Gynae problems

Question 1

The menstrual cycle stages

Answer 1

0-5d: uterine menses –> endometrium sheds, myometrium contracts
1-13d: follicular/proliferative phase –> GnRH stimulates FSH and LH, primary follicule secretes oestradiol and inhibin
14d: ovulation
14-28d: luteal phase –> follicule ruptures, corpus luteum secretes progesterone + oestrogen, inhibits LH and FSH

Question 2

Uterine polyps pathophysiology + management

Answer 2

Small, benign tumours in uterine cavity
40-50y/o when oestrogen levels are high
Presentation: asymptomatic, menorrhagia, IMB, prolapse through cervix
Dx: USS or incidental on hysteroscopy
Mx: polyp resection w/ cutting diathermy/avulsion to remedy bleeding

Question 3

Adenomyosis pathophysiology + management

Answer 3

When there is endometrium and underlying stroma in the myometrium
40y/o, assoc w/ endometriosis and fibroids
Symptoms subside after menopause: Oestrogen dependent
-PC: dymenorrhoea, menorrhagia
Ix: ?TVUSS, MRI confirms Dx
Mx: Progesterone IUD, COC+/- NSAIDS, ?hysterectomy

Question 4

Leiomyoma pathophysiology

Answer 4

Benign tumour of myometrium
By 50y/o+ ~75% of women have at least one (common in perimenopausal)
50% asymptomatic OR may have menorrhagia, timing unusually changed, intermenstrual loss if submucosal/polpoid, dysmenorrhoea

Question 5

Leiomyoma complications

Answer 5

If large: bladder compression = frequency/retention
Ureter compression = hydronephrosis
Fertility impairment as may prevent implantation
Can enlarge: mid pregnancy, HRT
Torsion
Degenerate due to inadequate blood supply: pain, uterine tenderness, haemorrhage and necrosis.
May be malignant: 0.1% (if in PMP or sudden onset of pain in any age)
May obstruct labour; PPH; premature; malpresentation; transverse lie

Question 6

Leiomyoma investigations and management

Answer 6

USS: size, number, position
MRI if unclear (differentiates between adenomysosi)
FBC: Hb low as bleeding

Mx medical:
1st line: Tranexamic acid, NSAIDs, progestogens
GnRH: temporary amenorrhoea and fibroid shrinkage.
SPRMS (selective progesterone receptor modulators): e.g. Ulipristal acetate which reduces HMB and fibroid size.

Mx surgery:
Hysteroscopy: GnRH for 1-2 months (shrink, reduce vascularity, thin endometrium)
Myomectomy: If medical Mx failed and need to preserve reproductive function.
Radical hysterectomy
Uterine aa embolization (reduces size, shorter hospital stay)
Ablation

Question 7

Endometrial malignancy types

Answer 7

Type 1: low grade, oestrogen sensitive, obesity assoc, less aggressive, atypia as precursor
Type 2: high grade, oestrogen insensitive, unrelated to obesity, more aggressive

Question 8

Endometrial malignancy risk factors

Answer 8

HRT, DM, early menarche, late menopause, nulliparity, Tamoxifen, 55+

Premalignant disease: endometrial hyperplasia w/atypia –> unopposed/erratic oestrogen -> hyperplasia -> atypical hyperplasia = abnormalities of cellular and glandular architecture

Question 9

Endometrial malignancy presentation + investigations

Answer 9

Post-menopausal bleeding
Premenopausal women: irregular/IMB or recent onset menorrhagia
Atrophic vaginitis co-existing

Ix: 
Investigate abnormal vaginal bleeding
USS + pipelle biopsy/hysteroscopy
MRI: ?myometrial spread invasion
FBC, U+E

Question 10

Endometrial malignancy staging

Answer 10

1A: endometrium
1B: myometrium
2: cervix
3A: ovary
3B: vagina
3C: lymph nodes
4A: bladder/bowel
4B: liver

Question 11

Endometrial malignancy management

Answer 11

Surgery: 75% pc with stage 1: total laparoscopic hysterectomy and bilateral salpino-oophorectomy
Pelvic/paraaortic lymphadenopathy if high risk

Adjuvant therapy
External beam RT: if high risk for LN involvement (^ risk of deep myometrial spread, poor grade, cervical stroma involvement)
Vaginal vault RT: reduces reoccurrence as commonly happens within 1st 3 years here
Chemotherapy