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Gynae > General gynaecologist problems > Flashcards

General gynaecologist problems Flashcards

1
Q

What is Endometriosis?

A
  • Presence of endometrial-like tissue outside the uterus
  • Causes a chronic, inflammatory reaction
  • Common (10-12%); predominantly in women of reproductive age – esp. nulliparous
  • Oestrogen dependent – cyclic symptoms
  • Adenomyosis = endometrial tissue within myometrium
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2
Q

What are Endometriomas?

A

• large, ovarian endometriotic cysts (endometriomas)
o Endometriomas – benign cysts form when endometrial tissue grow on the ovaries
o Typical endometriomas is that they are usually filled with a thick fluid of degenerated blood products = “chocolate cyst”
o Unlike functional ovarian cysts that arise as part of a woman’s normal monthly ovulatory cycle, endometriomas usually do not resolve on their own and therefore may require some form of medical or surgical intervention at some point

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3
Q

What does Endometriosis commonly affect?

A

• Pelvic organs and peritoneum most commonly affected
- Peritoneum
- Pouch of Douglas (POD) = recto-uterine pouch
- Ovary/tubes
- Ligaments
- Bladder
- Myometrium (adenomyosis)
• Extent: a few small lesions on otherwise normal pelvic organs, to large, ovarian endometriotic cysts (endometriomas)
o Endometriomas – benign cysts form when endometrial tissue grow on the ovaries
o Typical endometriomas is that they are usually filled with a thick fluid of degenerated blood products = “chocolate cyst”
o Unlike functional ovarian cysts that arise as part of a woman’s normal monthly ovulatory cycle, endometriomas usually do not resolve on their own and therefore may require some form of medical or surgical intervention at some point
• Extensive fibrosis and adhesion formation = marked distortion of pelvic anatomy
• Typically appears as superficial “powder-burn” or “gunshot” lesions, nodules or small cysts containing old haemorrhage

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4
Q

What are the clinical features of Endometriosis?

A

Symptoms:
• Dysmenorrhoea/cyclic pelvic pain
• Classic pain before, worse during, better after menses
• Deep dyspareunia
• Dyschezia (pain on defecation)
• Ovulation pain
• Urinary Sx
• Rectal/anal Sx
• Chronic pelvic pain
• Cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain
• Caesarean section/TOP history
• Chronic fatigue
Each of these symptoms can have other causes
A significant proportion of affected women are asymptomatic

Signs:
•	Tenderness
•	Endometriomas
•	Fixed retoverted uterus (adhesions)
•	Infertility (inflammation/adhesions)

On examination – most reliably detected when examination performed during menstruation
• Abdo: NAD
• Vulva/Vagina (v/v): NAD
• Cervix (Cx): NAD
• Uterus: fixed, retroverted (some people have this anyway as an anatomical variant), tender ++
• Retroverted uterus – tipped backwards, so it aims towards rectum instead of front of belly
• Adnexae: bilat tenderness ++
• Tender uterosacral ligaments
• Enlarged endometriosis
• More certain if:
• Deeply infiltrating nodules are palpated on uterosacral ligaments or in the pouch of Douglas and/or visible lesions are seen in the vagina/on cervix

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5
Q

What are the differentials of Endometriosis?

A

Establishing diagnosis on basis of symptoms alone can be difficult because the presentation is so variable and there is a considerable overlap with other conditions:

  • Adenomyosis
  • Chronic pelvic inflammatory disease
  • Chronic pelvic pain
  • Other causes of pelvic masses
  • IBS
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6
Q

What are the investigations for Endometriosis?

A
  • Visualisation of pelvis at laparoscopy + biopsy = “gold standard”
  • Transvaginal USS – to exclude endometrioma
  • MRI – for andenomyosis + peritoneal endometriosis (+ IVP)
  • CA-125 levels may be elevated in endometriosis, but has no value as a diagnostic tool
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7
Q

What is the treatment for Endometriosis?

A

Medical
• Analgesics – NSAIDs (symptom relief)
• Ovarian suppression (as endometriosis is oestrogen dependent) using either:
• COCP
• Progestogens
• Mirena IUS (endometrial +/- ovarian supp) – reduces pain
• GnRH analogues + HRT
• Danazol/gestrinone (androgens) – rarely used nowadays

Surgical
• Laparoscopic ablation of endometriotic spots – scissors, laser, or bipolar diathermy
• Laparoscopic resection of active lesions/scar tissue
• Dissection of adhesions + removal of endometriomas
• Endometrioma cyst  drain + either strip with forceps/ablate
• Laparoscopic cystectomy/oophorectomy
• Hysterectomy + BSO – concerns re age and will need HRT

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8
Q

What is Acute Pelvic inflammatory disease?

