General Gynaecology GTG - PMS, Ovarian masses, chronic pelvic pain Flashcards
PMS Pre and post menopausal cyst Chronic pelvic pain
When do core menstrual disorders present?
Luteal phase and abate with menstration.
What are the 5 subgroups of core menstrual disorders?
1) Pre-menstrual exacerbation of underlying disorder
2) Core menstral disorders
3) Progesterone induced PMS
4) PMD without menstruation
To be considered core pre-menstrual disorder instead of PMS, what must the patient describe?
Severe symptoms, affect daily function, interfere with work/school/interpersonal relationships
How many experience PMS?
4/10
How to Dx PMD?
Symptom diary over 2 diaries, GnRH analogues can be considered for definitive Dx if diary inconclusive
What are the 1st line Tx for PMD?
Exercise,
CBT,
Vitamin B6
Continuous or luteal SSRI (Day 15-28), low dose citalopram/esocitalopram 10mg
COCP (with drospirenon and short hormone free interval) cyclical or continuous
What are the 2nd line treatments offered for PMD?
Estradiol patches (100micrograms) + microginosed progesterone (100mg or 200mg OD (D17-28) or LNG-IUS 52mg (20mcg/day)
High dose citalopram/esocitalopram 20mg - continuous or D15-28
What are the 3rd line treatments offered for PMD?
GnRH analogues + add back therapy
(50-100 microginosed estradiol patch or 2-4 doses of estradiol gel combined) with microginosed progesterone 100mg/day (urtogestan) or tibalone 2.5mg
What are 4th line treatments for PMD?
Surgical TX and HRT
Which COCP should be used to treat PMS?
Drosprirenone containing COCs
Why should micronised progesterone be used? What other route can it be given?
Less likely to reintroduce PMS like symptoms.
Vaginally
What level is a normal CA125?
<35
What ovarian cancers will it be raised in? Which will it not be raised in/
Raised epithelial ovarian cancer
Not primary mucinpous
PM cyst <5cm - how many will
1) Disappear
2) Static
3) Enlarge
Disappear 52%
Static 28%
Enlarge 11%
How to calculated RMI score?
USS 1 point for each:
Multilocular, solid area, mets, ascites & BL lesions
U=0 (0 points, U=1 (1point) U= 3 (2-5 points)
Menopause status
Premenopause = 1
Post menopause = 3
CA125
RMI U x M X Ca125
Sensitivity and specificity off RMI score?
78% sensitive
87% specific
What RMI score cut off is used for low risk/high risk malignancy?
200
For low risk women, RMI < 200, when would you consider BSO?
Cysts with any of the features
- Symptomatic
- Non simple features
- >5cm
- Multilocular
- Bilateral
For low risk women, RMI < 200, and no concerning features, when would you offer repeat assessment? What tests would you perform?
After 4-6 months
- CA125
- TVUS/TAUS
At the follow up at 4-6 months, what you do if
1) Resolved
2) Persistent unchanged
3) Change in featues
1) Discharge
2) Repeat assessment 4-6 months
3) Consider intervention
If not resolved after 1 year can either discharge or intervene, decision individualised
If RMI > 200 what tests should be requested?
CT abdomen
Refer Gynae MDT
If MDT think high risk of ovarian malignancy?
Full staging procedure by trained gynae oncologist
If MDT think low risk gynae malignancy?
TAH + BSO + omentectomy + peritoneal cytology by suitably trained gynaecologist
If RMI < 200, what % of cysts will resolve by 3 months?
50%
If cystectomy is required in PM women, what surgery should be performed?
Lap (if possible) BSO
Remove through umbilical port without spill
What is the sensitivity and specificity of the IOTA rules?
Sensitivity 98%
Specificity 91%
What are the B rules?
- Unilocular
- Solid component <7mm
- Acoustic shadowing
- Smooth multilocular cyst <100mm diameter
- No blood flow on doppler
What are the M rules
- Irregular solid tumour
- Ascites
- 4+ papillary structures
- Irregular multilocular cyst >100mm
- Prominent blood flow on doppler
What % of women will have surgery in their life for ovarian mass?
10%
List 5 types of benign ovarian cyst
Functional
Endometrioma
Serous cyst adenoma
Mucinous Cystadenoma
Mature teratoma
List benign non ovarian adnexal mass
Paratubal cyst
Hydrosalpinges
TOA
Peritoneal pseudocyst
Appendices abscess
Diverticular abscess
Pelvic kidney
List malignant ovarian mass
Germ cell tumour
Epithelial carcinoma
Sex-cord tumour
In Germ cell tumour, what tumour markers are raised?
A-FP
bhCG
LDH
Should CA125 be measure to assess ovarian mass in premenopausal women
No, raised in multiple conditions
Only raised 50% epithelial ovarian carcinoma
Premenopausal cyst <50mm
No follow up
Premenopausal cyst 50-70
yearly FU - USS
Premenopausal cyst >70mm
Consider MRI or surgical intervention
Always aim laparoscopic if possible
Endometriomas over what size should be biopsied/removed?
> 30mm, rule out rare cases of malignancy
How common is chronic pelvic pain?
1 in 6
What is definition of chronic pelvic pain?
Intermittent or constant pain for at least 6 months, not exclusively with menstruation/intercourse
What criteria is used to Dx IBS?
ROME III criteria
What does the ROME criteria ask?
Continuous or recurrent abdo pain/discomfort on at least 3 days/month with onset >6months with at least 2
- Improvement on defecation
- Change in frequency of stool
- Change in form of stool
Incidence of nerve entrapment after 1 pfannestiel incision?
3.7%
Sharp stabbing pain, exacerbated by particular movements
When should CA125 for screening
> 50yrs
Bloating, early satiety, pelvic pain, urinary urgency/frequency, new IBS
Tx for IBS
Antispasmodics - mebeverine hydrochloride
