rarer causes?

Answer 1

fibroids and polyps

thyroid disease and haemostasis

Question 2

what is the subtle abnormalities that cause menorrhagia in women with regular cycles?

Answer 2

endometrial fibrinolytic

uterine prostaglandins

Question 3

what investigations would you do for heavy bleeding?

Answer 3

Hb-for blood loss
exclude systemic causes e.g. coagulation and thyroid causes
transvaginal US-assess uterine thickness for fibroids, intrauterine polyps
endometrial biopsy-exclude malignancy and pre malignancy
hysteroscopy-allows inspection of the uterine cavity-detects polyps and sub mucous fibroids

Question 4

treatment for menorrhagia?

Answer 4

1st line-IUS (copper coil) reduce by 90%
2nd line-anti-fibrinolytic (tranexamic acid), NSAIDs (mefanamic acid, inhibit prostaglandin synthesis), COCP (less effective if pathology)
3rd line-hysteroscopic

Question 5

list some of the hysteroscopic procedures to stop menorrhagia?

Answer 5

polyp removal
endometrial ablation
Transcervical Resection of fibroid
myomectomy (removal of fibroid from myometrium)
hysterectomy (last resort)
uterine artery embolisation (treats menorrhagia due to fibroids)

Question 6

list some causes of irregular and Intermenstrual bleeding

Answer 6

fibroids 
uterine and cervical polyps 
adenomyosis 
ovarian cysts 
chronic pelvic cysts 
malignancy-particularly endometrial (but also cervical and ovarian)

Question 7

investigations for irregular and intermenstrual bleeding

Answer 7

assess blood loss
exclude malignancy-smears
USS-masses
endometrial biopsy

Question 8

what are the causes of physiological amenorrhoea?

Answer 8

pregnancy
menopause
lactation

Question 9

what is hypogonadism and what are the 2 types?

Answer 9

hypogonadism refers to the lack of sex hormones
hypogonadotropic hypogonadism: lack of production of LH, FSH
hypergonadotropic hypogonadism: lack of response to LH and FSH (therefore low levels of oestrogen have a negative feedback causing high levels of LH and FSH)

Question 10

what are some causes of primary amenorrhoea?

Answer 10

hypogonadotropic hypogonadism 
hypergonadotropic hypogonadism
kallman syndrome 
congenital adrenal hyperplasia 
androgen insensitivity syndrome 
structural pathology

Question 11

what are the causes of secondary amenorrhoea?

Answer 11

pregnancy 
menopause 
hormonal contraception 
hypothalamic or pituitary pathology 
PCOS 
uterine pathology such as ashermans
thyroid pathology 
hyperprolactinaemia

Question 12

what is the definition of secondary amenorrhoea?

Answer 12

no menstruation for more than three months after previous regular menstrual periods
consider assessment and investigation after three to six months

Question 13

what happens when there is a low body weight or psychological stress for example leading to amenorrhoea?

Answer 13

hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress

Question 14

what are the pituitary causes of secondary amenorrhoea?

Answer 14

pituitary tumours such as prolactin secreting prolactinoma

pituitary failure due to trauma, radiotherapy, surgery or sheenan syndrome

Question 15

what hormone tests are done for secondary amenorrhoea?

Answer 15

bHCG, 
LH, FSH 
prolactin 
TSH 
testosterone

Question 16

what are the causes for post-coital bleeding?

Answer 16

cervical carcinoma
ectropion (when surface isn’t covered in healthy squamous epithelium)
benign polyps
atrophic vaginitis (bleeding from the vaginal wall)

Question 17

investigations and management for postcoital bleeding?

Answer 17

cervix is carefully inspected and smear taken
polyps avulsed and sent for histology
smear normal: cryotherapy
smear abnormal: colposcopy (rule out malignancy)

Question 18

what is the difference between primary and secondary dysmenorrhoea?

Answer 18

primary: no organic cause found, coincides with menstruation and responds to NSAIDs
secondary: when pain is due to pelvic pathology and often precedes or relived by menstruation

Question 19

what is dysmenorrhoea?

Answer 19

painful menstruation associated with high prostaglandin levels in the endometrium
due to high contraction and uterine ischaemia

Question 20

causes of secondary dysmenorrhoea?

Answer 20

fibroids
adenomyosis 
endometriosis 
pelvic inflammatory disease 
ovarian tumours

Question 21

what is precocious puberty?

Answer 21

menstruation before the age of 10 years or secondary sexual characteristics before the age of 8 years

growth spurt occurs early but final height is reduced due to early fusion of the epiphyses

Question 22

what is the treatment for precocious puberty?

Answer 22

GnRH agonists used to inhibit sex hormones

causes regression of secondary sex characteristics and cessation of menstruation

Question 23

what is a pathological cause for early onset puberty?