A

Infections of organs of a woman’s reproductive system/ upper genital tract.
• Most common presenting complaint is sudden onset, acute constant lower abdominal or pelvic pain in association with fever in a sexually active woman
• Usually associated with STI and is treated with antibiotics
• 5% gynaecological referrals
• “A diagnosis of PID should be considered, and usually empirical antibiotic treatment offered, in any sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified.
• The risk of PID is highest in women aged under 25 not using barrier contraception and with a history of a new sexual partner.”

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9
Q

What are the causes of Acute Pelvic inflammatory disease?

A

• Usually affects young, poor, sexually active, nulliparous women, with multiple partners, not using contraception
• Most commonly caused by ascending infection from the endocervix (typically STI, but non-STI if complication of childbirth/miscarriage), may also occur from descending infection from organs such as appendix
• Also can be caused by instrumentation (e.g. coil insertion)
• Can cause –
- endometritis
- salpingitis
- parametritis (connective tissue around uterus)
- oophoritis (rare)
- tubo-ovarian abcess
- and/or pelvic peritonitis
• Almost never occurs in presence of a viable pregnancy!!!

Infection – frequently polymicrobial (green = always screened for)
• Chlamydia trachomatis - up to 60% (usually asymptomatic + Sx due to secondary infection)
• Neisseria gonorrhoeae 10-15% (acute presentation)
• Mycoplasma genitalium 15%
• Bacterial vaginosis-associated organisms (anaerobes)
• Other organisms (eg streptococci, staphylococci, haemophilis, enterics, E coli)
• Mycobacterium tuberculosis
Always treat as an STI

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10
Q

What are the clinical features of Acute Pelvic inflammatory disease?

A

Signs and symptoms – NB 60% asymptomatic = no Hx and present later with subfertility/menstrual problems
Symptoms – recent onset (usually <30 days)…
• Bilateral lower abdominal pain with deep dyspareunia = hallmark
• Abnormal vaginal bleeding (inc. IMB, PCB and menorrhagia) or discharge (often purulent)
• Secondary dysmenorrhoea
Signs
• If severe – tachycardia + high fever + signs of lower abdominal peritonism
• On bimanual – bilateral adnexal tenderness, cervical excitation (pain on moving cervix) + a mass (pelvic abscess)

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11
Q

What are the complications of Acute Pelvic inflammatory disease?

A

• Abscess (e.g. tubo-ovarian) or pyosalpinx
- Systemically unwell, palpable mass, lack of Rx response
- A large pelvic abscess that ruptures may be life-threatening
• Tubal obstruction or damage (12%)
• Subfertility
- 10% 1 episode, 20% 2 episodes, 40% 3 episodes
- Multiple episodes of PID or delayed treatment increase the risk of infertility. Don’t delay starting treatment
• Chronic dyspareunia and pelvic pain (18%)
• Chronic pelvic infection
• Ectopic pregnancy – 6x more likely
• Peri-hepatitis (Fitz Hugh Curtis syndrome)
- Especially related to Chlamydia. In women <30y, RUQ pain is highly suggestive of perihepatitis rather than cholecystitis
 Overall, 25% of women with one episode of PID suffer subsequent pain, infertility or ectopic pregnancy

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12
Q

What do you tell patients with Acute Pelvic inflammatory disease?

A

• PID is the name given to inflammation of a woman’s reproductive organs: the womb (or uterus), fallopian tubes, ovaries and surrounding tissues
• In many women, PID is caused by an STI
• It is easy to treat, but untreated PID can cause serious problems
• Most women with PID can go on to become pregnant
NO SEX until they and their partner have completed treatment!!!!!!!
What are the investigations for Acute Pelvic inflammatory disease?
1. Pregnancy test – excludes ectopic pregnancy (unilateral pain)
2. NAAT from vulvovaginal swab for chlamydia, gonorrhoea and tirchomonas
3. Endocervical swabs for Chlamydia + gonorrhoea culture
4. Urine dipstick + MSU
5. Temperature – blood cultures if fever
6. Bloods for HIV + syphilis
7. Bloods – WCC (raised), CRP (raised), LFTs,
8. Specialist centre : microscopy for bacterial vaginosis, endocervical pus
Could consider:
9. Pelvic USS – excludes abscess/ovarian cyst (unilateral pain)
10. Laparoscopy + fimbrial biopsy and culture = ‘gold standard’ but not commonly performed

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13
Q

What is the treatment for Acute Pelvic inflammatory disease?

