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Gynaecology Week Flashcards

1
Q

define heavy menstrual bleeding

A

excessive menstrual blood loss which interferes with a woman’s physical, emotional, social and material quality of life

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2
Q

what is DUB

A

dysfunctional uterine bleeding not associated with any organic disease of the genital tract

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3
Q

what is uterine leiomyoma also known as

A

fibroids - benign growths which can cause heavy regular period

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4
Q

what is endometriosis

A

a condition where endometrial tissue can be found outside of the uterus. Causes painful peroids, persistent pain in the pelvic area and infertility

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5
Q

what is dysmenorrhoea

A

painful menstrual periods
primary tends to be idiopathic
secondary tends to be due to endometriosis or pelvic inflammatory disease

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6
Q

under what circumstances would NICE recommend biopsy of the endometrium

A

persistent intermenstrual bleeding
women aged > 40
failure of treatment

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7
Q

according to NICE under what circumstances should ultrasound imaging be used?

A

abdominally palpable uterus
PV reveals pelvic mass of uncertain origin
failure of pharmaceutical treatment

if US inconclusive hysteroscopy may be used

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8
Q

what symptoms may be suggestive of structural/histological abnormality in pts complaining of menorrhagia

A

intermentrual bleeding
post-coital bleeding
pelvic pain/pressure symptoms

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9
Q

what pharmaceutical agents are available for women with HMB

A 
the merina IUD
tranexamic acid
mefenamic acid
COC
GnRH analogues

(Norethisterone should NOT be used for regular menorrhagia)

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10
Q

what is tranexamic acid

A

it is an anti-fibrinolytic which can be taken during menses (1g tds) to reduce bleeding by around 50%
it is good for women unable to tolerate hormonal therapies

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11
Q

what is mefenamic acid

A

it is an NSAID with minor anti-inflammatory properties.
it can be used to menorrhagia and dysmenorrhoea as it is an analgaesic and reduces heavy bleeding (500mg tds).
NSAIDs work by reducing prostaglandin production by inhibit cyclo-oxygenase

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12
Q

what is norethisterone?

A

a progesterone which can be used to promote regular cycles (NOT to treat menorrhagia)
15mg od on days 5 -> 26 of the mentrual cycle.
in high doses can stop very heavy bleeding short term

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13
Q

under what circumstances might GnRH analogues such as leuprorelin or triptorelin be used

A

pre-op to shrink fibroids or if surgery is contraindicated
pt may require HRT as can experience hot flushes and bone demineralisation
limited to 6-12 months use

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14
Q

what are the surgical options for a woman with HMB

A 
endometrial ablation (HMB + uterus  10wks)
Hysterectomy
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15
Q

what happens in endometrial ablation

A

destruction of the endometrium down to the basal layer
decreases fertility but increases the chances of complications in pregnancy –> should use contraception
80-90% of women have significant improvement in symptoms and 30% become amenorrhoeic
20% will require a further procedure by 5 yrs

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16
Q

when might a hysterectomy be considered

A

other treatment options have failed/been declined
wish for amenorrhoea
upon woman’s request
no long wish to retain fertility

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17
Q

what are the red flag symptoms for ectopic pregnancy

A

pelvic tenderness
adnexal tenderness
abdominal tenderness
cervical motion tenderness

if combined with a positive pregnancy test must be urgently refered to early prenancy assessment service

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18
Q

what is the incidence of ectopic pregnancy

A

11 per 1000 pregnancies

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19
Q

what are the predisposing factors to ectopic pregnancy

A 
previous PID (UK: chlamydia; world: gonorrhoea)
previous ectopic pregnancy
tubal surgery
smoking
increasing maternal age
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20
Q

what investigations can be used to detect ectopic pregnancy

A 
serum hCG (likely intrauterine if increased by >63% in 48hrs)
TV US (locate foetal pole and heartbeat)
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21
Q

what are the common presenting symptom of ectopic pregnancy

A 
abdo/pelvic pain
amenorrhoea/missed period
vaginal bleeding
dyspareunia
cervical excitation
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22
Q

when would conservative treatment of ectopic pregnancy be appropriate

A

hCG< 1000 and unknown location
50% resolve spontaneously
monitor via weekly scan and twice weekly hCG assay

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23
Q

what is the first line medical treatment of ectopic pregnancy

A

systemic methotrexate (folate antagonist)
indicated if:
- no significant pain
- unruptured pregnancy with adnexal mass < 1500

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24
Q

how does methotrexate work and what are its side effects

A 
folate antagonist -> prevents DNA/RNA/protein synthesis in rapidly dividing cells
SE:
- abdo pain
- GI upset
- risk of tubal rupture
25
Q

under what conditions would surgery be considered first line treatment in ectopic pregnancy

A
  • significant pain
  • adnexal mass >35mm
  • visible foetal heartbeat
  • ectopic with serum hCG > 5000
26
Q

what should be offered to all rhesus negative women who have a surgical proceedure to manage an ectopic pregnancy or miscarriage

