Gynaecology Flashcards
What drug is used before myomectomy?
Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery which helps to reduce the size of the fibroids.
Who are the common target groups for uterine fibroids?
- Nulliparity
- Early menarche (< 10 years old)
- Age: 25–45 years
Fibroids are largely found in women of reproductive age
influenced by hormones (i.e., estrogen, growth hormone, and progesterone)
During menopause, hormone levels begin to decrease and leiomyomas begin to shrink - Increase incidence in African Americans - V.V. imp
- Obesity
- Family history
What are the typical symptoms of fibroids?
- may be asymptomatic - depending on the size, number and location
- Abnormal menstruation - menorrhagia and dysmenorrhea- increased total surface area as a result of the bulging uterine wall, impaired uterine wall contractility, or micro/macrovascular abnormalities.
- Features of mass effect:
i. Back or pelvic pain: cramping pains, often during menstruation
ii. urinary symptoms, e.g. frequency, may occur with larger fibroids and bowel symptoms (bloating, constipation) - Reproductive abnormality - Infertility and Dyspareunia (obstructed uterine cavity and/or impaired contractility of the uterus)
How are fibroids diagnosed?
Transvaginal US
What is the crude pathophysiology of fibroids?
Oestrogen-dependent benign tumours
What are the complications of fibroids during pregnancy?
Pain (red degeneration) -haemorrhage into tumour - commonly occurs during pregnancy
Premature labour
Malpresentation
Obstructed labour (cervical uterine fibroid)
Difficulty for CS (C-section)
What is primary Amenorrhoea? and what are the possible causes?
failure to start menses by the age of 16 years
- Turner’s syndrome
- testicular feminisation
- congenital adrenal hyperplasia
- congenital malformations of the genital tract
What is secondary Amenorrhoea? and what are the possible causes?
cessation of established, regular menstruation for 6 months or longer
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis*
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
What is oligomenorrhoea?
Menstruation occurs every 35days -6mths
What is hypothalamic hypogonadism? What are the hormone findings expected to be?
It is a cause of secondary amenorrhoea. It is caused due to psychological factors, low weight, anorexia nervosa and excessive exercise (atheletes).
GnRH, FSH , LH and oestradiol are all reduced.
(Bone density is reduced to low oestrogen)
What other gynaecological tests are required to rule out abdo pain in women?
In addition to routine diagnostic work up of abdominal pain, all female patients should also undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.
What are the features of mittelschmerz?
Usually mid cycle pain. (recurrent unilateral pain) Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours.
What type of ovarian cysts immediately require biopsy?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy
What is the commonest type of ovarian cyst seen in young women?
Follicular cysts - commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles
Functional cysts associated with hyperestrogenism and endometrial hyperplasia
Which ovarian cyst is more likely to be associated with intraperioteneal bleeding?
Corpus leuteal cyst - Unreleased corpus luteum may fill with blood or fluid and form a corpus luteal cyst
Functional cysts - Produces progesterone, which may delay menses
Associated with progesterone-only contraceptive pills and ovulation-inducing medication
What the broad types of ovarian cysts and give examples
Functional - Follicular cysts, Corpus leuteal cysts, Theca Leutin cyst
Non-functional - Benign germ cell tumours (Dermoid cysts), Benign epithelial tumours ( Serous cystadenoma, Mucinous cystadenoma)
What is the most common benign germ-cell ovarian tumour in woman under the age of 30 years
Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
What is the most common benign epithelial ovarian tumour?
Serous cystadenoma- the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
What are 6 gynaecological Differentials for abdo pain in females?
- Ovarian Torsion
- Ruptured ovarian cyst
- Endometriosis
- Ectopic pregnancy
- Mittelschmerz
- PID
How to differentiate ovarian torsion from ruptured ovarian cyst?
Ruptured ovarian cyst presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.
Ovarian or adnexal torsion can present similarly with sharp unilateral pain often associated with nausea and vomiting. There is a tender palpable adnexal mass on bimanual exam. Ultrasound shows an enlarged, oedematous ovary with impaired blood flow.
How is the risk stratification performed for ovarian cycts and tumours
RMI - Risk of malignancy index
U x M x CA125
o U = Ultrasound score (0/1/3)
o M = Menopausal status (1/3)
o CA125 = Serum cancer antigen 125 level (U/L)
RMI <25 - Low risk
RMI 25-250 - Moderate risk
RMI >250 - High risk
What is the management of ovarian cysts in premenopausal women?
In a premenopausal woman, cyst of <5cm should NOT cause concern unless:
o Other suspicious features
o /Patient is symptomatic (eg: pain)
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Consider laparoscopic cystectomy:
o Avoid spillage of contents (in all >5cm cysts & dermoid cysts)
o Can be done by removing cyst in an ‘endobag’
What is the follow up of ovarian cysts in premenopausal women if cyst is persistent after conservative theraphy and waiting
• Rescan in 6wks to see if the cyst has resolved:
o If cyst is persistent then monitor with:
USS
/CA125
What is the management of ovarian cysts in postmenopausal women?
By definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst
**Regardless of nature or size should be referred to gynaecology for assessment
Treatment include Bilateral laprosocopic oophorectomy or in high RMI cases - full staging laprotomy