Benign gynae Flashcards

Question

Cushing syndrome | - causes

Answer 1

Results from chronic exposure to excess glucocorticoids CAUSES ACTH dependent - Cushing's disease - ACTH-producing pituitary tumour - Ectopic ACTH syndrome - E.g. small cell lung cancer ACTH independent - Adrenal tumours - Adrenal hyperplasia Iatrogenic - Exogenous steroids

Answer 2

``` Moon face Bufalo hump Wide purplish striae Proximal muscle weakness Hirsutism HTN ```

Answer 3

Exclude exogenous High testosterone and DHEA Diagnosis is established when 2+ different first-line tests are unequivocally abnormal - Late night salivary cortisol - 24h urinary free cortisol excretion - Overnight 1mg dexamethasone suppression test

Answer 4

Very high rate of pregnancy complications - Pregnancy loss (40%) - FGR - Premature delivery (>50%) - Neonatal adrenal insufficiency Maternal morbidity high if untreated - HTN (up to 70%) - Diabetes (up to 25%) - Heart failure - Severe PET is common (15%) - Maternal mortality is increased (2-4%) If previous treated, or treated <20/40, then do well

Answer 5

Unlikely classic CAH, not picked up by newborn screening Increase in cortisol precursors, which are forced along the androgen pathway - 17-OH progesterone ACTH stimulation test to confirm diagnosis - Response to ACTH is exaggerated in NCCAH

Answer 6

Chromosomal - Most common is Turner syndrome 45X0 - Offer karyotype if amenorrhoea before age 30 - Fragile X Autoimmune - Linked to other autoimmune issues, therefore screen Resistant ovary syndrome - On biopsy there are oocytes but they don’t respond, but not required because doesn't change prognosis Pure gonadal dysgenesis Androgen-insensitivity syndrome - Absent ovaries and uterus with a 46XY karyotype Galactosaemia (carbohydrate metabolism, autosomal recessive) Premature menopause Surgical removal Chemotherapy Radiotherapy in proximity to the pelvic area Idiopathic

Answer 7

``` Serum FSH Serum estradiol Serum free testosterone (to rule out PCOS) HCG - rule out pregnancy Serum prolactin TSH +/- thyroid antibodies Autoimmune screen Karyotype - chromosomal analysis should be performed in all women with non-iatrogenic POI - Test for Y chromosome - Fragile X ```

Answer 8

X-linked disorder Decreased or absent levels of fragile X mental retardation protein (FMR 1 gene) Full mutation - In males causes classical FXS phenotype - developmental delay, intellectual disability, learning disabilities , ADHD, anxiety, autism, Seizures - Full mutation in girls is much more variable Premutation - Spectrum of clinical findings - Females: 1 in 250-300 in women - Premature ovarian insufficiency - Fragile X-associated tremor-ataxia syndrome later in life - Neurocognitive deficits

Answer 9

Spectrum disorder Menstrual irregularity associated with diminishing ovarian reserve in women <40y Characterised by menstrual disturbance (amenorrhoea or oligomenorrhoea for >4 months) with FSH levels in the post menopausal range (dependent on lab, >20 IU/l) on two occasions >4 weeks apart Prevalence 1%

Answer 10

Gynaecological surgical practice Lifestyle - smoking - No causal r/ship for smoking and POI, but there is in relation to early menopause Modified treatment regimens for malignant and chronic diseases

Answer 11

Untreated POI --> reduced life expectancy, mainly due to CVD Fertility - Small chance of spontaneous pregnancy (5-10%), as varying and unpredictable ovarian function - Donor oocyte and IVF if required Reduced BMD - Estrogen replacement is recommended - e.g. COCP - Measure BMD at diagnosis of POI Continue HRT until the age of natural menopause Annual BP, weight and smoking status Psychological wellbeing Sexual and GU function - Topical oestrogen Cognitive impairment

Answer 12

Presence of terminal (coarse) hairs in females in a male-like pattern Affects 5-15% of women Usually associated with an underlying endocrine disorder

Answer 13

Lanugo - soft hair densely covering fetus, shed in first 4/12 PP - Can be seen in women with disorders that include anorexia nervosa Vellus hair - soft, longer than lanugo hair (<2cm), non-pigmented, covers the body Terminal hair - longest, pigmented, makes up hair of eyebrows, scalp, axillary and pubic areas

Answer 14

Three phases of hair growth ○ Anagen - active growing phase ○ Catagen - involuting phase ○ Telogen - resting phase, hair is shed Androgens are the most important hormones regulating hair type, growth and distribution

Answer 15

Androgen excess - PCOS (70-80% of women with hirsutism ) - Androgen-secreting tumours - Late onset CAH - Cushing's syndrome - Drugs - Testosterone, danazol, anabolic steroids Drugs - Non-androgen factors - Phenytoin - Minoxidil - for baldness - High-dose corticosteroids Idiopathic hirsutism (6-7%)

