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Laura MRCOG Part 2 > 13) Gynaecological Problems - Pain related > Flashcards

13) Gynaecological Problems - Pain related Flashcards

1
Q

Incidence of endometriosis

A

2-10% of women

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2
Q

What percentage of infertile women have endometriosis?

A

50%

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3
Q

What is gold standard diagnosis for endometriosis?

A

Laparoscopy and biopsy (but negative histology doesn’t exclude and positive laparoscopy without histology doesn’t confirm)

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4
Q

Indications for laparoscopy in endo

A

Patient wish for definitive diagnosis
Subfertility
Deep infiltrating disease

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5
Q

What types of endometriosis can TVUS detect?

A

Ovarian endometriomas.

Rectal endometriosis.

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6
Q

What other imaging is useful in endometriosis?

A

MRI useful for assessing ureter/bladder/bowel involvement and NICE recommend should be considered before surgery for deep endometriosis.

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7
Q

Treatment for endometriosis

A

Initial treatment: 3/12 trial (suitable in primary care) of simple analgesia + hormonal contraception (any method). (Recommended for 3-6m before laparoscopy by RCOG)

If this has failed:

  • Consider need surgical treatment
  • GnRH agonists with add back HRT
  • Aromatase inhibitors (letrozole - for rectovaginal endometriosis only if all other therapies fail)
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8
Q

What surgical treatments are an option?

A
  • Ablation or excision of peritoneal endometriosis
  • Presacral neurectomy (effective for midline pain)
  • Excision of endometriomas
  • Surgical removal of deep endometriosis
  • Hysterectomy and ovarian removal
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9
Q

Role of pre-surgical hormone treatment in endometriosis

A

Doesn’t improve surgical outcomes but can be used as interim pain control

(But NICE recommend GnRH for 3/12 pre-surgery for deep endo)

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10
Q

What can be used to prevent adhesions at time of surgery for endometriosis?

A

Oxidised regenerated cellulose (don’t recommend icodextrin)

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11
Q

What should be considered before surgery for deep endo?

A

GnRH 3/12

MRI

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12
Q

What can be used to reduce risk of recurrence after surgery for endometriosis?

A

Mirena/COCP for 18-24 months post-op

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13
Q

Treatments on fertility in endometriosis

A
  • Hormonal treatment does not improve fertility
  • Offer operative laparoscopy with CO2 laser vaporisation for stage 1/2 endometrial
  • Excision of endometriomas
  • Can consider surgery in stage 3/4 disease if it is thought it will improve pregnancy outcomes
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14
Q

ART in women with endometriosis

A

Stage 1/2: IUI with controlled ovarian stimulation increases birth rate.

GnRH agonists for 3-6m prior to ART can improve clinical pregnancy rates in infertile women with endometriosis.

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15
Q

What HRT to use in women after menopause (even if surgically induced) due to endo?

A

COMBINED (EVEN IF THEY DON’T HAVE A UTERUS)

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16
Q

Risks of cancer and endometriosis

A

Overall incidence of cancer unchanged
Ovarian cancer and non-Hodgkin’s lymphoma more common in people with endometriosis.
Cervical cancer less common.

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17
Q

Symptoms which are strongest predictors of deep endometriosis

A

Dyschezia during menstruation and deep dyspareunia

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18
Q

Correlation between pain symptoms and degree of endo

A

Pain increases as depth of invasion increases (but not stage of disease)

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19
Q

Mean latency to diagnosis of endometriosis

A

8 years

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20
Q

Comparison of COCP and GnRH analogues for treatment of endometriosis

A

As effective

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21
Q

Percentage loss of BMD after 6 months on GnRH analogues

A

13%

22
Q

Ovarian failure rate after bilateral ovarian endometrioma cystectomies

A

2.4%

23
Q

Rate of complications associated with surgery for deep infiltrating endometriosis

A

2% intra-operative complications

14% post-operative complications

24
Q

Recurrence rates following colorectal endometriosis surgery

A

5-25%

25
Q

Dietary changes with evidence for endometriosis

A

Omega 3 fish oil
Vitamin B12
Diet high in vegetables and low in animal fats
Vitamin E + C benefits

26
Q

Incidence of IBS

A

10-15%

27
Q

Incidence of IBS after gastroneteritis

A

7-30%

28
Q

What type of foods exacerbate IBS?

