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
Most likely cause of abnormal uterine bleeding: Metorrhagia, especially after intercourse, no pain, normal sized uterus
Endometrial or cervical polyp
Most likely cause of abnormal uterine bleeding: Depression, constipation
Hypothyroidism (Note: Hyperthyroidism can also cause abnormal uterine bleeding)
Tx abnormal uterine bleeding - Outpatient options
(1) In hemodynamically stable pt, estrogen for 21-25 days to thicken endometrium (lowest effective dose possible for least amount of side effects) & After 25-28 days, progesterone daily for 10 days - Stopped leading to heavy withdrawal bleeding; OCPs - (2) Monophasic (same dose throughout, 35 mcg estradiol, starting 4 pills a day, taper by 1 pill a day until daily dosing reached, continue for at least q wk after bleeding subsides) (3) High-dose progestin for 5-10 days (Rx antinausea meds)
Tx abnormal uterine bleeding - Inpatient considerations
IV access for possible transfusion; Address volume status, may need to transfuse pt if hemodynamically unstable; Induce tamponade by inserting foley catheter 30 cc balloon transcervically into uterus and then inflating it; Most commonly, IV Primolut N (i.e., norethisterone = strong progesterone) q 4 h to stabilize & regrow endometrium (again, Rx antinausea med)… then switch over to outpt tx & taper over time
Contraceptive options for pt w/ long-term hx of abnormal uterine bleeding
Progesterone IUD; Also consider OCPs, progesterone pills
Dx feat of PID
Suspect PID in any sexually active with lower abdominal pain; Low threshold for dx; Tx empirically - CMT, leukocytosis, adnexal tenderness, new or purulent discharge, WBCs on wet prep, temp > 101, elevated ESR/CRP; Imaging may reveal thickened or fluid-filled fallopian tubes w/wo fluid in cul-de-sac;
Tx PID
Outpt: Ceftriaxone + Metronidazole + Doxycycline (2 wk), Clinical f/u 2-3 days; Inpt (also low threshold for admission): Cefoxitin + Doxycycline, Clindamycin + Gentamin, switch to oral therapy once improved and ready to go home on outpt oral tx
Pelvic prolapse clues
Pelvic pressure or heaviness, Obvious protrusion of tissue out of vagina, “feels like I’m sitting on egg”; Cystocele, Rectocele, Enterocele (small bowel into vagina - usually due to hysterectomy), Uterine prolapse
Tx Pelvic prolapse
Mild - Pelvic floor exercise and/or PT w/ behavior modification (e.g., timed voiding/defecation); Moderate - Pessaries; Severe - Surgical correction
