Gynaecology Conditions 2 Flashcards
Incidence of endometriosis? How common?
• Incidence of endometriosis:
- General population = 10-15%
- Dysmenorrhoea = 40 – 60%
• Most common gynaecological condition after fibroids.
Pathology of endometriosis?
- Endometriosis is the presence of endometrial like tissue outside the uterine cavity.
- It is oestrogen dependent and therefore mostly affects women during their reproductive years.
Common and rare locations of endometriosis?
- Common = pelvis. • Pouch of douglas • Uterosacral ligaments • Ovarian fossae • Bladder • Peritoneum - Rare = lungs, brain, muscle, eye
What is adenomyosis?
• Adenomyosis is invasion of myometrium by endometrial tissue, causes inflammation, pain and adhesions. Cause of chronic pelvic pain, dyspareunia and infertility
Risk factors for endometriosis?
o Early menarche, late menopause, long menstrual flow
o Obstruction to vaginal outflow
o Genetics – risk when 1st degree relative is 6x more
Protective factors for endometriosis?
o Multiparity
o Use of OCP
Aetiology of endometriosis?
o Unclear
o Retrograde menstruation with adhesion, invasion and growth of the tissue (most popular)
During menstruation, endometrial tissue spills into the pelvic cavity through the fallopian tubes (retrograde menstruation) and then implants and becomes functional, responding to the hormones of the ovarian cycle.
o Metaplasia of mesothelial cells
o Systemic and lymphatic spread
Endometrial tissues transported through the body by lymph or venous channels.
Explains the rare cases of distant sites for endometriosis
Common sites of endometriosis?
o Peritoneum, pouch of Douglas (POD), ovary/tubes, ligaments, bladder and myometrium
Classical symptoms of endometriosis?
Can be asymptomatic
o Severe, cyclical dysmenorrhoea
o Deep dyspareunia - Affects QoL
o Heavier bleeding
o Chronic, cyclical/continuous Pelvic pain
o Infertility
Adhesions and tubal/ovarian damage can affect ovulation
o Dysuria
o Dyschezia (pain on defecation) and cyclic pararectal bleeding
o Chronic fatigue, bloating, low back pain
Examination findings in endometriosis?
- Often normal
- Speculum= visible lesions in vagina/cervix
- Bimanual=fixed retroverted uterus (classic sign)
- Adnexal masses (endometriomas – ‘chocolate cysts’ on ovaries) or tenderness.
- Nodules/tenderness over uterosacral ligaments.
Investigations in endometriosis? When to avoid? Signs present?
• Transvaginal USS
- Identifies endometriosis + deep into bowel//bladder & endometriomas
- If not appropriate, can use transabdominal USS
• Laparoscopy with biopsy (gold standard)
o Histological verification
Positive is confirmative
Endometriomas >3cm should be resected to rule out malignancy (rare)
o If normal – woman does not have endometriosis
o Avoid within 3 months of hormonal treatment (leads to underdiagnosis)
o Signs present – red dots, black ‘powder burn’ dots, large raised red/black vesicles, white area of scarring with surrounding abnormal blood vessels.
Other investigations that can be performed in endometriosis?
• Pelvic MRI
- Used to assess extent of deep endometriosis involving bowel/urinary tract
What grading/staging is used in endometriosis?
• rASRM grading:
- Location
- Size
- Depth
- Adhesions
Scored from minimal to severe
DDx of endometriosis?
- Adenomyosis
- Chronic PID
- Ectopic pregnancy
- Uterine fibroids
- Primary dysmenorrhoea
- Appendicitis
- Ovarian accident
- IBS
- UTI
General treatment of endometriosis?
• Analgesia
o Paracetamol/NSAIDs 1st line
Naproxen
o If inadequate, consider other analgesia/referral
• Neuropathic Pain
o Amitryptiline/gabapentin/pregabalin
Hormonal management of endometriosis?
- COCP
• Cyclically or continuous PO/IM/SC
• Effect = ovarian suppression
• SE = headaches, N&V, diarrhoea, stroke. - Medroxyprogesterone acetate or other progestagens
• Effect = ovarian suppression
• SE = weight gain, bloating, acne, irregular bleeding, depression
Secondary care hormonal management of endometriosis if other do not work?