Answer 16

``` 0 = absence of terminal hair 4 = extensive terminal hair growth ``` ``` Modified score (current one) uses 9 sites - Upper lip, chin, chest, arm, upper abdomen, upper back, lower back, thighs ``` - Mild 8-15 - 16-25 moderate - >25 severe

Answer 17

Impact for women doesn't correlate with scores - Scoring systems used for research rather than clinical settings typically Ethnic variation - derived from population study of white women Most women have been using cosmetic measures by the time they see a clinician, so scores may not be accurate Intra-observer agreement appears to be relatively good, but inter-observer agreement appears poor

Answer 18

COCP - reduces free plasma testosterone levels Cyproterone acetate - strong progestogen, reduces LH - Wide variation, but expect to lower Ferriman-Gallwey score by 15-40% within 6 months Spironolactone (androgen inhibitor) - When used with COCP overall effectiveness improved - Cochrane review: superior to finasteride and low dose cyproterone acetate for up to 12 months after end of treatment Finasteride - inhibitor of 5 alpha-reductase enzyme

Answer 19

When symptoms cause impairment of daily activities and interpersonal relationships in cyclical fashion usually following ovulation and resolved by menstruation - Must demonstrate during the luteal phase of the menstrual cycle Symptoms are not an exacerbation of an underlying psychological or physical disorder PMS vs. PMDD The affective and/or somatic symptoms in physiological PMS are bothersome but are not disabling to the woman, whereas they would cause significant impairment of occupational or social function in PMDD

Answer 20

Most severe form Must have 5 / 11 symptoms, one of which must include mood - Mood swings - Anger, irritability Sense of hopelessness, - Tension, anxiety - Difficulty concentrating - Change in appetite - Diminished interest in usual activities - decreased energy - Feeling overwhelmed - Breast tenderness, bloating, weight gain, joint / muscle aches - Sleeping too much or not sleeping enough Luteal phase symptoms By definition, affective symptoms predominate but most women also have physical symptoms Must disrupt daily functioning

Answer 21

Revolves around the ovarian hormone cycle - Reinforced by absence prior to puberty, in pregnancy and after menopause Two theories 1. Some women are 'sensitive' to progesterone 2. Abnormalities in neurotransmitters (serotonin and GABA) --> progesterone hypersensitivity ○ Serotonin receptors are responsive to oestrogen and progesterone No evidence of hormone imbalance

Answer 22

Symptoms should be recorded prospectively, over two cycles, using a symptom diary - Useful comparison for effectiveness of treatment in future Symptom diary should be completed prior to commencing treatment GnRH analogues may be used for 3 months for a definitive diagnosis if the completed symptom diary alone is inconclusive

Answer 23

CBT - Consider routinely - Better maintenance of treatment effects compared with fluoxetine in one study - May avoid pharmacotherapy and potential adverse effects Benefit in trials for - Calcium, vitamin D - Vitex agnus castus (herbal supplement) Some benefit - Exercise - Evening primrose - Acupuncture Mixed results - vitamin B6 - Mg - St John's wort

Answer 24

``` SSRI - consider 1st line - luteal or continuous dosing - fluoxetine works within 24h Spironolactone - Can treat physical Sx ``` COCP - Drospirenone-containing COCP (Yasmin) - Caution about type of progestogen in pill - Continuous rather than cyclical use recommended Hormonal medical management - Percutaneous estradiol + cyclical progesterone has been shown to be effective - Consider LNG-IUS for endometrial protection Danazol - is effective in luteal phase for breast symptoms - Potential irreversible virilising effects - effect on lipid profile - must be on contraception Progesterone - good evidence that it is not appropriate - No evidence to support LNG-IUS use alone Hysterectomy + BSO - Trial GnRH analogues pre-op as a test of cure and to ensure HRT is tolerated - Use HRT post-op, especially if <45y

Answer 25

First half = follicular phase (of ovary) - Menstrual phase at the start, then proliferative phase of endometrium With menses, progesterone from previous luteal phase falls (as CL involutes), lifting the negative feedback on hypothalamic GnRH Rise in FSH --> maturation of follicles Increasing oestrogen produced by the follicles - at low levels cause negative feedback suppressing FSH Smaller follicles undergo atresia as they rely on FSH for development larger follicle continues to grow independently of FSH Dominant follicle makes large amount of oestradiol When certain oestrogen threshold is reached, leads to LH (and smaller FSH) surge (positive feedback) LH surge --> ovulation - Ovulation occurs approx 36h from the onset of surge

Answer 26

The permanent cessation of menstruation Defined retrospectively, 12 months after the final menstrual period Average age 51.5y

Answer 27

Early menopause -Before age 45, but after the age of 40 Premature menopause - Before age 40 - Primary ovarian insufficiency - POI affects ~1% of women

Answer 28

Time from the onset of menstrual cycle changes until one year after the final menstrual period Early menopause transition - marked by persistent difference of 7+ days in length of consecutive cycles Late - periods of amenorrhoea of 60 days or more, frequent anovulation, onset of perimenopausal symptoms Usually starts ~47y Can last 4-8y

Answer 29

Factors a/w earlier menopause - Hysterectomy - Smoking - Lower level of education - Living at an altitude >2000m - Being single Factors a/w later menopause: - Parity - Higher BMI - Oral contraceptive use

Answer 30

70-80% of women Most common reason for women to seek advice / treatment Usually start during the menopause transition Average duration = 4-5y 10% have symptoms for >10y

Answer 31

- Smear - Mammogram - Lipids - FBC - TSH - Renal and liver function - Ferritin - HbA1c - Vit D in at risk women Screen for anxiety and depression Offer lifestyle advice Dual x-ray Absorptiometry (DXA) - if high risk - Used to measure bone density in those with increased fracture risk

Answer 32

Use for 2y after the LMP in women <50y | Use for 1y after LMP in women >50y

Answer 33

``` Stress reduction Regular exercise Optimal weight management Appropriate diet Smoking cessation Weight bearing exercise Calcium / vitamin D intake Avoid excessive alcohol and caffeine ```

Answer 34

