Gynae disorders Flashcards
What is menorrhagia?
Heavy menstrual bleeding (HMB)
Excessive menstrual loss over several consecutive cycles which interferes with a woman’s physical, emotional, social & material QoL.
- In research: objectively measured loss of 60-80mls or more per menstruation (average is 30-40mls and 90% women have losses <80mls).
- 1/3 women describe periods as heavy, 1/20 age 30-49 consult GP for heavy periods, 12% of all gynaecological consultations.
Causes of menorrhagia?
What to ask in history?
- Dysfunctional uterine bleeding: 40-60% of cases (i.e. no underlying cause)
- Pelvic pathology (fibroids, endometrial polyps, endometriosis, PID, PCOS)
- Systemic diseases (coagulation disorders e.g. von Willebrands, hypothyroidism)
- Iatrogenic (anticoagulant treatment, IUCD)
History
• Age at menarche
• Number of days of menstruation / length of cycle
• How long she considers periods to be heavy
• What they were like previously
• Impact on life
• Inter-menstrual or post-coital bleeding
• Smear status
• Contraceptive use
• ALSO: consider underlying thyroid or coagulation disorder
What are symptoms suggestive of underlying pathology in menorrhagia?
- Persistent post-coital bleeding
- Persistent inter-menstrual bleeding
- Dyspareunia
- Dysmenorrhoea
- Pelvic pain +/- pressure symptoms
- Vaginal discharge
Examination and investigations in menorrhagia?
Examination:
• Abdominal: fibroids palpable abdominally?
• Pelvic: Speculum (+/- swabs / smear test). Bimanual palpation: (? uterine/adnexal enlargement or tenderness)
• Systemic signs: Anaemia, Endocrine (hirsutism, striae, thyroid enlargement, skin pigmentation)
• Coagulation disorders: bruises or petechiae
Investigations: FBC, thyroid function (if symptoms/signs suggestive), coagulation screen (if history/signs suggestive of bleeding disorder), TVUSS (if uterus palpable abdominally, if pelvic mass of uncertain origin, if has had treatment that has been ineffective).
Tx of menorrhagia? (in primary care)
1st line:
- Levonorgestrel-releasing intrauterine system (LNG-IUS) - provides long-term contraception
2nd line:
- Tranexamic Acid (anti-fibrinolytic, taken only during menstruation, >50% reduction of menstrual loss- superior to NSAIDs in controlling loss but not pain).
- Side-effects (few): GIT & CNS disturbances. Avoid if risks of thrombosis.
- NSAIDs (inhibits PG synthesis): Mefanamic acid, Naproxen, Ibuprofen (only during menstruation or just prior, improves dysmenorrhoea & dyspareunia).
- Few side effects: GIT & CNS disturbances. Contraindicated in dyspepsia, asthma, renal disorders
- COCP (Cycle regulation, reduction of flow + dysmenorrhoea - contraceptive but more reversible than LNG-IUS)
3rd line
- Oral Noristhisterone (Synthetic progestogen, taken during follicular + luteal phase (day 5-26) - may inhibit ovulation but NOT contraception
- Long-acting progestogens: depot medroxyprogesterone (Depot-Provera), IM injection every 12 weeks
If initial treatment ineffective, switch to an alternative treatment, add on additional drug e.g. tranexamic acid + NSAID / NSAID + COCP. –> Refer to secondary care.
Management of menorrhagia in secondary care (include investigations)?
- Endometrial biopsy (exclude endometrial cancer or atypical hyperplasia) - If persistent inter-menstrual bleeding, aged 45 years+, treatment ineffective
- Hysteroscopy (direct visualisation of the uterine cavity. opportunity to take biopsy, when ultrasound inconclusive)
- GnRH analogues: profound hypogonadal effect through down regulation resulting in no ovulation and no menses- significant adverse effects: perimenopausal (hot flushes, sweating, vaginal dryness)
Surgical treatments
- Endometrial resection (systematic removal of entire uterine lining including basal endometrium, together with underlying muscle to ensure known depth of tissue & muscle removed (not burned)
- Endometrial ablation (destroys endometrium and superficial myometrium, pregnancy after contraindicated but is not a contraception)
- Hysterectomy (Laparoscopic, vaginal, abdominal)
What types of pelvic pain are there?
Cyclical
o Gynae: endometriosis, adenomyosis, PID, primary dysmenorrhoea
o GI: IBS
Non-cyclical
o Gynae: PID, adhesions, hydrosalpinges, tumours
o GI: IBS
o Urological: recurrent UTI, interstitial cystitis
o Neurological: nerve injury / entrapment
o Musculoskeletal: myofascial pain
Four Ds: dyspareunia, dysmenorrhoea, dyschesia, dysuria
How to investigate pelvic pain?
Most common gynae referral (20% of all gynae consultations).
