Gynae Finals Summary in Flow Diagrams

The basics of what you need to know for finals broken down by easy ways to remember them

Transcript

1. Jacob Matthews 22/04/2015 1
2. “Classify or Die” – The science of Perfect Answers Question Causes Vascular Infection Trauma Autoimmun e Metabolic Idiopathic Neoplasia Drug Stats Common Uncommon Rare Super Rare IX Bedside Laboratory Non-rad imaging Rad imaging Invasive Rx Conservative Medical Interventional Surgical Palliative 22/04/2015 2
3. Contents Menstrual cycle Menorrhagia Menopause + HRT Amenorrheia Irregular bleeding Uro-gynae + prolapse Infertility Contraception Cancers Neonates 22/04/2015 3
4. Gynae hx ICE Any questions? Patient details Age + parity + Gravidity Occupation Menstrual LMP + bleeding days + regular + length + Normal Contraception Smear Mammography >50yo Hx Present Complaint General health, smoking Menses / pain Discharge Bowel/ bladder Past Gynae hx Surgery? STI, PID, ectopics, endometriosis Pregnancies, miscarriages, abortions Preg Obs Hx >24/52 PMHx + PSHx FHx + SHx Smoking drugs drinking Hereditary conditions = HT diabetes Cancer, fibroids, Endometriosis Occupation + Partner Drug Hx Chronic, otc, allergies Ex general abdo Bimanual, speculum USS 22/04/2015 4 Gravidity = pregnancies Parity = >24/52 + <24/52
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6. Gynae Conditions Dysmen 1 – Give NSAIDs 2 – USS treat cause + COP Irregular bleeding Anovulatary cycles – extremes of age Uterine Path TVUSS >35 + Smear+ FBC + Pipelle >40 IUS / COP Norethisterone / HRT Post coital bleed Ix Cancer- smear + colposcopy Ectropion – Cryotherpay PMS – Leuteal phase Menstrual mood diary Progesterone = problem SSRI + CBT / continuous oestrogen Oopherectmy + HRT Amen / Oligomen Hypothalamic- pituitary – gonadal Axis BhCG FSH, LH, FBC, PRL, TSH/ TFT, Testo, eostradiol, GnRH USS - PCOS Karyotype, Head MRI Endometriosis Extra-uterine, oestrogen, retrograde menstruation Choc cyst, adhesions, frozen peritoneum, bleeding Chronic pain – Pre bleed Diagnostic Laparoscopy TVUSS, MRI, Ca125 Malignancy Structural Polyps >40yo [tamoxifen] Surg - avulsion Haematometria - Fibroids Uro-gynae Infections - endometritis STI, FB, surgery Post menopause ?malignancy Evacuation of retained products Abx - ? Tazocin Infertility 22/04/2015 6
7. Gynae Conditions Endometriosis Extra-uterine, oestrogen, retrograde menstruation Diagnostic Laparoscopy Pregnancy or not? ablation Hysterectomy + oopheretomy TVUSS, MRI, Ca125 Choc cyst, adhesions, frozen peritoneum, bleeding Chronic pain – Pre bleed COP>POP>IUS Danazol - andorgens GnRH analogue- Goserelin <6/12 Pregnancy / menopause Sub-fertility Ablation + adhesiolysis IVF Adenomyosis - MRI 22/04/2015 7 http://www.patient.co.uk/doctor/endometriosis-pro
8. Gynae Conditions Fibroids >30yo, black, ¼ women Oestrogen dependent Heavy menstrual bleed + pain + subfertility Intramural = most common Rx Med NSAIDs + TXA COP / IUS GnRH Mifepristone, ullipristal, aromatase inhib Surg Myomectomy – Lap/Hyst Ablation Hysterectomy Uterine Art Emnolisatin Sub serosal Extra uterine Sub mucousal Uterine cavity Benign leomyiomata 22/04/2015 8 http://www.patient.co.uk/doctor/fibroids-pro
9. Gynae Conditions CIN Heterosexual + HPV <45yo Bleeding, discharge, pain STI screen - chlamydia Smear Mild – Test HPV Dyskaryosis - >moderate Colposcopy – asetic acid + iodine 16 + 18 + 31 + 33 vaccine 1 Can regress 90%, watch <24/12 Loop excision + histology 2 Loop excision 3 Cone biopsy Malignant 70% SCC CT/MRI scan staging FIGO 1-4 Cone biopsy Hysterectomy local Radical Wertheim’s Radiotherapy Chemo - Cisplatin Adeno / mixed 22/04/2015 9 http://www.patient.co.uk/doctor/cervical-carcinoma http://en.wikipedia.org/wiki/Cervical_intraepithelial_neoplasia http://en.wikipedia.org/wiki/Dyskaryosis
10. BRCA 1 + 2 Ovarian Path benign Functional cyst follicular luteal Cyst adenoma serous Risk of Malignancy Index (RMI) >50mm yearly USS mucinous Dermoid Cyst (teratoma) Fibroma (Meig’s syndrome) Sex cord tumour Granulosa – oestrogen + inhibin, Post-men Thecoma – oestrogen + androgens – precocious puberty Fibroma Germ cell tumours <30yo Teratoma – young, bilateral Dysgerminoma – common malignant, radiotherapy LDH, AFP, BhCG – all <40yo Epithelial tumour Serous adenocarcinoma most common Mucinous adenocarcinoma – big, rupture Clear cell carcinoma Endometroid carcinoma Malignant USS + CA125 (>35) CT/MRI scan staging 1-4 OOpherectomy CA 125 monitoring follow up 1/50, increase with age 22/04/2015 10 www.patient.co.uk/doctor/benign-ovarian-tumours Torsion, rupture, haemorrhage, infertility RMI = U x M x CA-125