``` Stress reduction Regular exercise Optimal weight management Appropriate diet Smoking cessation Weight bearing exercise Calcium / vitamin D intake Avoid excessive alcohol and caffeine ```

Answer 35

Shown to reduce troublesome VMS - Hypnosis - Cognitive behaviour therapy ``` No evidence for herbal supplements, acupuncture, chiropractic or homeopathy Methods not shown to reduce VMS - Yoga - Exercise - Diet - Supplements - Weight loss - Black cohosh and phytoestrogens - OTC / CAM - have not consistently been shown to be effective for VMS ```

Answer 36

Shown to be superior to placebo in some RCTs for management of VMS SSRIs - Paroxetine and fluoxetine should not be used in women taking tamoxifen SNRI Trial SSRI / SNRI for 4 weeks - should be sufficient to establish whether Rx if effective - Use at low to moderate doses for VMS - ADR: nausea, drowsiness, sexual dysfunction Centrally acting medications - gabapentin, clonidine Gabapentin - Only non-hormonal agent with equivalent efficacy to MHT for treating VMS - Side effects: drowsiness, headaches, GI upset Clonidine - ADR: dry mouth, drowsiness, visual disturbance Silicone-based lubricant more effective than water-based at reducing pain during sex in patients with breast cancer

Answer 37

``` Sexual dysfunction Sleep disturbance Mood swings Joint or muscle pains Quality of life ```

Answer 38

Personal Hx of breast cancer / estrogen-dependent cancer Undiagnosed vaginal bleeding ``` RELATIVE: High risk of VTE or thrombophilia Previous VTE (oral MHT contraindication) Personal wish not to use hormones Severe active liver disease Untreated HTN ``` Commencement after age 60y, or >10y after menopause, is generally not recommended Risks outweigh benefits

Answer 39

COCP provides: - Cycle control - Contraception - Relief from vasomotor symptoms and other symptoms Prevents bone loss Can be used in non-smoking women without CV or thrombotic risk factors until the age of 50y Skip placebo tablets to prevent VMS in the pill free week Oral E + LNG-IUS - Provides contraception - Reduces uterine bleeding - Can provide endometrial protection from systemic oestrogen Cyclical MHT - Will not provide contraception or regulate cycles

Answer 40

``` Oral estrogen PROS Convenience Reliable absorption for most users CONS Increased risk of VTE, cholelithiasis Increased SHBG and therefore decreased free testosterone Increased TBG - may need to adjust thyroxine dose Administration of higher total dose ``` ``` Transdermal preparations PROS Avoidance of gut and first-pass hepatic metabolism - No change in SHBG or TBG Little / no increase in VTE Lower total dose Convenient for some women ``` ``` CONS Patches can cause skin irritation Gel can be 'sticky' and inconvenient Occasionally poorly absorbed Women may forgot to change ```

Answer 41

Synthetic steroid with oestrogenic, progestogenic and weak androgenic effects Effective for vasomotor and urogenital symptoms Only use in women >12 months since menopause as may cause irregular bleeding in younger women Benefits in RCT - Alleviate VMS - Improve BMD - Reduce fracture risk - Modest effect on some domains of female sexual function - Stimulates the breasts less than combined MHT Side effects: - Headache, Acne, Increased hair growth, Occasionally, irregular bleeding Does not increase the risk of endometrial hyperplasia / cancer, VTE, breast cancer, or CVD risk Less bleeding in the first 3/12 of treatment Increased risk of stroke in women >65y, breast cancer recurrence

Answer 42

Start with low dose therapy May take up to 6-8 weeks before adequate symptom relief Aim for lowest dose, for shortest duration Initially review 6/12, then annual follow up Unscheduled bleeding in the first 6/12, but after that needs to be investigated Review general health status, update PMHx and FHx, and need for continued MHT No set min or max duration of therapy Most guidelines recommend use for up to 4-5y Cessation may lead to surgent symptoms in around 50% of women No optimum method for discontinuing

Answer 43

Not used for primary prevention of CHD In women within 10y of menopause, MHT does not increase the risk of coronary heart disease WHI RCT - CHD was not significantly differ during the intervention or post intervention phase for either estrogen only or combined therapy, c.f. placebo - In those 50-59y ○ Significantly reduced for users of estrogen only therapy ○ Not increased for users of combined MHT

Answer 44

Recent systematic review supports 'window of opportunity' for initiation of MHT in women within 10y of their last period for maximum benefit and minimal risk - Overall MHT conferred no protective effect on all-cause mortality, CV death, non-fatal infarction, angina or revascularisation ○ But did increase stroke and VTE risk - In women who start MHT <10y after the menopause, there was lower mortality and lower incidence of CHD ○ No increased risk of stroke in this group

Answer 45

Reduced fracture risk - MHT increased bone density Reduced colon cancer risk - Conferred by both combined MHT and tibolone use Reduced Alzheimer's disease - In MHT initiated around the time of menopause

Answer 46

Risk of breast cancer appears greater with: - Combined MHT c.f. estrogen alone - Greater exposure to progesterone (continuous > intermittent) - micronized ("natural") progesterone may be safer - Duration of use Breast cancer risk may persist after discontinuation of MHT - Risk decreases Uncertain if oestrogen alone increases breast cancer risk - Large RCTs suggest no increase in risk (may decrease risk) ~1 extra case per 1000 women using MHT for 1y Avoid MHT after breast cancer - May be safe if high inherited risk of breast cancer but no PMHx, but limited data

