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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
When do you consider surgical
If hormone hasn't worked after 3 months
26
What is the risk of endometrial ablation
Risk of miscarriage
27
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 ```
28
What causes cervical bleeding
``` Cancer Cervicitis - C+G Polyps Ectropian Prolapse Endometriosis Vasculitis ```
29
Characteristics of cervical
Commonly PCB More sporadic than uterine Can see on speculum
30
What causes vaginal bleeding
``` Atrophic vaginitis Genital ulcer Cancer but rare Trauma RT Fistula Benign growth TENS or STS ```
31
What causes vulval bleeding
``` STI Thrush Lichen sclerosis VIN Malignancy Trauma ```
32
What is dysfunctional uterine bleeding
Abnormal bleeding No structural cause found Dx of exclusion of other pathologies
33
What drugs will cause DUB
``` Contraception HRT Anti-coagulant Drugs that cause hyperprlactinaemia Chemo induced thrombocytopenia ```
34
What will cause bleeding diathesis
``` vWF Coag disorder Thrombocytopneia due to ITP / hypersplenism / renal failure Leukaemia Advanced liver disease ```
35
How do you Rx DUB
Same as menorrhagia
36
What does tranexamic do
Reduce blood loss | No regulation
37
What does mefanamic acid do
Reduce blood loss and pain | No regulation
38
How are hysterectomy performed
Abdominal Laparotomy Transvaginal
39
What are indications for hysterectomy
``` Malignancy Fibroids Heavy bleeding / menorrhagia Endometriosis PPH Prolapse ```
40
Why are hysterectomy rare now
Ablation Rx / mmirena coil used for heavy bleed
41
What does hormonal Rx do
Reduce bleeding, pain and regulates
42
If you take away uterus / ovary what do you need
HRT till 50
43
When can you not do ablation
Grossly distorted cavity Thin myometrium Sub-mucous fibroid <3cm
44
What do you need if endometriosis in ovary
Salpingo-oophorectomy
45
What is the most common cause of PCB
Cervical ectropion | - Columnar epithelium or cervix visible around os
46
What does it present with
Discharge PCB IMB Not usually pain
47
What are RF for ectropion
``` OCP OVulation Pregnancy Puberty All increase oestrogen so increased columnar cells on ectocervix ```
48
How do you treat
Smear to rule out cervical cancer | Cold coagulation / cryotherapy if troublesome
49
What is endometriosis
Endometrial tissue found outside uterine cavity
50
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
51
Where is endometriosis common
``` Pouch of Douglas Ovary Pelvic peritoneum Recto-vaginal septum COlon ```
52
Where is It rare
Lung Brain Eye Muscles
53
What is an endometrioma
Small deposits in ovary or larger cyst
54
What are main symptoms of endometriosis
Dysmenorrhoea Dyspareunia - deep Menorrhagia Premenstrual cyclical pelvic pain
55
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
56
What are signs of endometriosis
Tender nodules in recto-vaginal septum Limited uterine mobility Retroverted uterus Adnexal mass / thickening
57
What are symptoms if endometrioma ruptures
Intense pain Sudden Free fluid on USS
58
What are RF for endometriosis
``` 20/30's Low parity Early menarche Heavy bleeding FH ```
59
What improves
Pregnancy Breast feeding Increased progesterone which balances oestrogen
60
How do you Dx endometriosis
Clinical | Very difficult on imaging
61
What imaging options
Laparoscopy+biopsy = gold standard Transvaginal USS MRI if suspect adneomyosis as won't see at laparoscopy
62
What else should be done
Swab | Smear
63
When is laparoscopy done
Superficial Failed hormonal Rx Want to get pregnancy
64
What will trans-vaginal USS show
Endometrioma Fistula Ddx - exclude fibroid / cyst
65
When is MRI used
Rectal Deep Adenomyosis
66
What is 1st line Rx
``` NSAID / paracetamol Hormonal Rx to suppress ovulation - COCP = 1st line to reduce menstruation - Progesterone = 2nd line - IUS ```
67
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
68
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
69
What are complications of endometriosis
Scar tissue Adhesions Infertility Chronic pelvic pain
70
When does endometriosis not occur
Post menopause
71
DDX
Cyst | Fibroid
72
SE of GnRH analogue
``` Weight gain Oedema Fatigue Depression Hair growth Acne Reduce breast Loss of bone density so not sued long term ```
73
What causes endometirits
Post partum Intrauterine contraception PID Malignancy in post menopause
74
What are symptoms
``` Abnormal bleeding IMB / PCB Abdominal pain Uterine tenderness Fever Foul lochia Leucocytosis ```
75
What is adenomyosis
Endometrial tissue found deep in myometrium
76
What can adenomyosis be mistaken for
Fibroids as thickened wall
77
How does adenomyosis present
Menorrhagia Dysmenorrhoea Heavy painful prolonged period
78
What are the findings OE
Bulky tender boggy uterus | Differentiate from fibroid
79