- GnRH analogues
- Effect = ovarian suppression
- Mirena IUS
- Effect = Endometrial suppression (sometimes ovarian)
- Danazol (anti-androgenic)
- Effect = ovarian suppression
- SE= Irreversible voice changes, hirsutism, acne
Surgical management of endometriosis?
- Laparoscopic ablation/resection/cystectomy
• Coagulation, excision or ablation - Hysterectomy
• Last resort for severe endometriosis, not suitable if wanting to get pregnant
Subfertility treatment in endometriosis?
- Surgical ablation plus adhesiolysis
- In moderate to severe disease, IVF needed
Monitoring of endometriosis?
o Follow-up for patients with deep endometriosis or 1 or more endometriomas
Complications of endometriosis?
o Fibrosis/scarring o Infertility o Colonic/ureteric obstruction o Endometria rupture o Malignant change.
Define PID?
- Infection of upper genital tract
- Usually spread from cervix to the uterus (endometritis), Fallopian tubes (salpingitis), ovaries (oophoritis) or adjacent peritoneum (peritonitis)
- Severity ranges from chronic low-grade infection to acute infection (severe symptoms and abscess formation)
Who does PID usually affect?
- Women between 15-20, who are sexually active most at risk
Risk factors for PID?
o Age <25
o History of STIs
o New or multiple sexual partners
Protective factors for PID?
o Barrier contraception
o Mirena IUS
o COCP
Causes of PID?
o STIs (25% from chlamydia and gonorrhoea)
o Uterine instrumentation e.g. hysteroscopy, insertion of IUCD, TOP
o Post-partum – terminations or dilatation
o Descend from other infected organ (appendicitis)
Organisms in PID?
o Chlamydia trachomatis commonest
o Neisseria gonorrhoea, Mycoplasma genitalium, Ureaplasma urealyticum
o BV
o Other organsims - anaerobes, strep, staph
Symptoms of PID?
o Uni/Bilateral lower abdominal tenderness – constant or intermittent
o Vaginal discharge/bleeding – purulent/IMB/PCB/menorrhagia
o Deep dysparenuria
Sudden onset, constant
o Fever >38 degrees
o Malaise, nausea
o Secondary dysmenorrhoea
o Can be asymptomatic
Signs of PID?
o Lower abdominal tenderness
o Cervical motion tenderness on bimanual
o Adnexal tenderness
o Fever >38
Investigations in PID?
- Pregnancy test
- STI Screening - VVS NAAT swabs for chlamydia, gonorrhoea and trichomonas – M, C &S, Bloods for HIV and syphilis
- Endocervical swabs for gonorrhoea culture
- Urine dipstick + MSU
- Bloods – FBC, ESR, CRP, cultures (if shocked)
- Consider
o TVS, laparoscopy
Initial management of PID?
o IV fluids if shocked
o Urinalysis and send high vaginal swab and cervical swab (for chlamydia, gonorrhoea and M, C & S)
o Bloods – FBC, ESR, CRP, cultures (if sepsis/shocked)
o Refer to gynaecology
IV Abx if symptoms severe – IV Ceftriazxone plus doxyclycline
Outpatient Abx – IM stat Ceftriaxone 500mg + Oral doxycycline 100mg BDS + oral metronidazole 400mg BDS for 14 days
Follow-up 72h later
Admit urgently PID when?
o Ectopic pregnancy cannot be ruled out
o Signs of pelvic peritonitis
o Tubo-ovarian abscess suspected
o Surgical abdomen cannot be ruled out
Outpatient management of PID?
o Refer to GUM clinic – contact tracing for last 6 months
o Rest
o Analgesia – paracetamol/ibuprofen
o Empirical Abx (Ceftriaxone 500mg IM stat (or azithromycin 1g PO, if gonorrhoea) + doxycycline 100mg PO BD and metronidazole 400mg PO BD for 14 days)
o Removal of IUD if indicated
o No sex until they AND partner have been treated
o Follow-up 72h later
Complications of PID?
