Day 13 - Gyn2 Flashcards
Characteristic sx feat of endometriosis
Pelvic pain, most severe during menses (not necessarily happen in later half but occurs during menses, particularly around ovulation, pain resolves w/ end of menses); 3 D’s: Dysmenorrhea, Dyspareunia, Dyschezia; Difficulty w/ infertility
Physical signs of endometriosis
Localized tenderness in cul-de-sac or uterosacral ligaments, especially at time of menses; Palpable tender nodules in cul-de-sac, uterosacral ligaments, rectovaginal septum; Pain with uterine movement; Tender and large adnexal masses; Adhesions causing a fixed or retroverted uterus
Tx options for endometriosis
Expected mgt (minimal sx or perimenopausal); Pain control w/ NSAIDs; Hormonal therapy (OCPs dosed continuously to prevent bleeding and potential irritation of endometrial tissue); GnRH (continuous) agonist 6-12 mo. (induces medical menopause) if moderate to severe pain, mgt w/ add-back hormones (alleviate menopausal side effects); Progestin (2nd or 3rd line due to breakthru bleeding); Danazol (androgen can be used for 6 mo., also induces medical menopause but no add-back therapy so GnRH agonists can be more helpful); Aromatase inhibitors (may help in case of cysts develop); DEFINITIVE TX - SURGICAL: (1) IF FERTILE - Laparoscopy to confirm & ablate ectopic endometrial lesions/adhesions; (2) IF FUTURE FERTILITY NOT DESIRED - Hysterectomy w/ b/l salpingo-oophorectomy - lysis of adhesions/removal of endometrial implants
First line tx for young, fertile pt w/ obvious signs of endometriosis
Laparascopy (to confirm dx & ablate ectopic endometrial lesions or adhesions)
W/u abnormal uterine bleeding - history
Confirm excessive blood loss (change tampons in less than q 3 hrs, using more than 20 tampons per cycle, more than subtle need to change tampon overnight, pass clots > 1 in in diameter); HISTORY - Menses frequency & duration (recently v. past); Note: Irregular heavy bleeding often due to anovulation; Regular heavy bleeding ddx (fibroids, bleeding disorder, or adenomyosis); Bleeding assoc w/ coitus (atrophic vaginitis, endometrial/cervical colyps); trauma, foreign body abuse, bowel/bladder changes, breast discharge, hot flashes, hirsuitism, hypo/hyperthyroidism, weight changes, bleeding disorders or history of bleeding, etc.
w/u abnormal uterine bleeding - physical exam
Speculum exam, bimanual exam, thyroid palpation, general overview of pt
w/u abnormal uterine bleeding - labs
B-HCG (r/o pregnancy, especially molar), Pap smear, Wet prep, G/C prep (r/o infx), CBC (r/o bleeding diathesis), bleeding time (r/o vWD), PT/PTT/INR
Indications for endometrial bx in w/u of abnormal uterine bleeding
(1) F over age 35 (r/o endometrial hyperplasia or cancer - especially if risk factors: excess estrogen); (2) Age 18+ & Risk of ovarian CA (PH/FH breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation) - may ultrasound pelvis as well
Most likely cause of abnormal uterine bleeding: Most common
Anovulatory (aka dysfunctional) bleeding
Most likely cause of abnormal uterine bleeding: Positive B-HCG, Intrauterine pregnancy, closed os
Threatened abortion
Most likely cause of abnormal uterine bleeding: Enlarged uterus, Menometorrhagia for months
Uterine fibroid (i.e., Leiomyoma)
Most likely cause of abnormal uterine bleeding: assoc w/ severe menstrual pelvic pain
Endometriosis (classically pain not associated w/ bleeding, but some cases may have bleeding)
Most likely cause of abnormal uterine bleeding: Menorrhagia, perimenopausal
Endometrial hyperplasia (until proven otherwise)
Most likely cause of abnormal uterine bleeding: started w/ menarche, excessive menses
Hereditary bleeding disorder (e.g., vWD)
Most likely cause of abnormal uterine bleeding: positive Beta-HCG, no fetus in uterus on US, severe abdominal pain
Ectopic pregnancy
