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Year 3- placement > Menstrual period and urogynaecology > Flashcards

Menstrual period and urogynaecology Flashcards

1
Q

Primary amenorrhoea

A
  1. No menstruation by the age of 14 years accompanied by failure to develop sec. sexual characteristics.
  2. No menstruation by age of 16 when growth and sexual development are normal.
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2
Q

Secondary amenorrhoea

A
  1. Secondary absence of menses for six months (or greater than 3 times the previous cycle interval) in a women who has menstruated before.
  2. Pregnancy, lactation or hysterectomy must be excluded
  3. Prepubertal and post-menopausal conditions are also to be excluded as physiological causes
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3
Q

Amenorrhoea- outflow tract anomalies

A
  1. Imperforate hymen
  2. Transverse vaginal septum- failure of the Mullerian derived upper vagina to fuse with the urogenital sinus derived lower vagina
  3. Vaginal agenesis
  4. Testicular feminisation
  5. Asherman’s syndrome
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4
Q

Amenorrhoea- Cryptomenorrhoea

A
  1. Absence of normal vaginal opening or imperforate hymen, prevent menstrual loss from escaping
  2. Features: primary amenorrhoea in a teenage girl with normal sexual development present
  3. Complaining of lower abdo pain, possible difficulty of mict, palpable lower abdo swelling (haematometra). Bulging, bluish membrane at the lower end of the vagina (Haematocopos).
  4. Management: incise membrane
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5
Q

Amenorrhoea- Testicular feminisation (androgen insensitivity)

A
  1. Phenotype is woman. Genotype is man (xy) testes are present and mullerein inhibiting factor, testosterone levels as in male. Treatment: gonadectomy after puberty (HRT), there is a germ cell malignancy risk
  2. Treatment: vaginal reconstruction (dilation vs vaginoplasty)
  3. Inherited by an X-linked recessive gene… (familial)
  4. Resulting in absence of cytosol androgen receptor
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6
Q

Amenorrhoea- Asherman’s syndrome

A
  1. Secondary amenorrhoea following distruction of the endometrium by overzealous curettage, multiple synechae show up on Hysterography
  2. Management: under general anaesthetic, breakdown intrauterine adhesions through hysteroscope. Insert an IUCD to deter reformation and use hormone therapy
  3. When scar tissue, adhesions form within the uterus/cervix
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7
Q

Ovarian causes of amenorrhoea

A
  1. Chromosomal abnormalities- turner syndrome -> gonadal dysgenesis
  2. Gonadal agenesis: failure of gonadal development, no other congenital abnormalities
  3. Resistant ovary syndrome
  4. Premature menopause
  5. PCOS
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8
Q

PCOS

A

Most common cause of amenorrhoea
1. Mostly present with classical Stein-Leventhal syndrome (oligomenorrhoea, obesity, hirsuitism, and infertility).
2. Many women will have sec. amenorrhoea with no obesity or hirsuitism
3. Diagnosis is made by finding increased LH/FSH ratio +/- raised androg
4. USS + polycystic ovaries
5. Association with subfertility type 2 Diabetes and endometrial hyperplasia

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9
Q

Premature menopause

A
  1. Ovarian failure <40 years of age
  2. Auto-immune disease associated with Addisons
  3. Viral infection i.e. Mumps
  4. Cytotoxic drugs/radiotherapy
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10
Q

Pituitary causes of amenorrhoea

A
  1. Pituitary tumour causing hyperprolactinaemia. 40% of patients with hyperprolactinaemia will have a pituitary adenoma. Causes secondary amenorrhoea, can cause visual changes and some milk discharge from the nipple
  2. Craniopharyngioma- other intracranial tumour
  3. Sheehans syndrome- necrosis of the anterior pituitary due to severe PPH. Pan or partial hypopituitarism
  4. Other causes of increased prolactin- Drugs i.e. phenothiazine, methyldopa, metoclopramide, anti-histamines and morphine
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11
Q

Hypothalamic amenorrhoea

A
  1. Classic Kallmann syndrome (KS) and idiopathic hypogonadotropic hypogonadism (IHH)- rare genetic conditions
  2. Gonadotropin-releasing hormone (GnRH) deficiency
  3. Hypothalamic-pituitary function is otherwise normal, and hypothalamic-pituitary imaging reveals no space-occupying lesions.
  4. Anosmia (lack of sense of smell) or severe hyposmia is present in patients with Kallmann syndrome in contrast to idiopathic hypogonadotropic hypogonadism.
  5. Deficient hypothalamic GnRH secretion leads to the markedly abnormal gonadotropin secretion
  6. The result is hypogonadism; infertility; and absent, incomplete, or partial pubertal maturation. No periods or secondary sexual characteristics
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12
Q

Disorders of the Hypothalamus

A
  1. Commonest reason for hypogonadotropic secondary amenorrhoea
  2. Often associated with stress i.e. in migrants, young women when leaving home, university students
  3. Diagnosis by exclusion of pituitary lesions
  4. Hormone therapy or ovulation induction is not indicated unless patient wishes to become pregnant
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13
Q

