Flashcards in Week 204 - Gynaecology Deck (53):
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Week 204 - Gynaecology: Give a definition of menorrhagia and give the objective definition.
• Excessive loss of blood during menstruation.
• >80ml
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Week 204 - Gynaecology: Give a definition of dysmenorrhea.
Painful menstrual periods.
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Week 204 - Gynaecology: What is primary and secondary dysmenorrhea?
• Primary - no associated with organic disease or psychological cause.
• Secondary - A cause can be found (e.g. endometriosis, PID)
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Week 204 - Gynaecology: What is Dyspareunia?
Pain during sexual intercourse.
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Week 204 - Gynaecology: What are the three differentials for menorrhagia?
• Dysfunctional uterine bleeding.
• Uterine leiomyomas (Fibroids).
• Endometriosis or Adenomyosis.
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Week 204 - Gynaecology: What is the common name for uterine leiomyomas?
• Fibroids
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Week 204 - Gynaecology: What is dysfunctional uterine bleeding?
This is heavy menstrual bleeding that is not associated with organic disease of the genital tract.
8
Week 204 - Gynaecology: What are fibroids? What is the medical term for them?
• Uterine Leiomyomas.
• Benign growths in the uterus which can cause heavy menstrual bleeding.
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Week 204 - Gynaecology: What is endometriosis?
This is where endometrial tissue is found outside of the uterus. It can cause heavy bleeding, persistent pain and infertility.
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Week 204 - Gynaecology: What is adenomyosis?
This is where endometrial tissue grows within the myometrium.
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Week 204 - Gynaecology: What key feature of examination is used to distinguish between fibroids and dysfunctional uterine bleeding?
• The size of the uterus.
• DUB will typically be a normal sized uterus whilst fibroids will lead to an enlarged uterus.
12
Week 204 - Gynaecology: On examination you feel an enlarged uterus, what is your initial investigation?
• USS, this is to determine whether there are fibroids or an ovarian cyst.
13
Week 204 - Gynaecology: A 25yr olf lady presents with heavy menstrual bleeding? Is an endometrial biopsy required? When is a biopsy indicated?
No, this is normally only performed in patients over 40, since the risk of endometrial cancer increases after 40. It may indicated in a younger woman if she fails to respond to treatment.
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Week 204 - Gynaecology: What initial investigation should be offered to women who experience heavy menstrual bleeding?
FBC - to identify anaemia.
15
Week 204 - Gynaecology: What are the five medical treatments for menorrhagia?
• Tranexamic Acid
• Mefenamic Acid
• Combined Oral Contraceptive Pill
• Oral Progesterones.
• Mirena IUS
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Week 204 - Gynaecology: What is the role of Tranexamic acid in the treatment of menorrhagia?
• Antifibrinolytic.
• Taken during menstruation and can reduce blood loss by 50%.
17
Week 204 - Gynaecology: What is the role of Mefenamic Acid in the treatment of menorrhagia?
• NSAID
• Useful for dysmenorrhoea and also reduces blood loss.
• Can be used in conjuction with Tranexamic acid.
18
Week 204 - Gynaecology: What is the role of the oral contraceptive pill in the treatment of menorrhagia?
Reduces blood loss by 10-20%, and also helps with dysmenorrhoea.
19
Week 204 - Gynaecology: What impact does the Mirena IUS have on menorrhagia?
• Reduces blood loss by 90% and at 1 year 30% are amenorrhoeic.
20
Week 204 - Gynaecology: In patients who are very anaemic or constantly bleeding what is the treatment aim? And what treatments are used?
• To achieve Amenorrhoea rapidly.
• GnRHa - Inhibits release of Gonadotrophins so inhibits the release of oestrogen and androgen.
• High dose progesterones.
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Week 204 - Gynaecology: When is the use of surgery indicated in the treatment of menorrhagia and what are the options?
• Failure of medical treatment and when family is complete.
• Endometrial ablation - destruction of endometrium.
• Hysterectomy.
22
Week 204 - Gynaecology: Where are the six locations for an ectopic pregnancy and which is the most common?
• Interstitial/Cornual
• Isthmic Tubal
• Infundibular Tubal
• Ovarian
• Abdomial
• Ampullar Tubal (Most common, due to narrowing of fallopian tube).
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Week 204 - Gynaecology: What are the risk factors for developing fibroids?
• Age (Later reproductive years)
• Menarche (Early onset)
• Race (African)
• Hypertension / CV risk
• Family History
• Obesity
• Tamoxifen
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Week 204 - Gynaecology: Which drug, used in the treatment of breast cancer, is a risk factor for developing fibroids?
Tamoxifen
25
Week 204 - Gynaecology: What are the five locations of fibroids? Give a brief description of each.
• Intramural - This is completely enclosed in the endometrium.
• Submucosal - This is where it protrudes into the uterus but is covered by a layer of mucosa.
• Subserosal - Opposite of a submucosal, protrudes out the external wall of the uterus, but it covered by serosa.
• Pedunculated - Both subserosal and submucosal. Look like pendulums.
26
Week 204 - Gynaecology: What are the symptoms of fibroids?
• Asymptomatic - 50%
• Heavy menstrual bleeding.
• Haematological disorders.
• Dysmenorrhoea.
• Infertility.
27
Week 204 - Gynaecology: What investigations should be performed for suspected fibroids?
• FBC - Hb
• Tumour Markers - Ca125, CEA
• USS
• Endometrial biopsy (Women over 40)
• Hysteroscopy/Laparoscopy
28
Week 204 - Gynaecology: What are the medical treatments available for fibroids?
• Esmya
• GnRH agonists. - Shrink fibroid and reduce vascularity.