A

• Rest in severe disease. IV fluids if shocked
• Analgesia + Abx (outpatient):
Give effective treatment to cover chlamydia, gonorrhea, anaerobes and any other possible vaginal bacteria
• Parenteral cephalosporin: ceftriaxone 500 mg IM (with 1g PO azithromycin if chlamydia implicated), followed by
• Doxycycline 100mg bd PO 14 days PLUS
• Metronidazole 400mg bd PO 7-14 days
(or ofloxacin + metronidazole)
What covers what? cef – gonorrhoea, dox – chlamydia, met – anaerobes
If febrile = admit for IV therapy
NB This does not cover mycoplasma genitalium, which requires moxifloxacin
*Review at 24 hours if no improvement + perform laparoscopy
• Pelvic abscess (may not respond to Abx) = drainage under US-guidance/laparoscopy
• No sex until both they and their partner(s) have completed treatment and follow up (V. IMP FOR OSCE!!!)

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14
Q

What are the differentials of Acute Pelvic inflammatory disease?

A

Appendicitis, diverticulitis, UTI, IBS, ectopic pregnancy, endometriosis, ovarian cyst complications, ovarian torsion/rupture, functional pain (e.g. ovulation)

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15
Q

What is Chronic Pelvic inflammatory disease?

A
  • Persisting infection – result of non-Rx or inadequate Rx of acute PID
  • Dense pelvic adhesions + fallopian tubes may be obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx)
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16
Q

What are the clinical features of Chronic Pelvic inflammatory disease?

A

chronic pelvic pain/dysmenorrhea, deep dyspareunia, heavy + irregular menstruation, chronic vaginal discharge and subfertility
similar to endometriosis: abdominal + adnexal tenderness and fixed, retroverted uterus

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17
Q

What are the investigations for Chronic Pelvic inflammatory disease?

A

transvaginal US (fluid collections within fallopian tubes/surrounding adhesions), laparascopy (BEST DIAGNOSTIC TOOL), culture often –ve

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18
Q

What is the treatment for Chronic Pelvic inflammatory disease?

A

analgesics, Abx if infection evidence; if severe = adhesionolysis or sometimes salpingectomy

19
Q

What is chronic pelvic pain “Functional pain”?

A
  • Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
  • DIAGNOSIS OF EXCLUSION (Sx, not a diagnosis)
  • Chronic pelvic pain presents in primary care as frequently as migraine or low back pain  affects 15% of adult women
20
Q

What are the causes of Acute pelvic pain?

A

Gynaecological

  • PID – e.g. salpingitis (more common post menses)
  • Ectopic pregnancy – always do pregnancy test if any doubt re/ contraception; pain may be diffuse
  • Ovarian cyst accident – gradual onset, exclusively unilateral dyspareunia and palpation pain
  • Primary dysmenorrhea and Mittelschmerz
Non-gynaecological
-	GI 
•	Appendicitis – N&amp;V, no relation to menses
•	IBS/IBD
•	Strangulated hernia
-	Urological 
•	UTI (may be indistinguishable from PID)
•	Calculi
21
Q

What are the causes of chronic pelvic pain?

A 
Gynaecological
-	Endometriosis/adenomyosis – pain that varies considerably over the menstrual cycle (hormonally driven) 
-	Malignancy – esp. if post-menopausal (no oestrogen-related conditions)
-	Pelvic adhesions (e.g. chronic PID)
-	Fibroids
-	Cervical stenosis
-	Asherman’s syndrome
-	Dysmenorrhoea = common
•	1° = No cause
•	2° = underlying cause

Non-gynaecological
- GI
• Constipation – colicky pain, exacerbated by stress, L sided/posterior fornix
• IBS* (pain/cramps worse with food and better with defecation, bloating, diarrhoea, constipation)/IBD
• Hernias
- Urological
• Interstitial cystitis*
• Calculi
• Bladder pain syndrome – a chronic bladder health issue assoc. with pain and pressure in the bladder area
- Musculoskeletal
• Fibromyalgia – widespread pain especially in the shoulders, neck, and pelvic girdle. Characterized by tender points and a reduced pain threshold. Often shows cyclical exacerbations
- Psychological
• Depression
• Sleep disorders
• Hx of childhood and/or ongoing sexual/physical abuse
- Neurological