Answer 47

Risk greatest in first year of MHT use Combined MHT - increased VTE risk (2-fold) Oral estrogen also increased risk In absence of PMHx or FHx, screening for thrombophilia is not indicated before starting MHT Transdermal MHT does not appear to increase VTE risk in low VTE-risk women

Answer 48

Increased risk of stroke reported in women >60y or >10y from menopause using either oral oestrogen or combined MHT No increase with <50mcg transdermal dose used Increased risk of cholecystitis with oral MHT use - 12 extra cases per 1000 women per 5y

Answer 49

Large meta-analysis of observational studies - Increased risk of ovarian cancer - serous and endometrioid subtypes - Absolute increase in risk of uncertain clinical significance Reduced risk of clear cell and mucinous subtypes 1 large RCT

Answer 50

Non-hormonal options - Bisphosphonates or SERMs for osteoporosis - Statin and aspirin for CVD - SSRI, SNRI, clonidine, gabapentin - vasomotor symptoms - Vaginal lubricants for superficial dyspareunia - Anticholinergics for urinary urgency RANZCOG - reasonable therapeutic option for control of GU symptoms - discuss risk of small amount of systemic absorption Current data does not support MHT in these women - Cessation of tamoxifen may improve VMS

Answer 51

Bone density >2.5 standard deviations below the young normal mean Peak bone mass usually reached during a woman's 20s to 30s Oestrogen plays an important role in maintaining bone strength Osteoporosis occurs when resorption occurs more quickly than formation Low oestrogen levels --> increases in osteoclast numbers and activity --> sustained excess of bone resorption over bone formation Average woman loses up to 10% of her bone mass in the first 5y after menopause More than 50% of post-menopausal women have a fracture of some sort between menopause and death

Answer 52

``` Ethnicity - Polynesian or African descent - higher bone density and lower fracture risk than European or Asian Weight PMHx and FHx of fractures Smoking Glucocorticoid use - Also phenytoin and carbamazepine Falls Early menopause Thyroid or parathyroid disease Coeliac disease Rheumatoid arthritis Chronic kidney or liver disease ```

Answer 53

Underweight avoidance - Hip fracture risk increases steeply when BMI is <20 Smoking cessation Moderating alcohol intake Remaining physically active Falls prevention Dietary calcium - 1300mg/day for women >50y Vitamin D - ~5-15 mins of sunlight / day

Answer 54

Calcium supplements - minimal evidence influences fracture risk - increases BMD by 1% Vitamin D - can be helpful in frail elderly - caution as high amounts may cause bone resorption Bisphosphonates - bind to bone surfaces where they inhibit the activity of osteoclasts - IV 1-2 years or PO weekly - Can precipitate symptomatic hypocalcaemia if given to patients with severe vitamin D deficiency. Therefore give with vitamin D - Rare ADR: osteoporosis of the jaw, atypical femur fractures in long term use MHT SERM - Reduces vertebral fracture risk but not hip Denosumab 6 monthly sc injection - Monoclonal antibody, inhibits bone resorption

Answer 55

Presence of endometrial-like tissue outside the uterus which induces a chronic, inflammatory reaction Australia: 11.4% Up to 50% of infertile women

Answer 56

Uncertain - likely multifactorial Retrograde menstruation - widely accept theory, initiating step - Other factors, e.g. genetics, hormones, immune dysfunction, may be required to create favourable environment to promote endometriotic implant formation, proliferation and development Coelomic metaplasia - Transformation of peritoneal tissue into endometrial tissue through hormonal / immunological factors Genetic - lteration of cellular function that increases attachment of endometrial cells and evasion of these cells from immune clearance 7x increased risk of endometriosis if FHx Hormones - stromal cell defect associated with increased estrogen and prostaglandins - Growing evidence of progesterone resistance and therefore progesterone-mediated control of endometrial proliferation Oxidative stress and inflammation Apoptosis suppression

Answer 57

Inflammatory state --> toxic effect on gametes, embryos and impairing tubal motility, impairs implantation Peritoneal macrophages --> phagocytose sperm Pelvic adhesions and endometriomas --> anatomical distortion Reduced ovarian reserve Dyspareunia and chronic pelvic pain - impair normal sexual function Endometriosis medical treatment - while on prevents conception

Answer 58

Laparoscopy + histological verification = gold standard - Sensitivity 94%, specificity 79% Histological features (2/4 for diagnosis) - Endometrial stroma - Endometrial epithelium - New haemorrhage - Old haemorrhage (hemosiderin)

Answer 59

Delays form symptom onset to diagnosis ranging from 4 to 11 years - Australia - average 7y Menstruation-related myths and cultural misperceptions The assumption that dysmenorrhoea is a normal System - limits resources --> delays Patients may conceal severity due to embarrassment Healthcare professionals normalising or dismissing Sx

Answer 60

Ground glass echogenicity 1-4 compartments No papillary structures with detectable flow

Answer 61

``` Miscarriage Ectopic APH Abruption Placenta praevia MROP PTB PET NND ```

Answer 62

1. Develop the concept of an endometriosis network of expertise 2. Raise public awareness of endometriosis 3. Treatment and management of endometriosis 4. Understand endometriosis through research

Answer 63

Stage I = Minimal 1-5 points Superficial lesions No significant adhesions Stage II = Mild 6-15 points Some deep lesions, no significant adhesions ``` Stage III = Moderate 16-40 points Multiple implants Includes endometrioma Includes minor adhesions ``` Stage IV = Severe >40 points Severe adhesions with bowel and/or bladder involvement Severe damage to the pouch of Douglas