- Fibrosis and adhesions
- Ectopic Pregnancy – 5x risk
- Tubal factor Infertility
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis Syndrome (liver capsule inflammation with perihepatic adhesion)
Define ectopic pregnancy? When to consider?
- Gestational sac implantation outside the uterus
- Consider in any young female presenting with abdominal pain and vaginal bleeding especially with syncope
Pathology of ectopic?
o Implantation of gestational sac in Fallopian tubes may have three results:
Extrusion (tubal abortion) into peritoneal cavity
Spontaneous involution of pregnancy
Rupture through the tube causing pain and bleeding
o Implantation in uterine horn is particularly dangerous, may reach 10-14 weeks pregnancy before rupture
How common is ectopic pregnancy?
- Commonest cause of maternal mortality in first trimester
- Occurs in about 1% of pregnancies
o 96% fallopian tubes, 2% interstitial part of uterus, 1.5% intra-abdominally - 1 in 2000 lead to death
Risk factors for ectopic pregnancy?
o PID o Pelvic surgery/adhesions o Previous ectopic o Endometriosis o Assisted fertilisation o IUCD o Progesterone-only pill o Anatomical variants o Ovarian and uterine cysts o Smoking
Predisposing factors for ectopic pregnancy?
o Salpingitis, previous surgery, previous ectopic, endometriosis
Chronic symptoms of ectopic pregnancy?
o Often asymptomatic (e.g. unsure dates)
o Amenorrhea (usually 6-8 weeks)
o Pain (lower abdominal, often mild and vague, classically unilateral)
o Vaginal bleeding (usually small amount, often brown)
o Shoulder tip pain (diaphragmatic irritation from intra-abdominal blood)
o Diarrhoea
o Often have no specific signs
Uterus usually normal size
Cervical excitation/tenderness occasionally.
Adnexal tenderness
Adnexal mass (very rarely)
Acute symptoms of ectopic (ruptured)?
o Sudden severe lower abdominal pain
Can be more chronic
May be worse on defecation
o Collapse or fainting
o Vaginal bleeding – may have history of amenorrhoea 6-8 weeks
May be fresh, dark (like prune juice) and irregular
o Haemorrhage may cause shoulder tip pain (from blood irritating diaphragm)
o Nausea and vomiting
o Symptoms of pregnancy – breast tenderness
Signs fo ectopic pregnancy?
o Hypovolaemic shock o Abdominal tenderness – peritonism o Cullen’s sign (not usually important) o Bimanual vaginal examination Tender adnexa and sometimes a mass o Speculum shows vaginal blood
Investigations in ectopic pregnancy?
- Do not delay resuscitation and referral
- Pregnancy test – usually positive
- Refer to EPAU within 24 hours
o If pregnancy test positive and pain/pelvic tenderness/cervical motion tenderness
o Bleeding or pain or pregnancy - Transvaginal/transabdominal USS
o Demonstrates intrauterine pregnancy, free fluid in pouch of Douglas and adnexal mass
o Transvaginal better - May need laparoscopy
Initial management of ectopic pregnancy?
o Oxygen and IV access (two wide bore cannulas)
o Bloods (FBC, group and save (cross-match 6U of blood))
o Request Rhesus status and antibody status
o IV fluids (Crystalloid)
o Refer to gynaecology
What management of ectopic pregnancies are there?
Offer expectant or medical
Surgical
When to offer expectant or medical treatment in ectopic pregnancy?
- Asymptomatic/Mild symptoms
- hCG<1500IU
- Ectopic pregnancy <3cm on scan and no fetal heart activity
- No haemoperitoneum on TVS
Expectant management of ectopic pregnancy?
• If clinically well
- Test hCG day 2, 4 & 7
- Falling hCG >15% and above criteria
• Take serum hCG weekly
Medical management of ectopic pregnancy?
If hCG fallen <15% from day 2, 4 & 7
• Methotrexate - single dose, followed by hCG on day 4 and 7
• If hCG fallen by <15% then second dose given
• Need reliable contraception for 3 months afterwards - teratogenic
Surgical management of ruptured ectopic pregnancy?
