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OBG: Functional Gynaecology > Dysmenorrhoea > Flashcards

Dysmenorrhoea Flashcards

1
Q

What is meant by dysmenorrhoea?

A

Painful periods

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2
Q

What is the nature of the pain of dysmenorrhoea?

A

crampy lower abdominal pain, which starts at the onset of menstruation

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3
Q

What are the 2 categories that dysmenorrhoea can be classed into?

A
  1. Primary dysmenorrhoea
  2. Secondary dysmenorrhoea
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4
Q

What is the difference between primary and secondary dysmenorrhoea?

A

Primary dysmenorrhoea occurs with no underlying pelvic patholoy, whereas secondary is associated with pelvic pathology

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5
Q

What is the physiology that results in menses?

A
  • in the absence of fertilisation of the egg, the corpus luteum regresses and there is subsequent decline in oestrogen and progesterone production
  • endoetrial cells respond to decline in progesterone with prostaglandin release
  • prostaglandin release causes:
    • spinal artery vasospasm - leading to ischaemic necrosis and shedding superficial layer of endometrium
    • increased myometrial contractions
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6
Q

What is thought to cause primary dysmenorrhoea?

A

Thought to occur secondary to excessive release of prostaglandins (PGF2α and PGE2) by endometrial cells

may also relate to neuropathic dysregulation, venous pelvic congestion, psychological causes

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7
Q

What are 8 underlying causes for secondary dysmenorrhoea?

A
  1. Endometriosis
  2. Adenomyosis
  3. PID
  4. Pelvic adhesions
  5. Fibroids (not always)
  6. Cervical stenosis (iatrogenic post-LLETZ or instrumentation)
  7. Asherman’s syndrome
  8. Congenital abnormalities e.g. non-communicating cornua
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8
Q

What are 5 risk factors for primary dysmenorrhoea?

A
  1. Early menarche
  2. Long menstrual phase
  3. Heavy periods
  4. Smoking
  5. Nulliparity
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9
Q

What is the typical description of dysmenorrhoea?

A
  • lower abdominal or pelvic pain, which can radiate to the lower back or anterior thigh
  • Crampy pain
  • Lasts for 48-72 hours around the menstrual period
  • Characteristically worst at onset of menses
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10
Q

What are 2 places where primary dysmenorrhoea pain can radiate to?

A

Lower back or anterior thigh

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11
Q

How long does primary dysmenorrhoea pain usually last for each time is occurs?

A

48-72 hours

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12
Q

What are 5 symptoms that dysmenorrhoea pain may be associated with?

A
  1. Malaise
  2. Nausea
  3. Vomiting
  4. Diarrhoea
  5. Dizziness
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13
Q

What may be present on examination in primary dysmenorrhoea?

A

usually unremarkable, uterine tenderness may be present

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14
Q

Following what may primary dysmenorrhoea resolve?

A

Pregnancy

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15
Q

What are the 4 main causes of secondary dysmenorrhoea to exclude before a diagnosis of primary dysmenorrhoea is made?

A
  1. Endometriosis
  2. Adenomyosis
  3. Pelvic inflammatory disease
  4. Adhesions
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16
Q

What are 2 non-gynaecological differentials for primary dysmenorrhoea?

A

inflammatory bowel disease and irritable bowel syndrome

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17
Q

What are the investigations in primary dysmenorrhoea based upon and what are 2 examples?

A

No specific investigations, based on ruling out underlying pathology

  1. If risk of STI, high vaginal swab and endocervical swabs
  2. Tranvaginal ultrasound (TVS) if pelvic mass on examination
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18
Q

What is the aim of management of primary dysmenorrhoea?

A

symptomatic improvement

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19
Q

What are 3 groups of ways to manage primary dysmenorrhoea?

A
  1. Lifestyle changes
  2. Pharmacological
  3. Non-pharmacological
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20
Q

What key lifestyle change is recommended as treatment for primary dysmenorrhoea?

A

stop smoking -clear relationship with primary dysmenorrhoea

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21
Q

What are the first and second line treatments for primary dysmenorrhoea?

A
  1. First line: analgesia (NSAIDs±paracetamol)
  2. Second line: 3-6 months trial of hormonal contraception
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22
Q

What are the 2 key options for analgesia for primary dysmenorrhoea?

