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Obs & Gynae > Abnormal Bleeding + Pelvic Pain > Flashcards

Abnormal Bleeding + Pelvic Pain Flashcards

1
Q

What is dysmenorrhoea?

A

Painful period
Primary = no pathology
Secondary = pathology

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2
Q

What does primary dysmenorrhoea present?

A 
1-2 days before period 
Lower pelvic crampy pain
Can radiate to lower back / anterior thigh 
48-72 hours 
N+V / malaise / diarrhoea / dizzy
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3
Q

What is mittelchmerz

A

Pain in middle of cycle

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4
Q

What is secondary dysmenorrhoea

A

Usually begins after had a period

3/4 days before period begins

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5
Q

What can cause secondary dysmenorrhoea

A

Endometriosis
Adenomyosis
PID
Fibroid

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6
Q

How do you treat dysmenorrhoea

A

NSAID - mefanamic acid / Ibuprofen (inhibit prostaglandin)
COCP = 2nd line
IUS
Refer to gynaecologist for secondary causes

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7
Q

What is FIGO classification for abnormal bleeding

A 
PALMCOEIN
P - polyp
A - adenomyosis
L - leiomyoma
M - malignancy 
C - coagulation 
O - ovarian - PCO / cyst rupture
E - endocrine - thyroid / Cushing's / androgen
I - iatrogenic or infection -  drugs / contraception 
N - not yet classified
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8
Q

What causes bleeding in early teens

A

Anovulatory as HPO not established
Coagulation - VWD / ITP / leukaemia
Liver disease
Congenital adrenal hyperplasia

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9
Q

What causes bleeding in teens - 40

A 
Period 
Pregnancy
Infection - C+G / thrush
PID / endometritis 
Ectropian 
Contraception 
Endometriosis
Fibroids
Polyps
Cysts 
Endometrial hyperplasia
DUB
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10
Q

What causes bleeding in menopause age

A 
Perimenopause
Vaginal atrophy
HRT
Endometrial cancer - if no HRT
Warfarin / anti-coagulant
Hyper or hypothyroid
Hyperprolactin
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11
Q

What is menorrhagia and how do you investigate

A 
Heavy period
Subjective
>80ml 
Associated fatigue / SOB
FBC always 
Coag, iron study, TFT if indicated 
VE 
Transvaginal USS if abnormal VE or symptoms suggestive
Biopsy if >10mm in pre-menopause or >4 in post
Hysteroscopy if polyp
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12
Q

What can cause menorrhagia

A 
Fibroid = most common 
Endometriosis
Adenomyosis
Hypothyroid
PID 
Polup 
Blood disorder
Contraception - COCP / coil 
Endometrial cancer
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13
Q

What can cause PCB

A 
Cervicitis - C+G
Ectropion
Polyps 
Cervical cancer
Cancer 
Vaginal atrophy 
Trauma
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14
Q

What can cause PMB

A

Vaginal atrophy

Malignancy - endometrial

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15
Q

What can cause IMB

A 
Cervical ectropion
Cervical polyp / cancer
STI
Endometrial polyp / cancer 
Iatrogenic - contraception
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16
Q

What investigations for abnormal bleeding

A 
Abdominal + bimanual to look for local causes 
ALWAYS 
- mass / fibroid 
- tenderness suggest PID 
Pregnancy test
FBC - anaemia 
C+G
Coagulation if heavy since menarche or FH 
Thyroid only if indicated by symptoms coagulation 
Transvaginal USS 
Endometrial biopsy 
Hysteroscopy if persistent 
Laparoscopy
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17
Q

When is USS indicated

A

IMB
PMB - endometrial thickness
Pelvic pain

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18
Q

When do you test for chlamydia

A

IMB

PCB

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19
Q

When do you do hysteroscopy

A

Persistent IMB
Suspicion of endometrial cancer
Fibroids / polyps

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20
Q

How do you treat menorrhagia non-hormonal if no contraception needed

A

Reassure
Tranexamic acid = 1st line - reduce bleeding
Mefanamic acid (NSAID) - reduce bleeding and pain
Ferrous sulphate if anaemic

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21
Q

When do you do non-hormonal Rx

A

If no contraception needs

Mefanamic CI in pregnancy

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22
Q

What does tranexamic acid do

A

Anti-fibronlytic
Prevent conversion of plasminogen to plasmin
Start 1st day of period

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23
Q

What is hormonal Rx

A

Mirena coil = 1st line
Combined OCP 2nd line
POP
Noriestherione = short term

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24
Q

What are surgical Rx for menorrhagia

A

Hysterectomy
Salpingo-oophorectomy
Endometrial ablation
Remove anomaly e.g. polyp / fibroid

