Gynaecological Pathologies Flashcards
What are symptoms of Mittelschmerz?
- Usually mid cycle pain with often sharp onset.
- Little systemic disturbance.
- May have recurrent episodes that usually settles over 24-48 hours.
What are investigations and management for Mittelschmerz?
- Investigations
- Full blood count – usually normal
- Ultrasound – may show small quantity of free fluid
- Management is conservative
What are fibroids?
Fibroids are benign smooth muscle tumours of the uterus.
- More common in Afro-Caribbean women (50%) compared to white women (20%) in the later reproductive years)
- Rare before puberty, develop in response to oestrogen, and don’t tend to progress following menopause
What are symptoms and signs of Fibroids?
Symptoms
- May be asymptomatic
- Menorrhagia
- Lower abdominal pain: cramping pains, often during menstruation
- Bloating
- Urinary symptoms e.g. frequency
Signs
- Subfertility
- Rare features: polycythaemia secondary to autonomous production of erythropoietin
What are investigations for Fibroids?
- Transvaginal ultrasound
What is the immediate management for Fibroids?
- Symptomatic management
- 1st line: Levonorgestrel-releasing intrauterine system
- Other options include tranexamic acid, combined oral contraceptive pill etc
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
What is the definitive management for Fibroids?
- Surgery is sometimes needed:
- Myomectomy, Hysteroscopic endometrial ablation, Hysterectomy. This is done using magnetic resonance-guided focused ultrasound
- Uterine artery embolization
- Has a small risk of menopause when ovarian circulation arises dominantly from uterine arteries.
- An increased risk of abnormal placental implantation
What are complications of Fibroids?
- Subfertility
- Red degeneration: haemorrhage into tumour commonly occuring in pregnancy
What is Endometriosis?
- Common condition characterised by growth of ectopic endometrial tissue outside of the uterine cavity
- Predominantly found in pelvis – peritoneal lesions, superficial impacts or cysts on the ovary or deep infiltrating. Responds to cyclical hormonal changes and bleeds at menstruation
- 25% asymptomatic and 25% associated with pelvic organ pathology
What are aetiology of Endometriosis?
Unclear picture but thought to be due to:
- Retrograde menstruation
- Coelomic metaplasia
- Mullerian remnants
What are symptoms and signs of Endometriosis?
Symptoms
- Chronic pelvic pain
- Menstrual irregularity
- Dysmenorrhoea - pain often starts days before bleeding
- Deep dyspareunia
- Subfertility
- Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- Intermenstrual bleeding and post coital bleeding
What are examination signs of Endometriosis?
On pelvic examination
- Reduced organ mobility
- Tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
- Thicken uterosacral ligaments
- Fixed retroverted uterus
- Uterine tenderness
What are complications of endometriosis?
- Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
- Intra-abdominal bleeding may produce localised peritoneal inflammation
What is the investigations of Endometriosis?
- Laparoscopy is the gold-standard investigation
-
Ultrasound – may show free fluid
- Has a little role in investigations. If symptoms are significant, patient should be referred for a definitive diagnosis
What is the symptomatic managment of Endometriosis?
- 1st line: NSAIDs and/or paracetamol
- 2nd line: If analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
Referral to secondary care if analgesia/hormonal treatment does not improve symptoms or if fertility is a priority.
What are the surgical methods for managing endometriosis?
- Laparoscopic - diathermy, laser
- TAH+BSO
- Risk of bladder, ureteric, bowel injury
- Risk of subtotal hysterectomy
- Role of HRT
What is Ovarian Torsion?
- Partial or complete torsion of the ovary on its supporting ligament that may in turn compromise the blood supply.
- If the fallopian tube is also involved, it is referred to as adnexal torsion
What is the scoring system for identification of women with adnexal torsion?
- Unilateral lumbar or abdominal pain
- Vomiting
- Pain duration >8 hours
- Absence of leucorrhoea/metrorrhagia
- Ovarian cyst >5cm by ultrasounds
What are risk factors for Ovarian Torsion?
- Ovarian mass: present in around 90% of cases of torsion
- Being of a reproductive age
- Pregnancy
- Ovarian Hyperstimulation syndrome
What are symptoms of Ovarian Torsion?
- Sudden onset of deep-seated colicky lower abdominal pain
- May coincide with exercise
- Nausea, Vomiting and distress
- Fever in minority
What are signs of Ovarian Torsion?
- Pyrexia
- Tachycardia
- General abdominal tenderness, localised guarding, rebound
- Vaginal examination may reveal tender adnexal mass, cervical excitation and adnexal mass
What are investigations of Adnexal Torsion?
-
Ultrasounds: shows free fluid or whirlpool sign
- Whirls of the ovarian pedicle vessels seen in ovarian torsion
- Laparoscopy: usually diagnostic and therapeutic
- Blood Tests: Raised CRP and WCC
What is the management for Ovarian Torsion?
- Admit for IV fluids and pain relief
- Laparoscopy
What is the differentials of Ovarian Torsion?
- Functional ovarian cyst
- PID
- Appendicitis
- Fibroid torsion
- Renal colic
What is the definition of adenomyosis?
- Presence of endometrial tissue within the myometrium. More common in multiparous women towards end of their reproductive years
What are symptoms and signs of Adenomyosis?
- Dysmenorrhoea
- Menorrhagia
- Enlarged, boggy uterus
What is the management of Adenomyosis?
- GnRH agonists
- Diagnosed by histology after hysterectomy
What are long term complications of Vaginal Hysterectomy with anterior-posterior repari?
- Enterocoele
- Vaginal vault prolapse.
- Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.
What is Premenstrual Syndrome?
- Describes emotional and physical symptoms that women may experience in the luteal phase before the normal menstrual cycle. It only occurs in presence of ovulatory menstrual cycles but not in puberty, pregnancy or after menopause
- Emotional symptoms: anxiety, stress, fatigue, and mood swings
- Physical symptoms: bloating and breast pain
What is the management of Premenstrual Syndrome?
- Mild symptoms: Lifestyle advice include sleep, exercise, reduce smoking and alcohol, as well as regular, frequent, small, balanced meals rich in carbohydrates
- Moderate symptoms: COCP (e.g. Yasmin)
- Severe Symptoms: SSRI taken continuously or during the luteal phase (days 15-28 of menstrual cycle depending on its length)