Answer 64

- May not correlate with symptoms experienced / quality of life, reproductive outcome, recurrence risk - Poor prognostic information and predictive accuracy with respect to treatment outcomes But has been used for a long time, widespread use in research Stage classification helps to determine how to optimally deal with the disease surgically

Answer 65

Acupuncture appears to be moderately effective and safe but requires repeated treatments TENS - some effectiveness in the short term Cannabis has been shown to be moderately effective for relieving chronic pain - Benefits far outweighed by potentially serious side effects - No studies in women with endometriosis Inconclusive evidence - Exercise

Answer 66

Virtually no evidence for endo NSAIDs have a favourable effect on primary dysmenorrhoea and are widely used as first-line treatment - Can be useful in up to 50% of women with dysmenorrhoea Advantages: - Readily available - Inexpensive Disadvantages: - GI side effects - Around 50% of women will not find benefit

Answer 67

Most hormonal contraceptives have been shown to be equally effective Reduces endometriosis-associated dyspareunia, dysmenorrhoea, non-menstrual pain Theoretical benefits of progesterone > combined COCP - may reduce recurrence after surgery Progestagens - Inhibit growth of lesions by inducing decidualisation followed by atrophy of uterine-type tissues - Adverse effects: weight gain, fluid retention, depression, BTB - Medroxyprogesterone acetate, norethisterone - LNG-IUS - effective in reducing pain - Between 1/4 and 1/3 of women do not respond to treatment Danazol - don't use, high burden androgenic side effects GnRH agonists --> produces hypogonadotrophic-hypogonadal state through downregulation of pituitary gland As effective as other medical therapies in relieving pain - May reduce progression - No improvement in fertility Can be associated with severe side effects (hot flushes, urogenital atrophy, depression, loss of BMD)

Answer 68

The first definitive surgical intervention has been shown to deliver the greatest benefit - Pain improvements at 6 months ~83% vs. ~53% for second procedure Excision > ablative - better at 12 months, less dysmenorrhoea, dyschezia - No change to dyspareunia Surgery for deep endometriosis possible and effective - Incomplete resection may reduce symptomatic outcomes, but radical interventions increase the risk of major complications Consider hysterectomy + BSO + removal of all visible endometriosis if completed family and failed to respond to more conservative treatments - BSO reduces the risk of reoperation due to recurrent pelvic pain by 6x Counsel that may be only one form of chronic pelvic pain Surgical interruption of pelvic nerve pathways - Presacral neurectomy is effective as an additional procedure to conservative surgery to reduce endometriosis-associated midline pain

Answer 69

Secondary prevention = interventions to prevent the recurrence of pain symptoms or the recurrence of disease in the long-term defined as >6 months after surgery After cystectomy for endometrioma, recommend COCP for secondary prevention - effective at minimising recurrence rates after cystectomy Mirena or COCP for at least 18-24 months recommended for secondary prevention of endometriosis-associated dysmenorrhoea (but not for non-menstrual pelvic pain or dyspareunia)

Answer 70

Recurrence rate of symptoms and endometriotic lesions varies from 10-55% within 12 months Risk of requirement for repeat surgery is higher in women <30y at the time of surgery Also in those with deep / advanced endo, adhesions, those with high BMI time dependent - time dependent - 20% at 2y, 40% at 5y

Answer 71

At time of surgery: - Stage of disease - Hx of previous surgery - Presence of DIE and adhesions, how much residual disease remained - Presence and means of removal of endometrioma (drainage vs. excision) Following hysterectomy - 15% have persisting pain, 3-5% may have worsening pain post-op: - Chronic pain unrelated - Residual or microscopic disease - Preservation of ovaries, use of HRT where there is residual disease Risk factors for recurrence following surgery: - Not applying ongoing medication immediately following surgery - Not following up with patients regularly and in the long term

Answer 72

97% of women become painfree after menopause Combined HRT recommended over oestrogen only - unopposed oestrogen could theoretically could reactivate disease Options for natural menopause - Mirena and low dose oestrogen patch - Mirena appears to have the highest success rate for reducing endometriosis recurrence

Answer 73

There is no evidence that endometriosis causes cancer No increase in overall incidence of cancer in women with endometriosis Some cancers are slightly more common in women with endometriosis Ovarian cancer - clear cell, low-grade serous, endometrioid - Overall risk is low - lifetime risk is increased from ~1 in 100 to 2 in 100 - No evidence for screening Risk of ovarian cancer appears particularly increased in women with a long-standing history of untreated ovarian endometriosis

Answer 74

Intermittent or constant pain in the lower abdomen or pelvis of a woman of >6 months in duration, not occurring exclusively with menstruation or intercourse, and not associated with pregnancy symptom not a diagnosis

Answer 75

2 neurophysiological mechanisms implicated Nociceptive - Injury to a pain sensitive structure - Somatic, visceral Non-nociceptive - Neuropathic - Pain as a result of changes in the nerve itself - Psychogenic Central sensitisation - altered pain sensory processing and impaired central pain modulation - reduced ability of the CNS to diminish responses to peripheral stimuli

Answer 76

hyperalgesia - exaggerated response to noxious substances / pain triggers, through general increase in responsiveness of the tissues to pain Allodynia - Pain response from stimuli which do not normally provoke pain

Answer 77

IBS, painful bladder syndrome may develop due to shared neural pathways in the pelvis

