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GOSH > Benign Gynae > Flashcards

Benign Gynae Flashcards

1
Q

What is endometriosis?
How common is it?

What is an Adenomyosis?

What is an Endometrioma?

A
  • The presence of endometrial like tissue outside of the uterine cavity
  • 10% population
  • Adenomyosis= endometrial tissue within myometrium (classically causes painful periods-dysmenorrhoea) MRI PELVIS
  • Endometrioma= endometrial tissue in ovary
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2
Q

What hormone is involved in endometriosis thus who does it usually effect?

A
  • Oestrogen thus mostly affects women during their reproductive years
  • Symptoms worse around period
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3
Q

What causes endometriosis?

Whats the pathophysiology?

A
  • Theory of retrograde menstruation
  • 1st degree relative increases risk 6x

Pathophysiology
-Repeated episodes of bleeding and healing causes fibrosis and adhesions between pelvic organs (pain and infertility)

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4
Q

Symptoms of endometriosis?

A

Endometriosis-cyclical symptoms

  • Dysmenorrhoea (cyclical pelvic pain)
  • Deep dyspareunia
  • Urinary symptoms (Cyclical heamaturia, dysuria)
  • Rectal symptoms (cyclic haemochezia/dyschezia-pain defecating)
  • Can get in lung (cyclical heamoptysis)
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5
Q

Signs of endometriosis?

A
  • Tenderness
  • Endometriomas/chocolate cyst (a type of cyst formed when endometrial tissue grows in the ovaries)
  • Fixed retroverted uterus
  • Infertility (adhesions from chronic inflammation)
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6
Q

Investigations for endometriosis?

A
  • Gold standard is Laperoscopy (diagnostic and therapeutic)

- Transvaginal USS may be useful to look for endometriomas

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7
Q

Medical managment of endometriosis?

A

MEDICAL MANAGMENT ENDOMETRIOSIS

  • Analgesia (NSAIDS)
  • Oral contraceptives (ovarian suppression)
  • Mirena coil (endometrial and ovarian suppression)
  • GnRH analogues (ovarian suppression) e.g. prostate/gonapeptyl
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8
Q

Surgicalmanagment of endometriosis?

A

SURGICAL MANAGMENT ENDOMETRIOSIS
-Laparoscopic ablation/resection

  • Remove endometriosis (chocolate cysts)
  • Last resort = hysterectomy with sapling-oopherectomy
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9
Q

Differentials for acute pelvic pain?

A 
Gynae
• Early pregnancy compplications
	○ Ectopic pregnancy
	○ Miscarriage 
• PID
• Ovarian cyst accident (torsion, haemorrhage, rupture)
    ○ gradual, unilateral, tender,dyspareunia 
• Mittelschmerz (mid cycle)
• Primary dysmenorrhoea (unknown cause)

OTHER ABDO CAUSES (IBD/appendicitis/UTI)

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10
Q

Differentials for chronic pelvic pain?

A

Gynae

1) Endometriosis
2) Adhesions
3) Fibroids
4) Prolapse (dragging sensation)
5) Ashermans syndrome (intrauterine scarring)

Non-gynae

  • GI (constipation/hernias/IBD)
  • Urological (painful bladder syndrome)
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11
Q

What is PCOS?

A

Polycystic Ovary Syndrome

Polycystic ovary = a characteristic transvaginal US appearance of multiple (12 or more) small follicles (2-8mm) in an enlarged ovary (>10mL volume)

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12
Q

What is the criteria used for diagnosing PCOS? Explain the features

A

The Rotterdam criteria

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13
Q

What are the features of the Rotterdam criteria?

A

2 / 3 of:

1) Irregular periods or amenorrhoea

2) Clinical/biochemical features of hyperandrogegism:
- Acne
- Hirsutism
- Alopecia
- Raised serum testosterone

3) Polycystic ovaries on USS
- 12+ cysts, <9cm in size
- enlarged ovary

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14
Q

What are fibroids?
What are some other names for them?
How common are they ?

