Abnormal Bleeding + Pelvic Pain Flashcards
What is dysmenorrhoea?
Painful period
Primary = no pathology
Secondary = pathology
What does primary dysmenorrhoea present?
1-2 days before period Lower pelvic crampy pain Can radiate to lower back / anterior thigh 48-72 hours N+V / malaise / diarrhoea / dizzy
What is mittelchmerz
Pain in middle of cycle
What is secondary dysmenorrhoea
Usually begins after had a period
3/4 days before period begins
What can cause secondary dysmenorrhoea
Endometriosis
Adenomyosis
PID
Fibroid
How do you treat dysmenorrhoea
NSAID - mefanamic acid / Ibuprofen (inhibit prostaglandin)
COCP = 2nd line
IUS
Refer to gynaecologist for secondary causes
What is FIGO classification for abnormal bleeding
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
What causes bleeding in early teens
Anovulatory as HPO not established
Coagulation - VWD / ITP / leukaemia
Liver disease
Congenital adrenal hyperplasia
What causes bleeding in teens - 40
Period Pregnancy Infection - C+G / thrush PID / endometritis Ectropian Contraception Endometriosis Fibroids Polyps Cysts Endometrial hyperplasia DUB
What causes bleeding in menopause age
Perimenopause Vaginal atrophy HRT Endometrial cancer - if no HRT Warfarin / anti-coagulant Hyper or hypothyroid Hyperprolactin
What is menorrhagia and how do you investigate
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
What can cause menorrhagia
Fibroid = most common Endometriosis Adenomyosis Hypothyroid PID Polup Blood disorder Contraception - COCP / coil Endometrial cancer
What can cause PCB
Cervicitis - C+G Ectropion Polyps Cervical cancer Cancer Vaginal atrophy Trauma
What can cause PMB
Vaginal atrophy
Malignancy - endometrial
What can cause IMB
Cervical ectropion Cervical polyp / cancer STI Endometrial polyp / cancer Iatrogenic - contraception
What investigations for abnormal bleeding
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
When is USS indicated
IMB
PMB - endometrial thickness
Pelvic pain
When do you test for chlamydia
IMB
PCB
When do you do hysteroscopy
Persistent IMB
Suspicion of endometrial cancer
Fibroids / polyps
How do you treat menorrhagia non-hormonal if no contraception needed
Reassure
Tranexamic acid = 1st line - reduce bleeding
Mefanamic acid (NSAID) - reduce bleeding and pain
Ferrous sulphate if anaemic
When do you do non-hormonal Rx
If no contraception needs
Mefanamic CI in pregnancy
What does tranexamic acid do
Anti-fibronlytic
Prevent conversion of plasminogen to plasmin
Start 1st day of period
What is hormonal Rx
Mirena coil = 1st line
Combined OCP 2nd line
POP
Noriestherione = short term
What are surgical Rx for menorrhagia
Hysterectomy
Salpingo-oophorectomy
Endometrial ablation
Remove anomaly e.g. polyp / fibroid
When do you consider surgical
If hormone hasn’t worked after 3 months
What is the risk of endometrial ablation
Risk of miscarriage
What do you ask in Hx of bleeding
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
What causes cervical bleeding
Cancer Cervicitis - C+G Polyps Ectropian Prolapse Endometriosis Vasculitis
Characteristics of cervical
Commonly PCB
More sporadic than uterine
Can see on speculum
What causes vaginal bleeding
Atrophic vaginitis Genital ulcer Cancer but rare Trauma RT Fistula Benign growth TENS or STS
What causes vulval bleeding
STI Thrush Lichen sclerosis VIN Malignancy Trauma
What is dysfunctional uterine bleeding
Abnormal bleeding
No structural cause found
Dx of exclusion of other pathologies
What drugs will cause DUB
Contraception HRT Anti-coagulant Drugs that cause hyperprlactinaemia Chemo induced thrombocytopenia
What will cause bleeding diathesis
vWF Coag disorder Thrombocytopneia due to ITP / hypersplenism / renal failure Leukaemia Advanced liver disease
How do you Rx DUB
Same as menorrhagia
What does tranexamic do
Reduce blood loss
No regulation
What does mefanamic acid do
Reduce blood loss and pain
No regulation
How are hysterectomy performed
Abdominal
Laparotomy
Transvaginal
What are indications for hysterectomy
