Reproductive Health Workbook 1 Flashcards
What examinations could you do for a patient with HMB?
Look for signs of anaemia (pallor, glossitis, angular stomatitis)
Assess BMI
Speculum examination
Bimanual examination
What can cause HMB?
PALM COEIN
Structural causes:
Polyps
Adenomyosis
Leiomyomas (fibroids)
Malignancy and hyperplasia
Non-structural causes:
Coagulopathy (e.g. von Willebrand’s)
Ovulatory dysfunction (e.g. PCOS)
Endometrial (e.g. endometriosis)
Iatrogenic (e.g. anticoagulant treatment)
Not otherwise classified (e.g. systemic causes such as hypothyroidism, liver or kidney disease)
How would you investigate HMB?
Pregnancy test
FBC: to exclude anaemia
Thyroid function test and coagulation screen
Imaging:
transvaginal US to exclude local structural causes (fibroids, polyps)
Further investigations:
* Hysteroscopy: for direct visualisation of the uterine cavity
* Endometrial biopsy (e.g. if abnormal endometrial thickness, intermenstrual bleeding or postmenopausal bleeding)
* Vaginal swabs (if considering STI)
Mx options for HMB?
Tranexamic acid (anti-fibrinolytic): used before or just before the period
Mefenamic acid (NSAID): used during or just before the period, useful if dysmenorrhoea is also present
COCP
IUS
Norethisterone
Surgery (depends on cause, could be fibroidectomy, endometrial ablation, myomectomy, hysterectomy)
Advantages and disadvantages of IUS and COCP for HMB management?
IUS- also helps with dysmenorrhea, provides contraception, has to be inserted in a small procedure which comes with risks like infection and perforation
COCP- can be taken continuously to stop periods, provides contraception, risks including VTE and breast cancer
MOA of tranexamic acid? Mefenamic acid?
Tranexamic acid = anti-fibrinolytic, inhibits the interaction of plasminogen with plasmin and fibrin
Mefenamic acid = NSAID, inhibits prostaglandin synthetase
Complications of surgical intervention for HMB?
bladder or bowel perforation
vesicovaginal fistula
haemorrhage
infection
how do primary and secondary dysmenorrhea present differently?
Primary dysmenorrhoea usually starts 6–12 months after the menarche
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
Pelvic examination is normal
Secondary dysmenorrhoea often starts after several years of painless periods
The pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle
Other gynaecological symptoms (e.g. dyspareunia) are often present
Clinical features indicating a serious secondary cause of dysmenorrhoea include:
Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids)
Abnormal cervix on examination
Persistent intermenstrual or postcoital bleeding without associated features of PID
Differentials for secondary dysmenorrhea?
Endometriosis/adenomyosis —chronic pelvic pain frequently occurring prior to menstruation, accompanied by heavy menstrual bleeding and deep dyspareunia
Fibroids (myomas) — lower abdominal pain, menorrhagia, a pelvic mass may be identified on examination
PID — lower abdominal pain and tenderness that may be accompanied by dyspareunia, abnormal vaginal bleeding, and abnormal vaginal discharge
Ovarian cancer — pelvic or abdominal pain, abdo distension, early satiety/ loss of appetite, and urinary sxs
Cervical cancer — pelvic pain, dyspareunia, intermenstrual or postcoital bleeding, and blood-stained, mucoid, or purulent vaginal discharge
Recent IUD insertion
Non gynae e.g. IBS, lactose intolerance, appendicitis
Differentials for endometriosis?
Primary dysmenorrhoea
Uterine fibroids
Pelvic inflammatory disease
Ectopic pregnancy
Torsion of an ovarian cyst
Appendicitis
Irritable bowel syndrome
Investigations for endometriosis?
Pregnancy test
Baseline blood tests (FBC, U&Es, CRP): white cells may be raised in appendicitis or pelvis inflammatory disease
transvaginal ultrasound scan
Diagnostic laparoscopy
Describe the mechanism of action of three different hormonal therapeutics you might use to manage endometriosis related pain, their mode of administration, and their side effects
implant (Nexplanon) - inhibits ovulation and thickens cervical mucus, implant in the arm , ADRS = menstrual irregularities, complications with insertion and removal, decreased sex drive, mood swings and depression
injectable (Depot-provera) - high dose progesterone, inhibits ovulation, IM injections every 12 weeks, ADRS = menstrual irregularities and weight gain
levonorgestrel IUS (Mirena) - prevents implantation and reduces endometrial proliferation, thickens cervical mucus, ADRS= headaches, acne, breast tenderness
What are the constituents of HRT?
Oestrogen alone
Oestrogen and progesterone
Tibilone = synthetic, mimics oestrogen, progestogen and testosterone
Which women should take combined HRT?
women who have not had a hysterectomy
Oestrogen-alone HRT can stimulate the lining of the womb (endometrium), leading to thickening and possibly cancer
progesterone or a progestogen is added to counteract the effects of oestrogen
Risks v benefits of HRT?
