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2 - Y5 O&G > Gynae presentations - 2) Menorrhagia/HMB > Flashcards

Gynae presentations - 2) Menorrhagia/HMB Flashcards

1
Q

Define HMB/menorrhagia

A
  • Blood loss >80ml/period;
  • in practice it is diagnosed based on patient’s perception of blood loss, sanitary products used, and effect on QoL
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2
Q

What are the causes of menorrhagia (HMB)?

A

Structural: PALM

  • Polyps - endometrial
  • Adenomyosis
  • Fibroids (Leiomyoma)
  • Malignancies:
    • Endometrial cancer - younger patients
    • Cervical cancer

Hormonal:

  • Dysfunctional uterine bleeding

Infection:

  • Pelvic inflammatory disease

Systemic:

  • Thyroid disease
  • Haemostatic disorders
  • Anticoagulant therapy
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3
Q

What does PID and malignancies (cervical, endometrial & ovarian) usually present with alongside menorrhagia (HMB)?

A

Irregular bleeding

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4
Q

What are fibroids?

A

Benign tumours of uterine smooth muscle (leiomyomas)

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5
Q

How are fibroids classified/

A

According to location wrt to uterine wall:

  • Intramural (most common): confined to myometrium
  • Submucosal: underneath the endometrium; protrudes into uterine cavity
  • Subserosal: protrudes into serosal (outer) surface of the uterus
    • May be pedunculated
  • Cervical: located within the cervix
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6
Q

What is the aetiology of fibroids?

A

They are oestrogen-dependent benign tumours

  • Enlarge during pregnancy and in response to the hyperoestrogenic state, and shrink after menopause when oestrogen production ceases
  • Exact cause is unknown

They undergo degenerative change, usually when they outgrow their blood supply

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7
Q

What are the types of degenerative change that fibroids can undergo?

A
  • There are 3 forms of degeneration:
    • Red: haemorrhage and necrosis occurs within the fibroid, often in pregnancy
    • Hyaline: asymptomatic softening and liquefaction of the fibroid
    • Cystic: asymptomatic central necrosis leaving cystic spaces at the centre
      • Degenerative changes can initiate calcium deposition → calcification
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8
Q

RFs for fibroids?

A
  • obesity,
  • early menarche,
  • age in 40s,
  • FHx,
  • African-American
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9
Q

Symptoms of fibroids?

A
  • Vast majority are small and asymptomatic
  • Menorrhagia
    • Usually due to submucosal fibroids
  • Dysmenorrhoea
  • Pelvic mass, pressure, abdominal distension/bloating
    • Fibroids are usually multiple and can substantially increase the size of the uterus
    • May have bulk effects on adjacent structures:
      • Subfertility (mechanical distortion of uterine tubes/uterine cavity)
      • Urinary symptoms, constipation
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10
Q

Signs of fibroids O/E?

A
  • Abdo: palpable mass in pelvis
  • Bimanual: enlarged, firm, non-tender uterus
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11
Q

Ix for fibroids?

A
  • FBC (if HMB)
  • TAUSS (pelvic)
    • Mainstay of diagnosis
    • TAUSS detects larger intramural and subserosal fibroids
  • TVUSS
    • Mainstay of diagnosis
    • TVUSS detects submucosal and small intramural fibroids
  • Hysteroscopy
    • Can detect submucosal fibroids
    • Used to plan subsequent treatment or for actual treatment
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12
Q

What is the Mx of fibroids, if fertility is wished to be preserved?

A

Choice of Tx is determined by the PC and patient’s wishes for menstrual function and fertility

  • 1<u>st</u> line: Medical therapies (3-6 months)
    • GnRH agonists e.g., leuprorelin
      • Induces low oestrogen (menopausal) state → amenorrhoea → fibroid shrinkage
      • Only used prior to surgery (myomectomy/hysterectomy)
    • Antiprogesteronese.g., mifepristone
      • Shrinks fibroid
      • SEs: vasomotor symptoms, risk of endometrial hyperplasia
    • IUDe.g., Levonorgestrel
      • 1st line for fibroids <3mm + no uterine distortion
    • NSAIDs
      • Reduces HMB, also treats dysmenorrhoea and pelvic pain
    • Tranexamic acid
      • Reduces HMB & cause necrosis of fibroids
  • 1<u>st</u> line: Surgery
    • Myomectomy
      • Can be laparoscopic/abdo/hysteroscopic
      • But hysteroscopic → increased recurrence of fibroids, especially when multiple
      • ST risks: infection, bleeding, other organ injury, emergency hysterectomy due to bleeding
      • LT risks: uterine rupture during subsequent pregnancies, recurrence of fibroids
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13
Q

What is the Mx of fibroids, if fertility is not wished to be preserved?