A

FODMAP foods

29
Q

Incidence of IBS in women with endometriosis

A

2.5 x higher

30
Q

Management of IBS

A
  • Avoid foods e.g. insoluble fibres, beans, fatty food, caffeine, chocolate and sugar substitutes and alcohol
  • Moderate exercise
  • 1st line: Antispasmodics
  • 2nd line: TCAs/SSRIs
  • Laxatives/antidiarrhoeals (ondansetron can control diarrhoea in pt with IBS)
  • CBT, Hypnotherapy
  • Pregabalin
31
Q

How long does chronic pelvic pain have to have lasted for the definition?

A

6 months

32
Q

Incidence of chronic pelvic pain

A

1 in 6 women

33
Q

What is residual ovary syndrome?

A

Small amount of ovarian tissue left behind and gets trapped in adhesions

34
Q

What is trapped ovary syndrome?

A

Retained ovary becomes buried in dense adhesions?

35
Q

Rome III criteria for IBS

A
  • COntinuous/recurrent abdo pain
  • At least 3 days per month in last 3 months
  • Onset at least 6 months previously

Associated with two of:

  • Improvement with defaecation
  • Onset associated with change in frequency of stool
  • Onset associated with change in form of stool
36
Q

Number of negative laparoscopies in patients with chronic pelvic pain

A

1/3-1/2

37
Q

Incidence of bladder pain syndrome

A

2.5-6.5%

38
Q

Definition of bladder pain syndrome

A

Pelvic pain, pressure or discomfort perceived to be related to the bladder, lasting for at least 6 months (new definition: 6 weeks) and accompanied by at least one other urinary symptom in the absence of other identifiable cause.

39
Q

What makes bladder pain syndrome worse/better?

A

Worsens with certain food/drink
Worsens with bladder filling
Improves with urination

40
Q

Diagnosis of bladder pain syndrome

A
  • Diagnosis of exclusion.
  • Bladder diary, food diary.
  • Urine dipstick (consider testing ureaplasma/chlamydia if symptomatic sterile pyuria)
  • Urine cytology and cystoscopy if suspect malignancy
  • Bladder biopsy and hydrodistension NOT recommended to make diagnosis
41
Q

Management of bladder pain syndrome

A

1st line: Analgesia, stress relief, diet, physical therapy
2nd line: Amitryptiline, Cimetidine (if fails refer MDT/pain team/psychologist)
3rd line: Intravesical DMSO, heparin, botox A, lidocaine chondroitin sulfate, hyaluronic acid.
4th line: Neuromodulation (posterior tibial N, sacral N), oral ciclosporin A
5th line: Cystoscopy and hydrodistension

42
Q

Effect of pregnancy of BPS

A

Unkown

43
Q

BPS treatments which are safe in pregnancy

A

Oral amitryptiline\
Intravesical heparin
One course of intravesical DMSO pre-pregnancy

44
Q

Classification of BPS

A

Cystoscopy with hydrodistension:

  • Not done: X
  • Normal: 1
  • Glomerulations: 2
  • Hunner Lesions: 3

Biopsy:

  • Not done: X
  • Normal: A
  • Inconclusive: B
  • +ve: C
45
Q

Incidence of pelvic congestion syndrome

A

3.8%

46
Q

Who gets pelvic congestion syndrome?

A

Premenopausal multiparous women

47
Q

What happens in pelvic congestion syndrome?

A

Ovarian plexus varicosities secondary to:

  • Absence of ovarian vein valves allowing reflux
  • Venous dilatation in pregnancy leading to valvular incompetence
  • Compression of left renal vein (into which ovarian vein drains) between SMA and aorta (“nutcracker syndrome”)
48
Q

Characteristic features of pelvic congestion syndrome

A

Pelvic pain which is worse premenstrually, in pregnancy and when standing.
Throbbing ache after intercourse.

49
Q

Investigations for pelvic congestion syndrome

A

Gold standard is venography.

Can use USS/CT/MRI.

50
Q

Management of pelvic congestion syndrome

A 
Analgesia
Responds to ovarian suppression
Daflon is a vasoconstrictive drug with benefit
Surgical
Embolisation
Psychotherapy

Laura MRCOG Part 2 (56 decks)

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