Gynaecology Part 1 Flashcards
(44 cards)
Primary Amenorrhoea Definition
- Aged 13 with no periods with no other signs of pubertal development
- Aged 15 with no periods with other signs of pubertal development
Causes of Primary Amenorrhoea
- Hypogonadism (could be hypergonadotrophic or hypogonadotrophic)
- Kallmann Syndrome
- Congential Adrenal HYperplasia
- Structural Pathology
Difference between hypergonadotrophic and hypogonadotrophic hypogonadism
Hypo is issue with either the hypothalamus or the anterior pituitary, meaning lack of FSH/LH secretion and/or GnRH secretion
Hyper is when the issue is with the ovaries so you keep producing the LH and FSH but there’s no oestrogen being produced to cause negative feedback
Causes of hypogonadotrophic hypogonadism
- Damage to the hypothalamus/pituitary e.g. surgery, radiotherapy, cancer
- Hypopituitarism
- Kallmann Syndrome
Causes of hypergonadotrophic hypogonadism
- Damage e.g. torsion, cancer, mumps
- Congenital absence of ovaries
- Turner’s syndrome
How does congenital adrenal hyperplasia contribute to amenorrhoea?
absence of the 21-hydroxylase enzyme causes an underproduction of cortisol and aldosterone, and overproduction of androgens
- so you get too much testosterone
Structural pathology causing amenorrhoea
- imperforate hymen
- transverse vaginal septum
- absent uterus
- female genital mutilation
Management of primary amenorrhoea
- Bedside = Look for evidence of pubertal development
- Bloods = FBC for anaemia, anti-TTG for anaemia, FSH and LH, insulin-like growth factor for GH deficiency, prolactin for hyperprolactinaemia, testosterone raised in PCOS, CAH
- Imaging = x-ray of wrist for bone age and constitutional delay, US-abdo for ovaries, MRI head for hypothalamus and pituitary
Treatment = treat the underlying cause
Replace the hormones
Give pulsatile GnRH if hypogonadotrophic hypogonadism
COCP for same effect if pregnancy not wanted and for ovarian causes of amenorrhoea
Secondary amenorrhoea definition
No menstruation for more than 3 months after previous regular periods
Causes of secondary amenorrhoea
- Pregnancy
- Menopuase or premature ovarian failure
- Hormonal contraception
- Hypothalamic or pituitary pathology
- PCOS
- Asherman’s syndrome (scar tissue in the uterus)
- Reduced GnRH production in response to physiological or psychological stress
Management of secondary amenorrhoea
- Test for hCG in urine of blood
- Prolactin
- LH and FSH
- TSH
- Testosterone
- Treat the underlying cause
- Give replacement hormones
- Vitamin D and calcium if low oestrogen due to osteoporosis risk
What is premenstrual syndrome?
Psychological, emotional and physical symptoms which occur during the luteal phase of the menstrual cycle, resolves once menstruation occurs
What causes premenstrual syndrome?
- fluctuation of oestrogen and progesterone during the cycle
- possibly due to increased sensitivity to progesterone or an interaction between sex hormones and neurotransmitters serotonin and GABA
How does premenstrual syndrome present?
Common: low mood, anxiety, mood swings, irritability, bloating, fatigue, headaches, breast pain, reduced confidence, cognitive impairment, clumsiness, reduced libido
Can PMS still occur without menses?
yes after a hysterectomy, endometrial ablation, or on the mirena coil as the ovaries are still functioning and the normal hormonal cycle continues
can also occur secondary to COCP or cyclical hormone replacement therapy containing-progesterone, as is progestrone-induced PMS
How is PMS diagnosed?
- Symptom diary spanning two menstrual cycles which should demonstrate cyclical symptoms and resolve after the onset of menstruation
- Definitive = GnRH analogue will halt the cycle and induce menopause temporarily which will resolve the symptoms
How is PMS treated?
- Lifestyle (stress, alcohol, caffeine, smoking, exercise, sleep)
- COCP
- SSRIs if severe
- CBT
What is the definition of menorrhagia?
- excessive bleeding during menstruation of at least 80ml
Causes of menorrhagia
- dysfunctional uterine bleeding
- extremes of reproductive age
- fibroids
- endometriosis and adenomyosis
- pelvic inflammatory disease
- contraception esp. copper coil
- anticoagulants
- bleeding disorders
- connective tissue disorders
- PCOS
- endometrial hyperplasia or cancer
Diagnosis of menorrhagia
- based on symptoms
- changing pads every 1-2 hours, bleeding more than 7 days, passing large clots
Investigations for menorrhagia
Pelvic exam with a speculum and bimanual to assess for fibroids, ascites, and cancers
- FBC
- Outpatient hysteroscopy if suspected fibroids or endometrial pathology
- Pelvic and transvaginal US if large fibroids, adenomyosis, exam difficult
- Swabs, ferritin, coagulation screen, TFTs
How is menorrhagia managed?
- exclude anaemia, fibroids, bleeding disorders, cancer
- If no contraception needed: give tranexamic acid (if no pain - antifibrinolytic) or mefenamic acid (if pain - NSAID)
- If contraception wanted then 1. Mirena 2. COCP 3. Cyclical oral progestogens
What are fibroids?
Benign tumours of the smooth muscle of the uterus
What stimulates growth of fibroids?
oestrogen