A
  1. NSAIDs: ibuprofen, naproxen, mefenamic acid
  2. Used ± paracetamol
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23
Q

How do NSAIDs work to treat dysmenorrhoea?

A

inhibit production of prostaglandins, which are implicated in the pathogenesis of primary dysmenorrhoea

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24
Q

What are 2 types of hormonal contraception that can be used in a 3-6 months trial to treat primary dysmenorrhoea?

A
  1. Monophasic combined oral contraceptive pill - first line
  2. Intrauterine system (e.g. Mirena coil)
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25
Q

What are 2 non-pharmacololgical options to treat primary dysmenorrhoea?

A
  1. Local application of heat (water bottles or heat patch)
  2. Transcutaneous electrical nerve stimulation (TENS)
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26
Q

What is pelvic inflammatory disease?

A

Infective inflammation of the upper genital tract in females, which affects the endometrium uterus, fallopian tubes, ovaries and peritoneum

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27
Q

In which group of patients is the prevalence of PID highest?

A

sexually active women aged 15 to 24

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28
Q

What are 5 anatomical structures that can be affected by PID?

A
  1. Endometrium
  2. Uteris
  3. Fallopian tubes (salpingitis)
  4. Ovaries
  5. Peritoneum
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29
Q

What causes pelvic inflammatory disease?

A

spread of bacterial infection from the vagina or cervix to the upper genital tract

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30
Q

What 2 types of STI are responsible for 25% of cases of PID?

A
  1. Chlamydia trachomatis
  2. Neisseria gonorrhoea
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31
Q

What are 5 types of bacteria which can cause PID?

A
  1. Chlamydia trachomatis
  2. Neisseria gonorrhoea
  3. Streptococcus
  4. Bacteriodes
  5. Anaerobes
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32
Q

What are 7 risk factors for pelvic inflammatory disease?

A
  1. Sexually active
  2. Aged 15-24
  3. Recent partner change
  4. Intercourse without barrier contraceptive protection
  5. History of STIs
  6. Person history of PID
  7. Instrumentation of the cervix
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33
Q

How can instrumentation of the cervix lead to PID? What are 3 examples of instrumentation of the cervix?

A

Inadvertently introducing bacteria into female reproductive tract

  1. Gynaecological surgery
  2. Termination of pregnancy
  3. Insertion of intrauterine contraceptive device
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34
Q

What are 6 possible symptoms of PID? What are 3 further symptoms in advanced cases?

A
  1. Lower abdominal pain
  2. Deep dyspareunia
  3. Menstrual abnormalities e.g. menorhagia, dysmenorrhoea, IMB
  4. Post-coital bleeding
  5. Dysuria
  6. Abnormal vaginal discharge (especially if purulent or with unpleasant odour)

If advanced:

  1. Severe lower abdominal pain
  2. Fever >38oC
  3. Nausea and vomiting
35
Q

What are 4 possible features on vaginal examination in PID?

A
  1. Tenderness of uterus/ adnexae
  2. Cervical excitation (on bimanual palpation)
  3. Palpable mass in lower abdomen
  4. Abnormal vaginal discharge
36
Q

What are 4 possible differentials for pelvic inflammatory disease?

A
  1. Ectopic pregnancy
  2. Ruptured ovarian cyst
  3. Endometriosis
  4. UTI
37
Q

What are 7 possible investigations for suspected PID?

A
  1. Endocervical swabs: for gonorrhoea and chlamydia
  2. High vaginal swab: trichomonas vaginalis and bacterial vaginosis
  3. Full STI screen - HIV, syphilis, gonorrhoea, chlamydia = minimum
  4. Urine dispstick ± MSU (UTI)
  5. Pregnancy test
  6. Transvaginal ultrasound scan - if diagnostic uncertainty or severe
  7. Laparoscopy - severe/uncertainty
38
Q

How is testing from endocervical and high vaginal swabs performed in the UK and what should be remembered about this technique?

A

Testing is via nucleic acid amplification (NAAT)

negative swabs do not exclude the diagnosis

39
Q

What 4 STIs should be screened for when investigating suspected PID as a minimum?

