Gynaecological Problems Flashcards
Menorrhagia
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs/symptoms: Excessive blood loss with over flow reported(> 80 ml); anaemia; flooding and clots during menses
Possible aetiology:
- Fibroids
- Polyps
- Coagulopathy
- Iatrogenic: Anti-coagulants
- Adenomyosis
- Endocrine: Thyroid disease (hyper/hypo)
- Malignancy
- Increased risk for patients > 40
- Check risk factors in younger patients: Obesity, DM, PCOS, nulliparity, FHx HNPCC
Investigations
Hx: Quantify blood loss, duration, other red flag symptoms present, current medications, check current contraceptive method, check cervical smear testing is up to date and most recent results
Examination:
- Bimanual palpation to check for pelvic masses, abdominal palpation
- Check for stigmata of anaemia
Testing:
- FBC (check Hb levels)
- Check TFTs
- Check clotting
Imaging: TVUSS (+/- saline) or abdominal USS
- Visualise any fibroids
- Check uterine thickness (4 mm in follicular phase and 16 mm in luteal phase)
Endometrial biopsy
Management
Once local causes and malignancy have been excluded as the causation then symptomatic relief is the main stay of treatment.
Method used to provide relief is dependent up on whether patient is currently trying to conceive.
1st line if trying to conceive
- Tranexamic acid: To be taken on the first day of menses, for up to 4/7
- NSAIDs: Reduce prostaglandin levels, subsequently reducing blood loss e.g. mefenamic acid
1st line if not trying to conceive:
- Progesterone IUD
Other hormonal treatments: COCP or cyclical progestogen
If symptoms persist, or fibroid > 3 cm in diameter is present, then surgical intervention may be considered:
- Uterine artery embolisation: May retain fertility
- Myomectomy: May retain fertility
- Hysterectomy
Dysmenorrhoea
* Primary and Secondary *
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs and symptoms
Primary: Cyclical pain which occurs approximately 72 hours before the onset of menses and decreases with the onset of menses. Occurs in the absence of other gynaecological symptoms
Usually corresponds with the start of menstruation. Responds to NSAIDs or suppression of ovulation (e.g. COCP)
Secondary: Pain not consistently related to menstruation and occurs after several years of painless menstruation. When the pain experienced is due to pelvic pathology. Pain often preceeds, and is relieved by, the onset of menstruation. Occurs in the presence of other gynaecological symptoms e.g. dyspareunia, dyschezia, vaginal discharge, post-coital/intermenstrual bleeding
Possible aetiology:
Primary: Physiological (high levels of prostaglandins, uterine contraction and ischaemia)
Secondary: Endometriosis, adenomyosis, malignancy (cervical/ovarian), IUD insertion, PID
Investigations
Hx: Onset, duration, FHx present?, associated symptoms, Hx of STI, red flag symptoms present?
Examination: Pelvic examination including speculum, abdominal palpation to check for the presence of masses
Tests: Vaginal and endocervical swabs to test for the presence of STIs, pregnancy test (pain of ectopic pregnancy may be mistaken for menses related pain)
Imaging: To rule out fibroids, adexal pathology, check for the presence of IUDs
Management
Primary dysmenorrhoea:
NSAID analgesia
1st line: If not wishing to conceive then a trial of hormonal contraception may be used, COCP
NSAID and contraception may be combined if response to individual treatment is insufficient
If symptoms are severe or do not respond to treatment in 3-6 months then specialist referral should be considered
Secondary dysmenorrhoea
! Refer urgently if any of the following red flags are present: ascites, pelvic/abdominal mass, abnormal cervix, persistent intermenstrual and/or post-coital bleeding
Pelvic Inflammatory Disease (PID)
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs/symptoms:
- Pelvic/lower abdominal pain
- Deep dyspareunia
- Vaginal discharge
- Post-coital and/or intermenstrual bleeding
- RUQ pain (Fitz-Hugh-Curtis syndrome: Peri-hepatitis. A rare complication of PID which causes adhesions around the liver)
Possible aetiology:
- Ascending infection from the lower genital tract
- Chlamydia, gonorrhoea, mycoplasma genitalium
- Important differentials for pelvic pain: Ectopic pregnancy (+ive pregnancy and unilateral pain), appendicitis, ovarian cyst/torsion (unilateral pain), PID, tubo-ovarian abscess
Investigations:
Hx: Risk factors present e.g. multiple partners, previous STI, young age of first coitus, recent instrumentation of the uterus or interruption of the cervical barrier
Examination: Pelvic examination including speculum and bimanual - checking for cervical excitation and adexal masses/tenderness; abdominal palpation to check for pelvic tenderness
Tests: Pregnancy test, high vaginal and endocervical swabs, ESR/CRP to check for inflammation, blood cultures (if fever is present)
Management:
!!! Urgent admission if: Ectopic pregnancy suspected or pregnancy confirmed; severe symptoms; signs of pelvic peritonitis; surgical emergency (e.g. appendicitis) cannot be ruled out; suspicion of a tubo-ovarian abscess
- Analgesia: NSAID or paracetamol
