gynae - Bleeding Flashcards
what is a follicular cyst - physiological
- commonest type of ovarian cyst
- non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- regress after several menstrual cycles
what is a Corpus luteum cyst
- In absence of pregnancy corpus luteum usually breaks down
- If not, the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
- presents with intraperitoneal bleeding
what is a dermoid cyst
- Lined with epithelial tissue and hence may contain skin appendages, hair and teeth
- most common benign ovarian tumour
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
- benign epithelial tumour
- typically large and may become massive
- pseudomyxoma peritonei if rupture
Risk factors for endometrial cancer
obesity nulliparity early menarche late menopause unopposed oestrogen diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
Common features of endometrial cancer
post menopausal bleeding
change in bleeding pre-menopausally
uterine mass/fixed uterus
Investigation for post menopausal bleeding
Pelvic USS endometrial biopsy hysteroscopy Smear FBC: anaemia
Differentials for post-menopausal bleeding
Endometrial hyperplasia
endometrial polyp
endometriosis
cervical cancer
Management endometrial cancer
- hysterectomy
- +/- vaginal brachytherapy
what might you see in a transvaginal USS in endometrial cancer
- thickened endometrium
- <4mm is a good negative predictive factor value
In which part of the fallopian tube is an ectopic pregnancy most likely to RUPTURE
isthmus
where is an ectopic pregnancy most likely to occur
- 97% tubual - ampulla
- 3% ovaries, cervix or peritoneum
What is endometriosis
The endometrium is tissue that lines the inside of the uterine cavity. In endometriosis, this type of tissue is found outside the womb in the pelvic and tummy area
Symptoms of endometriosis
- menorrhagia - cyclically
- Deep, chronic pelvic pain
- dyspareunia
- sub-fertility
- fixed retroverted uterus
- depression is common
Investigations of endometriosis
- transvaginal USS
- gold standard is laparoscopy
Differentials for endometriosis
- PID
- IBS
- Ovarian cyst/cancer
- interstitial cystitis
Management of endometriosis if contraception is required
- Mirena coil
- COCP
- NSAIDs
Management of endometriosis if no contraception is required
- clomifene: controlled ovarian hyperstimulation
- therapeutic laparoscopy
- Mefanamic/tranexamic acid
Surgical management of endometriosis
- can only do surgical options when family has been completed
- adhesiolysis
- bilateral oophorectomy + Hysterectomy
Causes of Mennorrhagia
- endometriosis
- PCOS
- Fibroids (leiomyotoma)
- Miscarraige
- salpingitis/endometritis - PID
- Dysfunctional uterine bleeding
- bleeding disorder
- anticoagulation treatment
- hypothyroidism
- IUD
- (malignancies)
Causes of dysmenorrhoea
- primary dysmenorrhoea
- PID
- endometriosis
- adenomyosis
- Fibroids/polyps
- Ovarian cyst with haemorrhage
- ovarian torsion
- IUD
What are uterine fibroids - patient
A non cancerous overgrowth of smooth muscle cells in the womb that vary in size
What are the associations with fibroids
- more common in Afro-Caribbean women
* rare before puberty, develop in response to oestrogen, don’t tend to progress following menopause
What are the key featurse of fibroids
- may be asymptomatic
- menorrhagia
- lower abdominal pain: cramping pains, often during menstruation
- bloating
- urinary symptoms, e.g. frequency, may occur with larger fibroids
- subfertility
How ar fibroids diagnosed
trans-vaginal ultrasounds
What is the most common type of fibroid
intra-mural: grow within the muscle tissue of the womb
What are the problems with fibroids in pregnancy
- Increased risk of implantation probolems
- pain or discomfort if they grow too large for it’s blood supply/it twists
- increased need for c section
- Breech/footling lay
- preterm delivery
What causes fibroids
we aren’t entirely sure, however we do know that their growth is affected by hormones so tend to swell during periods of high hormones such as pregnancy.