A

anti-rhesus prophylaxis

27
Q

what would you expect to see if a pregnancy if viable

A

foetal heart beat
crown-rump length >7mm
gestational sac >25mm

28
Q

what would be the medical management of a missed or incomplete miscarriage

A

vaginal/oral administration of misoprostol

29
Q

what is misoprostol

A

a prostaglandin used to induce a labour for medical abortion
it can also be used vaginally to ripen the cervix before surgical abortion
it also has antisecretory and protective properties in the stomach lining

30
Q

what changes occur in the cervical mucous plug during ovulation

A

becomes alkaline, hypocellular and more elastic to allow the passage of sperm

31
Q

name 4 diiferent types of sperm dysfunction

A

azoospermia - absence of sperm in ejaculate
oligozoospermia - decreased sperm concentration
asthenozoospermia - poor sperm motility
teratozoospermia - abnormal shaped sperm

32
Q

what are the causes of ovulation disorders

A

hypothalamic pituitary dysfunction (eating disorders, excessive exercise, adenoma, prolactinoma, drugs)
PCOS (increased androgens leads to absence of ovulation)

33
Q

what are the features of PCOS

A

oligo/anovulation
infertility
excess androgens (hirsutism)

34
Q

treatment of PCOS

A 
oestrogen antagonists (chlomipjene citrate)
synthetic FSH +bhCG 
ovarian drilling
35
Q

what might cause tubal disorders

A

infection (chlamydia/gonorrhoea)
inflammation (endometriosis)
trauma/surgical damage

36
Q

treatment of tubal disorders

A

cuff salpingostomy
ablation of endometriosis
IVF

37
Q

what might be used for the induction of a late medical abortion

A

gemeprost

usually misoprostol following pre-treatment with mifepristone which sensitizes the uterus to prostaglandins

38
Q

how might bleeding due to incomplete miscarriage or abortion be controlled

A

ergometrine or oxytocin IM

in severe post partum haemorrhage carboprost

39
Q

what is mifepristone

A

an antiprogestogenic steroid

40
Q

during which days of the menstrual cycle is the follicular phase

A

days 1-14
also known as the proliferative phase
oestrogen is produced from testosterones in the granulosa cells under the influence of FSH
testosterones are produced in the theca interna cells under the infleunce of LH

41
Q

what does oestrogen stimulate in the follicular phase

A

growth of endometrial lining
development of follicles
watery secretions at the cervix to allow the passage of sperm

42
Q

what effect does oestrogen have on LH secretion

A

increased oestrogen at the follicular phase inhibits LH secretion (alpha receptor)
once oestrogen level pass a threshold then it begins to stimulate LH production by activating the oestrogen beta receptor

43
Q

what happens at ovulation on day 14

A

LH peak leads to release of ovum

increased testosterone levels due to LH surge causes other follicle to undergo atresia

44
Q

what happens to the ruptured follice post ovulation

A

it becomes a corpus luteum
theca cells undergo atrophy
granulosa cells under go hypertrophy

45
Q

during which days of the menstrual cycle is the luteal phase

A

days 15-28

the corpus luteum produces progesterone

46
Q

what does progesterone stimulate

A

further growth and maintenance of the endometrium

change in cervical secretions to prevent the entry of further sperm

47
Q

during which days of the menstrual cycle is menstruation

A

days 1-7
corpus luteum undergoes luteolysis
menstruation occurs due to progesterone withdrawal

48
Q

why does the corpus luteum undergo luteolysis in menses

A

decreased LH as progesterone inhibits its secretion

increased secretions of oxytocin and prostaglandins by the uterus

49
Q

what is the definition of the menopause

A

the 365th day after the start of a womans LMP

50
Q

what are fibroids

A

benign tumours of the myometrium formed from smooth muscle with fibrous elements

51
Q

which factors increase the risk of developing fibroids

A 
african ethnicity
tamoxifen
early onset of menarche
nuliparity
age
obesity
FHx
HTN
52
Q

name three types of fibroid

A

subserous - project externally out of the uterus, can become pedunculated
intramural - within the myometrium
submucous - project into the endometrium, can become pedunculated

53
Q

what are the pregnancy associated problems with fibroids

A

red degeneration
pre-term labour
malpresentation
post partum haemorrhage

54
Q

which haematological disorders can be symptoms of fibroids

A

anaemia

polycythenia - some fibroids may produce EPO

55
Q

which options are available for the medical treatment of fibroids

A

esmya (ulipristal acetate)
GnRH agonists
mirena IUD - no direct effect on fibroid but will decrease bleedign

56
Q

how do GnRH agonist work on fibroids

A

shrinks fibroid and decreases vascularity

can cause menopausal symptoms (osteoporosis risk)

57
Q

how does esmya work

A
  • on the fibroid: blocks progesterone receptors which inhibits cell proliferation and stimulates apoptosis
  • on the pituitary gland: selectively blocks progesterone activity which reduces LH and FSH levels causing amenorrhoea
  • on the endometrium: direct effects and reduces uterine bleeding

EMBRYOTOXIC- pregnancy must be excluded

58
Q

what are the surgical options available in fibroids

A

myomectomy
hysterectomy
UAE

59
Q

what are the complications associated with fibroids

A

degeneration ( haline change, calcification, red)
torsion of pedunculated fibroids
infections with pyometria
malignancy (RED FLAGS: rapid growth; post menopausal and not on HRT; poor response to GnRH agonists)

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