A
  1. Chlamydia
  2. Gonorrhoea
  3. HIV
  4. Syphilis
40
Q

When might you consider performing transvaginal ultrasound scan for suspected PID?

A

If there is severe disease or diagnostic uncertainty

41
Q

What is the difference between double and triple swabs?

A
  • Double swabs: endocervcial NAAT swab and high vaginal charcoal media swab
  • Triple swabs: endocervical NAAT swab, high vaginal charcoal media swab, endocervical charcoal media swab
42
Q

What 2 infections can the endocervical NAAT be used to detect?

A

chlamydia and gonorrhoea

43
Q

What can the endocervical charcoal media swab be used to detect?

A

gonorrhoea

44
Q

What 4 infections can the high vaginal charcoal media swab be used to detect?

A
  1. Trichomonas vaginalis
  2. Bacterial vaginosis
  3. Group B streptoccocus
  4. Candida
45
Q

What is laparoscopy used for in suspected PID and when should it be used?

A
  • used to observe gross inflammatory changes and to obtain peritoneal biopsy
  • indicated only in severe cases where there is diagnostic uncertainty
46
Q

What is the mainstay in the management of pelvic inflammatory disease?

A

Antibiotic therapy - 14 day course broad spectrum with good anaerobic coverage

47
Q

What kind of antibiotics are used to treat PID?

A
  • broad spectrum antibiotics with good anaerobic coverage for 14 days
  • Options include:
    • doxycycline, ceftriaxone and metronidazole
    • Ofloxacin and metronidazole
48
Q

When should antibiotics be started for PID?

A

Commence immediately, before result of swabs available

49
Q

In addition to antibiotic management, what are 4 other aspects of management of PID?

A
  1. Anagesics e.g. paracetmol
  2. Rest and avoid sexual intercourse until abx course completed and partner(s) treated
  3. All sexual partners from past 6 months should be tested and treated to prevent recurrence and spread
  4. Sometimes admitted to hospital
50
Q

What are 5 situations when someone with PID should be admitted to hospital?

A
  1. Pregnant and especially if risk of ectopic
  2. Severe symptoms: nausea, vomiting, high fever
  3. Signs of pelvic peritonitis
  4. Unresponsive to oral antibiotics, need for IV therapy
  5. Need for emergency surgery or suspicion of alternative diagnosis
51
Q

What 2 things increase the risk of complications of PID?

A
  1. Repeated episodes of pelvic inflammatory disease (recurrent PID)
  2. Delaying treatment
52
Q

What are 5 possible complications of PID?

A
  1. Ectopic pregnancy
  2. Infertility
  3. Tubo-ovarian abscess
  4. Chronic pelvic pain
  5. Fitz-Hugh Curtis syndrome
53
Q

Why can ectopic pregnancy occur as a complication of PID?

A

due to narrowing and scarring of Fallopian tubes

54
Q

What proportion of women with PID suffer from infertility?

A

1 in 10

55
Q

What is Fitz-Hugh Curtis syndrome?

A

complication of PID; perihepatitis that typically causes right upper quadrant pain

56
Q

What are 3 aspects of counselling to consider for a patient being treated for PID?

A
  1. Offer advice regarding practice of safer sex and consistent use of condoms
  2. Regular STI screening should be encouraged
  3. Inform about potential long-term sequelae of PID
57
Q

What is endometriosis?

A

chronic condition in which endometrial tissue is located at sites other than the uterine cavity

58
Q

What are 7 examples of places where endometrial tissue can be located in endometriosis?

A
  1. Ovaries
  2. Pouch of Douglas
  3. Uterosacral ligaments
  4. Pelvic peritoneum
  5. Bladder
  6. Umbilicus
  7. Lungs
59
Q

In which age group of women is a diagnosis of endometriosis most common?

A

between ages 25 to 40

60
Q

What location of endometrial tissue outside of the endometrium gives it a different name, other than endometriosis?

A

Endometrial tissue in uterine muscle (myometrium) - adenomyosis

61
Q

What is thought to be a potential cause of endometriosis in pathophysiological terms?

A

Retrograde menstruation: endometrial cells travel backwards from uterine cavity, through fallopian tubes, and deposit on pelvic organs where they can seed and grow

these cells may be able to travel to disant sites through lymphatic system and vasculature

62
Q

What is the symptomatology of endometriosis dependent on and why?

