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Year 3 GP > Women's health > Flashcards

Women's health Flashcards

1
Q

Ovarian cycle

A

Provide an environment for fertilisation

  • Follicular phase
  • Luteal phase
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2
Q

Uterine cycle

A

Receives fertilised oocyte and allows implantation

Proliferation phase - prior to ovulation
Secretory phase - after ovulation

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3
Q

Female HPG axis

A
  1. Pulsatile GnRH released from the hypothalamus
  2. Stimulates the anterior pituitary to release FSH and LH
  3. FSH stimulates granulocytes and theca interna and externa cells to proliferate
  4. FSH causes granulosa cells of the follicles to release oestrogen and inhubin and causes follicles to mature.

LH causes theca interna cells to release androgens which are aromatised to oestrogen under the influence of FSH.

  1. Oestrogen at low concentrations has a negative feedback on the hypothalamus. As follicles develop, oestrogen concentration increases and exerts a positive feedback
  2. Once the dominant follicle has been selected, inhibin causes negative feedback on the anterior pituitary so follicles stop maturing
  3. Oestrogen exerts a positive feedback on the hypothalamus, anterior pituitary and granulosa cells so oestrogen and inhibin are still produced.
  4. Once, LH conc is more than FSH, ovulation occurs
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4
Q

Male HPG axis

A
  1. Hypothalamus releases GnRH in pulsating manner as there is no ovarian hormone production and no negative feedback
  2. Stimulates the anterior pituitary to release FSH and LH
  3. FSH stimulates the sertolli cells to produce sperm and LH stimulates the Leydig cells to produce testosterone
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5
Q

Which phase of the ovarian cycle can be varied?

A

Follicular phase

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6
Q

Ovulation

A

Mature oocyte is extruded through the ovarian capsule into the peritoneal cavity where it is picked up by fimbrae and transported to the fallopian tube

Meiosis I is completed and Meiosis II starts

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7
Q

Endometrium

A

Stratum functionalis layer: Sheds during menstruation

Stratum basalis: contains stem cells and allows regrow the at the start of the cycle

Proliferates in response to oestrogen - thick and fat

Becomes more glandular and secretory in response to oestrogen and progesterone

Prevents blastocyst from implanting too far via the decidual reaction

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8
Q

Proliferation phase

A

Create a good environment for fertilisation

The functional layer proliferates and thickens
Simple straight glands coil

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9
Q

Secretory phase

A

Progesterone causes coiled glands to become secretory

Blood supply is established - spiral arteries

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10
Q

Oestrogen in the proliferative phase

A

Proliferation of the myometrium and endometrium
Increases fallopian tube motility
Thin, alkaline cervical mucous is produced

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11
Q

Normal menstrual cycle

A

21 - 35 days

Variation due to variation in follicular phase

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12
Q

Progesterone in the secretory phase

A

Create environment viable for pregnancy

Decreases myometrium motility
Further thickening of the endometrium
Thick, acid cervical mucus
Increased body temperature

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13
Q

Primary amenorrhoea

A

Absence of menstruation

Never had a period by the age of 16

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14
Q

Secondary amenorrhoea

A

Started periods but the periods have stopped for more than 6 months

Causes:

  • pregnancy
  • weight loss
  • menopause
  • birth control
  • hypothyroidism
  • hyperprolactinaemia
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15
Q

Oligomenorrhoea

A

Reduced menstruation

Cycle length is more than 35 days

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16
Q

Menorrhagia

A

Heavy menstrual bleeding
More than 80ml

Causes:

  • benign or malignant growth in the endometrium
  • clotting disorders
  • anticoagulation therapy
  • normal

Presentation:

  • fatigue
  • pallor

Ix:
Bloods - FBC
(anaemia)

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17
Q

Dysmenorrhea

A

Painful periods

Causes:
- endometriosis

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18
Q

Polycystic ovarian syndrome summary

A

Cause: idiopathic

Risks: COCP and obesity

Pathophysiology: Elevated LH causing hyperandrogenism

Presentation:
Raised insulin resistance - T2DM
Secondary amenorrhoea 
Infertility
Hirsutism 
Obesity

Ix: USS and blood test

Treatment: remove uterus

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19
Q

How long should menses last

A

7 - 9 days

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20
Q

Endometriosis cks

A

Pathophysiology: Endometrial tissue that occurs outside the uterine cavity (Oestrogen dependent)

