Gynaecology Flashcards
(86 cards)
– Cluster 1: Menstrual Cycle –
Describe the hormonal control of the menstrual cycle.
- follicular (days 1-14; variable): rise in FSH, causing growth of endometrium and increased depth of spiral arteries. Primordial follicle matures to a Graafian follicle, then a mature follicle. Receptibility to sperm increases, and mucous becomes abundant and watery
- ovulation (day 14): LH surge causes mature follicle to break, releasing an oocyte and producing the corpus luteum
- luteal phase (days 14-28): negative feedback by LH increases progesterone production (by corpus luteum, which also produces oestradiol); mucous thickens (hostile to sperm), and hypothalamic temperature increases
Describe the actions of FSH and LH.
- LH stimulates theca cells to produce progesterone and androstenedione by activating cholesterol desmolase
- FSH stimulates granulosa cells to convert androstenedione to testosterone, then to 17-beta-oestradiol, by aromatase
Describe the normal blood content of menses.
- Blood volume: ranges from slight spotting to 80ml (average 30ml)
- Menstrual blood is chiefly arterial (25% is venous)
- Usual duration of menstrual flow is 3-5 days (normal range 1-8 days)
- Blood contains prostaglandins, tissue debris, and fibinolysates (lyses clots)
- Loss >80ml is considered abnormal
– Cluster 2a: Menstrual disorders (PMS) –
Describe the physical, psychological, and behavioural changes observed in PMS.
- physical: headache, mastalgia, weight gain, fluid retention, joint/skin pain
- psychological: irritability, emotional lability, low mood, tension, mood swings
- behavioural: sleep disturbance, change in appetite, restlessness, poor conc., confusion, social withdrawal
What is the difference between PMD and PMDD?
- postmenopausal dysphoric disorder: occurs with accompanying mood swings, anxiety, and/or depression
- SSRIs can benefit
Describe the management options for PMD.
- lifestyle: sleep, exercise, smoking and alcohol, small balanced meals rich in complex carbohydrates
- 1st line: despiramine-containing COC (Yasmin, Eloine)
- 2nd line: GnRH agonists [can cause vasomotor symptoms, such as hot flushes, & osteoporosis]
- SSRIs/SNRIs, CBT
- hysterectomy with bilateral salpingo-oophorectomy: last resort
- additional: vitamin B6, oil of evening primrose, oestrogen patches/implants
- SSRIs / psychotherapy for PMDD
– Cluster 2b: Menstrual disorders (menorrhagia) –
Define heavy menstrual bleeding (HMB).
Blood loss that interferes with physical, social, emotional or material aspect of a woman’s life.
* previously defined as total blood loss >80ml/menses, but this is obviously difficult to quantify
* now is shifted to what the woman considers prolonged and increased flow
- accounts for 20% of gynae appts.
- most common cause of iron deficiency anaemia
What are the key causes of menorrhagia?
- gynae: fibroids, adenomyosis, polyps, endometrial hyperplasia, endometriosis, uterine/cervical malignancy
- obstetric: miscarriage, ectopic, gestational trophoblastic disease, placenta praevia
- sexual health: copper IUD, PID, surgical TOP, hormones (oestrogen/tamoxifen)
- endocrine: hormone-producing ovarian tumours, thyroid dysfunction, DM, adrenal disease, prolactin disorders
- vascular: AVM, coagulation disorders (von Willebrand, ITP, factor deficiencies)
- systemic: cirrhosis, renal disease
- drugs: anticoagulants (warfarin, clopidogrel, DOACs)
Define the relationship between dysfunctional uterine bleeding (DUB) and menorrhagia, and describe its investigation.
- DUB: non-organic menorrhagia occuring in the absence of pathology; therefore is a diagnosis of exclusion
- therefore requires exclusion of other causes of menorrhagia
– FBC
– systemic tests (TFTs, coag, renal, LFTs)
– TVUS (endometrial thickness, fibroids)
– endo sampling (Pipelle biopsy, D&C etc.)
– colposcopy (abnormal cervix)
Describe the management options for DUB.
- 1st line: Mirena coil IUS (LNG-IUS)
- 2nd line: tranexamic acid (anti-fibrinolytic) / COCP
- 3rd line: DMPA
- 4th line: surgery
- unsure in role: mefenamic acid (an NSAID; C/I in PUD, asthma); progestogens, GnRH agonists (goserelin, buserelin), androgen (danazol)
Describe the surgical management of DUB.