• Mirena IUS
29
Week 204 - Gynaecology: How does Esmya treat fibroids?
Three modes of action-
• Acts on the fibroid by reducing progesterone receptors which reduces cell proliferation and induces apoptosis.
• Acts on the pituitary to reduce Gonadotrophin secretion..
• Acts on the endometrium to have a direct affect to reduce bleeding.
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Week 204 - Gynaecology: What are the surgical options for the treatment of fibroids?
• Myomectomy - Surgical removal of fibroids.
• Hysterectomy
• Uterine Artery Embolisation - cut's off blood supply to fibroid.
31
Week 204 - Gynaecology: What are the complications of ovarian cysts?
• Pain
• Torsion
• Rupture
• Haemorrhage
• Malignancy
• Hormone Secretion
32
Week 204 - Gynaecology: What are the main types of ovarian cysts?
• Physiological - Follicular + Luteal
• Endometriomas
• Polycystic Ovaries
• Germ cell tumours
• Epithelial tumours
• Sex cord stromal tumours
33
Week 204 - Gynaecology: What is the Risk of Malignancy Index (For ovarian cysts)
• This is calculation that identifies the risk of a cyst developing into a cancer.
• RMI = U x M x CA125
• U is uss features. (Either 0,1or3)
• M is menopause (1 if pre, 3 if post)
• CA125 (Serum level in IU/ml)
34
Week 204 - Gynaecology: What are the USS features for RMI? How do they score?
• Multiolocular cysts, Solid Areas, Metastases, Ascites, Bilateral lesions.
• The presence of one scores one point.
• The presence of 2 or more scores three points.
35
Week 204 - Gynaecology: According to WHO in 2009, what should a good semen sample be? (Mls,Count,Motility,Normal)
Volume - 1.5ml to 6ml
Count - >15x10(6)/ml
Motility - >40%
Normal- >4%
36
Week 204 - Gynaecology: What is the definition of subfertility?
Involuntary failure to conceive.
37
Week 204 - Gynaecology: What are the causes of subfertility?
• Ovulation Disorder - 25%
• Sperm Dysfunction - 30%
• Tubal disease - 20%
• Endometriosis - 10%
• Coital failure, uterine abnormalities - 10%
38
Week 204 - Gynaecology: The menstrual cycle is divided into which three phases?
• Follicular phase
• Ovulatory phase
• Luteal phase
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Week 204 - Gynaecology: What occurs during the Follicular phase of the menstrual cycle?
• FSH slowly decrease, LH slowly increases.
• The follicle matures.
• Oestradiol slowly increase, progesterone remains at a low level.
• The endometrium breaks down and begins to build up again.
40
Week 204 - Gynaecology: What occurs during the ovulatory phase of the menstrual cycle?
• LH spikes, FSH has a slight increase.
• Ovulation
• Oestradiol peaks and then drops off, progesterone slightly rises.
• The endometrial wall is at its peak.
41
Week 204 - Gynaecology: What occurs during the Luteal phase of the menstrual cycle?
• LH and FSH starts low and slowly decreases.
• The corpus luteum forms.
• Progesterone reaches it's peak and then drops off, Oestradiol slowly decreases.
• The endometrium begins to breakdown.
42
Week 204 - Gynaecology: Ovulation disorders can arise due to a disruption of the hypothalamus-pituitary-ovarian axis, in what ways?
• Hypothalamus - Eating disorders, stress, exercise, underweight.
• Pituitary - Prolactinomas, Sheehans, Craniopharyngomas, hypophysectomy, radiotherapy, idiopathic.
• Ovarian - PCOS, Primary ovarian failure.
43
Week 204 - Gynaecology: What is the medical treatment of ovulatory disorders?
• Oestrogen antagonists.
• Gonadotrophins - FSH + LH
44
Week 204 - Gynaecology: What are the leading pathological causes of tubal disease?
• Infective - Chlamydia Trachomatis, Neisseria gonorrhoea.
• Inflammatory - Endometriosis
45
Week 204 - Gynaecology: What are the indications for assisted conception?
• Dysfunctional sperm
• Tubal disease
• Endometriosis
• Prolonged unexplained infertility (>2yrs)
• Preimplantation genetic diagnosis
• Failed fertility treatments
46
Week 204 - Gynaecology: Describe in vitro fertilisation.
• Oocyte is recovered transvaginally.
• Fertilised.
• Cultured 2-5days.
• Embryo transfer.
• Freezing of remaining embryos.
47
Week 204 - Gynaecology: What are the risks of assisted contraception?
• Ovarian hyperstimulation syndrome - Massive ovarian cysts, ascites, pleural and pericardial effusion, hypovolaemia.
• Multiple pregnancy.
• Pelvic/ovarian sepsis.
• Ovarian torsion.
48
Week 204 - Gynaecology: What is a molar pregnancy?
This is overgrowth of the placenta, also known as trophoblastic disease.
49
Week 204 - Gynaecology: If you were to have a woman with a +ve pregnancy test with an empty uterus on USS what are your differentials?
• Ectopic pregnancy
• Very early pregnancy
• Complete miscarriage
50
Week 204 - Gynaecology: What is the management of miscarriage?
• Expectant
• Medical with mifepristone and misoprostol
• Surgical
51
Week 204 - Gynaecology: In an intrauterine pregnancy what would you expect the HCG to rise by?
• >60% within 48hrs, if there is a suboptimal rise, suspect an ectopic pregnancy.
52
Week 204 - Gynaecology: What are the three regimens of HRT?
1) E2 only - for hysterectomised women only.
2) Sequential - E2 every day with progesterone for 14days/month, have monthly withdrawal bleed.
3) Continuous combined - E2 and progesterone daily, only give if LMP >1yr ago. No bleed.
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