Answer 78

These can lead to myofascial pain or "trigger points" in the abdominal wall (or pelvic floor) which shares the same spinal segment as the sensitised viscera Often described as severe, sharp, stabbing pains, sometimes perceived to be in the ovary, which can occur without pattern, or after exercise or prolonged time in one position

Answer 79

``` GYNAE Endometriosis Adenomyosis Adhesions Ovarian remnant syndrome Pelvic congestion syndrome ``` UROLOGIC Interstitial cystitis GIT IBS IBD Chronic constipation ``` MSK Pelvic floor dysfunction Myofascial pain syndromes Fibromyalgia Adhesions ``` ``` NEURO Postherpetic neuralgia Incisional neuroma Visceral hyperalgesia Pudendal neuralgia ```

Answer 80

Exercise programs CBT has a strong evidence base for managing chronic pain, can also improve sleep and stress Physical therapy - Internal manual therapy - Up to 70% of patients will have moderate to significant improvement in pain and voiding symptoms Nutrition Massage Acupuncture (poor quality evidence)

Answer 81

Paracetamol, NSAIDs Opioids should be avoided in the community - Risks are likely to outweigh benefits and may worsen her pain in the long-term via nerve pathway sensitisation Tricyclic antidepressants - Pain responds faster than depression to TCAs - Side effects: sedation and anticholinergic effects - Tend to use for short period of time (approx 8 weeks) Venlafaxine - Useful in pain and depression Gabapentin particularly useful for burning, lancinating pain, interstitial cystitis - Little evidence with pelvic pain Injections - trigger point injections - Botox - Nerve blocks

Answer 82

Sacral nerve stimulation - Reduces pain and improves voiding dysfunction in patients with interstitial cystitis and pelvic floor dysfunction - Not first line Neuroablative procedures, E.g. LUNA, presacral neurectomy - Insufficient evidence to recommend use in management of painful periods - Significant difference in midline abdominal pain after PSN Hysterectomy - 10% of hysterectomies for CPP - Success rates 60-95% Failure of hysterectomy to relieve CPP is associated with: - Lack of pelvic pathology - Age <30y - Lack of commercial insurance - Psychological problems Almost 40% of patients with no pelvic pathology with have persistent pain post-hysterectomy

Answer 83

deep endometrial tissue (non-neoplastic endometrial glands and stroma) surrounded by smooth muscle hyperplasia within the myometrium Focal or diffuse Traditionally a histological diagnosis post-hysterectomy, therefore true prevalence is not known

Answer 84

TV US + MRI - 80-90% accuracy - Similar diagnostic accuracy - Better quality USS = now similar sen + spec to MRI USS less predictive for adenomyosis if co-existing fibroids TVS features - Bulky, globular - Heterogeneous, venetian blind effect - Asymmetrical wall thickness (particularly fundal or posterior wall) - focal areas have indistinct borders compared to fibroids MRI features - Thickened endo-myometrial junction

Answer 85

USS - readily accessible - cheap - first line imaging for menorrhagia and dysmenorrhoea - user dependent - limited in obesity - TVS with 3D images - similar sen + spec to MRI - can look at other pathology MRI - expensive - ordered by specialist - less user dependent - limited is claustrophobia or metal wear - easily able to identify and measure transition zone

Answer 86

Unknown Endometrial invasion with alteration in the junctional zone - E.g. Disruption of the junction such as after pregnancy (especially with complications, e.g. prolonged labour, CS) and abdominal trauma, tissue injury Chronic myometrial contractions --> micro trauma Changes to myometrium mean that the uterus is not able to optimally contract and constrict vessels --> heavy periods Misplaced pluripotent Mullerian remnants May be a genetic component Coexists with endometriosis in 12% of women Risk factors: - Increasing parity - TOP - Uterine curettage - CS Appears to be an association with oestrogen exposure

Answer 87

Pathognomonic feature = presence of endometrial tissue within the myometrium - The ectopic endometrium usually has an immature proliferative pattern Diffuse adenomyosis – on gross inspection uterus is uniformly large and boggy Focal adenomyosis – on gross inspection can resemble a fibroid but without the pseudo-capsule so cannot be easily shelled out

Answer 88

Non-hormonal - NSAID, TXA COCP, with withdrawal bleed every 4-6 months LNG-IUD - Mirena --> reduction of junctional zone on MRI - Mirena equal to hysterectomy in bleeding improvements at 1y GnRHa agonist Hysterectomy +/- BSO - Consider trial of GnRH analogue prior to ensure pain is relieved completely with chemical suppression of the ovaries, especially in younger women Embolisation has been used to treat focal adenomyomas, but results are not encouraging Discrete adenomyomas can be excised laparoscopically and good success rates for pain relief have been reported Endometrial ablation - good results with superficial adenomyosis <2.5mm, but high failure rate with deep adenomyosis