- two major options: endometrial resection/ablation, and hysterectomy
- ablation: day-case procedure, requires combined HRT
- hysterectomy: major operation, oestrogen-only HRT
– Cluster 2c: Dysmenorrhoea –
Define dysmenorrhoea.
- excessive pain during the menstrual period
- primary: no underlying pathology, affects 50% of menstrual women
- secondary: due to underlying pathology
Describe the aetiologies of dysmenorrhoea.
- primary (no underlying pathology): normal examination
- endometriosis: endometrial tissue in the peritoneum/pelvic cavity; occurs with menorrhagia and dyspareunia
- adenomyosis: endometrial tissue between muscle layers of the uterus; occurs with prolonged menorrhagia
- fibroids: menstrual pain with pressure effects on adjacent organs
- chronic PID: history of STI, pain not limited to menstruation
Define adenomyosis and leiomyoma.
- adenomyosis: presence of endometrial tissue in the myometrium
- leiomyoma: benign, smooth muscle tumour
Describe the investigations of dysmenorrhoea.
- high vaginal and endocervical swabs (pelvic infection)
- pelvic USS (endometriosis, adenomyosis, fibroids)
- diagnostic laparoscopy (other investigations normal but symptoms persist, or when Hx is suggestive of endometriosis)
Describe the management of dysmenorrhoea.
- 1st line: NSAIDs (mefenamic acid, ibuprofen): effective in 80%
- 2nd line: COCP
- additional options: LNG-IUS, GnRH analogues
– Cluster 2d: Menstrual disorders (IMB/PCB/PMB) –
Describe the causes of IMB (intermenstrual bleeding).
- cervical ectropion
- PIDs, STDs
- endometrial/cervical cancers/polyps
- undiagnosed pregnancy/complications, hydatidiform molar disease
Define and describe the causes of PCB (postcoital bleeding).
- PCB: bleeding brought on by sexual intercourse
- most common cause is cervical ectropion
- cervical carcinoma, trauma, polyps
- atrophic vaginitis
- cervicitis secondary to STDs
Describe the pathology, presentation, investigation, and treatment of cervical ectropion.
- cervix develops a red, raw appearance that may bleed on contact, most often occuring due to high oestrogen states in pregnancy, or use of hormonal contraceptives (esp. COCP)
- commonly presents with PCB (raw area irritated by penis during intercourse) or IMB
- often diagnosed during smears or colposcopy
- treatment usually not necessary and ectropion resolves (3-6 months following birth). if Mx necessary: cauterisation
Describe the causes of PMB (postmenopausal bleeding).
-PMB in a woman >55 is endometrial cancer until proven otherwise
- atrophic vaginitis (most common)
- endometrial polyps, hyperplasia, carcinoma
- cervical carcinoma
- ovarian carcinoma
- vaginal carcinoma (rare)
Describe the investigation surrounding PMB.
-
TVUS is first-line to assess endometrial thickness
– <3mm: low likelihood of cancer
– >4mm: further Ix (endometrial biopsy)
– <5mm: cutoff for patients taking HRT - hysteroscopy + endometrial biopsy: indicated for patients on tamoxifen (thickened, cystic, irregular endometrium)
- CT/MRI of uterus, pelvis, abdomen
Describe the management of PMB.
- atrophic vaginitis: topical oestrogen, vaginal lubricants, HRT
- endometrial hyperplasia: D&C, progestogen (Mirena IUS first-line)
- cancer: refer to oncology
– Cluster 2e: Menstrual disorders (PCOS) –
Describe the pathology of PCOS.
- increased frequency of the GnRH pulse generator, causing an increase in LH pulses and androgen secretions
- hyperinsulinaemia and insulin resistance, hypertension etc.: mechanism not completely understood
Describe the clinical features of PCOS.
- subfertility, infertility
- oligo/amenorrhoea (increased risk of endometrial hyperplasia and carcinoma)
- hyperandrogenism (hirsutism, acne, acanthosis nigricans, virilisation)
- metabolic (obesity, insulin resistance, diabetes, lipid abnormalities, increased cardiovascular risk)