A

Choice of Tx is determined by the PC and patient’s wishes for menstrual function and fertility

Fertility not preserved; uterus preserved

  • 1<u>st</u> line: Surgery
    • Myomectomy
  • OR 1<u>st</u> line: Uterine artery embolisation
    • Uterine artery embolisation
      • Embolisation of both uterine arteries under radiological guidance guidance → reduced blood supply to uterus → infarction and degradation of fibroids (50% reduction in size)
      • Minimally invasive; avoids GA and surgery
      • Reduces fertility but doesn’t eradicate risk
      • ST risks: infection, bleeding, allergic reaction to contrast dye, PAIN, femoral artery puncture site haematoma, incomplete procedure, embolisation of other organs’ blood supply
      • LT risks: vaginal discharge, expulsion of fibroid material, infection, may cause premature ovarian failure and infertility, 1/3 women need subsequent treatment within 5yrs
  • PLUS, Pre-op adjunct medical therapies (see above)

Fertility not preserved; uterus not preserved

  • 1<u>st</u> line: Surgery
    • Hysterectomy
      • May be laparoscopic/abdo/vaginal
      • ST/LT risks: damage to urinary tract/bowel/vagina, risk of vaginal vault prolapse
  • OR 1<u>st</u> line: Uterine artery embolisation
    • Uterine artery embolisation
  • PLUS, Pre-op adjunct medical therapies (see above)
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14
Q

What are the complications of fibroids?

A
  • Recurrent growth
  • Complications of treatment (e.g., infertility, infection)
  • Malignant/sarcomatous transformation
    • 1 in 350
    • Suspect in postmenopausal period or when size rapidly increases
  • Obstetric complications:
    • Subfertility due to distortion of uterine tubes/cavity (removal can enhance fertility)
    • Risk of miscarriage is not increased once pregnancy is established
    • May enlarge in pregnancy → abnormal lie, obstruct vaginal delivery
    • Red degeneration → may precipitate uterine contractions if severe
    • PPH (due to inefficient uterine contraction)
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15
Q

What is the prognosis of fibroids?

A
  • Treatment is usually effective but may recur (unless hysterectomy)
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16
Q

What is an endometrial polyp?

A

An abnormal, benign, growth of issue which projects from a mucous membrane

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17
Q

Aetiology of endometrial polyp?

A
  • Benign tumours that grow into the uterine cavity; usually endometrial but may be from submucosal glands

Aetiology is unknown

  • Associated with high oestrogen, chronic inflammation, and atherosclerotic blood vessels
  • Do not respond to normal hormonal changes (like normal endometrium) → unscheduled vaginal bleeding
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18
Q

RFs and protective factors for endometrial polyps?

A

RFs:

  • high oestrogen (e.g., obesity, PCOS, nulliparity, HRT, tamoxifen, late menopause) (causes endometrial proliferation, myometrial growth & motility, etc.)
  • HTN

Protective factors:

  • any method that increases progesterone levels (e.g. IUS) (prevents endometrial proliferation, etc.)
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19
Q

What is adenomyosis

A
  • Disorder in which endometrial glands and stroma are present within the myometrium (uterine musculature),
  • → hypertrophy of the surrounding myometrium
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20
Q

Epidemiology of adenomyosis?

A

20-35% of women

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21
Q

RFs for adenomyosis?

A
  • parity (previous pregnancy)
  • endometriosis & fibroids
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22
Q

Sx of adenomyosis?

A
  • ⅓ are asymptomatic
  • HMB/menorrhagia
    • due to increased endometrial surface of the enlarged uterus
  • dysmenorrhea
    • due to bleeding and swelling of endometrial islands confined by myometrium
  • ~ chronic pelvic pain
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23
Q

What is seen O/E in adenomyosis?

