Gyane disorders

Heavy menstrual bleeding > 80mls per period
OR periods lasting > 7 days
Endometrial polyps
Dysfunctional uterine bleeding
Endometrial hyperplasia
Fibroids
Adenomyosis
Endometriosis
Chronic PID

Menstrual pain in absence of organic disease (primary)
Menstrual pain due to organic disease (secondary)
Endometriosis, fibroids, PID, adenomyosis, PCOS

Abnormal bleeding not attributable to organic (anatomic/systemic) disease
DUB is a diagnosis of exclusion

irregular cycle more than 35 days in length

28 days - lasting 3-5 days, 30-50mls

Anatomic or physical lesion (Polyp, Fibroid, Adenomyosis, Neoplasm, foreign body)
Haemostatic defect
Infection
Trauma
local disturbances in prostaglandins

PCOS
Thyroid dysfunction
Elevated prolactin
Rare oestrogen producing tumours
Stress
Wt loss
Exercise
Liver and kidney disease

bleeding at irregular intervals, particularly between expected menstrual periods

vaginal bleeding occurring at intervals < 21 days

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

Anovulation 90%
Dysfunction of corpus luteum and inadequate progesterone production or an atrophic endometrium (i.e. secondary to OCP)

The presence of endometrial tissue (glands and stroma) outside of the uterine cavity
It affects 10-15% of menstruating women

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

FHx
Obstructive anomalies of the genital tract
Nulliparity
Age > 25 years

Ovaries
broad ligament - vesicoperitoneal fold
periteonal surface of the cul-de-sac (uterosacral ligaments)
rectosigmoid colon
appendix

Dysmenorrhea
Dyspareunia
Dyschezia (difficulty defecating)
Dysuria, frequency, haematuria
Infertility

Definitive diagnosis - direct visualisation of lesions at laparoscopy + biopsy and histologic exam of specimens
CA125 may be elevated

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

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

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

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)

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

Complications of pregnancy: ectopic, miscarriage
Acute infection: endometritis, acute PID, tubo-ovarian abscess, pelvic thrombophlebitis
Adnexal mass: ovarian torsion, ruptured ovarian cyst, endometriosis,

Gynae:
Chronic PID; endometriosis; adenomyosis; fibroids
Surgical
Chronic appendicitis; diverticulitis, IBD, IBS, calculi

FOXY DOXY
Cefoxitin and doxycyline

FBC - infection, anaemia
Transvaginal and abdominal US
B-HCG
CA-125
Alpha fetoprotein and LDH

Urine or vaginal cervical swab - PCR

Diagnostic - nontreponemal antibodies (RPR, VDRL)
Confirm with treponemal antibodies

= painful defectation during menstruation caused by endometriosis

Most commonly ascending STI infection from endocervix
BUT occasionally after
miscarriage, abortion, following childbirth, a gynaecological operation

Intrauterine insemination
Ovarian hyperstimulation
IVF - lower rates than women who don't have endometriosis who have IVF