Gynae problems Flashcards
Which part of the menstrual cycle does PMS occur?
Luteal phase (in days prior to onset of menstruation)
During which parts of a woman’s life are PMS not present?
Before menarche
During pregnancy
After menopause
What is PMS caused by?
Fluctuation in oestrogen and progesterone hormones during menstrual cycle
*?increased sensitivity to progesterone
or
?interaction between sex hormones and serotonin/GABA
How does PMS present?
Depends on individual
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
Absence of menstruation after:
- hysterectomy
- endometrial ablation
- Mirena coil
Can PMS still occur in these situations?
Yes, as ovaries still function and hormonal cycle continues.
Aside from physiological PMS, when else can PMS occur?
COCP Cyclical HRT (containing progesterone)
When PMS features are severe and have a big impact on the quality of life, what is this called?
Premenstrual dysphoric disorder
How is PMS diagnosed conservatively?
Using symptom diary spanning TWO menstrual cycles
How is PMS diagnosed confirmed?
Administer GnRH analogues to halt menstrual cycle (temporarily induces menopause)
If symptoms resolve, then it is PMS
How is PMS managed conservatively?
Lifestyle changes - diet, exercise, alcohol, smoking, stress, sleep
How is PMS managed pharmacologically?
COCP (Drospirenone)
SSRI antidepressants
CBT
Oestrogen patches with progesterone cover (from endometrial hyperplasia from oestrogen)
GnRH analogues to induce menopause then HRT after to recover
Danazole/tamoxifen for breast pain
Spironolactone for physical symptoms of PMS such as breast swelling, water retention and bloating
How can PMS be managed surgically as a last resort?
Hysterectomy
Bilateral Oophorectomy
Give HRT if woman is under 45 to replace lost hormones from the operation.
In what form can progesterone be given for treating PMS?
Cyclical progestogens (norethisterone) Mirena coil
Which drug aims to tackle the physical symptoms of PMS (breast swelling, bloating, water retention)?
Spironolactone
What drug can be used to treat cyclical breast pain with PMS?
Danazole/tamoxifen
What is the risk of using oestrogen only (without progesterone cover) to treat PMS?
Oestrogen can induce endometrial hyperplasia.
Progesterone counteracts these effects.
Define dysmenorrhoea
Painful menstruation
What is the brief pathophysiology behind dysmenorrhoea?
High prostaglandins in endometrium causes contraction and uterine ischaemia
–> leads to pain during menstruation
What is primary dysmenorrhoea?
When no organic cause found for dysmenorrhoea.
*coincides with start of menstruation
Very common - particularly in adolescent women
What is the management of primary dysmenorrhoea?
Analgesia - NSAIDs
Ovulation suppression (OCP)
Reassurance in young adolescents
Pelvic pathology is more likely if medical treatment fails and should be followed up as such. (secondary dysmenorrhoea)
What is secondary dysmenorrhoea?
When pain is due to pelvic pathology.
*Pain often precedes and is relieved by onset of menstruation
How does secondary dysmenorrhoea present?
Pain often precedes and is relieved by onset of menstruation
Deep dyspareunia
Menorrhagia
Irregular menstruation
How is secondary dysmenorrhoea investigated?
USS pelvis
Laparascopy
What are the most significant causes of secondary dysmenorrhoea?
Fibroids Adenomyosis Endometriosis PID Ovarian tumours
Treat according to pathology
What are NON-MALIGNANT causes of intermenstrual bleeding?
Fibroids Uterine/cervical polyps Adenomyosis Ovarian cysts Chronic pelvic infection
What are MALIGNANT causes of intermenstrual bleeding?
Ovarian ca Cervical ca Endometrial ca (most)
What may a speculum examination on a women with intermenstrual bleeding reveal?
Cervical polyp
What investigations are carried out on a woman with intermenstrual bleeding?
Check blood loss: Hb
Exclude malignancy: cervical smear, USS uterus cavity +/- endometrial biopsy
What criteria are acceptable to perform an endometrial biopsy on a woman with abnormal bleeding?
Endometrium thickened on USS Polyp suspected Woman is >40 years of age IMB is significant Risk factors for endometrial cancer If endometrial ablation surgery or IUS gonna be used
What are pharmacological managements of intermenstrual bleeding?
