Gyane disorders Flashcards

dysfunctional uterine bleeding
Terms Definitions
Define menorrhagia
Name some causes
Heavy menstrual bleeding > 80mls per period
OR periods lasting > 7 days
Endometrial polyps
Dysfunctional uterine bleeding
Endometrial hyperplasia
Fibroids
Adenomyosis
Endometriosis
Chronic PID
Define dysmenorrhea
Name some causes
Menstrual pain in absence of organic disease (primary)
Menstrual pain due to organic disease (secondary)
Endometriosis, fibroids, PID, adenomyosis, PCOS
Define dysfunctional uterine bleeding
Abnormal bleeding not attributable to organic (anatomic/systemic) disease
DUB is a diagnosis of exclusion
Define oligomenorrhea
irregular cycle more than 35 days in length
Describe a normal menstrual cycle
Days, amount of blood
28 days - lasting 3-5 days, 30-50mls
Differential diagnosis for abnormal uterine bleeding that is typically cyclic
Anatomic or physical lesion (Polyp, Fibroid, Adenomyosis, Neoplasm, foreign body)
Haemostatic defect
Infection
Trauma
local disturbances in prostaglandins
Differential diagnosis for abnormal uterine bleeding that is unpredictable
PCOS
Thyroid dysfunction
Elevated prolactin
Rare oestrogen producing tumours
Stress
Wt loss
Exercise
Liver and kidney disease
Define metorrhagia
bleeding at irregular intervals, particularly between expected menstrual periods
Define polymenorrhea
vaginal bleeding occurring at intervals < 21 days
Treatment for dysfunctional uterine bleeding?
If acute haemorrhage - give IV oestrogen to stop bleeding (raises DVT risk)
Chronic DUB - NSAIDs (decreases blood loss by 20-50%)
In anovulatory women - hormonal therapy via oestrogen and progesterone OCPs, Mirena
Surgical - DC, if fertility is no longer needed can have uterine endometrial ablation to destroy uterine tissues, hysterectomy - definitive treatment
Main causes of dysfunctional uterine bleeding
Anovulation 90%
Dysfunction of corpus luteum and inadequate progesterone production or an atrophic endometrium (i.e. secondary to OCP)
Definition of endometriosis
The presence of endometrial tissue (glands and stroma) outside of the uterine cavity
It affects 10-15% of menstruating women
Pathogenesis of endometriosis
Not fully understood
1. Retrograde theory of Sampson: seeding of endometrial cells by transtubal regurgitation during menstruation
2. Immunologic theroy - altered immunity may limit clearance of transplanted endometrial cells from pelvic cavity
3. Undefined endogenous biochemical factor may induce undifferentiated peritoneal cells to develop into endometrial tissue
4. Lymphatic flow from uterus to ovary
5. Vascular or lymphatic dissemination of cells
Risk factors for endometriosis
FHx
Obstructive anomalies of the genital tract
Nulliparity
Age > 25 years
Which sites does endometriosis occur?
Ovaries
broad ligament - vesicoperitoneal fold
periteonal surface of the cul-de-sac (uterosacral ligaments)
rectosigmoid colon
appendix
Symptoms of endometriosis
Dysmenorrhea
Dyspareunia
Dyschezia (difficulty defecating)
Dysuria, frequency, haematuria
Infertility
What investigations should be done in suspected endometriosis
Definitive diagnosis - direct visualisation of lesions at laparoscopy + biopsy and histologic exam of specimens
CA125 may be elevated
Medical treatment of endometriosis
NSAIDs - reducing pain
Pseudopregnancy - OCP; depoprovera
Psuedomenopause - danazol - weak androgen; leuprolide - GnRH agonist
Medical treatments have common adverse effects and do not improve fertility
(second line only < 6 months due to osteoporosis
Surgical treatment of endometriosis
Conservative laparoscopy using laser, electrocautery +/- laparotomy
- best time to become pregnany is immediate after above surgery
Bilateral salpingo-oophorectomy +/- hysterectomy
Beneficial for infertility, possibly better long term results, but expensive and invasive
Common causes of dyspareunia
Intraoital - inadequate lubircation, vaginismus, rigid/intact hymen, vulvovaginitis (atrophic, chemica, infectious)
Lichen sclerosis
Midvaginal - urethritis, short vagina, trigonitis (squamous metaplastic changes that occur in the bladder)
Deep - endometriosis, adenomyosis (extension of endometrial glands and stroma into the myometrium), leimyomata, PID, uterine retroversion, ovarian cyst
List the causes of infection in the upper/lower genital tract
Lower:
Vulvovaginitis: Candidiasis; Bacterial vaginosis - Gardnerella vaginalis; Trichomoniasis (sexually transmitted) - trichomonoas vaginalis; Chlamydia; Gonorrhea; HSV; syphillis
Upper:
PID: (in order of frequency)
Chlamydia, Gonorrhea, Endogenous flora (E. Coli, Staph, Strep, Enterococcus, Bacteroides - associated with instrumentation), Actinomyces israelii (associated with IUDs)
Symptoms of PID
2/3 asymptomatic
Common: fever, lower abdominal pain and tenderness, abnormal discharge - cervical or vaginal
Uncommon: N/V, dysuria, AUB
Chronic (often due to chlamydia): constant pain, dyspareunia, palpable mass,
ON examination - must have cervical motion or adenxal tenderness
Causes of acute pelvic pain
Complications of pregnancy: ectopic, miscarriage
Acute infection: endometritis, acute PID, tubo-ovarian abscess, pelvic thrombophlebitis
Adnexal mass: ovarian torsion, ruptured ovarian cyst, endometriosis,
Causes of chronic pelvic pain
Continous pain > 6 months
Gynae:
Chronic PID; endometriosis; adenomyosis; fibroids
Surgical
Chronic appendicitis; diverticulitis, IBD, IBS, calculi
How do you treat PID?
FOXY DOXY
Cefoxitin and doxycyline
Investigations in chronic pelvic pain?
FBC - infection, anaemia
Transvaginal and abdominal US
B-HCG
CA-125
Alpha fetoprotein and LDH
How do you screen for chlamydia and gonorrhea
Urine or vaginal cervical swab - PCR
How do you screen for syphillus
Diagnostic - nontreponemal antibodies (RPR, VDRL)
Confirm with treponemal antibodies
What causes dyzchezia?
= painful defectation during menstruation caused by endometriosis
Causes of PID
Most commonly ascending STI infection from endocervix
BUT occasionally after
miscarriage, abortion, following childbirth, a gynaecological operation
Fertility management in endometriosis
Intrauterine insemination
Ovarian hyperstimulation
IVF - lower rates than women who don't have endometriosis who have IVF
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