Gynaecology Flashcards
What are fibroids?
Benign tumours of the smooth muscle of the uterus
Also called uterine leiomyomas
Affecting 40-60% of women in later reproductive years
Grow in response to oestrogen
Types of fibroids (4)
Intramural - within the myometrium
Subserosal - just below the outer layer of the uterus
Submucosal - just below the lining of the uterus
Pedunculated means on a stalk
How do fibroids present?
Often asymptomatic
Heavy menstrual bleeding (most common)
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain duringintercourse)
Reduced fertility
Investigating fibroids
Abdominal and bimanual examination may reveal a palpable pelvic mass
Hysteroscopy is the initial investigation
Pelvic ultrasound for larger fibroids
What is the management of fibroids <3cm?
Same as heavy menstrual bleeding
Mirena coil
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
What is the management of fibroids >3cm?
Referral to gynaecology
Medical management as <3cm
Surgery:
Uterine artery embolisation
Myomectomy
Hysterectomy
What are the potential complication of fibroids? (8)
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)
What is red degeneration of fibroids?
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
More likely in fibroids >5cm during 2nd/3rd trimester
How does red degeneration of fibroids occur?
Pregnant, hx of fibroids
Severe abdominal pain
Low-grade fever
Tachycardia
Often vomiting
What is endometriosis?
Where there is ectopic endometrial tissue outside the uterus
Endometrial tissue outside the uterus is described as an endometrioma
What are the symptoms of endometriosis?
Pelvic pain
Cyclical, dull, heavy or burning pain during menstruation
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites, such as haematuria`
What is found in examination of endometriosis?
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa
How is endometriosis diagnosed?
Ultrasound may reveal large endometriomas and chocolate cysts
Often unremarkable
Need referral to a gynaecologist for laparoscopy (GOLD STANDARD)
Staging of endometriosis
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
What does the management of endometriosis invole?
Initial management
Hormonal management
Surgical management
What is the initial management of endometriosis?
Establishing a diagnosis
Providing a clear explanation
Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
Analgesia as required for pain (NSAIDs and paracetamol first line
What is the hormonal management of endometriosis?
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
What is the surgical management of endometriosis?
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
What is menopause defined as?
Permanent end to menstruation
No periods for 12 months - then postmenopause
Around age of 51
What is premature menopause?
Period from 12 months after the final menstrual period onwards
What is perimenopause?
Time leading up to menopause and 12 months after
May experience vasomotor symptoms and irregular periods
Typically >45