Laparoscopy
Laparotomy if haemodynamically unstable
If contralateral tube healthy then salpingectomy, if not then salpingotomy
Expectant management of unruptured ectopic pregnancy?
If asymptomatic, hCG <1500IU/l, <3cm on scan
Take serum hCG day 2, 4 & 7 then weekly until <15IU
Medical management of unruptured ectopic pregnancy?
Methotrexate
• Offer if can return for follow up with no pain, adnexal mass <35mm, no heartbeat, serum hCG<1500IU/l, no intrauterine pregnancy
• Measure serum hCG at day 4, 7 and then weekly until negative result attained
• Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months after as methotrexate is teratogenic.
Surgical management of unruptured ectopic pregnancy?
• If unable to return to follow-up or significant pain, adnexal mass 35mm, foetal heartbeat, serum hCG >5000
• Performed laparoscopically
o Offer salpingectomy unless other risk factors for infertility
Take urine pregnancy test after 3 weeks, return if positive
o Salpingotomy alternative if risk factors
• Measure serum hCG at 7 days and weekly until negative
• Anti-D rhesus 250UIU to all Rh negative women
Prognosis of ectopic pregnancy?
o If untreated, spontaneous abortion in 50% of cases
o Recurrence rate in 20%
Complications of ectopic pregnancy?
o Tubal rupture
o Recurrent ectopic pregnancy
o Psychological effects
How common is molar pregnancy?
- Occurs in 1 per 1000 pregnancies.
- After 1 molar pregnancy, the risk rises to 1%
- 5% of complete moles turn malignant
Classification of molar pregnancy?
Premalignant Hydatiform mole (complete or partial) Malignant Invasive mole Choriocarcinoma PSTT, ETT
Pathology of molar pregnancy? What are the types of hydatiform mole?
Normally at conception, half chromosomes come from mother and father
Complete Mole - All genetic material from father, empty oocyte lacking maternal gene is fertilised
No foetal tissue
Partial Mole
Trophoblast cells triploid
Two sperm fertilise ovum at same time
Usually foetal tissue or blood cells
Pathology of invasive mole?
o Develops from complete mole and invades myometrium
Pathology of chroriocarcinoma?
o Follow molar pregnancy commonly, but can follow pregnancy/ectopic/abortion
o Ability to spread locally and metastasise
o Secretes hCG
Risk factors for molar pregnancy?
- Age = >45 and <16
- Ethnicity = higher in east Asia (esp. Korea and Japan)
- Previous molar pregnancy = 10x higher risk of developing subsequent molar pregnancy
Symptoms and signs in molar pregnancy?
• Irregular first trimester vaginal bleeding (>90%)
• Severe vomiting
• Uterus enlargement
• Vaginal passage of vesicles containing products of conception
• Abdominal pain (due to huge theca-lutein cysts)
• Exaggerated pregnancy symptoms
- Hyperemesis (10%)
- Hyperthyroidism (5%)
- Early pre-eclampsia (5%)
Investigations in molar pregnancy?
Urine and Blood hCG very high
Histology
o Definitive diagnosis by histology of product of conception
USS
- Complete mole
‘Snowstorm’ appearance of mixed echogenicity
Large theca lutein cysts.
- Partial mole
Fetus may be viable, with signs of early growth restriction or structural abnormalities.
Management of hydatiform mole?
o Surgical evacuation of products of conception – send for histology for confirmation
o Anti-D if Rh negative
o Urine Pregnancy test performed 3 weeks after medical management if products of conception not sent
o Avoid pregnancy for 6 months until hCG normal
Surveillance of hydatiform mole?
Two-weekly serum and urine hCG until normal
Complete – monthly hCG testing once normal for 6 months
Partial – normal levels are confirmed 4 weeks later and surveillance stopped
Future pregnancy management after hydatiform mole?
