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39 Cards in this Set

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Define primary and secondary amenorrhoea?
primary amenorrhoea = absence of period at 16 or failure of 2dry sexual characteristics by 14
secondary amenorrhoea = cessation of menstruation for >6 months not during pregnancy
Aetiology of amenorrhoea?
Pituitary:
- adenomas (prolactinoma)
- excessive weight loss/exercise
-Sheehan's
-Kallman's (GnRH def)
Ovarian disorders:
- Premature menopause (<35)
-anovulation
-PCOS
-Gonadal dysgenesis (45XO)
-Autoimmune
Tract/Uterus disorders:
- Mullerian Agenesis
- Transverse vaginal septum
- Ashermann's
-Imperforate hymen
-Absent cervix, uterus, vagina
Investigations of amenorrhoea?
Step 1: initial hormone steps
- BHCG, prolactin, TFTs, LH&FSH, Testosterone
-progesterone w/drawal test (if +ve likely anovulation)
Step 2:
if step 1 -ve then:
- orally active oestrogen for 21 days then progesterone w/drawal
- if failure to bleed then outflow tract abnormality
- if bleed then hypothalmic axis
Step 3:
-if excluded outflow tract disorder then repeat measures of FSH and LH
-if increased FSH on >2 occasions, 6 wks apart with no menstruation then premature ovarian failure
-if not elevated FSH then hypothalamus problem
Define primary an secondary dysmenorrhoea?
Primary = no organic pathology (50%)
Secondary = endometriosis, adenomyosis, pelvic congestion, chronic pelvic pain, Ashermann's
Prostaglandin responsible for 1ry dysmenorrhoea?
PF2-a
Clinical features of 1ry and 2ry dysmenorrhoea?
1ry: normal period pain
2ry: period pain described in endometriosis
Tx for dysmenorrhoea?
NSAIDs (inhibit PF2a)
Mefenamic acid (C/I in asthma)
OCP
Define menorrhagia?
>80ml per period (the level whcih reflects a fall in Hb and haematocrit [ ])
Types of Dysfunctional Uterine Bleeding?
Anovulatory: menopause, PCOS, menarche, obesity/stress
Ovulatory: ????
2ry to organic causes: fibroids, adenomyosis, PID, cancer, endocrine disorders, clotting disease, drug therapy
Screening q's for DUB?
- bleeding tendency?
- FHx of bleeding disorder
- excessive oestrogen
-pelvic pain (endometriosis, PID)
- pressure/mass (fibroid)
- infertility (PID, endometriosis)
- IMB, PCB (polyps, STI etc)
- sx ass w thyroid disease
Ix for DUB?
- exclude pregnancy
- FBE & ferritin/Fe studies
- Coags and TFTs
-D&C
- hysteroscopy
Medical Tx for DUB?
Medical:
- NSAIDs (inhibit PE)
- OCP
-Levenorgestrel intrauterine device
- GnRH agonist (inhibit FSH, LH)
- Danazol (competes with androgens and progesterone --> androgenic S/E)
- Tranexamic acid (antifibrinolytic effects)
Surgical Tx for DUB?
-Endometrial ablation
- Hysterectomy
Causes of postcoital bleeding (PCB)?
- Cervical neoplasms
- Atrophic vaginitis
- Infections
- cervicitis and ectropion
- endometrial polyps
Pharmacological tx for PMS?
- SSRIs
- COOP or progesterone pill
Symptoms of PMS (listed in diary)?
- Restlessness
- headaches
- breast tenderness
- depression
- verbal/physical aggression
- irritable feelings
-tiredness
-swelling of abdomen, hands, feet
-tampons/pads used
PCOS criteria?
- ovarian dysfunction (due to oligomenorrhoea)
- hyperandrogenism (clinical/biochemical)
- polycystic ovaries on U/S (>10 follicles)
Incidence of PCOS?
25% have polycystic ovaries; yet only 4-5% have the syndrome
Hormonal/pathological changes which occur in PCOS?
-Increased LH to FSH ratio (2:1, normally 1:2).