11. Post-men bleed TVUSS <4mm 1 episode Watch and wait >1 bleed hysteroscopy TVUSS >4mm Hysteroscopy Pipelle biopsy Hyperplasia - premalignant Progesterones TCRE - resection hysterectomy Younger, Intermen bleed Endometrial Carcinoma MRI staging, CXR hysterectomy Most common GU tract malignancy 60 yo 1/100 Obesity, Oestrogen, PCOS, HNPCC Granuloma cell tumour – oestrogen secreting Tamoxifen COP, pregnancy 22/04/2015 11 http://www.patient.co.uk/doctor/endometrial-hyperplasia www.patient.co.uk/doctor/endometrial-cancer
12. Amenorrhea 1 >14yo, Ix>16yo Constitutional GU malformation CAH Imperforate hymen Uterine horns Unicornate uterus/ Septum Testicular feminisation Turner’s 2 Hypothalamic failure Anorexia Pituitary failure Hyper-prolactin- aemia, Shehan’s Hypothyroidism, phenothiazines, Heroin, Metoclopramide Contraception Dopamine antagonists Gonadal Failure/ structural Asherman’s AID – Prem Ovarian Failure Androgens, weight loss, PCOS Cushings’s, CAH, Adrenal Tumour 22/04/2015 12 http://www.patient.co.uk/doctor/amenorrhoea
13. Menorrhagia >80ml/day DUB 40-60% Local Structure Fibroids, polyps Tumour >40yo tissue Endometriosis, adenomyosis, endometrial hyperplasia PID systemic Hypo-thyroid, obesity, liver + kidney failure Bleeding disorders, vW disease Contraception 1/3 of women, Affects QOL 22/04/2015 13 http://www.patient.co.uk/doctor/menorrhagia
14. Menorrhagia >80ml/day Hx Ex Mass Tender anaemia Ix FBC, Clotting, TFT TVUSS Pipelle Biopsy hysteroscopy Rx Med IUS - Mirena TXA 1g + Mefanamic acid COP LARC Progesterones, Goserelin <6/12 surg Hysteroscopic removal + ablation TCRE/TCRF Myomectomy Uterine Art Embolisation Hysterectomy 22/04/2015 14 http://www.patient.co.uk/doctor/menorrhagia
15. 40-58 yo = Average 51yo 12/12 no period Menopause Prem <40yo Fhx Ovarian Failure Hysterectomy + oopherectomy Early <45yo Symptoms Hormonal/ vasomotor Urological UTI, atrophic vaginitis Mood FSH level 2/5 5/7 x2 >30IU Reassure, lifestyle Contraceptives 2y<50, 1y>50 Local - oestrogens Clonidine, tibolone, SSRI, Gabapentin HRT - vasomotor Uterus or not? 22/04/2015 15 http://en.wikipedia.org/wiki/Clonidine Women's Health Initiative (WHI) the Million Women Study (MWS http://www.patient.co.uk/doctor/hrt-initial-consultation http://www.patient.co.uk/doctor/menopause-and-its-manageme http://www.patient.co.uk/doctor/hormone-replacement-therapy- including-risks-and-benefits
16. Infertility Hypothalamic failure Anorexia / Exercise Systemic disease SLE, antiphospholipid, CKD, diabetes Pituitary failure Hyper-prolactin- aemia, Shehan’s, Simmond’s Hypothyroidism, phenothiazines, Heroin, Metoclopramide Contraception Dopamine antagonists Gonadal Failure AID – Prem Ovarian Failure Turner’s Structural Tubal PID, ectopic, surgery, endometriosis Hystero- salpingogram Uterine Fibroid, congenital, Asherman’s Androgens, weight PCOS 2/3 oligomen, USS, Hirsuitism 80% anovulatory infertility Raised insulin + testosterone LH>FSH Cushings’s, CAH, Adrenal Tumour Male Poor sex Genetic, XXY IVF/ ICSI 1 – never conceived 2 – conceived – may have miscarried 22/04/2015 16 Mid-luteal progesterone level to assess ovulation day 21/28 Clomifene 6/12 – oestrogen blocker increases FSH/LH release days 2-6, USS day 10 check Endometrial thickness Metformin for PCOS, Goserelin – pulsed, Bromocriptine for PRL-oma www.patient.co.uk/doctor/infertility-female •Unexplained infertility (no identified male or female cause) (25%) •Ovulatory disorders (25%) •Tubal damage (20%) •Factors in the male causing infertility (20%) •Uterine or peritoneal disorders (10%) www.patient.co.uk/doctor/infertility-male www.patient.co.uk/doctor/infertility-treatments
17. Uro-gynae UTI Painful bladder syndrome Bladder training, Analgesia, TCA Incontinence Stress – 50% Urodynamics Pelvic floor training Duloxetine Tension free vaginal tape, Mixed OAB – 35% ?MS Urgency, Frequency, nocturia Urodynamics – detrusor activity Advice, bladder training oxybutynin., Oestrogens, Botulinum toxin Surgery last resort Prolapse Urethrocele Cystocoele Vault prolapse Enterocole, rectocoele Bimanual ex, Sim’s spe USS, Urodynamics Pessary + HRT Pelvic floor repair Lose weight, pelvic floor exercises Retention 22/04/2015 17 http://en.wikipedia.org/wiki/Cystometry