A
24
Q

Epidemiology of endometrial polyps?

A

Common in women aged 40-50yo

25
Q

Symptoms of endometrial polyps?

A
  • Often asymptomatic
  • Endometrial:
    • Intermenstrual bleeding (usually spotting)
    • Irregular menstrual bleeding,
    • HMB
    • Vaginal discharge (white/yellow mucus)
26
Q

What is seen O/E in endometrial polyps?

A
  • Usually unremarkable
  • ~ Endometrial may prolapse through the cervix → may look like cervical polyp
27
Q

Ix for ?endometrial polyp?

A
  • Speculum examination
    • usually unremarkable
    • ~ Endometrial may prolapse through the cervix → may look like cervical polyp
  • TVUSS
    • Endometrial: endometrial thickening, hypoechoic protrusion from the endometrium
      • May use hysterosonography (saline injected into uterus) → clearer view during USS
  • Hysteroscopy
    • Visualisation of polyp
  • Histological examination of polyp after removal
28
Q

Mx of endometrial polyp?

A

Symptomatic women:

  • Polypectomy
    • Endometrial: polypectomy via hysteroscope; outpatient procedure +/- local anaesthesia
    • Histological examination to exclude malignany
  • Medical management:
    • Can control bleeding with tranexamic acid, NSAIDs, COCP etc.

Asymptomatic premenopausal women:

  • Management is based on risk of endometrial cancer
    • If high risk or subfertile → polypectomy

Asymptomatic postmenopausal women:

  • Polypectomy (as higher risk of endometrial cancer than premenopausal)
29
Q

Complications and prognosis of endometrial polyp?

A

Complications:

  • Subfertility (may block cervical canal, prevent implantation if multiple)
  • Recurrence (10%)
  • 1% risk malignant transformation (endometrial/cervical cancer)
  • Complications of polypectomy: bleeding, infection, uterine perforation (rare)
    • Do not attempt to remove polyps that are not easily visible without Ix (i.e. from cervical canal)

Excellent prognosis after removal

30
Q

What is endometrial cancer?

A

Carcinoma of the endometrium of the uterus

31
Q

What are the types of endometrial cancer?

A
  • adenocarcinoma - 90%
  • serous carcinoma,
  • mucinous carcinoma,
  • clear-cell carcinoma
  • mixed
32
Q

What is the aetiology of endometrial cancer (adenocarinoma)?

A
  • Chronic oestrogen exposure unopposed by progesterone
  • → endometrial hyperplasia (proliferation of endometrial glands)
  • → further stimulation predisposes to abnormalities of cellular/glandular architecture
  • → Endometrial hyperplasia with atypia (premalignant disease)
  • → 25-50% risk of progression to endometrial cancer
  • ~ → tumour spreads directly though myometrium to cervix and upper vagina
  • ~ → lymphatic spread to pelvic/para-aortic nodes
33
Q

How is endometrial hyperplasia seen histologically?

A

greater gland-to-stroma ratio than normal

34
Q

What are the RFs for endometrial cancer?

A
  • unopposed oestrogen:
    • Endogenous oestrogen:
      • early menarche,
      • late menopause,
      • nulliparity,
      • PCOS (chronic anovulation),
      • obesity,
      • ovarian tumours (granulosa/theca cell)
    • Exogenous oestrogen:
      • oestrogen-only HRT,
      • tamoxifen (oestrogen antagonist in breast but agonist in uterus)
  • FHx endometrial/ ovarian/breast/colon cancer (Lynch syndrome)
35
Q

What are the protective factors for endometrial cancer?

A
  • cyclical or continuous progesterone e.g.,
    • COCP
    • POP
  • pregnancy,
  • hysterectomy (women with Lynch syndrome offered prophylactic hysterectomy)
36
Q

What staging system is used for endometrial cancer?