- insulin resistance and hyperinsulinaemia
- elevated androgens and increase in oestrogen (peripheral conversion of androgen to oestrogen in fat tissue)
- anovulation (therefore progesterone remains low)
Sx of PCOS?
- oligo/amenorrhoea
- hirsutism, acne, deeping voice, androgenic alopecia, virilism
- sufertility
- obesity
-acanthosis nigricans
Long term cx of PCOS?
- DM2, metabolic, CVD
- Endometrial ca
Ix of PCOS?
- U/S
-FSH:LH ratio
-androgens
- insulin
-lipid status
Tx of PCOS?
-weight loss
-OCP (cyproterone acetate)
- metformin
-clomiphene for fertility, tamoxifen
Surgically can have ovarian resection
Order of 2dry sexual characteristics in females?
-growth spurt
- therlarche
-adrenarche
-menarche
Delayed puberty?
Absence of 2dry sexual characteristics by 14 OR menarche >2 yrs after 2dry characteristics
Which medication is OCP efficacy decreased with?
- phenytoin
- warfarin
-heparin
- thyroxine
-clozepam?
Phenytoin - antiepileptics increase the liver's ability to break down the OCP so not covered for same length as normal females
Causes of delayed puberty?
- Constitutional delay (Fhx, bone scan)
- hypergonadotrophic hypogonadism (intersex, Turner's)
- hypogonadtrophic hypogonadism (hypopituitary, hypothyroidism, congenital, past of current anorexia)
- eguonadism (delay with normal gonadal function: mullerian agenesis, androgen insensitivity)
Ix for delayed puberty?
- XR for bone age
- brain imagining
- hormone levels (inc prolactin)
- steroid levels
- TFTs
- karotype
- pelvic U/S
Causes of acute pelvic pain?
- miscarriage
- ectopic
- acute salpingitis
- tubal or ovarian abscess
- endometritis (chlamydial)
- pelvic peritonitis
- ovarian cyst rupture, haemorrhage or torsion
- Mittelschmertz
- retrograde menstruation
- primary dysmenorrhoea
- cystitis
- ureteric colic
- acute appendicitis
-diverticulitis
-ABO
- constipation
etc
Causes of chronic pelvic pain?
- PID
- Endometriosis, adenomyosis
- ovarian tumour
- fibroids
- pelvic vascular congestion
- unruptured ectopic
- low grade PID
- PCOS
- prolapsed ovaries
-genital prolapse
- appendiceal abscess
- intra-abdominal adhesions
- diverticulitis
- IBS, IBD
- malignancy
- musculoskeletal disorder
The uterus, cervix and adnexae share the same visceral innervation as what?
Lower ileum, sigmoid colon and rectum. Signals travel via sympathetic system via T10 to L1 (ant thigh and groin). Hence the difficult of diagnosing between gynae and GIT pain
General gynae examination?
- Vital sx
- Abdominal palpation
- Inspect the vulva (discharge, trauma, bleeding, foreign bodies, irritation)
- Bimanual: uterine size, consistency and tenderness, mobility, shape; adnexae for massess, tenderness, fixability
- speculum: to visualise the cervix and vagina for infection, discharge, trauma etc
Adenomyosis? Incidence?
Diffuse or localised presence fo endometrial tissue (glands or stroma) in the myometrium.

- 10-25%, usually multiparous, 3rd and 4th decade
Sx of adenomyosis?
- colicky dysmenorrhoea, dyspareunia, pelvic pain particularly pre-menstrually
RF for adenomyosis?
- endometriosis
- fibroids
- long periods of secondary subfertility
- multiparity and C/S
- increasing age
Pathophysiology of adenomyosis?
Enlarged uterus w absence of fibroids; micoscopically irregular nests of endometrial stroma, with or without glands arranged within the myometrium and separated from the basalis by at least 2-3mm.
Tx for adenomyosis?
- danazol, mirena
- hysterectomy is only definitive tx
Endometriosis?
Incidence?
Presence fo functioning endometrial tissue outside of the endometrial cavity. Most often involves ovaries, uterosacral ligaments and POD; has been found in lungs and umbilicus
10-15% of women
Proposed aetiologies of endometriosis?
- retrograde menstruation
- metaplasia
lymphatic or haematological emboli?