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Yr4: Obstetrics & Gynaecology > Gynae: Uterine Disorders > Flashcards

Gynae: Uterine Disorders Flashcards

1
Q

What are fibroids also known as?

What are fibroids?

A
  • Uterine leiomyomas
  • Benign tumours of uterine smooth muscle
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2
Q

Are fibroids common?

A

Very; affect 40-60% women in later reproductive years

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3
Q

Fibroids are oestrogen sensitive; what does this mean?

A

Grow in response to oestrogen

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4
Q

State and describe the four types of fibroids

A
  • Intramural: within the myometrium (can distort shape of uterus as they grow)
  • Subserosal: just below outside layer of uterus- can become large and start to fill abdo cavity
  • Submucosal: just below endometrium
  • Pedunculated: on a stalk
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5
Q

State some risk factors for fibroids

A
  • Obesity
  • Early menarche
  • Increasing age
  • FH
  • African American ethnicity
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6
Q

Describe typical presentation of fibroids

A

Often asymptomatic however can present in numerous ways:

  • Menorrhagia (most common)
  • Prolonged menstruation (>7 days)
  • Abdo pain (worse during menstruation)
  • Bloating/feeling full in abdo
  • Pressure symptoms leading to urinary frequency or chronic retention or bowel problems
  • Deep dyspareunia
  • Reduced fertility
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7
Q

What might you find on abdominal & bimanual examination of a pt with fibroids?

A
  • Palpable pelvic mass
  • Enlarged, firm, non-tender uterus
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8
Q

What investigations would you consider in a pt with suspected fibroids?

A
  • Initial investigation: ultrasound uterus (transabdominal & transvaginal)
  • Hysteroscopy can be useful for submucosal fibroids
  • MRI pelvis: if considering surgery and need more information and size, shape & blood supply

**CHECK ON PLACEMENT AS SOURCES VARY

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9
Q

Management of fibroids can fall under 3 categories; outline these

A
  • If asymptomatic no treatment needed- just monitor growth & if any symptoms develop
  • Management of menorrhagia secondary to fibroids
  • Management to shrink or remove fibroids (to relieve pressure symptoms, improve fertility, improve menorrhagia etc..)
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10
Q

Discuss the medical management of secondary menorrhagia due to fibroids

A

Pharmacologic options depends on whether or not patient wants contraception:

Pharmacological if want contraception:

  • Mirena coil (LNG-IUS)*First line*
  • COCP
  • Cyclical progesterone’s (e.g. norethisterone 5mg 3x daily for days 5-26) **CHECK IF ACTS AS CONTRACEPTION AS TEACH ME OB&GYN and ZtF ARE DIFFERENT

Pharmacological if don’t want contraception:

  • If no associated pain= tranexamic acid (antifibrinolytic that reduces bleeding). Take only during menses.
  • If associated pain= mefenamic acid (NSAID that reduces bleeding & pain). Take only during menses.
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11
Q

Outline what surgical options are available for fibroids

A

Smaller fibroids <3cm

  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy

Larger fibroids >3cm

  • Uterine artery embolisation
  • Myomectomy (+/- neoadjuvant GnRH agonists)
  • Hysterectomy
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12
Q

For uterine artery embolisation, discuss:

  • Who performed by
  • How it is performed
  • How it works
A
  • Interventional radiologist
  • Insert catheter into femoral artery, pass this through to uterine artery under x-ray guidance. Particles that cause blockage are then injected into the arterial supply to fibroid
  • Fibroid is starved of oxygen so shrinks
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13
Q

What is a myomectomy?

When is it a good option?

A
  • Surgical removal of fibroid (laparoscopic or laparotomy)
  • Only treatment known to potentially improve fertility in pts with fibroids
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14
Q

Explain why GnRH agonists e.g. goserelin (Zoladex) or leuprorelin (Prostap) may be used in pts with fibroids

A
  • May be used prior to surgery to shrink fibroids
  • Usually only used short term
  • Induce menopause-like state (as GnRH is usually pulsatile so giving continuous GnRH causes desensitisation so reduces oestrogen production which in turn shrinks fibroids as they are oestrogen dependent)
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15
Q

Explain how endometrial ablation workds

A
    • Destroy endometrium
  • Used to be done via hysteroscopy & direct destruction but can now do via non-hysteroscopic techniques (e.g. balloon thermal ablation- insert balloon into endometrial cavity and fill with high-temp fluid that burns endometrial lining)
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16
Q

What is a hysterectomy?