In future pregnancies, serum hCG measured at 6 and 10 weeks postpartum as possibility of choriocarcinoma
When would you start chemotherapy in hydatiform mole?
hCG levels rise, plateau or are still abnormal 6 months after surgical evacuation Choriocarcinoma Metastases Heavy vaginal bleeding Serum hCG >20000
Chemotherapy given in hydatiform mole?
Most are given methotrexate and folinic acid.
Metastases from choriocarcinoma are seen in the lung, liver and brain
Treatment of choriocarcinoma?
3 specialist centres
Chemotherapy based on methotrexate
How common are fibroids?
- Most common non-cancerous tumours in women of child-bearing age
- Uterine fibroids are present in 20-40% of women
- Most common indication for hysterectomy
Define uterine fibroid?
• Uterine fibroids = benign tumours arising from the myometrium of the uterus (also called leiomyomata).
- Smooth muscles and contain ECM with disordered collagen
- Start as multiple, single-cell seedlings and increase slowly stimulated by oestrogen and progestogens
- Centre may calcify as they grow due to inadequate blood supply
Types of uterine fibroid?
- Intramural = located within the myometrium.
- Submucosal = >50% projection into the endometrial cavity.
- Subserosal = >50% of the fibroid mass extends outside the uterine contours.
o Can be uterine, cervical, intra-ligamentous, pedunculated
What are endometrial polyps? Seen commonly when? Treatment?
- Endometrial polyps (adenoma)
o These are focal overgrowth of the endometrium and are malignant in <1%.
o They are more common in women >40 but may occur at any age.
o Treatment is usually resection during hysteroscopy and the polyp should be sent for histological assessment
Risk factors for fibroids?
o Obesity
o 3x more common in African-American women
o FHx of fibroids
o Early menarche
Protective factors for fibroids?
o Exercise
o Increased parity
o Smoking
Symptoms of uterine fibroids?
• Oestrogen dependent so enlarge during pregnancy and on COCP, atrophy during menopause • Many women are asymptomatic. • Symptoms o Dysmennorhoea o Menorrhagia Heavy and prolonged periods Anaemia o Pressure symptoms (esp. frequency)/Palpable mass o Pelvic pain Due to torsion of pedunculated fibroid, similar symptoms to torted ovarian cyst o Infertility Interfere with implantation
Signs of uterine fibroids?
o Palpable abdominal mass arising from pelvis
o Enlarged, often irregular, firm, non-tender uterus on bimanual pelvic examination
o Signs of anaemia
What is red degeneration of fibroid in pregnancy?
Thrombosis of capsular vessels is followed by venous engorgement and inflammation causing abdominal pain, vomiting, fever
Usually in last half of pregnancy or puerperium
Treated expectantly (bed rest, analgesia) with resolution over 4-7 days
o If fibroid large enough, CS may be planned
Investigations in fibroids?
• Pregnancy Test
• Bloods – FBC, ferritin
• Pelvic USS
o Transvaginal or abdominal USS can differentiate the types and dimensions of the fibroids.
• MRI if USS not definitive and considering myomectomy
• Hysteroscopy with biopsies (definitive, if needed)
Management of asymptomatic fibroids?
No treatment may be necessary
Medical management of symptomatic fibroids?
o Mefanamic Acid - NSAIDs o Tranexamic acid to reduce menorrhagia o COCP if patient requires contraception o Mirena IUS Reduces menstrual loss and uterus size
Medical management prior to surgery?
o GnRH analogues (goserelin)
Shrink fibroids but then they regrow so only used 3-6 months pre-surgery
o Ullipristal Acetate
Selective progesterone receptor modulator, taken 3-6 months pre-surgery to shrink fibroid
Surgical management of fibroids - indications?
Excessively enlarged uterus
Pressure symptoms
Medical management not enough
Fibroid is submucous and fertility reduced
Surgical management of fibroids - options?
Myomectomy
• Used to maintain reproductive potential
Hysterectomy
• Women who have either completed their family or are over 45 years.
• Guaranteed cure of fibroids.
Uterine artery embolization
How common are ovarian cysts?