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25
Q

When do you consider surgical

A

If hormone hasn’t worked after 3 months

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26
Q

What is the risk of endometrial ablation

A

Risk of miscarriage

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27
Q

What do you ask in Hx of bleeding

A 
Onset, duration, variation, progression 
Clots / flooding / number of pads or tampon
Compared to normal period 
IMB / PCB?
Frequency 
Regularity
LMP
Date of 1st period 
Contraception 
Do you get period
Last smear
QOL 
Other Sx - pain / discharge / weight 
If pain with heavy flow or pre-menstrual
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28
Q

What causes cervical bleeding

A 
Cancer
Cervicitis - C+G
Polyps
Ectropian
Prolapse
Endometriosis
Vasculitis
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29
Q

Characteristics of cervical

A

Commonly PCB
More sporadic than uterine
Can see on speculum

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30
Q

What causes vaginal bleeding

A 
Atrophic vaginitis
Genital ulcer
Cancer but rare
Trauma
RT
Fistula
Benign growth
TENS or STS
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31
Q

What causes vulval bleeding

A 
STI
Thrush
Lichen sclerosis
VIN 
Malignancy
Trauma
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32
Q

What is dysfunctional uterine bleeding

A

Abnormal bleeding
No structural cause found
Dx of exclusion of other pathologies

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33
Q

What drugs will cause DUB

A 
Contraception
HRT
Anti-coagulant
Drugs that cause hyperprlactinaemia
Chemo induced thrombocytopenia
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34
Q

What will cause bleeding diathesis

A 
vWF 
Coag disorder
Thrombocytopneia due to ITP / hypersplenism / renal failure
Leukaemia 
Advanced liver disease
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35
Q

How do you Rx DUB

A

Same as menorrhagia

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36
Q

What does tranexamic do

A

Reduce blood loss

No regulation

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37
Q

What does mefanamic acid do

A

Reduce blood loss and pain

No regulation

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38
Q

How are hysterectomy performed

A

Abdominal
Laparotomy
Transvaginal

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39
Q

What are indications for hysterectomy

A 
Malignancy
Fibroids
Heavy bleeding / menorrhagia 
Endometriosis
PPH 
Prolapse
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40
Q

Why are hysterectomy rare now

A

Ablation Rx / mmirena coil used for heavy bleed

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41
Q

What does hormonal Rx do

A

Reduce bleeding, pain and regulates

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42
Q

If you take away uterus / ovary what do you need

A

HRT till 50

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43
Q

When can you not do ablation

A

Grossly distorted cavity
Thin myometrium
Sub-mucous fibroid <3cm

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44
Q

What do you need if endometriosis in ovary

A

Salpingo-oophorectomy

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45
Q

What is the most common cause of PCB

A

Cervical ectropion

- Columnar epithelium or cervix visible around os

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46
Q

What does it present with

A

Discharge
PCB
IMB
Not usually pain

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47
Q

What are RF for ectropion

A 
OCP 
OVulation
Pregnancy 
Puberty 
All increase oestrogen so increased columnar cells on ectocervix
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48
Q

How do you treat

A

Smear to rule out cervical cancer

Cold coagulation / cryotherapy if troublesome

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49
Q

What is endometriosis

A

Endometrial tissue found outside uterine cavity

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50
Q

What is endometriosis dependent on

A

Oestrogen so causes pain during menstruation as bleed around local tissue
Chronic pelvic pain can develop if inflammation of local tissue

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51
Q

Where is endometriosis common

A 
Pouch of Douglas
Ovary 
Pelvic peritoneum
Recto-vaginal septum
COlon
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52
Q

Where is It rare

A

Lung
Brain
Eye
Muscles

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53
Q

What is an endometrioma

A

Small deposits in ovary or larger cyst

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54
Q

What are main symptoms of endometriosis

A

Dysmenorrhoea
Dyspareunia - deep
Menorrhagia
Premenstrual cyclical pelvic pain

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55
Q

What are other symptoms

A

Non-cyclical chronic pain can develop
Subfertility
Dyschezia - pain when move bowel
IMB - rare
Bleeding from diff sites - rectal / umbilical / haematuria - cyclical
Urinary Sx - dysuria / urgency / haematuria

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56
Q

What are signs of endometriosis

A

Tender nodules in recto-vaginal septum
Limited uterine mobility
Retroverted uterus
Adnexal mass / thickening

57
Q

What are symptoms if endometrioma ruptures

A

Intense pain
Sudden
Free fluid on USS

58
Q

What are RF for endometriosis

A 
20/30's 
Low parity
Early menarche
Heavy bleeding
FH
59
Q

What improves

A

Pregnancy
Breast feeding
Increased progesterone which balances oestrogen

60
Q

How do you Dx endometriosis

A

Clinical

Very difficult on imaging

61
Q

What imaging options

A

Laparoscopy+biopsy = gold standard
Transvaginal USS
MRI if suspect adneomyosis as won’t see at laparoscopy