Presentation:

  • early menarche
  • menorrhagia
  • dysmenorrhea
  • AUB
  • infertility
  • dyspareunia
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21
Q

Management of dysmenorrhea

A

NSAIDs
COCP
Intrauterine device
GnRH analogues

Surgery - hysterectomy

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22
Q

Menopause

A

No menstruation periods for 12 consecutive months and no other biological or physiological cause identified

Due to loss of ovarian follicular activity

Ovaries can no longer produce follicles - oestrogen decreases

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23
Q

Early menopause

A

Menopause occurring before 45

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24
Q

Premature menopause (pathological)

A

Cessation of menopause as all ovarian follicles depleted before 40

(Premature ovarian failure)

25
Q

Menopausal transition

A

Time between onset of irregular menses and permanent cessation of menstruation

Average - 4 years

26
Q

What age does ovarian function decline

A

45 - 55 years old

Average - 50yrs old

27
Q

Premenopause

A

Time before menopause

  • less oestrogen secretion
  • Reduced fertility
  • cycle relatively unchanged
28
Q

Perimenopause

A 
Transitional phase 
Physiological changes:
- mood swings
- hot flushes
- infrequent menstruation

Follicular phase shortens and ovulation is early or absent

29
Q

Post menopause

A

Time after a women has experience amenorrhoea for over 12 months

No longer able to conceive

30
Q

Hormone measured to diagnose physiological menopause

A

FSH - increases significantly

As oestrogen no longer secreted so no inhibition

31
Q

Symptoms of menopause

A 
Itchy - puritis 
Twitchy - restless limbs 
Sweaty 
Sleepy
Bloated
Moody 
Forgetful
32
Q

Early signs of menopause

A 
Hot flushes
Sweating
Insomnia 
Irregular menstruation 
Mood swings
Depression
33
Q

Intermediate menopause symptoms

A 
Vaginal atrophy
Dyspareunia
Skin atrophy - breasts 
Urge stress continence 
Frequent UTIs - atrophy of urethra and bladder lining
Reduced pubic hair
34
Q

Late menopause symptoms

A

Osteoporosis - increased osteoclasts activity

Atherosclerosis - CHD, CVD - increased cholesterol and less HDLs

35
Q

Hormone replacement therapy (for symptomatic relief only)

A

Oestrogen

  • pill
  • vaginal cream
  • transdermally - patch
36
Q

Red flags

A

Endometrial cancer

  • haematuria + high blood glucose
  • Post menopausal bleeding

Ovarian cancer - Ascites and abdominal distension

Vulval cancer - lump and bleeding

37
Q

Oocyte maturation

A
  1. Germ cells colonise the gonadal cortex and differentiate into oogonia
  2. Oogonia proliferate by mitosis
  3. Arrange in clusters surrounded by squamous epithelial cells
  4. Some enter meiosis till prophase I forming primary oocytes
  5. Atresia
  6. Surviving primary oocytes surrounded by follicular cells - primordial follicles
  7. Preantral stage - from squamous to straitidied cuboidal - granulosa cells
  8. Granulosa cells secrete glycoprotein forming zona pellucida
  9. Antral stage - fluid filled spaces form between granulosa cells and coalesce forming antrum
  10. Preovulatory stage - induced by surge of LH, meiosis I complete and arrest in meiosis II (metaphase II)
38
Q

Post coital bleeding

A

Causes:

  • Infection - STI
  • cervical or endometrial polyps
  • vaginal or cervical cancer
  • trauma

Ix:

  • pregnancy test
  • STI screen
  • Blood tests - clotting, FSH (menopause)
  • Trans- vaginal USS
  • cancer screening
39
Q

When to refer for menorrhagia

A
  • ascites
  • abdominal mass
  • compression symptoms e.g. dyspareunia
  • fibroids > 3cm
40
Q

Mx of menorrhagia

A
  1. Iron tablets - if anaemia with iron deficiency
  2. Levonorgestrel intrauterine system
  3. Tranexamic acid or NSAID
  4. COCP or POP
  5. Surgery - remove fibroids if > 3cm or uterine artery embolisation
  6. Endometrial ablation
  7. Hysterectomy
41
Q