History: chronicity, dysmenorrhoea, dyspareunia, dyschesia, associated bloating / constipation / diarrhoea / nausea, recent weight change, recent appetite change
Exam: abdominal masses + trigger points, bimanual: size & mobility of uterus, uterosacral ligaments (palpable? nodules?), adnexal masses
Investigations:
• Triple swabs
• MSU
• Pelvic USS (If abnormal findings on examination, if 1st treatment unsuccessful) -NB normal USS does not exclude pathology
What is endometriosis?
How common?
Risk Factors?
Eutopic endometrium (glands + stroma) present outside the uterus: induces a chronic, inflammatory reaction. • Ovaries • Utero-sacral ligaments • Pouch of Douglas • Broad ligament • Rarely: lung, nasal septum, CNS
Very common: 2-10% in menstruating women (1.5 million), 50% in women with subfertility & 35% in teenagers.
Risk factors: low birth weight, early menarche, short menstrual cycle, late menopause, genetics, red meat, obesity.
Protective factors: fruit + veg, multiple pregnancy, omega 3 & prolonged breastfeeding
What may cause endometriosis?
Multiple theories: retrograde menstruation, hereditary, genetic, environmental, coelomic metaplasia of multipotent cells, spread through blood vessels / lymphatics, altered immune function, direct transfer: C-section, or combination. Predominantly oestrogen dependent.
How may endometriosis present (3 main types)
Types of presentation:
- ovarian lesion
- superficial peritoneal lesion (powder burn or gun shot lesion)
- deep infiltration endometriosis (solid endometriosis mass situated >5mm deep under the peritoneal surface)
Staged I to IV, mainly for fertility (not helpful for all patients).
Symptoms of endometriosis?
May be asymptomatic!
Pain: o Cyclical (both pain & GIT symptoms) o Dysmenorrhoea o Deep dyspareunia o Chronic pelvic pain o Dyschesia o Ovulation pain
- Infertility / subfertility
- Urinary: dysuria, urgency, haematuria
- Chronic fatigue
How is endometriosis assessed / diagnosed?
Include differentials?
Pelvic examination: ? reduced organ mobility, tender nodularity in posterior vaginal fornix & visible vaginal endometriotic lesions
Diagnosis
Gold standard: laparoscopy + histological verification: aim to treat at same time. (means earlier Dx + Tx, but still delays as women told symptoms were normal, hormonal drugs provided temporary relief, inadequate tests applied, overlap with IBS, PID + laparoscopy is invasive)
- Laparoscopy for pelvic pain: 38-45% endometriosis 25-40% normal 5-15% PID 4-13% post-op adhesions 5-8% uterine malformations 2-5% ovarian cyst
- TVUSS: ovarian endometriosis (endometrioma – ground glass appearance) + rectal endometriosis: little role for this in primary care, should be referred for definitive diagnosis if symptoms are significant.
- MRI / CT
Differentials: adenomyosis, leiomyomata, PID, uterine myoma / large polyp, ovarian cyst, IBD, interstitial cystitis
Treatment of endometriosis?
- Simple analgesia: NSAIDs + paracetamol
- Hormonal (empirical therapy is acceptable for short duration): Progestogens, COCP, Mirena: LNG-IUS reduces blood flow + dysmenorrhoea, supports retrograde theory
GnRH agonists +/- add back HRT (if given continuously, acts like a GnRH antagonist causing ↓GnRH receptors on pituitary and ↓FSH/LH/oestrogen > inhibition of endometrial cell proliferation, if given in pulsatile manner will increase these hormones – used in infertility)
Cochrane: all hormonal treatments of equal efficacy for symptom control + all usually cause disease regression but all are contraceptive therefore no role if desiring pregnancy + recurs after treatment is stopped in majority of cases
- Conservative surgical (aim to destroy all visible endometriosis)
o Diathermy / ablation
o Excision
o Laser (e.g. lasering cysts may improve fertility) - Radical surgical
o Remove uterus, ovaries & nodules
Surgery improves fertility in minimal-mild endometriosis & improves pain in women with endometriosis. Excision preferred to ablation as disease deep.
Involve other specialities (e.g. colorectal, pain team, support groups). Severe disease refer to tertiary level service unless locally available.
Complications: infertility, adhesions (inflammation or post-surgery), post-surgical ovarian failure, increased risk of autoimmune diseases and mental health conditions
What is Asherman Syndrome?
Tx?
Irreversible damage of single layer thick basal endometrium does not allow normal regeneration of endometrium. Endometrial cavity undergoes fibrosis & adhesion formation. Results in reduced or absent menstrual shedding: can occur with curettage of uterine cavity during evacuation of RPOC (miscarriage / secondary PPH). In this ‘soft’ uterine state myometrium (including basal layer) can be inadvertently excavated. The same principle is deliberate in endometrial destruction (surgical treatment for menorrhagia where diathermy loop or ball (1st generation) and ablative methods (2nd generation – hot water balloon, bipolar diathermy, laser, microwave) are used to destroy the basal layer. TB & schistosomiasis can also cause Asherman syndrome.
Mainstay of treatment is preventative but hysteroscopic techniques may be used to manually break down or lyse the adhesions.