A
  • Fibroids are benign growths arising from myometrium (smooth muscle)
  • Mostly smooth muscle but may contain fibrous tissue
  • Also called leiomyomata, myomas, fibromas
  • very common (25%). Half are asymptomatic
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15
Q

What are the risk factors for developing fibroids?

A

RF for fibroids include increased lifetime exposure to oestrogen:

  • obesity
  • early menarche
  • age
  • afro caribbean (3x more likely than white)-similar to keloids
  • FH

(protective = menopause, exercise and increased parity)

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16
Q

What are the types of firbroid?

A

Majority are uterine, cervical are relatively uncommon ( surgical difficulty due to the proximity to the bladder and ureters)

  1. Submucosal (majority inside endometrial cavity)
    - menorhhagea/irregular IMB
  2. Intramural (within myometrium) MOST COMMON
  3. Subserous (majority outside uterus)
    - pain/pressure symptoms

Can get pudunculated (mushroom like-prone to torsion) and parasitic (attached to other structures)

17
Q

What are the signs/symptoms of fibroids?

A

Up to half are asymptomatic but can cause major symptoms:

1) Dysmenorrhoea (pain)
2) Menorrhagia (heavy) (submucosal)
3) Pressure symptoms (bloating/urinary freq) (subserous)
4) Pelvic pain
5) Infertility (<10% of cases)
6) Symptoms of anaemia due to menorrhagia

Larger fibroids = heavier bleeding due to a variety of factors promoting angiogenesis

18
Q

How may a uterine fibroid affect a pregnancy?

A
  • can get pain from degeneration
  • abnormal lie
  • obstruction if cervical
  • can cause difficulty in CS
19
Q

How do you diagnose fibroids?

A

Bedside
-Abdo exam-palpable hard, irregular mass

Bloods

  • FBC for anemia
  • TFT
  • ßHCG
  • FSH/LH/oestrogen

Imaging

  • 1st line TA and TV USS (number/size/position of fibroids, and vasculature)
  • Pelvic MRI IS GOLD STANDARD (distinguish between adenomyosis)
20
Q

Differentials for fibroids?

A

Uterine

  • pregnancy
  • heamatoma
  • malignancy

Non uterine

  • ovarian cyst
  • ectopic pregnancy
  • pelvic abbess
  • malignancy (ovaries, bladder and bowel)
21
Q

Managment of fibroids?

A

CONSERVATIVE

  • No treatment may be required if minimal symptoms
  • Assess and manage anemia
  • Monitor annually for changes

MEDICAL
-1st line is levonorgestrel IUS if <3cm
Others include:
-Hormonal: COCP or a cyclical oral progestogen (such as oral norethisterone).
-Non hormonal: NSAIDS/tranexamic acid

SURGICAL (GnRH analogues before to shrink)

  • Uterine artery embolisation
  • Myomectomy (presserves fertility)
  • Hysterectomy if don’t require fertility or 45+ (cure)
22
Q

What is an endometrial polyp?

Who are they more common in?

What is the treatment?

A

What?

  • Endometrial polyp= Adenoma
  • These are focal overgrowth of ENDOMETRIUM and are malignant in <1%

Who?
-Pretty common, more so in women >40yr but can occur at any age

Treatment?
-Hysteroscopic polypectomy and sent to histology

23
Q

What is symptoms of polyps?

A

Polyp symptoms

  • Abnormal bleeding (unpredictable)
  • Heavy bleeding
  • IMB
  • PMB
  • Infertility
24
Q

What is cervical ectropion?
What causes it?
What are the symptoms?
Whats the management?

A
  • Collumner endothelium becomes visible
  • Caused by 3Ps of hormonal changes (puberty/pill/pregnancy)

Symtoms

  • post coital bleeding/intermenstrual bleeding
  • excessive clear/watery/oderless discharge

Management

  • switch pill
  • cryotherapy
  • smear to rule out cervical carcinoma
25
Q

What is Ashermans syndrome?