IUS or COCP used first line. Induces regular and lighter menstruation. (Use less in older women due to complications)
High dose progestogens given cyclically to mimic normal menstruation
HRT can also regulate erratic uterine bleeding during perimnopause
What are surgical managment options for intermenstrual bleeding?
Cervical polyp can be avulsed + sent for histology
Resection of fibroid
Hysterectomy in last resort
Uterine artery embolisation to treat abnormal bleeding due to fibroids. Suitable if woman wants to retain uterus.
How much blood do women lose blood during menstruation on average?
What is deemed excessive?
What is the medical term for this?
40ml
> 80ml
Menorrhagia (heavy menstrual bleeding)
What are symptoms of menorrhagia?
Changing pads every 1-2 hours
Bleeding lasting more than 7 days
Passing large clots
What are possible differential causes of heavy menstrual bleeding? List at least 4.
Dysfunctional uterine bleeding (DUB) Extremes of reproductive age Fibroids Endometriosis and Adenomyosis PID Contraceptives - e.g. copper coil Anticoagulant medications Bleeding disorders (VWD) Endocrine disorders (diabetes/hypothyroidism) Connective tissue disorders Endometrial hyperplasia or cancer Polycystic ovarian syndrome (PCOS)
What are key things to ask about in any presentation with gynaecological problem?
Age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening history
Migraines with or without aura (for the pill)
Past medical history and past drug history
Smoking and alcohol history
Family history
What examination and investigations can be carried out for menorrhagia?
Pelvic exam with speculum and bimanual - assess for fibroids, ascites and cancers
FBC - check for iron deficiency anaemia
Hysteroscopy (if ?submucosal fibroids,?endometrial pathology, peristent IMB)
Pelvic + transvaginal USS (if large fibroids, adenomyosis, obese, declined hysteroscopy)
Additional tests to consider:
- Swabs (?infection)
- Coagulation screen (family hx clotting or heavy periods since menarche)
- Ferritin if clinical anaemia
TFTs (if features of hypothyroid)
What is the pharmacological management for heavy menstrual bleeding?
Exclude causes suggesting underlying pathology
Offer contraception: 1st line - Mirena coil 2nd line - COCP 3rd line - cyclical oral progestogens (also progesterone only pill or long-acting progesterone - depo or implant)
If contraception declined:
Tranexamic acid - when no associated pain (antifibrinolytic - bleeding)
Mefenamic acid - when associated pain (NSAID - bleeding and pain)
Refer for secondary care if failed
What are the 2 main surgical options for heavy menstrual bleeding in secondary care (i.e. when pharmacological options have failed)?
Endometrial ablation
Hysterectomy
What is balloon thermal ablation and what is it used for?
Passing special balloon into endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining.
2nd generation, non-hysteroscopic endometrial ablation technique
What are the 4 types of fibroids?
Intramural
Subserosal
Submucosal
Pedunculated
What are fibroids?
Benign tumours of the smooth muscle of uterus.
Which hormone induces growth of fibroids?
Oestrogen
How do fibroids present?
Asymptomatic usually.
HMB is the most frequent symptoms
Prolonged menstruation, lasting more than 7 days
Abdo pain, worse during menstruation
Bloating/feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility
Abdo + bimanual examination may reveal palpable pelvic mass or an enlarged firm non-tender uterus.
Abdominal and bimanual examination of fibroids may reveal what?
Palpable pelvic mass
or
Enlarged firm non-tender uterus
What investigations can be done for fibroids?
Hysteroscopy (submucosal fibroids with HMB)
Pelvic USS (larger fibroids)
MRI scanning (consider before surgery - size, shape and blood supply of fibroids)
What are the management options for fibroids less than 3cm?
Same as with HMB
- Mirena coil (1st line)
- Symptomatic management (NSAIDs + tranexamic acid)
- COCP
- Cyclical oral progestogens
Surgical options:
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
What are the management options for fibroids more than 3cm?
Referral to gynaecology
- Symptomatic management (NSAIDS + tranexamic acid)
- Mirena coil
- COCP
- Cyclical oral progestrogens
Surgical options:
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
GnRH agonists (goserelin, leuprorelin) can be used to reduce the size of fibroids before surgery.
Which artery is used to gain access in uterine artery embolisation?
Femoral artery
What are complications of fibroids?
- HMB (often with iron deficiency anaemia)
- Reduced fertility
- Pregnancy complications - miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and UTI
- Red generation of fibroid
- Torsion of fibroid (usually affects pedunculated fibroids)
- Malignant change to leiomyosarco (very rare <1%)
What is red degeneration of fibroids?