A
  • Removal of uterus (and in case of fibroids therefore removes fibroids)
  • Laparoscopy, laparotomy or vaginal
  • Ovaries may be left or removed (depends on pt preference, risk & benefits)
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17
Q

State some potential complications of fibroids

A
  • Menorrhagia (often with Fe deficiency anaemia)
  • Reduced fertility
  • Pregnancy complications
    • Miscarriage
    • Premature labour
    • Obstructive delivery
  • Constipation
  • Urinary outflow obstruction (can lead to retention & UTIs)
  • Torsion of fibroid (usually pedunculated fibroids)
  • Red degeneration of fibroid
  • Malignant change to leiomyosarcoma (very rare <1%)
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18
Q

Discuss the prognosis of fibroids

A

Usually regress after menopause as oestrogen dependent

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19
Q

For red degeneration of fibroids, discuss:

  • What is is
  • When it is most likely to occur (and why)
  • Presentation
  • Management
A
  • Ischaemia, infarction & necrosis of fibroid due to disrupted blood supply
  • More likely in larger fibroids (>5cm) during 2nd & 3rd trimester because:
    • Fibroid may be rapidly enlarging during pregnancy and outgrowing it’s blood supply
    • Uterus expands and changes shape during pregnancy causing kinking of blood vessels
  • Presentation:
    • Severe abdo pain
    • Low grade fever
    • Tachycardia
    • Vomiting
  • Management is supportive:
    • Rest
    • Fluids
    • Analgeisa
20
Q

What is endometriosis?

What is a endometrioma?

What are enometriomas in ovaries also known as?

A
  • Growth of ectopic endometrial tissue outside of uterus
  • Endometrioma= lump of endometrial tissue outside uterus
  • Endometriomas in ovaries often called chocolate cysts
21
Q

Exact cause of endometriosis is unclear however there are some possible theories (4); briefly describe these

A

No specific genes found; but do think there is genetic component. Theories include:

  • During menstruation retrograde menstruation occurs (endometrial lining flows backwards through fallopian tubes and out into pelvis & peritoneum. Endometrial tissue then seeds and grows)
  • Embryonic cells destined to become endometrial tissue remain in areas outside uterus during fetal development
  • Spread of endometrial cells through lymphatic system
  • Metaplasia of cells outside uterus into endometrial cells
22
Q

State some risk factors for endometriosis

A
  • Early menarche
  • FH
  • Short menstrual cycles
  • Long duration menstrual bleeding
  • Menorrhagia
  • Defects in uterus or fallopian tubes
23
Q

Describe typical presentation of endometriosis

A

Can be asymptomatic or present with:

  • Cyclical abdominal or pelvic pain
    • Pain may be constant in cases were adhesions formed
  • Deep dyspareunia
  • Dysmenorrhoea
  • Infertility
  • Cyclical bleeding from other sites (e.g. haematuria)
  • Urinary symptoms (dysuria, urgency)
  • GI symptoms (dyschezia= painful bowel movements)
24
Q

Explain, in terms of pathophysiology, why pts with endometriosis get symptoms

A

Cyclical pain

Ectopic endometrial tissue responds to hormones in same way endometrial tissue in uterus does. Hence, during menstruation get shedding of ectopic endometrial tissue which causes irritation & inflammation of tissue

Constant/chronic, non-cyclical pain

Inflammation leads to adhesions; can cause chronic, non-cyclical pain that is sharp, stabbing, pulling with associated nausea

Haematuria, blood in stools etc…

Shedding of ectopic endometrial tissue → bleeding

Reduced fertility

Not clear but may be due to adhesions around ovaries & fallopian tubes blocking release of eggs. Endometriomas in ovaries may also damage eggs and/or prevent effective ovulation

25
Q

What might you find on abdominal, pelvic & speculum examination of pt with endometriosis?

A
  • Tender abdomen/pelvis
  • Tenderness in vagina, cervix & adnexa
  • Fixed cervix on bimanual examination
  • Endometrial tissue in vagina on speculum examination (particularly in posterior fornix
26
Q

What investigations are done for endometriosis? Highlight gold standard

A
  • Pelvic ultrasound: often unremarkable but may find large endometriomas and chocolate cysts
  • Laparoscopic surgery (GOLD STANDARD): can do biopsy for definitive diagnosis and surgeon can also remove deposits of endometriosis during laparoscopy to potentially help symptoms
27
Q

What staging system is used for endometriosis?

*NOTE: the staging system not used in NICE guidelines- they advise giving detailed descriptions of endometriosis instead.

A

ASRM (American Society of Reproductive Medicine). Does not predict symptoms or difficulty in managing condition.