A

FIGO staging

37
Q

Describe each of the stages of endometrial cancer

A

Stages 1-4

  • Stage 1: lesions confined to uterus (75% patients present with stage 1)
    • 1A: < 50% myometrial invasion
    • 1B: > 50% myometrial invasion
  • Stage 2: cervical invasion (but does not extend beyond uterus)
  • Stage 3: local or regional spread
    • 3A: invades serosa of uterus or adnexae
    • 3B: invades vagina and/or parametrium
    • 3Ci: pelvic node involvement
    • 3Cii: para-aortic node involvement
  • Stage 4: further spread
    • 4A: bowel or bladder
    • 4B: distant metastases
38
Q

What is the grading of each stage of endometrial cancer?

A
  • Grades 1-3 is also included for each stage,
    • G1 being well-differentiated
    • G3 being mostly abnormal cells
39
Q

What is the epidemiology of endometrial cancer?

A
  • Most common gynae cancer; lifetime risk 1%
  • Peak prevalence at 60yo; uncommon <40yo
40
Q

What are the symptoms of endometrial cancer?

A

Pre-menopausal:

  • irregular/intermenstrual bleeding (IMB)
  • menorrhagia (HMB)

Post-menopausal

  • post-menopausal bleeding (PMB)

Late** **disease (despite state of menopause):

  • abdo pain,
  • bladder/bowel disturbance (incl. haematuria),
  • resp symptoms
41
Q

What is the Mx of Stage 1 endometrial cancer?

A
42
Q

What is seen O/E in endometrial cancer?

A
  • often normal unless advanced;
  • If advanced:
    • bulky & fixed uterus,
    • uterine mass,
    • ~ adnexal mass
43
Q

Ix for ?endometrial cancer?

A

In primary care:

  • Bloods:
    • FBC (anaemia),
    • U&Es (renal involvement),
    • LFTs (liver/bone involvement)
  • Bimanual exam
  • Speculum exam

In secondary care:

  • TVUSS
  • Endometrial biopsy (+ ~ Hysteroscopy - may be used to guide biopsy; not always performed)
    • essential for diagnosis
  • If cannot tolerate biopsy → hysteroscopy, dilatation & curettage
44
Q

What is the cut-off for endometrial thickness, in order for a biopsy to be indicated?

A
  • <4mm → no biopsy, no further Ix
  • ≥4mm → biopsy +/- hysteroscopy
45
Q

What Ix are used to stage endometrial cancer, once the diagnosis has been confirmed by biopsy?

A
  • CXR,
  • MRI,
  • CT CAP,
  • PET CT
46
Q

What are the different pathways and their eligibility criteria for TVUSS and further Ix?

A
  • Rapid access clinic (2 week wait) → one-stop clinic for urgent Ix:
    • REFER for those aged ≥ 55yrs, with PMB
    • CONSIDER for those aged <55yrs, with PMB
  • Direct access USS (in primary care) to assess for endometrial cancer:
    • those aged ≥55yrs, with:
      • unexplained symptoms of vaginal discharge who:
        • are presenting with these symptoms for 1st time or
        • have thrombocytosis or
        • report haematuria, or
      • visible haematuria AND:
        • low Hb or
        • thrombocytosis, or
        • high glucose
47
Q

What is the Mx of Stage 2 endometrial cancer?

A
48
Q

What is the Mx of Stage 3 endometrial cancer?

A
49
Q

What is the Mx of Stage 4 endometrial cancer?

A
50
Q

What is the Mx of endometrial hyperplasia with atypia (pre-malignant disease)?

A
51
Q

Complications of endometrial cancer?

A
  • Metastatic spread
  • Complications of treatment
52
Q

Complications of Surgery for endometrial cancer?

A
  • infertility,
  • bladder instability,
  • lymphoedema,
  • sexual dysfunction
53
Q

Complications of radiotherapy for endometrial cancer?

A
  • bladder/bowel fistulae (incontinence),
  • vaginal stenosis
  • vaginal atrophy
54
Q

Complications of chemotherapy for endometrial cancer?

A
  • nausea,
  • hair loss,
  • mouth ulcers,
  • etc
55
Q

Prognosis of endometrial cancer?

A

Presents early so high survival rates

  • 5-year survival:
    • stage 1: 85%; - most cases present at this stage
    • stage 2: 70%;
    • stage 3: 50%;
    • stage 4: 25%

2 - Y5 O&G (15 decks)

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