Contraindications for tranexamic acid

A

Fibrinolytic conditions following DIC
Convulsions
Severe renal impairment
History of DVT/PE

42
Q

Mx of menopausal symptoms

A

Conservative:

  • hot flushes - wear thin layers
  • Low mood - adequate sleep

Vasomotor symptom control
- SSRI

Mood disorders - antidepressants

Urogenital symptoms - moisturiser and lubricants

43
Q

HRT

A

With uterus - oral or transdermal combined oestrogen - progesterone

Without uterus - oestrogen only pill or transdermal patch

Follow up after 3 months

44
Q

Risks of HRT

A

VTE - greater in oral preparations

Combined HRT increases risk of breast cancer

45
Q

Causes of post coital bleeding

A
  • Infection
  • Cervical or endometrial polyps
  • Vaginal cancer
  • Cervical cancer
  • Trauma or sexual abuse
46
Q

Investigations of post coital bleeding

A
  • pregnancy test
  • STI screen
  • Blood tests - clotting, FSH (menopause suspected)
  • Trans vagina ultrasound - structural abnormality
  • Referral for cancer screening
47
Q

Mx of post coital bleeding

A
  • pregnancy test
  • STI screen
  • Blood tests - clotting, FSH (menopause suspected)
  • Trans vagina ultrasound - structural abnormality
  • Referral for cancer screening
48
Q

Causes of inter menstrual bleeding:

A 
• Ectopic pregnancy 
• Gestational trophoblastic disease 
• Vaginal spotting may occur during the time of ovulation 
• Vaginal adenosis - benign metaplastic endometrial/ cervical epithelium 
• Vaginal cancer 
• Cervical infection 
	◦ Chlamydia 
	◦ Gonorrhoea 
• Cervical cancer 
• Uterine Fibroids 
• Polyps 
• Iatrogenic 
	◦ Tamoxifen 
	◦ After smear 
	◦ Missed oral contraceptive pill
49
Q

Causes of menorrhagia

A
  • 50% idiopathic
  • Uterine fibroids
  • Endometriosis
  • PID
  • Polyps - endometrial
  • PCOS
  • Endometrial hyperplasia
  • Coagulation disorders e.g. Von Willebrands disease
  • Hypothyroidism
  • Diabetes mellitus
  • Hyperprolactinaemia
50
Q

Ix for menorrhagia

A
  • look for related symptoms
  • Look for causative condition - Bloods FBC (iron deficiency anaemia), clotting, HbA1C, TSH
  • Abdo exam - fibroids
  • Bimanual pelvic examination
  • Ultrasound - polyps
51
Q

Causes of amenorrhoea

A 
• constitutional delay - FHx 
• Structural defect - imperforate hymen 
• Androgen resistance syndrome 
• Hyperprolactinaemia- hypothyroidism or pituitary tumour 
• Pregnancy 
• Chemotherapy 
• Hypothalamic failure 
	◦ Anorexia 
	◦ Stress 
	◦ Chronic illness 
	◦ Excessive exercise 
• PCOS 
• Cushing’s syndrome
52
Q

Ix of amenorrhoea

A 
• BMI 
• Abdo exam 
• Pelvic examination 
• Blood test
	◦ Androgens
	◦ Cortisol 
	◦ FSH 
	◦ Prolactin 
	◦ TSH 
• Pregnancy test  
• Pelvic ultrasound 
• Karyotyping - exclude Turners 
• MRI head - pituitary tumour
53
Q

Cyclical HRT

A

monthly or trimonthly with break in between so know when period has stopped

54
Q

Continuous HRT

A

Given when periods have stopped for at least 12 months or over 51 yo

55
Q

Endometriosis presentation

A

Vague pelvic pain
Deep dyspareunia
Pain on defecation

Dysuria
Haematuria
Urgency

56
Q

Adenomyosis presentation

A

Dysmenorrhoea
Dyspareunia
Menorrhagia

57
Q

PID presentation

A

Chronic pelvic pain

Deep dyspareunia

58
Q

Fibroids presentation

A

Pelvic pain

Menorrhagia

59
Q

Endometriosis Ix and Mx

A
  • refer to secondary care for laparoscopy

Mx:

  • NSAIDs +/- paracetamol
  • COCP/POP
  • refer to secondary care for: GnRH analogues, surgery

Year 3 GP (20 decks)

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