• Nerve entrapments – trapped in fascia/narrow foramen or in scar tissue after surgery; classically results in pain and/or dysfunction in nerve distribution
• Neuropathic pain – results from actual damage to the nerve (surgery, infection, or inflammation); classically described as shooting, stabbing, or burning
Other theories: ‘pelvic congestion syndrome’ – pelvic venous congestion said to cause chronic pain and ‘myofascial syndrome’ (pain originates in muscle trigger points or trapped nerves)

22
Q

What are the investigations for chronic pelvic pain?

A

• Principles:
o Many women want an explanation for their pain
 They may have a theory or a concern about the origin of the pain: this should be discussed in the initial consultation
o Allow enough time for history – address psychological/social issues
 Often more than one component: physical (gynaecological and non-gynaecological), psychological, social factors
 Discuss + explore multifactorial nature from the start
o May be associated with a Hx of sexual/physical abuse
o Just because no cause is found, doesn’t mean it does not exist
• History:
o Questions about pattern of pain and association with other problems: e.g. psychological, bladder, bowel symptoms, effect of movement and posture on the pain
o RED FLAGS – exclude Ca (weight loss, IMB/PCB, systemic Sx etc)
o Pain diary for 2-3 menstrual cycles
• Examination and Investigations: (as appropriate)
o Samples to screen for infection (chlamydia, gonorrhoea) if any suspicion of PID
o May have mild tachycardia and fever  HR and temperature
o Transvaginal USS
o MRI
o Laparoscopy

*Women often have symptoms of irritable bowel syndrome or interstitial cystitis
• May be a primary cause or a component of chronic pelvic pain

23
Q

What is the treatment for chronic pelvic pain?

A
  • Appropriate analgesia – inc. amitriptyline or gabapentin
  • If Sx suggestive of IBS = dietary change + trial of antispasmodics
  • If cyclical pain = therapeutic trial of COCP or GnRH analogue + add-back HRT for 3-6mths
  • Also consider progestogen IUS
  • If pain unresolved after above = diagnostic laparoscopy (50% -ve, consider implications)
  • Counselling and psychotherapy
  • Referral to pain clinic or pain management programmes (relaxation therapy, sex therapy, diet and exercise)
  • If infection detected = antibiotics
  • If the history suggests to the patient and the doctor that there is a non-gynaecological component to the pain = referral to the relevant healthcare professional
24
Q

What are Fibroids?

A

Benign Tumour. Non-cancerous growths that develop in or around the womb (uterus), the growths are made of muscles and fibrous tissue
• =lieomyomata
• Benign tumours of the myometrium
• Present in 25% of women
• More common approaching the menopause, in Afro-Caribbean women and those with a family history
• Less common in parous women (women who have children) and those who have taken the combine oral contraceptive pill/injectable progestogens

25
Q

What is the pathology/aetiology Fibroids?

A

Pathology
• Few millimetres to massive tumours filling the abdomen
• Fibroid may be intramural, subserosal or submucosal, and pedunculated
• Submucosal fibroids occasionally form intracavity polyps
• Smooth muscle and fibrous elements are present
• Fibroid has a “whorled” appearance in transverse section

Aetiology
• Fibroid growth is oestrogen- and probably progesterone-dependent
• Growth increases in pregnancy and with combined contraceptives
• Regresses after menopause

26
Q

What are the clinical features of Fibroids?

A

History:
• 50% asymptomatic, discovered only at pelvic or abdominal examination
• Symptoms are related more to the site that the size
• Menstrual problems
o Menorrhagia in 30%
o Timing of menses usually unchanged
o Intermenstrual loss may occur if fibroid is submucosal or polypoid
o Fibroids are common in the perimenopausal woman, and may be incidental:
 Menstrual problems may also be the result of hormonal irregularities or malignancy
• Pain:
o Fibroids can cause dysmenorrhoea
o They seldom cause pain, unless torsion, red degeneration or sarcomatous change occur
• Other symptoms:
o Large fibroids pressing on the bladder can cause frequency and occasionally urinary retention
o Those pressing on the ureters can cause hydronephrosis
o Other pressure effects may also be felt
o Fertility can be impaired if the tubal ostia are blocked, or submucous fibroids prevent implantation
Examination:
• A solid mass may be palpable on pelvic or even abdominal examination
• It will arise from the pelvis and be continuous with the uterus
• Multiple small fibroids cause irregular “knobble” enlargement of the uterus

27
Q

What are the investigations for Fibroids?