A

Dependent on individual’s menstrual cycle - because endometrial tissue is sensitive to oestrogen

Will have bleeding from ectopic tissue during menstruation, resulting in pain and bloating/ distension at ectopic sites

63
Q

What can bleeding from endometriosis sites lead to in the long term?

A

Repeated inflammation and scarring can occur, leading to adhesions

64
Q

What are 2 situations when symptoms of endometriosis will be reduced?

A
  1. Pregnancy
  2. Menopause
65
Q

What are 6 risk factors for endometriosis?

A
  1. Early menarche
  2. Family history of endometriosis
  3. Short menstrual cycles
  4. Long duration of menstrual bleeding
  5. Heavy menstrual bleeding
  6. Defects in the uterus or fallopian tubes
66
Q

What are 8 symptoms of endometriosis?

A
  1. Cyclical pelvic pain - occurs at time of menstruation/ immediately before
  2. Constant pelvic pain - if adhesions have formed
  3. Dysmenorrhoea
  4. Dyspareunia
  5. Dysuria
  6. Dyschezia (difficult, painful defecating)
  7. Subfertility
  8. Focal symptoms of bleeding if endometriosis at distant sites
67
Q

What is 1 example of a feature of endometrial tissue at a distant site?

A

haemothorax - if ectopic tissue in lungs

68
Q

What are 3 possible findings on bimanual examination of endometriosis?

A
  1. Fixed, retroverted uterus
  2. Uterosacral ligament nodules
  3. General tenderness
69
Q

What are 4 differentials to rule out when diagnosing endometriosis?

A
  1. Pelvic inflammatory disease
  2. Ectopic pregnancy
  3. Fibroids
  4. Irritable bowel syndrome
70
Q

What is the gold standard investigation of endometriosis?

A

Laparoscopy

71
Q

Why is laparoscopy particularly useful in suspected endometriosis and what are 3 possible findings?

A

Useful at differentiating between endometriosis and pelvic inflammatory disease

  1. Chocolate cysts
  2. Adhesions
  3. Peritoneal deposits
72
Q

What is chocolate cyst?

A
  • Dark brown ovarian cyst - fluid filled, have their colour due to bleeding into them
  • (aka endometriomas)
73
Q

In addition to laparoscopy, what is another investigation that can be performed in suspected endometriosis?

A

Pelvic ultrasound scan

74
Q

What is the purpose of performing a pelvic ultrasound scan in endometriosis?

A

Can determine severity of endometriosis and should be performed before any surgery

75
Q

What are 2 things that a skilled operator may be able to demonstrate on pelvic ultrasound in endometriosis?

A
  1. Kissing ovaries: bilateral endometrioma adherent together
  2. Pelvic mobility can be demonstrated, including any bowel involvement
76
Q

What is the treatment in endometriosis based upon?

A

individual requirements of each patient; if asymptomatic, no treatment neeed

77
Q

What are 3 aspects of management of endometriosis?

A
  1. Pain treatment
  2. Ovulation suppression
  3. Surgery
78
Q

What type of pain management may be used for endometriosis?

A

Analgesia or NSAIDs; follow analgesic ladder

79
Q

Why might you aim to achieve ovulation suppression in endometriosis?

A

can cause atrophy of endometriosis lesions and therefore reduction in symptoms

80
Q

How long is ovulation suppressed in endometriosis?

A

6-12 months

81
Q

What are 4 types of hormone thearpy that can be used to achieve ovulation suppression in endometriosis?

A
  1. COCP - low dose
  2. Norethisterone - synthetic progesterone
  3. Injected hormones
  4. Intrauterine devices e.g. Mirena
82
Q

What are 4 types of surgery which can be used to manage endometriosis?

A
  1. Excision
  2. Fulgaration - diathermy
  3. Laser ablation
  4. Hysterectomy and removal of ovaries with hormone replacement until menopausal
83
Q

What is a limitation of surgical management of endometriosis such as ablation, fulgaration, excision?

A

relapses will almost certainly occur, surgery may have to be repeated

84
Q

What may end up being the ultimate management of endometriosis?

A

hysterectomy with removal of ovaries and hormone replacement until menopausal age

OBG: Functional Gynaecology (7 decks)

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