Gynae - Menstrual conditions Flashcards
What is PCOS?
common endocrine disorder characterised by excess androgen production and presence of multiple immature, follicles (cysts) within the ovaries
What is the pathophysiology of PCOS?
hormonal imbalance - excess androgens
insulin resistance - suppressing SHBG
increased androgen circulation + inhibiting ovulation
what are some risk factors of developing PCOS?
- diabetes
- irregular menstruation
- family history of PCOS
how might PCOS present?
- oligomenorrhoea
- infertility
- hirsutism & acne
- obesity
- chronic pelvic pain
- depression
what are some clinical signs you may notice in PCOS?
O/E → acne, hirsutism, acanthosis nigricans, male pattern hair loss, obesity and hypertension
What are some differentials for PCOS?
hypothyroidism
hyperprolactinaemia
cushings
how is PCOS diagnosed?
Rotterdam criteria - 2/3
- oligo or anovulation
- clinical or biochemical signs of hypernandrogenism
- polycystic ovaries on imaging
what investigations are carried out for PCOS?
pelvic USS - ovarian cysts
FSH, LH, TSH, SHBG, TSH, testosterone, prolactin
oral glucose tolerance
how is PCOS managed?
COCP, dydrogesterone for endometrial protection
weight reduction
clomifene + metformin to induce ovulation for infertility
anti-androgens for hirsutism -> eflornithine
Acne mx
What are fibroids and what types are there?
🩸 benign smooth muscle tumours of the uterus
- most common benign tumours in women - 20-40% incidence
- leimyoma
types - intramural, submucosal, subserosal
what are some risk factors for fibroids?
obesity
early menarche
increasing age
family history
ethnicity - Americans
how might fibroids present, when they are symptomatic?
pressure sx - urinary frequency, retention
abdo distention
menorrhagia
sub-fertility
acute pelvic pain
what might you feel on examination of fibroids?
- solid mass or enlarged uterus may be palpable on abdominal or bimanual examination
- uterus is usually non-tender
- mobile
what are some differentials for fibroids?
endometrial polyps
ovarian tumours
leiomyosarcoma
adenomyosis
how might you investigate a fibroid?
- pelvic ultrasound
- MRI - if sarcoma suspected
- bloods if diagnosis uncertain, pre-op surgery ix
how might you manage fibroids?
medication - tranexemic acid, COCP, GnRH analogue Zolidex, ulipristal to reduce size
surgical - hysteroscopy and transcervical resection, myomectomy, uterine artery embolisation , hysterectomy
what are some complications of fibroids?
iron deficiency anaemia
compression of pelvic organs - recurrent UTI, incontinence, hydronephrosis, retention
sub fertility or infertility
degeneration
torsion
what is endometriosis?
chronic condition where endometrial tissue is located at sites other than the uterine cavity - 2 million in UK suffer, 25 to 40 year olds
what is the pathophysiology of endometriosis?
retrograde menstruation - endometrial cells travel backwards from uterine cavity, through fallopian tubes and deposit on pelvic organs
symptoms arise due to the ectopic tissue and their response to oestrogen
repeated inflammation + scarring → adhesions
where is the ectopic endometrial tissue commonly found?
ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs
what are some risk factors of developing endometriosis?
- early menarche
- family history
- short menstrual cycles
- long duration of menstrual bleeds
- heavy menstrual bleeds
- uterus or fallopian defects
what is the presentation of endometriosis?
- cyclical pelvic pain
- constant painmay suggest adhesions
- dysmenorrhoea, deep dyspreunia, dysuria, dyschezia, subfertility
- focal sx of bleeding → haemothorax at time of menstruation
what would the bimanual examination show for endometriosis?
- fixed, retroverted uterus
- tenderness in posterior fornix
- uterosacral ligament nodules
- general tenderness
- enlarged, tender, boggy uterus = adenomyosis
what are the differential diagnosis for endometriosis?
PID
ectopic pregnancy
fibroids
IBS
how would endometriosis be investigated?
gold - laparoscopy shows chocolate cysts, adhesions, peritoneal deposit s
pelvis USS - kissing ovaries
how is endometriosis managed?
pain - NSAIDs
ovulation - suppress for 6-12m with COCP, norethisterone, mirena coil
surgery - excision, fulguration and laser ablation to remove ectopic tissue, hysterectomy
what are the differences between cervical and endometrial polyps?
cervical - benign growths protruding from the inner surface of the cervix
endometrial - small soft growths on the endometrium of uterus
what is the pathophysiology of cervical polyps?
- focal hyperplasia of thecolumnar epitheliumof the endocervix
- chronic inflammation, abnormal response to oestrogen, localised congestion of cervical vasculature
what is the pathophysiology of endometrial polyps?
overgrowth of tissue lining, no cause known
what are some risk factors for endometrial polyps?
endometrial - obesity, tamoxifen use, hypertension, cervical polyps
what is the presentation of cervical polyps?
asymptomatic
abnormal vaginal bleeding
increased vaginal discharge
cervix blocked and may cause infertility
o/e - polyphoid growths progesting though external os
what is the presentation of endometrial polyps?
- asymptomatic
- irregular menstrual bleeding
- intermenstrual menstrual periods
- menorrhagia
- post-menopausal bleeds
- infertility
what are the investigations done for cervical polyps?
- histological examination after removal
- triple swabs - if infection suspected, endocervical + high vaginal + vulvovaginal
- cervical smear - rule out neoplasia (CIN)
- USS of endometrial cavity if sx persists
what investigations are done for endometrial polyps?
- pelvic exam - seen if protruding through cervix
- pap smear
- USS
- hysteosalpingogram
- dilation and curretage for biopsy
- hysteroscopy
how is cervical polyps managed?
- small - polypectomy with forceps in primary care setting + silver nitrate cautery
- large - diathermy loop excision in colposcopy clinic, or under GA
*<0.5% malignancy transformation risk
what is the management of endometrial polyps?
- watch & wait - polyps small and not sx
- medication - shrink polyp
- removal - during hysteroscopy, curettage
- hysterectomy?
what are some complications of endometrial polyp removal?
- infection
- haemorrhage
- uterine perforation
what is the physiology of the endometrial response to the menstrual cycle?
🩸 lining of uterus which changes during menstrual cycle in response to oestrogen release
- after ovulation, progesterone levels increase and prepares uterus for implantation
- with the lack of this progesterone levels drop and the endometrial lining is shed → menstruation
what is the pathophysiology of endometrial hyperplasia?
- imbalance of hormones cause endometrial thickening and overgrowth
- too much oestrogen etc
- two types based on cell kind
- simple (without atypia) - consists of normal cells, not cancerous
- complex atypical endometrial hyperplasia - pre-cancerous and results form overgrowth of abnormal cells
what are some risk factors for endometrial hyperplasia?
- menopause transition
- family history of colon, ovarian and uterine cancer
- diabetes
- nullparity
- PCOS
- smoking
- hormone therapy
- early menarche and late menopause
what is the presentation of endometrial hyperplasia?
- heavy menstrual bleeding
- post-menopausal bleeds
- menstrual cycles shorter than 21 days
how is endometrial hyperplasia investigated?
- hormonal bloods
- USS - transvaginal USS to see thickness of lining
- biopsy - of uterus lining
- hysteroscopy - abnormalities
- dilation and curettage
how is endometrial hyperplasia managed?
- progestin - orally, via injection, vaginal, IUD
- for atleast 6m
- stops further proliferation, prepares for shedding, opposes oestrogen
- hysterectomy if atypical endometrial hyperplasia, no improvement after 12m, relapse, bleeding not stopping