What are RF for adenomyosis
High parity C-section Surgery FH
80
How do you Dx
``` Difficult Histology of muscle post hysterectomy USS - normal MRI = gold standard Others won't show as inside muscle ```
81
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 ```
82
What are fibroids
Benign tumour from myometrium | Mainly smooth muscle
83
What causes fibroids to develop
``` Oestrogen dependent Rare before puberty Rare after menopause COCP / parity = protective More common in Africans ```
84
What are types of fibroid
Submucous Intramural Subserous Pedunculated
85
What are sub mucous
Protrude into cavity Affect implantation Most symptomatic
86
What are intramural
Within uterine wall >2.5cm Least symptomatic
87
What are subserous
Project out of uterus into peritoneal cavity Pressure Sx e.g. if pressure on bladder No effect on fertility
88
What are pedunculate
On a stalk either inside or outside uterus
89
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 ```
90
What are RF for fibroids
``` Age FH Obesity African Early menarche ```
91
What are signs of fibroid OE
Irregular enlarged uterus | Non-tender
92
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
93
How do you treat fibroids
``` Sx relief Assess for anaemia Standard menorrhagia RX - Tranexamic - Mefanmic acid ```
94
What is 1st line
IUS
95
What can you do before surgery
GnRH analogue to shrink as cause menopause and reduce oestrogen
96
Why would you do surgery
Help with fertility | Hormonal doesn't work
97
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
98
Complications of surgery
Adhesion Bladder injury Uterine prolapse
99
What are complications of fibroids
``` Urinary obstruction -> hydronephrosis Ascites Infertility / anovultion Bleeding / anaemia Torsion ```
100
How do fibroids present in pregnancy
``` Pain Malpresentation Obstruction in labour Pre-term Miscarriage Haemorrhage into tumour ```
101
How does haemorrhaging fibroid present
Pain Vomitnig Fever Often occurs in pregnancy
102
What does surgical Rx increase risk of
Hysterectomy being required
103
What is a uterine polyp
Benign endometrial growth on uterus
104
How does uterine polyp present
Irregular bleed Heavy Prolonged PMB
105
What are RF
Early post menopause due to transition Oestrogen replacement Tamoxifen
106
Risks of polyp
Prolapse
107
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 ```
108
What causes localised pain
Inflammation
109
What causes cramping pain
Spasm in organ
110
What causes sudden pain
Blood supply issue
111
What causes slow developing
Intestinal obstruction | Appendix
112
What causes pain across whole abdomen
Accumulation of blood/. pus
113
What causes pain aggravated by movement
Irritation of lining
114
Pain inrelation to sex or menstrual cycle
Likely gynae cause
115
How do you investigate acute pelvic pain
Pregnancy test FBC, U+E, LFT, coag Urinanalysis Smear test - PID / C+G
116
What is 1st line imaging
USS
117
Other imaging
CT Laparoscopy X-Ray COlonoscopy
118
What is PID
``` Inflammation of pelvic organs Uterus Ovary Fallopian tube Usually spreads up from the cervix ```
119
What causes PID
Chlamydia Gonorrhoea Mycoplasma
120
What are the main symptoms of PID
Lower abdominal tenderness Cervical excitation Adnexal tenderness BIlateral
121
Other Sx of PID
``` Fever Deep dyspaurenia Discharge Dysuria Menorrhagia Abnormal bleeding - IMB / PCB Vaginal tenderness RUQ pain in 1-% Increased CRP ```
122
What causes RUQ
Fitz Hugh Curits - when PID causes inflammation of liver capsules / adhesions May think cholecystitis
123
How do you Dx
``` FBC Screen C+G Transvaginal USS + biopsy Laparoscopy ```
124
What does USS show
Thick fluid filled tube Tubo-ovarian abscess Free fluid
125
What may hysterosalpingraphy show
Blocked tube
126
How do you Rx
Ax | Remove IUD
127
What Ax
Ceftriaxone Metronidazole Doxyclicne
128
When do you admit
``` Pregnant Immunosuppresed Pelvic abscess IUD High fever + severe N+V Failed outpatient Fertility issue Can't exclude surgical emergency ```
129
What are complications
Infertility Chronic pelvic pain Ectopic in future
130
How does tuba-ovarian abscess present
Shock if rupture Bilateral palpable fixed tender mass Abdo pain Peritonitis
131
What is chronic pelvic pain
>6 months
132
What causes chronic
``` Menstrual Endometriosis Fibroids Adhesions / scar tissue Cyst Poly Malignancy IBS / urinary / nervous ```
133
How do you Dx
Normal FBC Normal USS GnRH to see if true
134
Medical Mx of fibroids if
<3cm | Not distorted cavity
135
What should you do for pelvic pain
USS to look for cyst
136
What is vaginsmus
Involuntary contraction of vaginal muscles causing pain during intercourse/ touching vagina
137
How do you treat
Physio
138
What are differentials
UTI / infection | Vaginal atrophy

Obs & Gynae (23 decks)

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