62
Q

What else should be done

A

Swab

Smear

63
Q

When is laparoscopy done

A

Superficial
Failed hormonal Rx
Want to get pregnancy

64
Q

What will trans-vaginal USS show

A

Endometrioma
Fistula
Ddx - exclude fibroid / cyst

65
Q

When is MRI used

A

Rectal
Deep
Adenomyosis

66
Q

What is 1st line Rx

A 
NSAID / paracetamol 
Hormonal Rx to suppress ovulation
- COCP = 1st line to reduce menstruation 
- Progesterone = 2nd line
- IUS
67
Q

What do you do if hormonal Rx fails or want to get pregnant

A

GnRH analogue (Danazole)
Induce medical menopause
Test for cure to see if coming from pelvic organs

68
Q

How do you destroy endometriosis

A

Diathermy / laser ablation at laparoscopy= 1st line to improve fertility
Surgical excision - may improve fertility
Hysterectomy + salpingoophorectomy if doesn’t work but this doesn’t always guarantee
Draining and stripping of ovarian endometrioma

69
Q

What are complications of endometriosis

A

Scar tissue
Adhesions
Infertility
Chronic pelvic pain

70
Q

When does endometriosis not occur

A

Post menopause

71
Q

DDX

A

Cyst

Fibroid

72
Q

SE of GnRH analogue

A 
Weight gain
Oedema
Fatigue
Depression
Hair growth
Acne
Reduce breast
Loss of bone density so not sued long term
73
Q

What causes endometirits

A

Post partum
Intrauterine contraception
PID
Malignancy in post menopause

74
Q

What are symptoms

A 
Abnormal bleeding
IMB / PCB
Abdominal pain
Uterine tenderness 
Fever
Foul lochia
Leucocytosis
75
Q

What is adenomyosis

A

Endometrial tissue found deep in myometrium

76
Q

What can adenomyosis be mistaken for

A

Fibroids as thickened wall

77
Q

How does adenomyosis present

A

Menorrhagia
Dysmenorrhoea
Heavy painful prolonged period

78
Q

What are the findings OE

A

Bulky tender boggy uterus

Differentiate from fibroid

79
Q

What are RF for adenomyosis

A

High parity
C-section
Surgery
FH

80
Q

How do you Dx

A 
Difficult
Histology of muscle post hysterectomy 
USS - normal
MRI = gold standard 
Others won't show as  inside muscle
81
Q

How do you Rx

A 
Hormonal Rx
Often failed surgical Rx
GnRH agonist 
Uterine artery embolisation / ablation can be used with medical 
Hysterectomy only definite Rx
82
Q

What are fibroids

A

Benign tumour from myometrium

Mainly smooth muscle

83
Q

What causes fibroids to develop

A 
Oestrogen dependent 
Rare before puberty 
Rare after menopause
COCP / parity = protective 
More common in Africans
84
Q

What are types of fibroid

A

Submucous
Intramural
Subserous
Pedunculated

85
Q

What are sub mucous

A

Protrude into cavity
Affect implantation
Most symptomatic

86
Q

What are intramural

A

Within uterine wall
>2.5cm
Least symptomatic

87
Q

What are subserous

A

Project out of uterus into peritoneal cavity
Pressure Sx e.g. if pressure on bladder
No effect on fertility

88
Q

What are pedunculate

A

On a stalk either inside or outside uterus

89
Q

What are symptoms of fibroids

A 
Related to site NOT size 
Menorrhagia = most common
Dysmenorrhoea 
Deep dyspareunia 
IMB - less likely as no stimulation 
Pressure symptoms - constipation / frequency 
Bloating
Pelvic pain 
Sciatica
Abdo mass if large
Infertility
90
Q

What are RF for fibroids

A 
Age 
FH
Obesity
African 
Early menarche
91
Q

What are signs of fibroid OE

A

Irregular enlarged uterus

Non-tender

92
Q

How do you Dx

A

Transvaginal and abdo USS
Always refer for imaging if feels bigger than 10 week pregnancy
MRI = gold standard to differentiate from adenomyosis
Hysterosocpy if suspicious of inside cavity

93
Q

How do you treat fibroids

A 
Sx relief
Assess for anaemia 
Standard menorrhagia RX
- Tranexamic
- Mefanmic acid
94
Q

What is 1st line

A

IUS

95
Q

What can you do before surgery

A

GnRH analogue to shrink as cause menopause and reduce oestrogen

96
Q

Why would you do surgery

A

Help with fertility

Hormonal doesn’t work

97
Q

What are surgical options

A

Resection
Hystereoscopy if <3mm as have to pull through cervic
Myomectomy - retain fertility = removal of fibroid
Uterine artery embolisation to cut off blood supply = shrink
Hysterectomy if no children + very symptomatic