  • Stage 1: small superficial lesions
  • Stage 2: mild, but deeper lesions than stage 1
  • Stage 3: deeper lesions with lesions on ovaries & mild adhesions
  • Stage 4: deep & large lesions affecting ovaries & extensive adhesions
28
Q

Discuss the management of endometriosis

A
  • First line= analgesia with NSAIDs and/or paracetamol
  • Hormonal treatments
    • e.g. COCP, progestogens e.g. progesterone only pill, mirena coil, medroxyprogesterone acetate injection (depo) etc….
    • GnRH analogues
  • Surgical options:
    • Laparoscopic surgery to excise or laser ablate endometrial tissue & remove adhesions (adhesiolysis)
    • Hysterectomy & bilateral salpingo-oophorectomy
29
Q

Briefly explain how each of the following work for endometriosis:

  • Hormonal medications (e.g. COCP, mirena coil)
  • GnRH agonists
  • Laparoscopic surgery
  • Hysterectomy with bilateral salpingo-oophorectomy
A
30
Q

What is adenomyosis?

A

Endometrial tissue inside the myometrium

31
Q

State some risk factors for adenomyosis

A
  • High parity
  • Increasing age (seen towards end of reproductive years)
  • Uterine surgery
  • Previous caesarean section
  • FH

*Thought to occur when endometrial stroma communicates with underlying myometrium after uterine damage; such damage may be associated with pregnancy & childbirth, uterine surgery

32
Q

Why, like fibroids & endometriosis, do symptoms of adenomyosis tend to regress after menopause?

A

Oestrogen dependent

33
Q

Adenomyosis can commonly occur alongside other conditions; state 2

A
  • Fibroids
  • Endometriosis
34
Q

Describe typical presentation of adenomyosis

A

Most commonly presents with:

  • Dysmenorrhoea (progressive- starts cyclical then becomes constant)
  • Menorrhagia
  • Dyspareunia

May also present with:

  • Subfertility
  • Pregnancy related complications
  • ⅓ asymptomatic
35
Q

What might you find on examination of pt with adenomyosis?

A
  • Enlarge uterus
  • Tender uterus
  • Softer than uterus containing fibroids
36
Q

What investigations would you do for suspected adenomyosis?

A
  • First line= transvaginal ultrasound pelvis
  • Others:
    • Transabdominal ultrasound pelvis
    • MRI pelvis
  • Gold standard= histological examination of uterus after hysterectomy
37
Q

Discuss the management of adenomyosis

A

Main aims are to control dysmenorrhoea and menorrhagia. Only curative therapy is hysterectomy.

When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:

Management of menorrhagia

Don’t want contraception:

  • Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
  • Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Management when contraception is wanted or acceptable:

  1. Mirena coil (first line)
  2. Combined oral contraceptive pill
  3. Cyclical oral progestogens

Progesterone only medications such as the pill, implant or depot injection may also be helpful.

Other options are that may be considered by a specialist include:

  • GnRH analogues to induce a menopause-like state
  • Endometrial ablation
  • Uterine artery embolisation
  • Hysterectomy
38
Q

Adenomyosis is associated with numerous complications in pregnancy; state some of these

A
  • Infertility
  • Miscarriage
  • Preterm birth
  • Small for gestational age
  • Preterm premature rupture of membranes
  • Malpresentation
  • Need for caesarean section
  • Postpartum haemorrhage
39
Q

What is Asherman’s syndrome?

A

Adhesions form within uterus following damage to uterus

40
Q

State some potential causes of Asherman’s syndrome

A
  • Commonly occurs after pregnancy-related dilatation & curettage (e.g. to remove retained products of conception)
  • Uterine surgery (e.g. myomectomy)
  • Pelvic infections (e.g. endometritis)
41
Q

Explain the underlying pathophysiology of Asherman’s syndrome

A
  • Damage to endometrium
  • Damaged tissue may heal abnormally forming scar tissue
  • Scar tissue may connect areas of uterus (e.g. bring uterine walls together, within endocervix sealing it shut)
42
Q

Are asymptomatic adhesions classed as Asherman’s syndrome?

A

No

43
Q

Describe typical presentation of Asherman’s syndrome

A

Typically presents with hx of recent dilatation & curettage, uterine surgery or endometritis with:

  • Secondary amenorrhoea
  • Hypomenorrhoea
  • Dysmneorrhoea
  • Infertility

*Can also cause recurrent miscarriages

44
Q

What investigations might you consider for pts with suspected Asherman’s syndrome?

A

Options:

  • Gold standard= hysteroscopy (can dissect & treat adhesions during)
  • Hysterosalpingography (inject contrast into uterus and image wit x-rays)
  • Sonohysterography (fill uterus with fluid & ultrasound)
  • MRI pelvis
45
Q

Discuss the management of Asherman’s syndrome

A

Dissection of adhesions during hysteroscopy

46
Q

Discuss the prognosis of Asherman’s syndrome

A
  • Reoccurrence after treatment is common
  • Increased risk miscarriage
  • Increased risk stillbirth

Yr4: Obstetrics & Gynaecology (24 decks)

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