General Gynaecology

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

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

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

Primary = no organic pathology (50%)
Secondary = endometriosis, adenomyosis, pelvic congestion, chronic pelvic pain, Ashermann's

PF2-a

1ry: normal period pain
2ry: period pain described in endometriosis

NSAIDs (inhibit PF2a)
Mefenamic acid (C/I in asthma)
OCP

>80ml per period (the level whcih reflects a fall in Hb and haematocrit [ ])

Anovulatory: menopause, PCOS, menarche, obesity/stress
Ovulatory: ????
2ry to organic causes: fibroids, adenomyosis, PID, cancer, endocrine disorders, clotting disease, drug therapy

- 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

- exclude pregnancy
- FBE & ferritin/Fe studies
- Coags and TFTs
-D&C
- hysteroscopy

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)

-Endometrial ablation
- Hysterectomy

- Cervical neoplasms
- Atrophic vaginitis
- Infections
- cervicitis and ectropion
- endometrial polyps

- SSRIs
- COOP or progesterone pill

- Restlessness
- headaches
- breast tenderness
- depression
- verbal/physical aggression
- irritable feelings
-tiredness
-swelling of abdomen, hands, feet
-tampons/pads used

- ovarian dysfunction (due to oligomenorrhoea)
- hyperandrogenism (clinical/biochemical)
- polycystic ovaries on U/S (>10 follicles)

25% have polycystic ovaries; yet only 4-5% have the syndrome

-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)

- oligo/amenorrhoea
- hirsutism, acne, deeping voice, androgenic alopecia, virilism
- sufertility
- obesity
-acanthosis nigricans

- DM2, metabolic, CVD
- Endometrial ca

- U/S
-FSH:LH ratio
-androgens
- insulin
-lipid status

-weight loss
-OCP (cyproterone acetate)
- metformin
-clomiphene for fertility, tamoxifen
Surgically can have ovarian resection

-growth spurt
- therlarche
-adrenarche
-menarche

Absence of 2dry sexual characteristics by 14 OR menarche >2 yrs after 2dry characteristics

Phenytoin - antiepileptics increase the liver's ability to break down the OCP so not covered for same length as normal females

- 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)

- XR for bone age
- brain imagining
- hormone levels (inc prolactin)
- steroid levels
- TFTs
- karotype
- pelvic U/S

- 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

- 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

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

- 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

Diffuse or localised presence fo endometrial tissue (glands or stroma) in the myometrium.

- 10-25%, usually multiparous, 3rd and 4th decade

- colicky dysmenorrhoea, dyspareunia, pelvic pain particularly pre-menstrually

- endometriosis
- fibroids
- long periods of secondary subfertility
- multiparity and C/S
- increasing age

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.

- danazol, mirena
- hysterectomy is only definitive tx

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

- retrograde menstruation
- metaplasia
lymphatic or haematological emboli?