When do fibroids normally begin to shrink
after menopause
Management of fibroids
- observation
- medication to improve symptoms or shrink fibroid
- surgery
What medications improve the symptoms of fibroids
- Tranexamic acid
- NSAIDs
- COCP
- IUS - mirena coil
What medications shrink fibroids
gonadotrophin-releasing hormone (GnRH) analogue: decreases oestrogen levels i the body
What is the downside of GnRH analogues
Essential put you through the menopause so can experience hot flushes, mood changes, osteoporosis etc.
NB. given for a maximum of 6 months
Surgical management of fibroids
- hysterectomy
- myomectomy
- uterine artery embolism
- myolysis - shrinkage of fibroid e.g. endometrial abltion
What red degeneration
- haemorrhage infarct of the fibroid.
- Often occurs during pregnancy
- Presents with abdominal pain, low grade fever and often vomiting.
- Management is conservative.
Differential diagnoses for inter-menstrual bleeding
Cervical ectropion / polyp / cancer
Sexually transmitted infection
Endometrial polyp / cancer
Iatrogenic contraception related bleed
Differential diagnoses for post-coital bleeding
Often no cause is found Cervical ectropion Cervical inflammation secondary to infection (e.g. Chlamydia) Cervical cancer Atrophic vaginitis Polyps Other cancers (e.g. vaginal or endometrial) Trauma
what investigations should you complete in woman with menorrhagia
- Pelvic exam
- Transvaginal pelvic US
Indications for transvaginal pelvic US in woman with menorrhagia
Abnormal pelvic examination
Postcoital bleeding
Intermenstrual bleeding
Other abnormal pelvic symptoms (i.e. pelvic pain)
What is the management of menorrhagia in woman who do not want contraception
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding) Mefanamic acid (NSAID – reduces bleeding and pain)
What is the management of menorrhagia in woman who do want contraception
- Mirena coil
- Combined pill
- Progesterone pills (e.g. norethisterone)
- Long acting progesterone (e.g. depo injection)
- endometrial ablation and hysterectomy.
What are the complications of Fibroids
- Complications in pregnancy relating to the space they occupy (e.g. premature labour, blocking vaginal delivery, miscarriages).
- Infertility
- Heavy bleeding (leading to anaemia)
- Constipation
- Urinary outflow obstruction / urinary tract infections
- Red degeneration AKA corneous degeneration
What is a cervical ectropion
- Columnar epithelium of the endocervix is displayed on the ectocervix and is visible on speculum
- caused by increased oestrogen levels
- can cause discharge or post-coital bleeding.
How is a cervical ectropion managed
Treatment in symptomatic cases is with silver nitrate or diathermy.
What is the transformation zone
the border between the columnar epithelium of the endocervix (the canal) and the stratified squamous epithelium of the ectocervix (the area visible on speculum examination).
What is Ashermans syndrome
- adhesions (sometimes called synechiae) form within the uterus
- Excessive scraping of the endometrium can damage the bottom layer of the endometrium.
- This then heals abnormally creating scar tissue connections between areas that are not normally connected (for example one side of the uterus to the other).
What is the result of Asherman;s Syndrome
- menstruation abnormalities (amenorrhea, dysmenorrhea)
- infertility
- recurrent miscarriages.
How do you diagnose Asherman’s Syndrome
- Sonohysterography (pelvic ultrasound after the uterus is filled with fluid)
- Hysteroscopy is the gold standard investigation.
How do you treat Asherman’s Syndromw
Adhesions can also be dissected during hysteroscopy.
What is the presentation of ovarian cysts
- Mostly asymptomatic, often found incidentally
- Pelvic pain
- Bloating
- Fullness in the abdomen
- Very large cysts (such as Mucinous Cystadenomas) can be felt as a pelvic mass.
What are the complications of ovarian cysts
Torsion
Haemorrhage cyst – bleeding into the cyst causing increased pain
Rupture – bleeding into the peritoneum