Weight loss- amenorrhoea

A
  1. A loss of >10kg is frequently associated with amenorrhoea. Typically in young women and teenage girls
  2. Joggers amenorrhoea: in athletes due to redistribution between proportion of body fat mass and body muscle mass. May also be mediated by exercise related changes in beta-endorphins
  3. Anorexia nervosa- associated with secondary amenorrhoea
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14
Q

Examination of patient with amenorrhoea

A
  1. Breast development, abdominal and pelvic examination
  2. Presence of hirsutism, virlization
  3. Beta-hCG, FSH, TSH
  4. Prolactin, pelvic ultrasound scan
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15
Q

Amenorrhoea- breast absent

A
  1. Uterus absent: Gonadal agenesis in 46XY
  2. Gonadal failure/agenesis in 46XX
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16
Q

Amenorrhoea- breasts present

A
  1. Uterus absent: enzyme deficiency in testosterone synthesis, Testicular feminization, Mullerian agenesis
  2. Uterus present: Disruption of the hypothalamic pituitary axis. Hypothalmic, pituitary or ovarian pathogenesis. Congenital abnormalities of the genital tract
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17
Q

Investigations for amenorrhoea

A
  1. FSH ,LH, Prolactin level and TFT
  2. Karyotyping…if chromosomal. anomaly is suspected on clinical grounds
  3. Progesterone withdrawal test to check endogenous estrogen. if bleeding PV-reactive endometriosis. and patent outflow tract.
  4. USS pelvis
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18
Q

Amenorrhoea- karyotyping

A
  1. 46- XY: androgen insensitivity (TSF syndrome)
  2. 46- XX: Mullerian agenesis
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19
Q

Management of amenorrhoea

A
  1. Infertility-Restoration of ovulatory function
    2.Estrogen deficiency -If possible HRT and prevention of osteoporosis and atherosclerosis
  2. Endometrial hyperplasia- Progesteron for prevention of endometrial hyperplasia in patients with normal estradiol levels
  3. Vaginal reconstruction in vaginal agenesis
  4. Gonadal tumors-If there is Y chromozome gonadectomy following puberty
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20
Q

Most common causes of amenorrhoea

A
  1. Polycystic ovary syndrome
  2. Hypothalmic amenorrhoea
  3. Hyerprolactinaemia amenorrhoea
    4.Ovarian failure
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21
Q

Urogynaecology conditions

A
  • Prolapse
  • Painful bladder
  • Urinary incontinence
  • Congenital abnormalities
  • Obstetric trauma: OASI, fistula
  • Female genital mutilation
22
Q

Examination of prolapse

A
  1. Height, weight, BMI
  2. Abdomino-pelvic examination: pelvic mass, vaginal atrophy
  3. Speculum examination
23
Q

Urinary incontinence

A
  1. Any involuntary urinary leakage, under reported
  2. Stress urinary incontinence is more common then urgency urinary incontinence
  3. Investigations: urine dip/MSU, urodynamics, bladder diaries, QoL questionaires
  4. Risk factors: age, POH, menopause, hysterectomy, obesity, smoking, functional/cognitive impairment, neuro disease
24
Q

Effect of urinary incontinence

A
  1. Psychological: depression, feelings of shame, loss of self confidence/self esteem
  2. Social isolation
  3. Sexual problems
  4. Loss of sleep from nocturia
  5. Constipation: limiting fluid intake
  6. Falls and fractures in the elderly
25
Q

Classification of urinary incontinence

A
  1. Overactive bladder (OAB)/urge incontinence: due to detrusor overactivity, the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
  2. Stress incontinence: leaking small amounts when coughing or laughing
  3. Mixed incontinence: both urge and stress
  4. Overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
  5. Functional incontinence: comorbid physical conditions impair the patient’s ability to get to a bathroom in time, causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
26
Q

Management- urge incontinence

A
  1. Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  2. Bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
  3. Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
  4. Botulinum toxin A
  5. Sacral nerve stimulation
  6. Augmentation cystoplasty
  7. Urinary diversion
27
Q

Management- stress incontinence

A
  1. Pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
  2. Surgical procedures: e.g. retropubic mid-urethral tape procedures
  3. Duloxetine may be offered to women if they decline surgical procedures. A combined noradrenaline and serotonin reuptake inhibitor
  4. Intramural bulking agents
  5. Artificial urinary sphincter
28
Q

Pressures in the bladder

A
  1. If urethral pressure > bladder pressure, urine does not exit
  2. Urethral pressure- urethral muscle, pelvic floor, abdominal pressure
  3. Bladder pressure- detrusor pressure and abdominal pressure
29
Q

Risk factors for uro-genital prolapse

A
  • Age
  • Parity
  • Menopause
  • High BMI
  • Previous pelvic surgery
  • Heavy lifting and manual work
  • Smoking
  • Genetic predisposition
  • Connective tissue disease (e.g. Marfan, Ehlers-Danlos)
30
Q

Braden- Walker system: uro-genital prolapse

A
  1. Grade 0: normal
  2. Grade 1: descent halfway to hymen
  3. Grade 2: descent to hymen
  4. Grade 3: descent halfway past the hymen
  5. Grade 4: maximum possible desecent/procidentia
31
Q

