Counselling about risk in Gyanecology

Presenting information on risk :

 

Term	Numerical ratio	Colloquial description
Very common	1/1 to 1/10	A person in family
Common	1/10 to 1/100	A person in street
Uncommon	1/100 to 1/1000	A person in village
Rare	1/1000 to 1/10 000	A person in small town
Very rare	Less than 1/10 000	A person in large town

 

 

 

 

RCOG Consent Advice 9 - Perineal Tears Following Childbirth :

 

Serious risks -

1. Incontinence of stools and/or flatus - 
 Common

1/10 to 1/100

A person in street

 
2. Delivery by caesarean section in future pregnancies may be recommended if symptoms of incontinence persist or investigations suggest abnormal anal sphincter structure or function.

Uncommon:

1/100 to 1/1000

A person in village

  
 3. Haematoma. 
 4. Consequences of failure of the repair requiring the need for further interventions in the future such as secondary repair or sacral nerve stimulation.

Rare:

1/1000 to 1/10 000

A person in small town

5.  Rectovaginal fistula.

Very rare:

Less than 1/10 000

A person in large town

 

 

RCOG Consent Advice 10 - Surgical evacuation of the uterus :

 

Serious risks include:

• Uterine perforation, up to five in 1000 women (uncommon-A person in village)
• Significant trauma to the cervix (rare-A person in small town)

Frequent risks include:

• Bleeding that lasts for up to 2 weeks is very common but blood transfusion is uncommon (1–2 in 1000 women)
• Need for repeat surgical evacuation, up to five in 100 women (common)
• Localised pelvic infection, three in 100 women (common).

RCOG Consent Advice 12 - CS for placenta previa :

 

In all women with placenta praevia:

• Emergency hysterectomy, up to 11 in 100 women (very common)
• Massive obstetric haemorrhage, 21 in 100 women (very common).
• Need for further laparotomy during recovery from the caesarean, 75 in 1000 women (common)
• Thromboembolic disease, up to three in 100 women (common)
• Bladder or ureteric injury, up to six in 100 women (common)
• Future placenta praevia, 23 in 1000 women (common)

Links for cancer information

For detailed & well-presented information about cancers -
 Must read  -  
 Cervical cancer
 Endometrial cancer

Anorexia nervosa

• Onset typically before the age of 25 years
• One of the most important causes of secondary amenorrhoea in adolescents
• Amenorrhoea frequently pre-dates weight loss

• Weight loss >25% original body weight
• Distorted body image with implacable attitude towards eating

• Exclude medical illness that could cause weight loss
• Exclude other psychiatric disorders

• Associated with lanugo hair, bradycardia , hypotension, constipation, hypothermia, vomiting (may be self-induced) and periods of over-activity

• Psychiatric referral required  

• May occur in adolescents and present with primary amenorrhoea

• FSH and LH levels are low and may be undetectable

• Oestradiol and progesterone low. Progesterone challenge test typically negative

• Cortisol elevated

• Prolactin normal

• TSH and T4 levels are normal but T3 and reverse T3 are elevated

• Changes revert to normal with weight gain but 30% remain amenorrhoeic

• Response to GnRH is regained at ~15% below the ideal body weight and occurs before the resumption of menses

Kallman Syndrome

 - X-linked recessive disease
- Reduced or complete absence of the sense of smell (anosmia-caused by the absence of the olfactory bulbs),  
- underdeveloped genitalia  - infertility
- lack of secondary sexual characteristics, 
- gynaecomastia, 
- short 4th metacarpal bone
- Males affected (1 in 10,000). 

- Presents at puberty

- Normal life-span 

- reduced or absent GnRH, with hypogonadotrophic hypogonadism. 

 - Hypothalamus is also affected

WHO classification of ovulation disorders

Patients are classified as :

WHO-1  - hypo-gonadotropic, hypo-estrogenic, (15%)

WHO-2  - normo-gonadotropic, normo-estrogenic, (80%) and 

WHO-3 - hyper-gonadotropic, hypo-estrogenic (5%)


( Class 1 has hypothalamic-pituitary failure
  Class 2 has hypothalamic-pituitary-ovarian axis dysfunction
  Class 3 has ovarian failure )



 The WHO criteria for classification of anovulation include :
the determination of -
- oligomenorrea (menstrual cycle >35 days) or 
- amenorrhoea (menstrual cycle > 6 months) in combination with -concentration of prolactin, follicle stimulating hormone (FSH) and estradiol (E2). 

  The vast majority of anovulation patients belong to the WHO-2 group and demonstrate very heterogeneous symptoms ranging from anovulation, obesity, biochemical or clinical hyperandrogenism and insulin resistance.

Premature ovarian failure - Aetiology

Aetiology -

• Unknown in most cases

• Genetic - up to 40% of cases. 

Karyotypic abnormalities -commonest being 45X and 47XXY followed by mosaiciams and structural abnormalities of sex chromosomes

• More common in families with fragile X syndrome

• Auto-immune disorder in some cases and associated with increased risk of other auto-immune diseases such as thyroid disease and pernicious anaemia

• Infections - mumps

• Irradiation / chemotherapy

Premature ovarian failure - Pathophysiology

• Definition - Ovarian failure before the age of 40 years

• Incidence ~1% and 0.1% between the ages of 15-29 years

• Usually caused by accelerated follicular atresia rather than absence of primordial follicles

• Associated with increased risk of cardiovascular disease and osteoporosis but not ovarian cancer

Secondary amenorrhoea - causes

• Auto-immune diseases such as 

1. Addison's disease, 
2. thyroid disease and 
3. diabetes mellitus 

are associated with premature ovarian failure. 