A

• To establish diagnosis:
o USS is helpful
o Laparoscopy may be required to distinguish the fibroid from the ovarian mass
o Hysteroscopy is used to assess distortion of the uterine cavity]
• To establish fitness
o Hb concentration may be low as a result of vaginal bleeding

28
Q

What is the treatment for Fibroids?

A

• Asymptomatic patients with small or slow growing fibroids need no treatment
• Risk of malignancy is small enough not to warrant routine removal
• Larger fibroids that are not removed should be serially measured by examination or USS because of the remote possibility of malignancy
• Is the fibroid malignant? Uncommon but more likely if…
o Pain and rapid growth
o Growth in postmenopausal woman not on HRT
o Poor response to GnRH agonists

• Medical treatment
o Tranexamic acid, NSAIDs or progestogens
o Often ineffective when menorrhagia is due to fibroids
o GnRH agonists cause temporary amenorrhoea and fibroid shrinking by inducing a temporary menopausal state
 Side effects, bone density loss max 9 months
 Usually near menopause/to make surgery easier
 Concomitant HRT may prevent effects without causing enlargements, allowing longer administration
• Surgical treatment
o Hysteroscopic:
 Resection of fibroid polyp or small submucous fibroid that is causing menstrual problems or subfertility
o Radical
 Hysterectomy
 Fibroids account for the reason for 20% of hysterectomies
 Myomectomy: removal from uterus. Blood loss may be heavy and small fibroids can be missed
- May be performed if medical treatment has failed but preservation of reproductive function is needed
 3 months GnRH analogue treatment first
o Embolization
 Uterine artery embolization by radiologists
 80% success rate, but pain symptoms may worsen
 Alternative to hysterectomy

29
Q

What is the Natural history/complications of fibroids?

A

• Enlargement
o Can be very slow
o Fibroids stop growing and often calcify after the menopause, although oestrogen in HRT may stimulate further growth
o In mid-pregnancy they enlarge
o Pedunculated fibroids occasionally undergo torsion, causing pain
• Degenerations
o Normally the result of an inadequate blood supply
o “Red degeneration” characterized by pain and uterine tenderness
o Haemorrhage and necrosis occur
o In “hyaline degeneration” and “cystic degeneration”, the fibroid is soft and partly liquefied
• Malignancy

30
Q

What is the relationship between Fibroids and pregnancy?

A
  • Premature labour, malpresentations, transverse lie, obstructed labour and postpartum haemorrhage can occur
  • Red degeneration is very common in pregnancy and can cause severe pain. Rapid outgrowth of fibroid can outgrow the blood supply. As well as, changing in shape and distribution of blood vessels leads to necrosis and infarction.
  • Fibroids should not be removed at Caesarean section as bleeding can be heavy
  • Pedunculated fibroids may tort postpartum
31
Q

What is the relationship between Hormone replacement therapy (HRT) and fibroids?

A
  • HRT can cause continued fibroid growth after menopause

* Treatment is as for premenopausal women or the HRT is withdrawn

32
Q

What are Ovarian Cysts?

A
  • Ovarian cysts – fluid filled sac that develops in ovaries and may cause no symptoms.
    The overwhelming majority of adnexal masses are benign, regardless of patient age:
    BUT: all women with a solid ovarian neoplasm should have an laparoscopic excision
    And the CA-125 tumour marker should not be used to determine the need for surgery
33
Q

What are Benign Ovarian Cysts?

A

The sonographic appearance of irregular borders, ascites, papillations, or septations within an ovarian cyst should increase concern about malignancy

34
Q

What are Functional cysts?

A

Benign
o Cysts that develop and develop as part of the menstrual cycle. Most common type.
o Most common clinically detectable enlargements of the ovary occurring during the reproductive years.
o 2 types - Persistently enlarged follicles (follicular) or corpus luteum (lutein) – so only found in premenopausal women
o COCP protects against functional cysts as it inhibits ovulation
o They may be large simple cysts or hemorrhagic corpus luteum cysts. The majority will spontaneously resolve in 4-6 weeks
o Lutein cysts tend to cause more Sx
• 2. Pathological ovarian cysts (COMPLEX) – cysts that form as a result of abnormal cell growth these are much less common; see below

35
Q

What are Dermoids?