+ relief of menopausal symptoms
+ prevention of osteoporosis
+ protection against heart disease
- increased risk of breast cancer
- increased risk of ovarian cancer
- increased risk of endometrial cancer
- increased risk of VTE (unless transdermal)
- increased risk of stroke
What is endometrial hyperplasia?
irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio, may progress to cancer if left untreated
The most common presentation of endometrial hyperplasia is abnormal uterine bleeding
This includes HMB, intermenstrual bleeding, unscheduled bleeding on HRT and postmenopausal bleeding
What causes endometrial hyperplasia?
unopposed oestrogen exposure (relatively high oestrogen and low progesterone levels)
Increased age, nulliparity
Anovulatory cycles- PCOS, perimenopause
Obesity
Diabetes Mellitus
Ovarian tumors- granulosa cell tumors
HRT
HNPCC or Lynch syndrome
Describe normal physiology of urinary continence
micturition is made up of the storage/continence phase, when urine is stored in the bladder and the voiding phase, where urine is released through the urethra
storage requires relaxation of the detrusor muscle of the bladder, and simultaneous contraction of both the internal urethral sphincters (IUS) and external urethral sphincters (EUS)
detrusor relaxation and IUS contraction are under autonomic control: pontine continence centre = sympathetic innervation of detrusor muscle and IUS via spinal cord and hypogastric nerve (nerve roots T10-L2)
EUS contraction is under voluntary somatic control : pudendal nerve (nerve roots S2-S4) = contraction
What should you look for on examination of a patient with urinary incontinence?
General examination: weight, gait, and indicators of neurological disease
Examine the abdomen for a palpable bladder or a mass
Perform a pelvic examination:
Ask the woman to cough and observe external urethral meatus for leakage (stress)
Assess pelvic muscle tone and contraction during bimanual examination
While performing the pelvic examination, also look for:
Evidence of pelvic organ prolapse
Urethral diverticulum — sac-like protrusion between the periurethral tissues and the anterior vaginal wall
Pelvic mass
Atrophic vaginitis
How should you investigate urinary incontinence?
vaginal examination
urine dipstick and culture - to test for blood, glucose, protein, leucocytes, and nitrites
bladder diaries should be completed for a minimum of 3 days
urodynamic studies
Lifestyle advice for women with incontinence?
reduce caffeine intake
avoid excessive / reduced fluid intake
smoking cessation
weight loss
What is duloxetine? ADRs?
SNRI
increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction of EUS
nausea, dry mouth, fatigue, constipation
Give 2 options that are available for surgical mx of stress incontinence?
Colposuspension: lifting up the tissue around the neck of the
bladder, and suspending it in this lifted position using synthetic stitches
Rectus fascial sling: sling made from abdominal fascia is placed behind the urethra to support it
Complications of surgery for urinary incontinence?
infection
bleeding / needing a transfusion
damage to bladder and bowel
nerve damage
retention
What ligaments are in place to support the uterus?
Broad Ligament: double layer of peritoneum attaching the sides of the uterus to the pelvis (mesometrium, mesosalpinx, mesovarium)
Round Ligament: A remnant of the gubernaculum, maintains the anteverted position of the uterus
Ovarian Ligament: Joins the ovaries to the uterus
Cardinal Ligament: Located at the base of the broad ligament, extends from the cervix to the lateral pelvic walls, contains the uterine artery and vein
Uterosacral Ligament: Extends from the cervix to the sacrum
Define cystocele, rectocele and enterocele
cystocele = bladder bulges into vaginal space
rectocele = bulging of the anterior wall of the rectum into the posterior wall of the vagina
enterocele= small intestine prolapses into vaginal space
outline the different degrees of uterine prolapse
First degree: The cervix drops into the vagina
Second degree: The cervix drops to the level just inside the opening of the vagina
Third degree: The cervix is outside the vagina
Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia
How may urogenital prolapse present?
feeling of pressure or heaviness in the pelvis, urinary incontinence, difficulty emptying the bladder or bowel, lower back pain, and pain during sex
How can urogenital prolapse be managed?
physiotherapy, particularly directed pelvic floor muscle training (PFMT)
pessaries
surgery:
anterior or posterior colporrhaphy
surgical mesh placement
What are the risks of surgery for urogential prolapse?
Surgery done through vagina = quicker procedure and recovery, risk of pain during sex afterwards
Surgery done with an abdominal incision may result in less pain during sex, but there is a risk of damage to the intestines and adhesions and also a longer recovery time
Vaginally placed mesh has a significant risk of complications, including mesh erosion, pain, infection, and bladder or bowel injury
What is an adenexal mass? Causes?
a growth that develops around the uterus in the adenexa
Ovarian cysts
Noncancerous ovarian tumors
Ovarian cancer
Ectopic pregnancy
Broad ligament leiomyoma
Hydrosalpinx
Chronic pelvic pain is any pain in the lower abdomen or pelvis that lasts for more than 6 months. What can cause it?
endometriosis
PID
interstitial cystitis (bladder inflammation)
adhesions
trapped or damaged nerves in the pelvic area
pelvic organ prolapse
musculoskeletal pain
irritable bowel syndrome (IBS)
depression, including postnatal depression
traumatic experiences, such as sexual and/or physical abuse
What is surgical menopause? What are the potential risks?
acute onset of menopause due to oophorectomy
risks:
osteoporosis
cardiovascular disease
low libido
vaginal dryness
infertility