- Empirical antibiotics as soon as a presumptive diagnosis is made
Ceftriaxone, deoxycycline and metronidazole
- In patients with a IUD in place, removal should be considered and the need for emergency contraception discussed
Menopause
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs and symptoms:
- Cessation of menses for 12 months - defines menopause
- Vasomotor symptoms: Hot flushes, night sweats, vaginal dryness
- Changes in menstruation: Frequency, heaviness, duration
- Sleep disturbance
Possible aetiology
- Physiological
- Chemotherapy and pelvic radiation
- Smoking: Hastens menopause
Investigations
Hx: LMP, presence of other symptoms?, mothers age at menopause
Examination: Symptoms dependent
Tests: Serum FSH levels (elevation suggests impending menopause), pregnancy test - indicated in all sexually active women with amenorrhoea, serum estradiol (predominant pre-menopausal oestrogen)
Management
Relief of vasomotor symptoms in the presence of other menopausal symptoms
-
Hormonal:
- Combined therapy for women with a uterus: Oestrogen and progesterone
- Oestrogen only therapy for those without a uterus
- Continuous HRT for those with absent menses for last 12 months
- Cyclical HRT, with cyclical progesterone and breakthrough bleeds for those who still experience menses
NOTE: Unscheduled vaginal bleeding is a common side effect of HRT
-
Non-hormonal:
- SSRI/SNRI: Paroxetine
- Clonidine (alpha agonist that acts to reduce vasomotor symptoms and hot flushes)
Altered sexual function
- Testosterone may be offered if HRT alone is not effective
Urogenital atrophy
- Vaginal oestrogen should be offered, including those on systemic HRT
Amenorrhoea
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs/symptoms:
Cessation of menses
Possible aetiology:
Primary in the presence of development of secondary sexual characteristics (no menses by 16 years of age)
- Constitutional delay
- Genito-urinary malformations: Imperforate hymen, absent vagina or uterus, transverse septum
- Endocrine disorders: Hypo/hyperthyroidism, hyperprolactinaemia, Cushing’s syndrome, PCOS
- Androgen insensitivity syndrome*
Primary with no development of secondary sexual characteristics (manifestation of delayed puberty - no secondary sexual characteristics by 14 years of age)
- Primary ovarian insufficiency: Chromosomal abnormalities, gonadal agenesis
- Hypothalmic dysfunction: Environmental, tumours, syndromes (Kallman’s, Prader-Willi, Laurence-Moon-Biedl syndromes)
- Causes of ambiguous genitalia: 5-alpha-reductase deficiency, congenital adrenal hyperplasia, androgen-secreting tumours
Secondary (cessation of menses for 3/12)
- Pregnancy
- Lactation
- Menopause
- Premature ovarian insufficiency: Chemo/radio therapy, autoimmune conditions
- Hypothalmic dysfunction: Stress, exessive exercise, weight loss
- Pituitary causes: Sheehan syndrome, prolactinoma
- Uterine causes: Cervical stenosis, Asherman’s syndrome (may follow evacuation of retained products of conception)
- Thyroid disease
- Iatrogenic
Investigations
Hx: Establish whether primary or secondary, check for environmental factors which may be responsible, FHx
Examination: Look for peripheral signs indicative of endocrine disorders or syndromes, abdominal palpation, pelvic examination
Tests: Karyotyping, serum hormone levels (TSH, FSH, LH, testosterone, prolactin)
Imaging: Pelvic ultraosund to check for any structural abnormalities
Management
Referral
Premature menopause: HRT or COCP
* Androgen insensivity syndrome: Genetically male (XY chromosomes) but unable to responds to androgens. Subsequently the body has a female external genitalia phenotype or mixed male-female appearance. Complete androgen insensitivity leads to female appearance with the abscence of a uterus - hence unable to menstruate or conceive - but also have undescended testicals.
Endometriosis
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs and symptoms:
- Cyclical pelvic pain related to ovulation/menses
- Deep dyspareunia
- Dysmenorrhoea
- Dyschezia
- Urinary symptoms
- Reduced fertility
Possible aetiology: Ectopic endometrial tissue responds to the cyclical release of hormones from the reproductive system. The tissue undergoes cyclical bleeding, causing local inflammation and damage. Adhesions form - if occuring in the fallopian tubes this can reduce fertility.
Investigations
Hx: Relation of symptoms/pain to menses, problems conceiving, pain on opening the bowels
Examination: Pelvic and abdominal examination to check for masses and endometriomas
Tests:
Imaging: TVUSS to look for endometriomas
Surgical: Diagnostic laparoscopy with biopsy
Management
- Analgesia: NSAID
- Prevention of ovulation: COCP, Mirena, GnRH (→ induce menopause), danazol
- Surgical: Complete hysterectomy
Bartholin’s Cyst/Abscess
Expected signs/symptoms, possible aetiology, investigations, management
Expected signs/symptoms:
- Swolling in the perineal area
- Redness, heat and pain for abscess with a more acute presentation
- Pain on sitting/intercourse/walking
Possible aetiology
Blockage of the mucus secreting gland → cyst formation → infection of the cyst → abscess
Abscesses may develop primarily.