Answer 89

Imaging to diagnose adenomyosis is becoming more advanced However, the clinical diagnosis of adenomyosis prior to hysterectomy is often inaccurate This is due to: - Variability and non-specific nature of symptoms, which tends to mimic any combination of uterine fibroids, endometriosis and HMB due to ovulatory or endometrial dysregulation - Variability of the sensitivity and specificity of pelvic ultrasound to diagnose adenomyosis - No standardized way to diagnose or classify adenomyosis on imaging and no diagnostic threshold

Answer 90

Frequency of menses = 24-38 days Duration <8 days ``` Regularity (shortest to longest cycle variation) Regular <7-9 days* <9 days - 18-25y and 42-45y <7 days for 26-41y Irregular >8-10 days ``` Flow volume - patient determined ALWAYS ABORMAL - Intermenstrual bleeding - either random or cyclic - Unscheduled bleeding on progestin +/- oestrogen

Answer 91

FIGO approved classification system for the causes of non-gestational AUB PALM - generally discrete / structural entities COEIN - non-structural ``` P = Polyp A = Adenomyosis L = Leiomyoma M = Malignancy and hyperplasia ``` ``` C = Coagulopathy O = Ovulatory dysfunction E = Endometrial disorders I = Iatrogenic N = Not otherwise classified ```

Answer 92

HMB since menarche PPH, surgical-related bleeding, bleeding associated with dental work Bruising 1-2 times / month, epistaxis 1-2x/month, frequent gum bleeding, FHx of bleeding symptoms 90% sensitive for presence of coagulopathy in women with HMB Tests may include assays for von Willebrand factor, Ristocetin cofactor, partial thromboplastin time (PTT) vWD is most common

Answer 93

Required if ET >4mm or >16mm OR Persistent IMB >45y with treatment failure Irregular bleeding while on HRT or tamoxifen

Answer 94

COCP - Effective treatment as increase fibrinogen, prothrombin, FVII, FVIII and/or vWF LNG-IUS - Effective management of HMB Endometrial ablation - Effective - One study found 3/7 women needed hysterectomy Desmopression acetate and vWF replacement may be needed to control HMB Surgery - hysterectomy - Get advice from haematology - Timing and need for infusion determined by factor vWF and factor VII levels pre- and post-op

Answer 95

General anaesthetics with associated risks Not appropriate if distorted endometrial cavity (fibroids, septum) Mirena: - 90% reduction in menstrual flow - 85% patient satisfaction Ablation - 80% effective - 20% women go on to have hysterectomy in the future ``` Device failure Pain, bleeding, infection Cervical trauma Perforation +/- organ injury Chronic pain, especially in previous tubal ligation Haemtometra ``` Not recommended if future pregnancy desired – increased risk of miscarriage, ectopic pregnancy, abnormal placentation Reliable contraception required

Answer 96

Atrophy - up to 60% Hormonal effect Polyps Hyperplasia Endometrial carcinoma Ovarian, tubal, cervical malignancy

Answer 97

Ovarian causes - 1-2% of women will spot at ovulation - Oestrogen secretin tumours can cause IMB Uterine causes - Iatrogenic - Hormonal contraceptives and implants - SSRIs, anticoagulants - Infective - Endometritis - Structural - benign, Polyps, fibroids, adenomyosis - Structural - malignant, Endometrial cancer Cervical causes - Iatrogenic - Following exam, smear - Cervicitis secondary to infection (chlamydia, gonorrhoea) - Cervical ectropion - Cervical polyps - largely benign (malignancy 0.1%, dysplasia 0.5%) - Cervical cancer - 3-18% prevalence in PCB Vaginal causes - Atrophic vaginitis - Trauma, foreign bodies, sexual abuse - Vulvovaginitis secondary to Trichomonas vaginalis or Candida albicans if severe oedema or excoriation - Vaginal cancer Vulval causes - Herpes simplex, Genital warts - cancer

Answer 98

Rare Largely acquired lesions - usually following pregnancy event Usually present with AUB - Often episodic, torrential, can result in significant anaemia or even shock USS - Subtle myometrial heterogeneity and multiple tubular or spongy anechoic or hypoechoic areas within the myometrium - Colour Doppler - intense vascularity with turbulent, multidirectional flow Resuscitation - Could use foley catheter to stem bleeding Medical - COCP - Danazol - Thought it decreases blood flow to the AVM, allowing the lesion to thrombose Uterine artery embolisation- Consider if life threatening bleeding Hysterectomy - Definitive treatment

Answer 99

Localised hyperplastic overgrowths of endometrial glands and stroma which form projections over the endometrial surface Proposed that polyps lose their apoptotic cell regulation and overexpress oestrogen and progesterone receptors causing them to grow

Answer 100