- Ovarian cysts are extremely common and frequently physiological
- 30% of women with regular menses
- Mostly premenopausal
- Due to follicular cyst (<3cm) and corpus luteal cyst (<5cm) formation during the menstrual cycle.
Classification of ovarian cysts?
o Functional (25%) o Benign (70%) Malignant (5%)
Describe functional ovarian cysts?
Enlarged or persistent follicular or corpus luteum cysts
Considered normal <5cm, usually resolve over 2-3 cycles
Name three types of benign ovarian cysts?
Epithelial neoplastic cysts (serous cystadenoma, mucinous cystadenoma)
Cystic tumours of germ cells (benign cystic teratoma, benign mature teratoma)
Solid Tumours
Describe epithelial neoplastic of benign ovarian cysts?
- Serous Cystadenoma – papillary growths, common in women 40-50, 20% bilateral and 25% malignant
- Mucinous cystadenoma – large, filled with mucinous material, common in 20-40
Describe cystic germ cell tumours of benign ovarian cysts?
- Benign cystic – rarely malignant
- Benign mature teratoma – may contain well-differentiated tissue (hair/teeth)
- 20% bilateral and most common in young women
Describe solid tumours of benign ovarian cysts?
• Fibroma
o Associated with Meig’s syndrome
Pleural effusion (right) + benign ovarian fibroma and ascites
• Thecoma
• Adenofibroma
• Brenner’s tumour (display variant which may look malignant)
Risk factors for ovarian cysts?
o Obesity
o Infertility
o Early menarche
o Tamoxifen therapy
Symptoms of ovarian cysts?
• Asymptomatic • Symptoms o Chronic pain o Dull ache o Pressure on other organs (urinary frequency or bowel disturbance) o Dyspareunia (endometrioma) o Cyclical pain (endometrioma) o Abnormal uterine bleeding o Hormonal effects – androgenic features o Mass in pelvis (adnexal)
3 acute presentations of ovarian cyst?
o Rupture - contents into peritoneal cavity= intense pain. (esp with endometrioma or dermoid cyst)
o Haemorrhage - pain. Peritoneal cavity haemorrhage = severe + hypovolemic shock.
o Torsion of pedicle - infarction and pain
Investigations in ovarian cysts?
• Pregnancy Test • Bloods – FBC • Urinalysis • USS o Transvaginal preferable over transabdominal
USS findings and follow up?
o Premenopausal women - a cyst of <5cm should not cause concern (or referral) unless there are other suspicious features or she is symptomatic (e.g. pain)
A re-scan at 6 weeks is recommended (when she will be at another point in her scan to see if the cyst has resolved
Other investigations needed in ovarian cysts?
- CT/MRI need if US not definitive
- Diagnostic laparoscopy and FNA and cytology needed in some cases
- Tumour Markers
What tumour markers and when would you perform them in ovarian cysts?
o Ca125 – in women >40
o LDH, AFP and hCG – in women <40
What is the RMI in ovarian cysts?
- RMI = USS x Menopausal status x CA125
- RMI >200 – should have CT abdomen and pelvis
Management of ovarian cysts if unstable, stable or acute pain?
- Admit to hospital if acute, severe pain
- If stable, urgent TVS
- If unstable, urgent laparoscopy
Management of ovarian cysts in premenopausal women? Monitoring?
- Aim to exclude malignancy and preserve fertility.
- Re-scan in 6 weeks.
- If cyst <5cm and asymptomatic – no surgical intervention
- If cyst >5 cm, symptomatic or features a dermoid/endometriosis – laparoscopic ovarian cystectomy
o Do not spill cyst contents (can cause peritonitis or can disseminate an early ovarian cancer) - Monitor with yearly USS
Management of post-menopausal ovarian cysts? What is it dependent on?
- Low RMI (<25), simple, <5cm cyst and normal CA125
o Follow up USS and CA125 every 4 months
o If no change after 1 year then discontinue monitoring
o If change and RMI still low or woman requests removal = laparoscopic oophorectomy.
- Moderate RMI (25 – 250) o Oophorectomy (usually bilateral) is recommended.
- Severe RMI (>250)
o Refer to cancer centre for full staging laparotomy.