A

Germ cell tumours
• Dermoids (benign cystic teratomas)
• Represent 25% of all ovarian neoplasms. Common – especially in young premenopausal women
• They vary in size from a few millimeters to 25cm in diameter and are bilateral in 10-15% of cases.
• They are usually complex cystic structures that contain elements from all 3 germ cell layers (endoderm, mesoderm, ectoderm)
• Originate from primordial germ cells
• Rupture very painful
• Malignant = dysgerminoma (causes Gonadotropin release and positive PT) – most common malignancy in younger woman

36
Q

What are cystadenomas?

A

Epithelial tumours/cysts
• Serous cystadenomas
• Are common uni or multilocular cysts (10-20% are bilateral)
• Malignant version is most common ovarian malignancy
• Mucinous cystadenomas
• Are multilocular, lobulated and smooth surfaced
• Bilateral lesions are rare.
• These lesions may become huge, occasionally weighing >50kg.
• Rarely malignant

37
Q

What are Ovarian endometriomas?

A
  • “chocolate cysts”
  • Are cystic areas of endometriosis that are usually bilateral and may reach 15-20cm in size.
  • On bimanual examination, the adnexae are often tender and immobile due to associated inflammation and adhesions. Endometriomas are homogenous complex masses that can be more clearly diagnosed with pelvic MRI
38
Q

What are Granulosa cell tumours?

A

Hormone secreting tumours
• Hormone secreting tumours oestrogen and inhibin (so stimulates endometrium)
 Bleeding, endometrial hyperplasia, endometrial malignancy, and rarely, precocious pubery
• Normally malignant

39
Q

What is Thecoma?

A

Hormone secreting tumours
• oestrogen and progesterone
• Rare and benign
• Raised hCG

40
Q

What is a Fibroma?

A

Hormone secreting tumours
• Rare and benign
• Meig’s syndrome – ascites/hydrothorax (pleural effusion)/hydropericardium with ovarian mass
• also seen with fibroadenomas, Brenner tumour or granulosa cell tumour

41
Q

What are the clinical features of Ovarian Cysts?

A
  • Abdominal distension – if >14cm
  • Pressure on rectum, bladder or lymphatics
  • Constipation
  • Urinary retention/frequency
  • Back pain
  • Pain – often due to complications – Torsion, rupture, haemorrhage
  • Torsion = severe pain, vomiting and peritonism
  • Haemorrhage = acute severe pain and peritonism, shock
  • Rupture = acute severe pain, peritonism, shock
  • Hormonal symptoms – menstruation changes – rare
  • Weight loss – exclude malignancy
  • Ascites – dullness to percussion/shifting dullness if ascites
  • Freely mobile mass indicates benign
42
Q

What are the investigations for Ovarian Cysts?

A
  • Bloods – FBC, CRP, serum B-HCG
  • Pregnancy test – negative
  • Urinalysis
  • HVS/endocervical swab
  • Diagnosis = USS pelvis (vaginal may be required if small) – shows if simple (filled with fluid) or complex (filled with blood/hard substances)
  • Ca-125 – premenopausal women cyst >5cm AND persisting for >6 weeks, post-menopausal women in any csyst >5 cm OR persisting for > 6 weeks
  • CXR/IV urogram/CT if malignancy suspected
43
Q

What is the treatment for Adnexal Mass (mass in adnexa of uterus) in Premenopausal Women?

A
  • Size <10 cm, simple cyst, unilateral, no ascites, normal Ca-125 = expectant management (+ analgesia)
  • <50mm: generally do not require follow-up; likely to resolve within 3 menstrual cycles
  • 50-70mm: yearly US follow-up (larger simple cysts = consider MRI/surgical intervention)
  • If mass disappears or becomes smaller – continue expectant management
  • Mass persists in size or increases in size (unlikely to be a functional cyst) OR if size >10cm, solid, complex, symptomatic, fixed, bilateral, ascites present
  • Immediate laparoscopic exploration and removal
  • In children and younger women (wishing to preserve maximum fertility), cystectomy may be preferable to oophorectomy
44
Q

What is the treatment for Adnexal Mass (mass in adnexa of uterus) in Postmenopausal Women?

A

In postmenopausal women:
• Simple cysts will be followed expectantly unless they are symptomatic
o Many will resolve over time
• All complex masses should be considered potentially malignant and surgically excised (laparoscopic)

Gynae (6 decks)

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