Investigations
Hx: Symptoms?
Examination: Inspection of the external genitalia, check for features that may indicate a more sinister cause
Tests: ? Sampling abscess contents
Management
Asymptomatic cyst: Warm compress and bathing to aid drainage
Symptomatic cyst: Marsupilization, Abx
Abscess: Marsupilization (if spontaneous rupture does not occur), Abx
Intermenstrual bleeding
Significance and investigation
Significance:
- An abnormal type of bleeding
- Could indicate serious pathology
Possible Ddx:
- Malignancy
- STD
- Genital tract lesions, including ectropium
- Iatrogenic: HRT, COCP
- Fibroids, polyps
- Ovulation bleed (approximately 14 days prior to menses)
- Perimenopausal changes
Investigation
- Hx: Onset, duration, volume, consitency/colour, discharge?, pain, (deep) dyspareunia, post-coital bleeding sexual history including contraception, cervical smears
- Examination: Genitals, speculum, swabs, bimanual palpation
- Bloods: FBC (?anaemia), clotting screen
- Pregnancy test
- Pelvic USS
- Endometrial biopsy (for persistent IMB)
Postcoital bleeding
Significance and investigation
Significance
Possible Ddx:
- Ectropium
- STDs
- Polyps or fibroids
- Cervical bleeding (pre-malignant or malignant changes)
- Vaginal bleeding (pre-malignant or malignant changes)
Investigation
- Examination of the genitals, speculum and bimanual examination
- Triple swabs
- USS
Post-menopausal bleeding
Significance and investigations
Significance
‘Bleeding occurring at least 12 months after the LMP’
Possible ddx
- ! Malignancy - uterine (endometrial), cervical, ovarian
- Endometrial hyperplasia
- Atrophic vaginitis
- Cervical polyps
- Iatrogenic: Sequential HRT - regular bleeds
Investigations
- Hx: Duration, onset, volume, associated discharge - colour, odour, smear testing history
- Examination: Genital examination, speculum, bimanual examination, triple swabs
- Endometrial sample
- Transvaginal sonography (measures endometrial thickness)
Menstrual Irregularity
Significance and investigations
Significance
Differential diagnoses
- Anovulatory cycles: Common at extremes of reproductive age
- PCOS
- Thyroid diseases
- Pathology
- Iatrogenic: Contraceptive pill, IUS
- Extreme weight loss/gain, stress or exercise
Investigations
- Genital, speculum and bimanual palpation examination
- USS - for women > 35 years or for younger women in whom medical treatment* has failed. Followed by endometrial biopsy, if: The endometrium is thickened, polyp is suspected, patient is > 40 years of age, there are risk factors for endometrial malignancy.
* Medical treatment: Cyclical progesterone to
Lifestyle adjustments: Healthy diet, regular exercise, reduce stress levels
Ovarian cysts
Emergency investigation and management
Emergency investigation:
- FBC, CRP, U&Es, LFTs, lactate, pregnancy test, urinalysis
- USS (transvaginal or abdo)
- May show oedema and reduced blood flow in ovarian torsion
- Tumour markers
- CA125
- Germ cell tumours markers for under 40s - LDH, alpha fetoprotein, hCG
- Pregnancy test/beta-hCG
Management:
- Ovarian torsion → urgent surgery to prevent necrosis of the ovary
- Presents with vague presentation of acute pelvic pain, localises in late stages
- Sharp pain, worse on one side and associated with nausea and vomiting
- Raised CRP, WCC and lactate
- NOTE the larger the ovarian cyst the greater the risk of ovarian torsion for the associated ovary
- Cyst rupture or haemorrhage → Leaked fluid/blood can irritate the peritoneum, causing pain. Usually resolves with simple analgesia
Demonstrate knowledge and some experience in benign conditions of the lower genital tract including pruritis vulvae, vaginal discharge (both physiological and pathological).
Demonstrate a detailed knowledge and understanding of the emergency investigation and management of Bartholin’s abscess/cyst.
Bartholin’s gland: 2 small pea-sized glands located posteriorly and to the left/right of the vaginal opening. They act to provide lubrication during sexual intercourse.
Bartholin’s gland becomes blocked → Bartholin’s cyst forms → infection of the cyst → Bartholin’s abscess forms
Symptoms
Bartholin’s cyst: Swelling in the area of the gland
Bartholin’s abscess: Swelling, erythema, pain, systemic fever
Management
Cyst: Analgesia PRN, Sitz bath
Abscess: Drainage (with contents sent to microbiology), marsupialisation of the abscess, abx
Demonstrate understanding of the diagnosis and management of pelvic pain (including that arising from endometriosis, adhesions, and that of uncertain origin).
