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Gynecological conditions Exam
Question with Verified Answers
Define menopause - Answer -Permanent cessation of menstruation resulting from loss of ovarian follicular activity for 12 consecutive months. Average age is 51-52yo (<40yo is premature menopause) Explain the physiology behind menopause - Answer -1. Reduced number of primordial follicles
- Reduced available binding sites of circulating gonadotrophins (FSH/LH)
- Reduced sensitivity of the ovary to FSH/LH
- Reduced level of OE
- Drives px of menopause and loss of negative feedback loop from an increase in FSH/LH List the risk factors of early menopause - Answer -Chemotherapy & pelvic radiation (can destroy ovarian follicles), smoking, oophorectomy, Turners/Downs syndrome, CAH (can't make sex hormones), DM, thyroid dysfunction
List the px of peri-menopause - Answer -Wt gain (lower abdomen, buttocks, thighs), Menstrual irregularities (10% experience abrupt cessation of menses but most go through 4- 5yrs of varying cycle length due to progressive ovarian failure) List the px of menopause and post-menopause
- Answer -- Vasomotor instability (From increase in FSH/LH, hot flushes 70%, most prevalent in the 1st year, eps lasting 3min w/nausea, palp, sweats), - Osteoporosis
- Genital atrophy (vagina, labia, urethra are all OE-dependent)
- Sexual dysfunction (dyspareunia, vaginal dryness, vaginismus)
- Urinary px (dysuria, urgency, stress/urge incontinence common from reduced OE leading to weakening of collagen in pelvic floor muscles)
- Increased risk of UTI (raised pH of vagina as reduced reproduction of bacilli from vaginal wall thinning)
- OE alone HRT for F w/hysterectomy or mirena coil
- OE plus progesterone HRT for F w/o hysterectomy (combined w/progesterone to protect the uterus from unopposed action of OE and prevent endometrial hyperplasia)
- Testosterone patches for libido
- Bisphosphonates for OP
- Statins and anti-HTN Compare combined HRT regimes between peri vs post-menopause - Answer -- Peri- menopause: OE and cyclical progesterone where for the entire month give continuous OE (Oestradiol 0.1mg) then only for the last 2 weeks of the month give progesterone (Provera 10mg)
- Post-menopause: OE and continuous progesterone List the side effects of HRT - Answer -- Wt gain
- OE caused: fluid retention, bloating, breast tenderness/enlargement, nausea, HA, leg cramps
- Progesterone caused: fluid retention, breast tenderness, HA, mood swings/depression, acne, lower abdominal pain List the risks of HRT - Answer -- Oral HRT causes 3x increased risk of VTE (therefore should give transdermal for those already with high risk)
- Same as above w/stroke, breast Cx, endometrial Cx List the C/I of HRT - Answer -Uncontrolled HTN, active breast Cx Define primary amenorrhea - Answer -Failure to start menses by 16yo OR absence of 2ndry sexual characteristics (e.g. no breast development by 14yo) List the causes of primary amenorrhea - Answer -+ve 2ndry sexual characteristics - imperforate hymen, transverse septum, thyroid dysfunction, hyperprolactinemia, Cushings -ve 2ndry sexual characteristics - primary ovarian insufficiency from Turner's syndrome,
underlying cause), uterine fibroid, endometriosis, PID, hypoThy (irregular periods), DM, coagulation disorder/liver/renal disease List the hx questions to ask for menorrhagia - Answer -- Menstrual hx: cycle length, regularity, quantify
- To exclude endometrial polyp/fibroid/adenomyosis/hyperplasia: Pain, Abnormal bleed (PCB, IMB), Dyspareunia, Vaginal discharge
- Bleeding problems (easy bruising, postpartum haemorrhage, anticoagulants) Outline the Ix for menorrhagia - Answer -FBC to exclude Fe-deficiency anemia which occrus in 2/3 of F, TFT only if clinically hypoThy, TVUS to exclude uterine fibroid/polyps Outline the Mx for menorrhagia in the order of effectiveness - Answer -1. Mirena coil (can cause irregular bleeding for the first 4-6m) most effective
- Long cycle oral progestogens
3. COCP