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply.
*Usually occurs in larger fibroids (5cm+) during 2nd and 3rd trimester
In which part of pregnancy does red degeneration of fibroids usually occur?
2nd or 3rd trimester
Why does red degeneration usually occur during pregnancy?
Fibroid enlarges during pregnancy, outgrowing its blood supply and becomes ischaemic.
Also due to kinking in blood vessels as uterus changes shape and expands during pregnancy.
How does red degeneration of fibroids usually present?
Red degeneration presents : Severe abdominal pain Low-grade fever Tachycardia Often vomiting.
What is the management for red degeneration of fibroids?
Supportive management only
Rest
Fluids
Analgaesia
Pregnant women with history of fibroids presents with severe abdo pain and a low-grade fever.
What is the likely diagnosis?
Red degeneration of fibroids
The vast majority of ovarian cysts in premenopausal women are ______.
Benign
Cysts in postmenopausal women are more concerning for ________ and need further investigation.
Malignancy
Patients with multiple ovarian cysts have a “____________” appearance to the ovaries.
“String of pearls”
What is the triad necessary to diagnose PCOS over simply having multiple ovarian cysts?
Anovulation
Hyperandrogenism
Polycystic ovaries on USS
What are the two types of functional cysts?
*Functional cysts are related to fluctuating hormones of the menstrual cycle. Very common in premenopausal women.
Follicular cysts (most common)
Corpus luteum cysts
___________ cysts can cause pelvic discomfort, pain or delayed menstruation.
Often seen in early pregnancy.
Corpus luteum cysts
What are 5 types of non-functional cysts?
Serous cystadenoma
Mucinous cystadenoma
Endometrioma
Dermoid cysts/Germ cell tumours (teratomas)
Sex cord-stromal tumours
Serous cystadenoma are what?
Benign tumours of epithelial cells
Non-functional cyst
Mucinous cystadenoma are what?
Benign tumour of epithelial cells.
*can become huge, taking lots of space in the pelvis
Endometrioma are what?
Lumps of endometrial tissue in ovary - occur in patients with endometriosis.
*cause pain and disrupt ovulation
Dermoid cysts/germ cell tumours are what?
Benign ovarian tumours
Teratomas
*associated with ovarian torsion
Sex-cord stromal tumours are what?
Rare benign OR maligant stroma/sex cord tumours
*Several types - Sertoli-Leydig cell tumours and granulosa cell tumours
What features suggest malignancy in ovarian cysts?
- Abdo bloating
- Reduced appetite
- Early satiety
- Weight loss
- Urinary symptoms
- Pain
- Ascites
- Lymphadenopathy
What are risk factors for ovarian malignancy?
- Age
- Post-menopause
- Increased number of ovulations
- HRT
- Smoking
- Breastfeeding (protective)
- Family history and BRCA1/BRCA2 genes
More number of times woman ovulates during life _____ risk of ovarian cancer.
Increases risk of ovarian cancer
Factors that reduce the number of ovulations are:
Later onset of periods (menarches)
Early menopause
Any pregnancies
Use of COCP
What blood tests are done for women with ovarian cysts?
Less than 5cm on USS? No blood test needed
CA125 is the tumour marker for determining malignancy potential of ovarian cyst.
LDH
AFP
HCG
Women under 40 yo with complex ovarian mass require tumour marker blood tests for a possible __________ tumour
Germ cell tumour
CA125 is a tumour marker for epithelial cell ovarian cancer - not very specific and many non-malignant causes of raised CA-125 such as:
(List 6)
Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
Risk of malignancy index estimates risk of ovarian mass being malignant. Takes into account 3 things:
Menopausal status
USS findings
CA125 level
How is possible ovarian cancer referred?
2 week wait referral to gynae oncology specialist
How are possible dermoid cysts referred?
Referred to gynae for further investigation and consideration of surgery.
Simple ovarian cysts in premenopausal women are managed based on their size how?
- <5cm
- 5cm - 7cm
- 7cm+
- <5cm - Resolve within 3 cycles. Do not require a followup scan.
- 5cm - 7cm - Require routine referral to gynae and yearly USS monitoring.
- 7cm+ - MRI scan/surgical evaluation as difficult to characterise with USS
Persistent or enlarging cysts may require surgical intervention. List 2 types of surgery.