What can cause it?

How does it present?

Whats the management

A

-Ashermans syndrome is an irreversible damage to stratum basalis (fibrosis and adhesion formation)

Caused by:

  • past curettage of uterus
  • severe pelvic infection

Presents:

  • Decreased or absent menstrual bleeding
  • Subfertility

Management
-Hysteroscopic adhesiolysis

26
Q

1st line investigation for ovarian cyst?

A

1st line: TV USS and TA USS

27
Q

What is a functional cyst?

What are some examples of functional cysts? (which ones are complex vs simple)

A

FUNCTIONAL CYST (normal process if disturbed)

  • follicular cyst (simple)
  • corpus luteal cyst (simple)
  • theca lutein (complex)
  • endometriaoma (chocolate cyst) (complex)

PATHOLOGICAL

28
Q

Explain corpus luteal cyst?

A

Corpus luteal cyst (simple)

  • Corpus lute fails to regress after releasing ovum
  • fills with blood/fluid
  • can be haemorragic/rupture
29
Q

Explain follicular cyst?

A

Follicular cyst (simple)

  • dominant follicle fails to rupture
  • seen in PCOS
30
Q

Explain theca lutein cyst?

A

Theca lutein cyst (complex)
+++++++ BHCG (molar pregnancy)
-usually resolve few weeks after evacuation of molar pregnancy
-rare in uncomplicated pregnancies

31
Q

Explain Endometrioma?

A

Endometrioma/chocolate cyst (complex)

  • endometriosis on ovary
  • cyclical pain and fixed cyst
32
Q

Features of simple vs complex cyst?

A

Simple

  • usually 2-3cm but can be up to 10cm
  • clear serous fluid
  • smooth internal lining
  • dont cause problems dont need treatment

Complex

  • contain blood or solid substance
  • need to be biopsied (malignancy)
33
Q

Name the epithelial pathological cysts (which ones are benign or cancerous)

A 
Serous cystadenoma (benign)
-most common benign epithelial

Mucinous cystadenoma (benign)

  • second most common benign epithelial
  • if rupture may cause psuedomyxoma peritoniti (cancer in abdomen)
Serous adenocarcinoma (malignant) 
-most common ovarian cancer
34
Q

Name the germ cell pathological cysts (which ones are benign or cancerous)

A

GERM CELL MORE COMMON IN YOUNGER WOMEN

Teratoma/dermoid cytst (benign)

  • most common benign ovarian tumour <30 years
  • large>rupture/torsion

Dysgerminma (malignant)
-most common malignant ovarian tumour in <30 years

Yolk sac tumour (malignant)

35
Q

Managment of ovarian cysts all women?

symptomatic/?malignancy

A

Pre menopausal women

  • If symptomatic=gynae referral
  • If malignant suspicion=2ww referral +CA125
36
Q

Managment of asymptomatic ovarian cysts in pre menopausal women? (simple and complex)

A

Asymptomatic
SIMPLE
-small <5cm no action/follow up in 4 months
-large >5cm gynae referral

COMPLEX
-gynae referral (biopsy/Ca125, Bhcg, afp)

37
Q

Managment of cysts in post menopausal women? (simple and complex)

A

Simple

  • <3cm do Ca125
    - if raised: 2ww
    - if not raised: do benign gynae referral/follow up Ca125

Complex
-2ww +Ca125 (unlikely to be functional because not ovulating)

38
Q

What is used in RMI?

A

-Ca125 X menopausal status X USS findings

>200 is high risk of malignancy

39
Q

Managment of cysts based off RMI?

A

Low RMI <25

  • follow up for 1 year with USS and Ca125 every 4 month s
  • if no change or women’s request: laparoscopic oophorectomy
Moderate RMI (25-250)
-oophorectomy (normally bilateral) 
High RMI (>250)
-Full staging laperoscopy

GOSH (29 decks)

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