- Transexamic acid 1g/6hrs for 4 days (anti- fibrolynitic), 5. Ibuprofen (Mefanamic acid no longer used as it's a clotter so not good for pmhx of clots)
- IM progesterone (e.g. norethisterone) *Surgery (endometrial ablation or uterine artery embolisation if no need to retain fertility) List the Ddx for menorrhagia - Answer -PALM COEIN Define endometriosis - Answer -Development of ectopic endometrial tissue outside the uterus. These areas are called endometrioma and includes ovaries and pelvic peritoneum most commonly, then pouch of douglass (most commonly), bladder, utero-sacral ligaments. It affects 8-10% of F in reproductive age. List the risk factors of endometriosis - Answer - Nulliparity, late 20 - early 30yo, early menarche, fmhx, menorrhagia
State the gold standard for Dx of endometriosis and its characteristic finding - Answer - Laparoscopy - "chocolate spots/cysts" which are deposits of endometrial tissue and old blood within the ovaries with brown appearance, "kissing ovaries" where bilateral endometria have adhered the ovaries together. Adhesions can also occur with bowels. (TVUS to start off in primary care and treat pain whilst waiting for result - takes about 8w and refer to gynae) Outline the Mx for endometriosis - Answer -1. Analgesia - NSAIDs, paracetamol, codeine
- Hormonal Mx to suppress ovulation and reduce growth of endometrium - COCP, POP, Mirena coil, GnRH agonists (reduces release of FSH/LH to induce menopause like state so give HRT together)
- Laparoscopic surgery, laser ablation, diathermy List the Ddx of endometriosis - Answer -PID, ectopic pregnancy, fibroid, IBS
Define fibroids (Leiomyomata) - Answer -Most common benign tumour of vaginal tract myometrium, very common (70-80% of F by menopause) List the risk factors of fibroids - Answer -Peaks at 40yo then increasing age until menopause, obesity, black ethnicity, Fmhx, nulliparity Describe the classification of fibroids - Answer - Subserosa (outer serosal surface of uterus which extends into the peritoneal cavity), Intramural (within myometrium), Submucosal (inner mucosal surface of uterus and extend into the uterine cavity), Pedunculated (on a stalk) Explain the pathophysiology of fibroids - Answer -Originates from the myometrial layer and grows stimulated by OE and progesterone. Persists until menopause when they shrink. List the px of fibroids - Answer -No px (most common), dysmenorrhea, menorrhagia & longer cycles (anemia px), pelvic pain,
Outline the Mx for fibroids depending on their size - Answer -- No px: annual follow up to monitor size & growth
- <3cm: Mx menorrhagia (Mirena coil, COCP, NSAID)
3cm: specialist referral for secondary Mx (Hormonal options and myomectomy to preserve fertility, otherwise UAE or hysterectomy) Explain the hormonal therapy for fibroids - Answer -GnRH agonists e.g. Goserelin, leuprorelin IM injections at set intervals for 3 months. This suppresses OE/Progesterone resulting in fibroid atrophy. Used peri- operatively as an adjunct. Define ovarian cysts - Answer -Fluid filled sac in the ovarian tissue common in pre-menopausal F Describe the different types of functional ovarian cysts - Answer -- Follicular (most common): follicle that failed to rupture but still
secretes fluid, disappears after a few menstrual cycles
- Corpus luteum: survives and grows even when there's been no implantation, risk of rupture & haemorrhage
- Theca-lutein: associated w/OHSS, subfertility Mx, excess maternal androgen, diseappears as hCG level falls Describe the different types of benign ovarian cysts - Answer -- Serous cystadenoma (most common): >40yo, cysts filled w/cuboidal epithelium like fallopian tube, malignant change can occur in >50yo
- Mucinous cystadenoma: tall columnar epithelium, contains mucin, risk of rupture & torsion
- Dermoid: <40yo, teratoma, bilateral What is a Meigs syndrome - Answer -Triad of ovarian fibroma, pleural effusion and ascites List the px of ovarian cysts - Answer -Most have no px, pelvic pain, bloating, early satiety, palpable mass