Management of uterovaginal prolapse

A
  1. Address lifestyle factors
  2. Physiotherapy
  3. Pessaries
  4. Surgery- anterior and posterior repair. Vault/cervical support: SSF, sacrohysterpexy, Colpocleisis, Mesh No.
32
Q

Dysmenorrhoea definition and feature

A

Definition: excessive pain during the menstrual period

Features
* pain typically starts just before or within a few hours of the period starting
* suprapubic cramping pains which may radiate to the back or down the thigh

33
Q

Primary and secondary dysmenorrhoea

A

Primary dysmenorrhoea: no underlying pelvic pathology, affects 50% of menstruating women, usually due to excessive endometrial prostanglandin production

Secondary dysmenorrhoea: due to an underlying pelvic pathology, pain starts 3-4 days before the onset of the period

34
Q

Causes of secondary dysmenorrhoea

A
  • Endometriosis
  • Adenomyosis
  • PID
  • Copper coil
  • Fibroids
35
Q

Menorrhagia- definition and investigations

A

Definition= Total blood loss >80ml per menses

Investigations:
* FBC
* Transvaginal ultrasound scan: if suggestion of structural or histological abnormality

36
Q

Menorrhagia treatment- does not require contraception

A
  • Either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
  • If no improvement then try other drug whilst awaiting referral
37
Q

Menorrhagia treatment- requires contraception

A
  • Intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill
  • Long-acting progestogens

Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

38
Q

Side effects of HPV vaccine

A

Redness/pain/swelling at injection site
Headaches
Fever/nausea
Itchy rash
Anaphylaxis

39
Q

Fraser guidelines

A

Guidelines outline conditions under which children under 16 can be prescribed contraception without parental consent.
If they are mature/intelligent enough, can’t be persuaded to discuss with parents, if they are likely to have intercourse regardless, physical/mental health would suffer without it

40
Q

Mental capacity act

A

Can they understand the decision
Can they retain the information
Weigh up pros and cons
Communicate decision

41
Q

FGM act

A

A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl’s labia majora, labia minora or clitoris.

42
Q

When can informed consent not be obtained

A
  • When patients are incapacitated but need the emergency treatment to save their life
  • When patients with severe mental health conditions lack the capacity to consent
  • When the patient needs hospitalisation for severe mental health conditions
  • When the patient needs an additional emergency procedure during an operation
  • When the patient is a risk to public health i.e. TB
  • When a patient is severely ill and living in unhygienic conditions
43
Q

What makes consent valid

A
  • Must be voluntary i.e. made by the person and not influenced
  • Informed i.e. the person must know all the information to include benefits and risks, alternatives etc
  • Capacity i.e the person must be able to understand the information
44
Q

How to manage situations when consent cant be obtained

A
  • See if there is a valid advance refusal
  • See if there is a donee/attorney
  • If there is no advanced refusal / attorney then the HCP should determine what the persons best interest would be (past/present wishes, beliefs and values etc) and go ahead with the treatment they believe first this
45
Q

What nerve innervates an erection/penile ejaculation

A
  • Erection: Parasympathetic prostatic plexus (S2-S4)
  • Emission: L1-L2
  • Expulsion: Somatic pudendal
46
Q

Process of erection

A
  1. Smooth muscle relaxation due to NO release
  2. Dilation of arteries (pudendal)
  3. Veins flattened, blood is trapped
  4. BP increased, erection
47
Q

Criteria for effective screening intervention

A
  • the condition should be an important health problem
  • the natural history of the condition should be understood
  • there should be a recognisable early symptomatic stage
  • there should be a test that is easy to perform & interpret, accurate, reliable, sensitive & specific
  • there should be an accepted treatment recognised for the disease
  • treatment should be more effective if started early
  • there should be a policy on who should be treated
  • diagnosis & treatment should be cost-effective, acceptable & safe
  • case-finding should be a continuous process
48
Q

When is genetic screening in pregnancy recommended

A
  • one or both partners known they have a genetic abnormality
  • family members have a genetic abnormality
  • partner belongs to a high risk ethnic group
49
Q

8 STI’s with greatest incidence and incurable STI’s

A

Greatest incidence: Chlamydia, Gonorrhoea, Syphilis, Trichomoniasis, Hep B, Herpes, HIV, HPV

Incurable: Hep B, Herpes, HIV, HPV

50
Q

What opportunities are there to improve women’s health in adolescents

A

Onset of menstruation, activity and fertility
Reproductive health education delivered at school
HPV vaccination
Chlamydia screening

51
Q

What opportunities are there to improve womens health in reproductive years

A

Contraception and healthy lifestyle advice
Help with menstrual disorders like heavy bleeding
Pregnancy - during this time women interact with health professionals on multiple occasions and often feel motivated to make positive changes to their health behaviours

52
Q

Opportunities to improve womens health in post-reproductive years

A

Managing transition through the menopause helps provide opportunities to promote healthy lifestyle and prevent onset of chronic disease
Pelvic floor health - prevent incontinence and prolapse

Year 3- placement (34 decks)

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