In addition, any severe endocrine disorder can cause amenorrhoea
• The Down's syndrome female has ovaries containing a reduced number of smaIl follicles, which have a greatly increased rate of atresia
• Bulimia & anorexia nervosa associated with secondary amenorrhoea
  (Androgen insensitivity syndrome associated with primary amenorrhoea)

Pituitary micro-adenoma

• Carbegoline - long-acting dopamine agonist, better side-effect profile compared to bromocriptine

-Prolactin levels fall within a few days of therapy and a reduction in tumour volume occurs within 6 weeks

• Interpretation of serum prolactin levels in pregnancy is difficult

• In women with micro-adenomas, risk of symptoms in pregnancy 2-5%

Hyperprolactinemia

Psychotrophic agents - diazepam, phenothiazines, tricyclic anti-depressants, opiates, haloperidol
Anti-hypertensives - methyldopa, reserpine, propranolol
Hormones - oestrogen, COCP, TRH
Anti-emetics - metoclopramide, sulpiride

(L-dopa is a dopamine agonist which would inhibit prolactin release)

Turner's syndrome

• 45X0


• Associated with increased nuchal transluscency, coarctation of the aorta, atrial septal defects, cystic hygroma, fetal hydrops.


• There is -

1. short stature with no adolescant growth spurt, 
2. webbed neck, 
3. wide carrying angle, 
4. hypoplasia of the nails and short fourth metacarpals, 
5. broad chest with widely spaced nipples and 
6. a low hair line
7. peripheral lymphoedema in 40% of cases.

• Streak ovaries with primary amenorrhoea (menstruation may occur in some and pregnancy has been reported).


• Increased risk of systemic hypertension and Hashimoto's thyroiditis.


• Normal intellectual development.

Primary amenorrhoea

In a 16 year old woman with primary amenorrhoea but normal breast, pubic and axillary hair development  -
- possible causes can be -
1. Uterine agenesis
2. CAH

Not - Androgen insensitivity syndrome & Kallman's syndrome

• Androgen insensitivity syndrome - absent / scanty pubic and axillary hair, short blind-ending vagina, absent uterus and cervix
• Kallman's syndrome is characterised by hypogonadism and infantile sexual development

Androgen activity in females

• 85% of testosterone is bound to sex hormone binding globulin and is metabolically inactive. 

10-15% bound to albumin and 1-2% free 

- free and albumin-bound testosterone are biologically active
• Testosterone is converted to the biologically active dihydrotestosterone by 5-alpha reductase 

- increased activity of this enzyme may result in the manifestations of androgen excess
• 2/3rd daily female testosterone production is of ovarian origin 

(total = 0.35mg/day - of which -
 0.1mg = direct ovarian production; 
 0.2mg = peripheral conversion of androstendione; 
 0.05mg = peripheral conversion of DHEA).

PCOS

1) Decreased sex hormone binding globulin production by the liver with a resultant increase in free, biologically active androgens and oestradiol

2) About 50% of women with PCOS have elevated levels of DHEA-S, an adrenal androgen

3) Raised androgens - testosterone / androstendione - ovarian hypersecretion

PCOS - Long-term consequences

1. Increased incidence of multiple pregnancy following ovulation induction
2. Increased incidence of gestational diabetes
3. Increased incidence of pregnancy induced hypertension
4. Increased risk of endometrial cancer -5-fold
5. Cardiovascular disease -mortality is not significantly increased although women with PCOS have abnormal lipid profiles
6. Increased risk of adult onset diabetes mellitus ~ 40% risk of NIDDM by the age of 40 years

PCOS - infertility Rx

• Both recombinant FSH and human menopausal gonadotrophin (hMG) are effective ovulation induction agents in women with clomiphene resistant PCOS (about 20-30% of women with PCOS).
• No advantage in routinely using GnRH analogues in conjunction with gonadotrophins in these women - no increase in pregnancy rate and their use may be associated with an increased risk of ovarian hyperstimulation.
• Risk of first trimester miscarriage is increased and this is not reduced by supression of LH hypersecretion

PCOS - Diagnosis

• PCOS is a biochemically and clinically heterogeneous condition
• Women with clinical or biochemical evidence of PCOS but with normal ovarian morphology on ultrasound scan should be considered as having hyperandrogenic chronic anovulation
• Women with PCOS may have normal LH:FSH ratio and a normal body mass index

• Rapidly progressive virilisation would indicate an androgen-secreting tumour

Contraceptive vaginal ring - contents

NuvaRing delivers -
        15 µg of ethinyl estradiol  and  
        120 µg of etonogestrel (a progestin) each day of use.

Combined contraceptive patch - contents

- Releases 20 µg/day of ethinyl estradiol and  
                 150 µg/day of norelgestromin.

- Only currently available patches are - Ortho Evra in US & Evra in UK

Yuzpe regimen

- 100 mcg Ethinyl estradiol + 500 mcg levonorgestrel  

- two doses -12 hours apart

- Licensed in 1984
- Now replaced with POEC (Progesterone only emergency contraception)