``` Age - Incidence increases with age, peaks in 5th decade of life, then declining at menopause Tamoxifen Obesity MHT FHx - Lynch syndrome ```

Answer 101

>1cm less likely to regress 6-10% can potentially regress Risk of malignancy - 95% benign - Risk of malignancy / hyperplasia more in post-menopausal and those who are symptomatic - Size not associated with risk of malignancy

Answer 102

Smooth muscle tumours of the uterus with a monoclonal origin 77% of uterine histology specimens 12-25% of reproductive age women

Answer 103

``` Ethnicity - Black 2-3x increase > white Early menarche (<10y) Age (advancing age) Parity - >1 pregnancy beyond 20/40 reduces risk Hereditary - Familial predisposition in some families DES exposure ```

Answer 104

AUB - Abnormal vasculature, impaired endometrial haemostasis, increased endometrial surface area, altered contractility Pain - Altered contractility, increased bleeding and clots, degeneration, deep dyspareunia Pressure if large Infertility / obstetric complications - Distortion of uterine cavity --> increased miscarriage, altered endometrium overlying fibroid, changes in uterine contractility

Answer 105

Hyaline degeneration - Relatively common - Presents as painful enlarged fibroids due to hyaline / cystic degeneration pathological process Red degeneration - typically occurs due to infarction at mid-pregnancy Calcification - Typically in postmenopausal women Sarcomatous change - 0.2% risk Infection - Relatively rare Torsion of pedunculated fibroids

Answer 106

Subserosal - Do not appear to have a significant effect Intramural - May be associated with reduced fertility and increased miscarriage rate - insufficient evidence to determine whether myomectomy improves fertility outcomes >8cm associated with infertility, <5cm not major role Submucosal - Associated with reduced fertility and an increased miscarriage rate - Hysteroscopic myomectomy is likely to improve fertility outcomes, but only poor quality studies - >2cm may have space effect

Answer 107

0-2 = submucosal 0 = pedunculated 1 <50% intramural 2 >50% intramural 3 =. contacts endometrium but 100% intramural 4-5 intramural 6 subserous 7 subserous pedunculated 8 - other, e.g. cervical

Answer 108

Depo provera - Reduced menstrual loss and fibroid volume after 6/12 Mirena - Fibroids <3cm and not distorting uterine cavity - Reduces blood loss, increases Hb and relieves symptoms GnRH agonists - Zoladex - Works for 12-13 weeks - Low oestrogen state with menopausal side effects - Limit to 6 months - Usually used pre-op - Can make surgical planes difficult, but may need can change approach (e.g. pfannenstiel vs. midline)

Answer 109

Ensure appropriate imaging assessment prior to UAE (Doppler USS and ideally MRI) to exclude malignancy Conscious sedation and LA Involves angiographic catheter into the uterine arteries via the common femoral artery, followed by injection of embolic particles until the flow becomes sluggish Reduced pressure symptoms in ~60% Reduced AUB (heavy) in 70-90% Reduced pain in ~80% 25% chance of requiring hysterectomy within 5y

Answer 110

``` ABSOLUTE Asymptomatic fibroids Pregnancy PID (recurrent or current) Suspected or known uterine malignancy Anaphylaxis to contrast ``` RELATIVE Desire to conceive - High quality data lacking Postmenopausal status Fibroid location - Submucosal or subserosal with narrow stalk - sterile peritonitis or intrauterine infection Number / size of fibroids

Answer 111

Risk of minor adverse outcome 30-45% Risk of major complications - 5% Early: - 'Embolisation syndrome' - Pain, nausea, malaise, fever - Vaginal discharge - Pelvic infection - including pyomyoma - Expulsion of necrotic submucosal fibroid (5-8%) - Sepsis requiring urgent hysterectomy - 1% Late: - Ovarian failure / insufficiency - Recurrence - Failure of response - Fibroid expulsion and impaction - Fistula - Bladder / vaginal injury - VTE (0.3%) - Sepsis - Delayed diagnosis of cancer

Answer 112

Increased: - Minor complications (short and long-term) - Number of unplanned reviews and re-admissions after discharge - Surgical reintervention rate Decreased: - Length of hospitalisation - Procedure duration - Resumption of ADL No significant difference in: - Intra procedural complications - Short or long term major complications - Patient satisfaction at 2 and 5y - No difference in long-term ovarian failure rates

Answer 113

due to lack of good quality evidence, caution should be employed to avoid routine use of UAE in young patients wishing to conceive Concerning outcomes that could affect reproductive potential: - Non-target embolisation --> ovarian embolisation and impaired ovarian reserve - Decrease in endometrial volume due to an inadequate blood supply 1 RCT comparing UAE to myomectomy - Pregnancy rates were significantly higher, with lower miscarriage rates in myomectomy group

Answer 114

Thermoblative technique causing tissue destruction High frequency ultrasound waves produced heat to denature proteins --> cell death and shrinkage of proteins For premenopausal women with fibroids Limited data

Answer 115

Hysterectomy associated with lower surgical risks than abdominal myomectomy and will achieve definitive symptoms cure, therefore reserve for those wanting to preserve fertility Improves spontaneous fertility if <41y Retreatment rate 20% over 2-5y Bleeding --> hysterectomy in 1% Deliver by CS

Answer 116

Type 0 and 1 submucosal fibroid Lower chance in size >5cm Reduces intracavity fibroid size by 90-100% Decrease HMB >80% Improve fertility (40-60%) Secondary treatment required in 2y in 10% Complication rate 1-2%

Answer 117

Second half = luteal phase (of ovary) Fixed at 14 days (the life span of the corpus luteum) Secretory of endometrium Corpus luteum is formed from the remnant of the ovarian follicle - Luteinized theca and granulosa cells ``` CL is maintained by LH Initially - If pregnant, HCG maintains CL CL secretes - Progesterone - at high levels suppresses GnRH. Makes endometrium receptive to implantation of fertilised gamete - Oestrogen - Inhibin - negative feedback on FSH ``` If no pregnancy, CL involutes Concentrations of oestradiol and progesterone drop --> level of FSH starts to rise as negative feedback disappears

Answer 118

In the first half of the cycle, when oestradiol present, lining proliferates With rising progesterone, the endometrium goes through staged series of development - Spiral arteries continue to grow - Uterine glands secrete more mucous - After day 15, window for fertilisation closes as cervical mucus thickens and is less hospitable for sperm - Window of implantation approx half way through the luteal phase where the endometrium is receptive to an embryo

Answer 119

strongly discourages the performance of any surgical or laser procedure that lacks current peer reviewed scientific evidence other than in the context of an appropriately constructed clinical trial At present, no evidence they are effective, enhance sexual function, or improve self-imageRefers to devices that deliver thermal energy to the vaginal mucosa Marketed for the treatment of vaginal menopausal symptoms, sexual dysfunction, urinary incontinence

Answer 120

Refers to devices that deliver thermal energy to the vaginal mucosa Marketed for the treatment of vaginal menopausal symptoms, sexual dysfunction, urinary incontinence