Summary Final year MD notes - gynaecology

GYNAECOLOGY
COMMON COMPLAINTS - DDx
Irregular Menstruation (abnormal uterine bleed)

Irregularities in menstrual cycle, affecting frequency, duration, regularity of the cycle length and the volume of menses. Irregular
menstrual periods indicate anovulation (a lack of ovulation) or irregular ovulation. This occurs due to disruption of normal hormonal levels in
the menstrual cycle, or ovarian pathology caused by:


• Extremes of reproductive age (early periods or perimenopause)
• Polycystic ovarian syndrome
• Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
• Medications, particularly progesterone only contraception, antidepressants and antipsychotics
• Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin


Abnormal Uterine Bleeding - AUB (PALM COEIN)

Intermenstrual bleeding (IMB) refers to any bleeding that occurs between menstrual periods. This is a red flag that should make you consider
cervical and other cancers, although other causes are more common.

Structural causes


• Polyps /ectropion / cysts
• Adenomyosis – dysmenorrhoea
• (> 30 yo) Leiomyomas (fibroids)
• (> 30 yo) Malignancy (endometrial, cervical, vaginal)

Non-structural causes


• Coagulopathies
• (<20yo) Ovulatory issue (PCOS, pregnancy, M/C, hypothyroidism)
• Iatrogenic / infection (STI) / meds (SSRI, anti-coags, contraception)
• (<20yo) Endometriosis
• Unknown origin


Dysmenorrhoea (painful periods)

• Primary dysmenorrhoea (no underlying pathology) Investigations for HMB
Ø Speculum + bimanual = fibroids, ascites and cancers
o Any AUB ® any POC è REMOVE with D+ C
Vs. Secondary Amenorrhoea
o Any AUB ® foetal body parts è Remove in OT
Ø FBC (Hb and HCT) = Fe def. anaemia
• Endometriosis or adenomyosis Ø Swabs – M/C/S and NAAT (STI)
Coag screen
• Fibroids ( submucosal)
Ø
Ø TFT
• Pelvic inflammatory disease Ø Pelvic and TVUS
• Copper coil o ?fibroids, adenomyosis,
• Cervical or ovarian cancer o Hysteroscopy declined or very abuse
Ø Outpatient hysteroscopy
o Suspected fibroids, endometrial cancer, hyperplasia
Menorrhagia (HMB) - (PALM COEIN)
↓
General Mx for HMB
• Dysfunctional uterine bleeding (no identifiable cause)
Rx underlying cause
• Extremes of reproductive age 1) IUD (mirena) = 1st line
• Fibroids a. 2nd line = cyclical oral progestogens (e.g. 5mg
norethirsterone tds from day 5-26) – esp. if risk factors for high
• Endometriosis and adenomyosis E2 exposure (E.g. obesity, PCOS)
• Pelvic inflammatory disease (infection) b. 2nd line = cyclical estrogen (only if peri-menopausal)
• Contraceptives, particularly the copper coil 2) If does not want OCP ® ANTI-FIBRINOLYTICS
• Anticoagulant medications a. TXA (if not in pain) + NSAID/PPI OR
b. Mefenamic acid (if there is pain -NSAID component)
• Bleeding disorders (e.g. Von Willebrand disease)
3) Referral to secondary care if treatment unsuccessful
• Endocrine disorders (diabetes and hypothyroidism) a. Endometrial ablation e.g. balloon thermal ablation
• Connective tissue disorders b. Hysterectomy
• Endometrial hyperplasia or cance
• Polycystic ovarian syndrome

, Postcoital Bleeding

Postcoital bleeding (PCB) refers to bleeding after sexual intercourse. This is a red flag that should make you consider cervical and other
cancers, although other causes are more common. Often no cause is found. The key causes are:


• Cervical cancer, ectropion or infection
• Trauma
• Atrophic vaginitis
• Polyps
• Endometrial cancer
• Vaginal cancer


Pelvic Pain


Complications of PID:
• Chronic pelvic pain – abscess,
peritonitis
• Ectopic
• Infertility
• Septic arthritis, endocarditis



Toxic Shock Syndrome:
• MOF due to S. aureus exotoxin
• RF: tampon use, wound infections,
post-partum infections
• Sx: high fever, sore throat, shock, skin
peeling on palm and plantar surface
• Rx: Remove infective sources ®
debride necrotic tissue ® B-
lactamase ABx




Vaginal Discharge

• Bacterial vaginosis
• Candidiasis (thrush)
• Chlamydia
• Gonorrhoea
• Trichomonas vaginalis
• Foreign body
• Cervical ectropion
• Polyps
• Malignancy
• Pregnancy
• Ovulation (cyclical)
• Hormonal contraception




Pruritus Vulvae

Pruritus vulvae refers to itching of the vulva and vagina. There are a large number of causes:


• Irritants such as soaps, detergents and barrier contraception
• Atrophic vaginitis
• Infections such as candidiasis (thrush) and pubic lice
• Skin conditions such as eczema
• Vulval malignancy
• Pregnancy-related vaginal discharge
• Urinary or faecal incontinence
• Stress