Benign Gynae Flashcards
What is endometriosis?
How common is it?
What is an Adenomyosis?
What is an Endometrioma?
- 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
What hormone is involved in endometriosis thus who does it usually effect?
- Oestrogen thus mostly affects women during their reproductive years
- Symptoms worse around period
What causes endometriosis?
Whats the pathophysiology?
- 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)
Symptoms of endometriosis?
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)
Signs of endometriosis?
- Tenderness
- Endometriomas/chocolate cyst (a type of cyst formed when endometrial tissue grows in the ovaries)
- Fixed retroverted uterus
- Infertility (adhesions from chronic inflammation)
Investigations for endometriosis?
- Gold standard is Laperoscopy (diagnostic and therapeutic)
- Transvaginal USS may be useful to look for endometriomas
Medical managment of endometriosis?
MEDICAL MANAGMENT ENDOMETRIOSIS
- Analgesia (NSAIDS)
- Oral contraceptives (ovarian suppression)
- Mirena coil (endometrial and ovarian suppression)
- GnRH analogues (ovarian suppression) e.g. prostate/gonapeptyl
Surgicalmanagment of endometriosis?
SURGICAL MANAGMENT ENDOMETRIOSIS
-Laparoscopic ablation/resection
- Remove endometriosis (chocolate cysts)
- Last resort = hysterectomy with sapling-oopherectomy
Differentials for acute pelvic pain?
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)
Differentials for chronic pelvic pain?
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)
What is PCOS?
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)
What is the criteria used for diagnosing PCOS? Explain the features
The Rotterdam criteria
What are the features of the Rotterdam criteria?
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
What are fibroids?
What are some other names for them?
How common are they ?
- 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
What are the risk factors for developing fibroids?
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)
What are the types of firbroid?
Majority are uterine, cervical are relatively uncommon ( surgical difficulty due to the proximity to the bladder and ureters)
- Submucosal (majority inside endometrial cavity)
- menorhhagea/irregular IMB - Intramural (within myometrium) MOST COMMON
- Subserous (majority outside uterus)
- pain/pressure symptoms
Can get pudunculated (mushroom like-prone to torsion) and parasitic (attached to other structures)
What are the signs/symptoms of fibroids?
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
How may a uterine fibroid affect a pregnancy?
- can get pain from degeneration
- abnormal lie
- obstruction if cervical
- can cause difficulty in CS
How do you diagnose fibroids?
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)
Differentials for fibroids?
Uterine
- pregnancy
- heamatoma
- malignancy
Non uterine
- ovarian cyst
- ectopic pregnancy
- pelvic abbess
- malignancy (ovaries, bladder and bowel)
Managment of fibroids?
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)
What is an endometrial polyp?
Who are they more common in?
What is the treatment?
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
What is symptoms of polyps?
Polyp symptoms
- Abnormal bleeding (unpredictable)
- Heavy bleeding
- IMB
- PMB
- Infertility
What is cervical ectropion?
What causes it?
What are the symptoms?
Whats the management?
- 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
What is Ashermans syndrome?
What can cause it?
How does it present?
Whats the management
-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
1st line investigation for ovarian cyst?
1st line: TV USS and TA USS
What is a functional cyst?
What are some examples of functional cysts? (which ones are complex vs simple)
FUNCTIONAL CYST (normal process if disturbed)
- follicular cyst (simple)
- corpus luteal cyst (simple)
- theca lutein (complex)
- endometriaoma (chocolate cyst) (complex)
PATHOLOGICAL
Explain corpus luteal cyst?
Corpus luteal cyst (simple)
- Corpus lute fails to regress after releasing ovum
- fills with blood/fluid
- can be haemorragic/rupture
Explain follicular cyst?
Follicular cyst (simple)
- dominant follicle fails to rupture
- seen in PCOS
Explain theca lutein cyst?
Theca lutein cyst (complex)
+++++++ BHCG (molar pregnancy)
-usually resolve few weeks after evacuation of molar pregnancy
-rare in uncomplicated pregnancies
Explain Endometrioma?
Endometrioma/chocolate cyst (complex)
- endometriosis on ovary
- cyclical pain and fixed cyst
Features of simple vs complex cyst?
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)
Name the epithelial pathological cysts (which ones are benign or cancerous)
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
Name the germ cell pathological cysts (which ones are benign or cancerous)
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)
Managment of ovarian cysts all women?
symptomatic/?malignancy
Pre menopausal women
- If symptomatic=gynae referral
- If malignant suspicion=2ww referral +CA125
Managment of asymptomatic ovarian cysts in pre menopausal women? (simple and complex)
Asymptomatic
SIMPLE
-small <5cm no action/follow up in 4 months
-large >5cm gynae referral
COMPLEX
-gynae referral (biopsy/Ca125, Bhcg, afp)
Managment of cysts in post menopausal women? (simple and complex)
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)
What is used in RMI?
-Ca125 X menopausal status X USS findings
>200 is high risk of malignancy
Managment of cysts based off RMI?
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