Ovarian cystectomy (removal of cyst)
Oophorectomy (removal of affected ovary)
What are complications of ovarian cysts?
*Patients present with acute onset pain
Ovarian torsion
Haemorrhage into cyst
Rupture, with bleeding into peritoneum
What is the triad of Meig’s syndrome?
Ovarian fibroma (type of benign ovarian tumour)
Pleural effusion
Ascites
Which population does Meig’s syndrome usually occur in?
Older women
How is Meig’s syndrome managed?
Removal of tumour
*results in complete resolution of pleural effusion and ascites! :)
What is PID?
Pelvic inflammatory disease - inflammation/infection of pelvis organs caused by infection spreading up through the cervix.
What are 3 causes of pelvic inflammatory disease?
STDs:
- Neisseria genorrhoeae (severe PID)
- Chlamydia trachomatis
- Mycoplasma genitalium
Less commonly, non-STDs:
- Gardnerella vaginalis (associ. with BV)
- Haemophius influenzae (assoc. with resp infections)
- E. coli enteric bacteria assoc. with UTIs)
What are risk factors for PID?
Not using barrier contraception
Multiple sexual partners
Younger age
Existing STDs
Previous PID
Intrauterine device (copper coil etc)
How may a woman with PID present?
Pelvic/lower abdomen pain Abnormal vaginal discharge Abnormal bleeding (IMB or postcoital) Dyspareunia Fever Dysuria
What may an examination on a woman with PID reveal?
Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
Fever or septic signs possible too!
What are the investigations for PID?
Same as STD testing
NAAT swabs (gonorrhoea/chlamydia)
NAAT swabs for Mycoplasma genitalium
HIV test
Syphilis test
High vaginal swab - BV, candidiasis, trichomoniasis
Microscopy to look for pus cells on vagina or endocervix. Absence = exclude PID
Pregnancy test with women with lower abdo pain - exclude ectopic pregnancy
Inflammatory markers (CRP/ESR) raised in PID and can help support diagnosis
How are PID patients managed?
GUM referral, contct tracing
Empiric antibiotics while swab results awaited
Abx:
Ceftriaxone and doxycycline (for many bacteria inc gonorrhoea and chlamydia)
Sepsis? -> IV abx and admit.
Pelvic abscess? -> drainage
What are complications of PID?
Sepsis Pelvic abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome?
How does it present?
How is it found + treated?
Complication of PID
Caused by inflammation/infection of liver capsule (Glisson’s capsule) => adhesions between liver and peritoneum.
Bacteria spread from pelvis via peritoneal cavity, lymph or blood
RUQ pain -> referred to right shoulder tip if diaphragm irritated.
Laprascopy to visualise
Treat adhesions by adhesiolysis
What is adenomyosis?
Endometrial tissue within the myometrium
What is endometriosis?
Ectopic endometrial tissue outside the uterus (endometrioma)
What are “chocolate cysts”?
Endometriomas in the ovaries
What is a possible cause for endometriosis?
Retrograde menstruation
*During menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum
What is the main symptom of endometriosis?
Pelvic pain - especially during menstruation
What are complications of endometriosis?
Blood in urine/stools (deposits of endometriosis in bladder or bowel)
Adhesions
Reduced fertility (due to adhesions blocking eggs)
How may a woman with endometriosis present?
Cyclical abdo or pelvic pain Deep dyspareunia Dysmenorrhoea (painful periods) Infertility Cyclical bleeding from other sites (such as haematuria)
Urinary symptoms
Bowel symptoms
What may an examination of a women with endometriosis reveal?
Endometrial tissue visible in vagina on speculum examination
Fixed cervix on bimanual examination (adhesions)
Tenderness in vagina, cervix and adnexa
How is endometriosis investigated?
Pelvic USS - large endometriomas and chocolate cysts
Lap surgery - gold standard to diagnose abdo and pelvic endometriosis. Take biopsy for definitive diagnosis.
How is endometriosis managed?
Initial
Hormonal
Surgical
Analgesia as required
Hormonal management
- COCP
- progesterone only pill
- Depo-Provera injection
- Nexplanon implant
- Mirena coil
- GnRH agonists
Surgical management
- Lap surgery to excise/ablate endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy
How do GnRH agonists work to manage endometriosis and give 2 examples of these drugs?
Induce menopause-like state to improve endometriosis symptoms
Goserelin
Leuprorelin