98
Q

Complications of surgery

A

Adhesion
Bladder injury
Uterine prolapse

99
Q

What are complications of fibroids

A 
Urinary obstruction -> hydronephrosis 
Ascites
Infertility / anovultion 
Bleeding  / anaemia 
Torsion
100
Q

How do fibroids present in pregnancy

A 
Pain
Malpresentation 
Obstruction in labour 
Pre-term
Miscarriage
Haemorrhage into tumour
101
Q

How does haemorrhaging fibroid present

A

Pain
Vomitnig
Fever
Often occurs in pregnancy

102
Q

What does surgical Rx increase risk of

A

Hysterectomy being required

103
Q

What is a uterine polyp

A

Benign endometrial growth on uterus

104
Q

How does uterine polyp present

A

Irregular bleed
Heavy
Prolonged PMB

105
Q

What are RF

A

Early post menopause due to transition
Oestrogen replacement
Tamoxifen

106
Q

Risks of polyp

A

Prolapse

107
Q

What are Ddx of acute pelvic pain

A 
Ectopic
Ruptured ectopic 
Miscarriage
PID 
Ovarian torsion 
Ruptured ovarian cyst
CL haematoma
Tubo-ovarian abscess
Twisted fibroi
UTI 
Appendicits 
Intraperitoneal inflammation
Contraction of smooth muscle
108
Q

What causes localised pain

A

Inflammation

109
Q

What causes cramping pain

A

Spasm in organ

110
Q

What causes sudden pain

A

Blood supply issue

111
Q

What causes slow developing

A

Intestinal obstruction

Appendix

112
Q

What causes pain across whole abdomen

A

Accumulation of blood/. pus

113
Q

What causes pain aggravated by movement

A

Irritation of lining

114
Q

Pain inrelation to sex or menstrual cycle

A

Likely gynae cause

115
Q

How do you investigate acute pelvic pain

A

Pregnancy test
FBC, U+E, LFT, coag
Urinanalysis
Smear test - PID / C+G

116
Q

What is 1st line imaging

A

USS

117
Q

Other imaging

A

CT
Laparoscopy
X-Ray
COlonoscopy

118
Q

What is PID

A 
Inflammation of pelvic organs
Uterus
Ovary
Fallopian tube
Usually spreads up from the cervix
119
Q

What causes PID

A

Chlamydia
Gonorrhoea
Mycoplasma

120
Q

What are the main symptoms of PID

A

Lower abdominal tenderness
Cervical excitation
Adnexal tenderness
BIlateral

121
Q

Other Sx of PID

A 
Fever
Deep dyspaurenia
Discharge
Dysuria 
Menorrhagia 
Abnormal bleeding - IMB / PCB 
Vaginal tenderness 
RUQ pain in 1-%
Increased CRP
122
Q

What causes RUQ

A

Fitz Hugh Curits - when PID causes inflammation of liver capsules / adhesions
May think cholecystitis

123
Q

How do you Dx

A 
FBC
Screen C+G
Transvaginal USS 
\+ biopsy 
Laparoscopy
124
Q

What does USS show

A

Thick fluid filled tube
Tubo-ovarian abscess
Free fluid

125
Q

What may hysterosalpingraphy show

A

Blocked tube

126
Q

How do you Rx

A

Ax

Remove IUD

127
Q

What Ax

A

Ceftriaxone
Metronidazole
Doxyclicne

128
Q

When do you admit

A 
Pregnant
Immunosuppresed
Pelvic abscess
IUD
High fever + severe N+V
Failed outpatient 
Fertility issue
Can't exclude surgical emergency
129
Q

What are complications

A

Infertility
Chronic pelvic pain
Ectopic in future

130
Q

How does tuba-ovarian abscess present

A

Shock if rupture
Bilateral palpable fixed tender mass
Abdo pain
Peritonitis

131
Q

What is chronic pelvic pain

A

> 6 months

132
Q

What causes chronic

A 
Menstrual 
Endometriosis
Fibroids
Adhesions / scar tissue
Cyst
Poly
Malignancy
IBS / urinary / nervous
133
Q

How do you Dx

A

Normal FBC
Normal USS
GnRH to see if true

134
Q

Medical Mx of fibroids if

A

<3cm

Not distorted cavity

135
Q

What should you do for pelvic pain

A

USS to look for cyst

136
Q

What is vaginsmus

A

Involuntary contraction of vaginal muscles causing pain during intercourse/ touching vagina

137
Q

How do you treat

A

Physio

138
Q

What are differentials

A

UTI / infection

Vaginal atrophy

Obs & Gynae (23 decks)

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