Answer 23

increased oestrogen secretion-hormone predicting tumours of the ovary or adrenal glands can cause premature sexual maturation

Question 24

what are the causes of ambiguous development?

Answer 24

congenital adrenal hyperplasia

androgen insensitivity syndrome

Question 25

what is congenital adrenal hyperplasia?

Answer 25

increased androgen function in the genetic female autosomal recessive result of 21 hydroxylase deficiency ACTH excess causes increased androgen production (androgen secreting tumours, Cushing's syndrome)

Question 26

what is androgen insensitivity syndrome?

Answer 26

reduced androgen function in genetic male therefore converted peripherally to oestrogen appear to be female but present with amenorrhoea

Question 27

what is premenstrual syndrome?

Answer 27

psychological, behavioural, physical symptoms that are experienced on a regular basis during the luteal phase of the menstrual cycle and resolve by the end menstruation dependent on normal ovarian function and progesterone (therefore exogenous progesterones cause PMS symptoms)

Question 28

presentation of premenstrual syndrome?

Answer 28

cyclical natura | tension, irritability, aggression, depression, loss of control

Question 29

treatments for premenstrual syndrome

Answer 29

SSRIs endometrial ablation-reduces hormones continuous oral contraceptive (containing drospirenone) HRT oestrogen GnRH agonist and add on oestrogen therapy

Question 30

what are fibroids?

Answer 30

benign tumours of myometrium (leiomyomata) oestrogen sensitive more common approaching menopause, those with family history less common in parous women or those on COCP or depo

Question 31

what are the different types of fibroids?

Answer 31

``` intracavity pedunculated submucosal (inner) subserosal (outer) intramural (inside wall) ```

Question 32

what is the presentation of fibroids?

Answer 32

menorrhagia, intermenstrual bleeding (submucosal) pain (dysmenorrhoea) bladder (large fibroids may cause frequency, urinary retention, hydronephrosis) fertility-block tubes or prevent implantation

Question 33

what are the complications of fibroids?

Answer 33

enlargement-may calcify after menopause (HRT may restimulate) degeneration-inadequate blood supply malignancy-0.1% are leiomyosarcomata, may undergo malignant change pregnancy-red generation is more common, severe pain. may cause preterm labour, malpresentation, transverse lie, obstructed labour, PPH torsion-pedunculated fibroid

Question 34

investigations for fibroids

Answer 34

USS-large fibroids MRI, laparoscopy-distinguish between ovarian mass or adenomyosis hysteroscopy or HSG-assess distortion of uterine cavity, particularly in fertility issues

Question 35

treatment for fibroids

Answer 35

asymptomatic-no treatment required, risk of malignancy is so small medical management-tranexamic acid, NSAIDs, progestogens GnRH-halts menstruation temporary shrinkage and amenorrhoea (only used 6 months) may be given HRT along side (<3cm)- Mirena, COCP surgical-hysteroscopy (3-4mm), hysterectomy, myomectomy, embolisation uterine artery

Question 36

what is red degeneration of fibroids?

Answer 36

ischaemia, infarction and necrosis due to disrupted blood supply large fibroids >5cm treatment: supportive, rest, fluids, analgesia

Question 37

presentation of red generation of fibroids?

Answer 37

severe abdominal pain low grade fever tachycardia vomiting

Question 38

what is adenomyosis?

Answer 38

presence of endometrium tissue in the storm of the myometrium oestrogen dependent associated with endometriosis and fibroids

Question 39

what increases the risk of adenomyosis?

Answer 39

later reproductive age | multiparous

Question 40

how is adenomyosis diagnosed?

Answer 40

TV USS - not as clear MRI gold standard histological examination after hysterectomy

Question 41

what is the treatment for adenomyosis in those that do and don't want contraception?

Answer 41

no contraception 1. tranexamic acid 2. mefemic acid contraception 1. Mirena 2. COCP 3. cyclical progestogen

Question 42

symptoms of adenomyosis

Answer 42

dysmenorrhoea menorrhagia dyspareunia

Question 43

other treatments for adenomyosis that may be used?

Answer 43

GnRH analogues endometrial ablation uterine artery embolisation hysterectomy

Question 44

what is endometritis?

Answer 44

inflammation of the endometrium often secondary to STI, complication of surgery due to retained tissue infection in post-menopausal uterus commonly due to malignancy

Question 45

what is pyometra?

Answer 45

pus accumulates and is unable to escape

Question 46

treatment of endometritis?

Answer 46

``` antibiotics occasionally ERPC (evacuation of retained products of conception) ```

Question 47

Name some other benign conditions of the uterus

Answer 47

endometritis intrauterine polyps haematometroa congenital uterine malformation