Malignancy Fibroids Heavy bleeding / menorrhagia Endometriosis PPH Prolapse
Why are hysterectomy rare now
Ablation Rx / mmirena coil used for heavy bleed
What does hormonal Rx do
Reduce bleeding, pain and regulates
If you take away uterus / ovary what do you need
HRT till 50
When can you not do ablation
Grossly distorted cavity
Thin myometrium
Sub-mucous fibroid <3cm
What do you need if endometriosis in ovary
Salpingo-oophorectomy
What is the most common cause of PCB
Cervical ectropion
- Columnar epithelium or cervix visible around os
What does it present with
Discharge
PCB
IMB
Not usually pain
What are RF for ectropion
OCP OVulation Pregnancy Puberty All increase oestrogen so increased columnar cells on ectocervix
How do you treat
Smear to rule out cervical cancer
Cold coagulation / cryotherapy if troublesome
What is endometriosis
Endometrial tissue found outside uterine cavity
What is endometriosis dependent on
Oestrogen so causes pain during menstruation as bleed around local tissue
Chronic pelvic pain can develop if inflammation of local tissue
Where is endometriosis common
Pouch of Douglas Ovary Pelvic peritoneum Recto-vaginal septum COlon
Where is It rare
Lung
Brain
Eye
Muscles
What is an endometrioma
Small deposits in ovary or larger cyst
What are main symptoms of endometriosis
Dysmenorrhoea
Dyspareunia - deep
Menorrhagia
Premenstrual cyclical pelvic pain
What are other symptoms
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
What are signs of endometriosis
Tender nodules in recto-vaginal septum
Limited uterine mobility
Retroverted uterus
Adnexal mass / thickening
What are symptoms if endometrioma ruptures
Intense pain
Sudden
Free fluid on USS
What are RF for endometriosis
20/30's Low parity Early menarche Heavy bleeding FH
What improves
Pregnancy
Breast feeding
Increased progesterone which balances oestrogen
How do you Dx endometriosis
Clinical
Very difficult on imaging
What imaging options
Laparoscopy+biopsy = gold standard
Transvaginal USS
MRI if suspect adneomyosis as won’t see at laparoscopy
What else should be done
Swab
Smear
When is laparoscopy done
Superficial
Failed hormonal Rx
Want to get pregnancy
What will trans-vaginal USS show
Endometrioma
Fistula
Ddx - exclude fibroid / cyst
When is MRI used
Rectal
Deep
Adenomyosis
What is 1st line Rx
NSAID / paracetamol Hormonal Rx to suppress ovulation - COCP = 1st line to reduce menstruation - Progesterone = 2nd line - IUS
What do you do if hormonal Rx fails or want to get pregnant
GnRH analogue (Danazole)
Induce medical menopause
Test for cure to see if coming from pelvic organs
How do you destroy endometriosis
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
What are complications of endometriosis
Scar tissue
Adhesions
Infertility
Chronic pelvic pain
When does endometriosis not occur
Post menopause
DDX
Cyst
Fibroid
SE of GnRH analogue
Weight gain Oedema Fatigue Depression Hair growth Acne Reduce breast Loss of bone density so not sued long term
What causes endometirits
Post partum
Intrauterine contraception
PID
Malignancy in post menopause
What are symptoms
Abnormal bleeding IMB / PCB Abdominal pain Uterine tenderness Fever Foul lochia Leucocytosis
What is adenomyosis
Endometrial tissue found deep in myometrium
What can adenomyosis be mistaken for
Fibroids as thickened wall
How does adenomyosis present
Menorrhagia
Dysmenorrhoea
Heavy painful prolonged period
What are the findings OE
Bulky tender boggy uterus
Differentiate from fibroid
What are RF for adenomyosis
High parity
C-section
Surgery
FH
How do you Dx
Difficult Histology of muscle post hysterectomy USS - normal MRI = gold standard Others won't show as inside muscle
How do you Rx
Hormonal Rx Often failed surgical Rx GnRH agonist Uterine artery embolisation / ablation can be used with medical Hysterectomy only definite Rx
What are fibroids
Benign tumour from myometrium
Mainly smooth muscle
What causes fibroids to develop
Oestrogen dependent Rare before puberty Rare after menopause COCP / parity = protective More common in Africans
What are types of fibroid
Submucous
Intramural
Subserous
Pedunculated
What are sub mucous
Protrude into cavity
Affect implantation
Most symptomatic
What are intramural
Within uterine wall
>2.5cm
Least symptomatic
What are subserous
Project out of uterus into peritoneal cavity
Pressure Sx e.g. if pressure on bladder
No effect on fertility
What are pedunculate
On a stalk either inside or outside uterus
What are symptoms of fibroids
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
What are RF for fibroids
Age FH Obesity African Early menarche
What are signs of fibroid OE
Irregular enlarged uterus
Non-tender
How do you Dx
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
How do you treat fibroids
Sx relief Assess for anaemia Standard menorrhagia RX - Tranexamic - Mefanmic acid
What is 1st line
IUS
What can you do before surgery
GnRH analogue to shrink as cause menopause and reduce oestrogen
Why would you do surgery
Help with fertility
Hormonal doesn’t work
What are surgical options
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
Complications of surgery
Adhesion
Bladder injury
Uterine prolapse
What are complications of fibroids
Urinary obstruction -> hydronephrosis Ascites Infertility / anovultion Bleeding / anaemia Torsion
How do fibroids present in pregnancy
Pain Malpresentation Obstruction in labour Pre-term Miscarriage Haemorrhage into tumour
How does haemorrhaging fibroid present
Pain
Vomitnig
Fever
Often occurs in pregnancy
What does surgical Rx increase risk of
Hysterectomy being required
What is a uterine polyp
Benign endometrial growth on uterus
How does uterine polyp present
Irregular bleed
Heavy
Prolonged PMB
What are RF
Early post menopause due to transition
Oestrogen replacement
Tamoxifen
Risks of polyp
Prolapse
What are Ddx of acute pelvic pain
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
What causes localised pain
Inflammation
What causes cramping pain
Spasm in organ
What causes sudden pain
Blood supply issue
What causes slow developing
Intestinal obstruction
Appendix
What causes pain across whole abdomen
Accumulation of blood/. pus
What causes pain aggravated by movement
Irritation of lining
Pain inrelation to sex or menstrual cycle
Likely gynae cause
How do you investigate acute pelvic pain
Pregnancy test
FBC, U+E, LFT, coag
Urinanalysis
Smear test - PID / C+G
What is 1st line imaging
USS
Other imaging
CT
Laparoscopy
X-Ray
COlonoscopy
What is PID
Inflammation of pelvic organs Uterus Ovary Fallopian tube Usually spreads up from the cervix
What causes PID
Chlamydia
Gonorrhoea
Mycoplasma
What are the main symptoms of PID
Lower abdominal tenderness
Cervical excitation
Adnexal tenderness
BIlateral
Other Sx of PID
Fever Deep dyspaurenia Discharge Dysuria Menorrhagia Abnormal bleeding - IMB / PCB Vaginal tenderness RUQ pain in 1-% Increased CRP
What causes RUQ
Fitz Hugh Curits - when PID causes inflammation of liver capsules / adhesions
May think cholecystitis
How do you Dx
FBC Screen C+G Transvaginal USS \+ biopsy Laparoscopy
What does USS show
Thick fluid filled tube
Tubo-ovarian abscess
Free fluid
What may hysterosalpingraphy show
Blocked tube
How do you Rx
Ax
Remove IUD
What Ax
Ceftriaxone
Metronidazole
Doxyclicne
When do you admit
Pregnant Immunosuppresed Pelvic abscess IUD High fever + severe N+V Failed outpatient Fertility issue Can't exclude surgical emergency
What are complications
Infertility
Chronic pelvic pain
Ectopic in future
How does tuba-ovarian abscess present
Shock if rupture
Bilateral palpable fixed tender mass
Abdo pain
Peritonitis
What is chronic pelvic pain
> 6 months
What causes chronic
Menstrual Endometriosis Fibroids Adhesions / scar tissue Cyst Poly Malignancy IBS / urinary / nervous
How do you Dx
Normal FBC
Normal USS
GnRH to see if true
Medical Mx of fibroids if
<3cm
Not distorted cavity
What should you do for pelvic pain
USS to look for cyst
What is vaginsmus
Involuntary contraction of vaginal muscles causing pain during intercourse/ touching vagina
How do you treat
Physio
What are differentials
UTI / infection
Vaginal atrophy
