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Gynaecology Conditions 2 Flashcards

1
Q

Incidence of endometriosis? How common?

A

• Incidence of endometriosis:
- General population = 10-15%
- Dysmenorrhoea = 40 – 60%
• Most common gynaecological condition after fibroids.

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2
Q

Pathology of endometriosis?

A
  • 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.
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3
Q

Common and rare locations of endometriosis?

A 
-	Common = pelvis.
•	Pouch of douglas
•	Uterosacral ligaments
•	Ovarian fossae
•	Bladder
•	Peritoneum
-	Rare = lungs, brain, muscle, eye
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4
Q

What is adenomyosis?

A

• Adenomyosis is invasion of myometrium by endometrial tissue, causes inflammation, pain and adhesions. Cause of chronic pelvic pain, dyspareunia and infertility

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5
Q

Risk factors for endometriosis?

A

o Early menarche, late menopause, long menstrual flow
o Obstruction to vaginal outflow
o Genetics – risk when 1st degree relative is 6x more

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6
Q

Protective factors for endometriosis?

A

o Multiparity

o Use of OCP

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7
Q

Aetiology of endometriosis?

A

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

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8
Q

Common sites of endometriosis?

A

o Peritoneum, pouch of Douglas (POD), ovary/tubes, ligaments, bladder and myometrium

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9
Q

Classical symptoms of endometriosis?

A

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

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10
Q

Examination findings in endometriosis?

A
  • 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.
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11
Q

Investigations in endometriosis? When to avoid? Signs present?

A

• 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.

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12
Q

Other investigations that can be performed in endometriosis?

A

• Pelvic MRI

- Used to assess extent of deep endometriosis involving bowel/urinary tract

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13
Q

What grading/staging is used in endometriosis?

A

• rASRM grading:

  • Location
  • Size
  • Depth
  • Adhesions

Scored from minimal to severe

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14
Q

DDx of endometriosis?

A
  • Adenomyosis
  • Chronic PID
  • Ectopic pregnancy
  • Uterine fibroids
  • Primary dysmenorrhoea
  • Appendicitis
  • Ovarian accident
  • IBS
  • UTI
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15
Q

General treatment of endometriosis?

A

• Analgesia
o Paracetamol/NSAIDs 1st line
 Naproxen
o If inadequate, consider other analgesia/referral

• Neuropathic Pain
o Amitryptiline/gabapentin/pregabalin

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16
Q

Hormonal management of endometriosis?

A
  • 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
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17
Q

Secondary care hormonal management of endometriosis if other do not work?

A
  • GnRH analogues
  • Effect = ovarian suppression
  • Mirena IUS
  • Effect = Endometrial suppression (sometimes ovarian)
  • Danazol (anti-androgenic)
  • Effect = ovarian suppression
  • SE= Irreversible voice changes, hirsutism, acne
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18
Q

Surgical management of endometriosis?

A
  • Laparoscopic ablation/resection/cystectomy
    • Coagulation, excision or ablation
  • Hysterectomy
    • Last resort for severe endometriosis, not suitable if wanting to get pregnant
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19
Q

Subfertility treatment in endometriosis?

A
  • Surgical ablation plus adhesiolysis

- In moderate to severe disease, IVF needed

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20
Q

Monitoring of endometriosis?

A

o Follow-up for patients with deep endometriosis or 1 or more endometriomas

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21
Q

Complications of endometriosis?

A 
o	Fibrosis/scarring
o	Infertility
o	Colonic/ureteric obstruction
o	Endometria rupture
o	Malignant change.
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22
Q

Define PID?

A
  • 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)
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23
Q

Who does PID usually affect?

A
  • Women between 15-20, who are sexually active most at risk
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24
Q

Risk factors for PID?

A

o Age <25
o History of STIs
o New or multiple sexual partners

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25
Q

Protective factors for PID?

A

o Barrier contraception
o Mirena IUS
o COCP

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26
Q

Causes of PID?

A

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)

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27
Q

Organisms in PID?

A

o Chlamydia trachomatis commonest
o Neisseria gonorrhoea, Mycoplasma genitalium, Ureaplasma urealyticum
o BV
o Other organsims - anaerobes, strep, staph

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28
Q

Symptoms of PID?

A

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

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29
Q

Signs of PID?

A

o Lower abdominal tenderness
o Cervical motion tenderness on bimanual
o Adnexal tenderness
o Fever >38

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30
Q

Investigations in PID?

A
  • 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
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31
Q

Initial management of PID?

A

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

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32
Q

Admit urgently PID when?

A

o Ectopic pregnancy cannot be ruled out
o Signs of pelvic peritonitis
o Tubo-ovarian abscess suspected
o Surgical abdomen cannot be ruled out

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33
Q

Outpatient management of PID?

A

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

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34
Q

Complications of PID?

A
  • Fibrosis and adhesions
  • Ectopic Pregnancy – 5x risk
  • Tubal factor Infertility
  • Tubo-ovarian abscess
  • Fitz-Hugh-Curtis Syndrome (liver capsule inflammation with perihepatic adhesion)
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35
Q

Define ectopic pregnancy? When to consider?

A
  • Gestational sac implantation outside the uterus

- Consider in any young female presenting with abdominal pain and vaginal bleeding especially with syncope

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36
Q

Pathology of ectopic?

A

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

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37
Q

How common is ectopic pregnancy?

A
  • 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
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38
Q

Risk factors for ectopic pregnancy?

A 
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
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39
Q

Predisposing factors for ectopic pregnancy?

A

o Salpingitis, previous surgery, previous ectopic, endometriosis

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40
Q

Chronic symptoms of ectopic pregnancy?

A

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)

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41
Q

Acute symptoms of ectopic (ruptured)?

A

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

42
Q

Signs fo ectopic pregnancy?

A 
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
43
Q

Investigations in ectopic pregnancy?

A
  • 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
44
Q

Initial management of ectopic pregnancy?

A

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

45
Q

What management of ectopic pregnancies are there?

A

 Offer expectant or medical

Surgical

46
Q

When to offer expectant or medical treatment in ectopic pregnancy?

A
  • Asymptomatic/Mild symptoms
  • hCG<1500IU
  • Ectopic pregnancy <3cm on scan and no fetal heart activity
  • No haemoperitoneum on TVS
47
Q

Expectant management of ectopic pregnancy?

A

• If clinically well
- Test hCG day 2, 4 & 7
- Falling hCG >15% and above criteria
• Take serum hCG weekly

48
Q

Medical management of ectopic pregnancy?

A

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

49
Q

Surgical management of ruptured ectopic pregnancy?

A

 Laparoscopy
 Laparotomy if haemodynamically unstable
 If contralateral tube healthy then salpingectomy, if not then salpingotomy

50
Q

Expectant management of unruptured ectopic pregnancy?

A

 If asymptomatic, hCG <1500IU/l, <3cm on scan

 Take serum hCG day 2, 4 & 7 then weekly until <15IU

51
Q

Medical management of unruptured ectopic pregnancy?

A

 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.

52
Q

Surgical management of unruptured ectopic pregnancy?

A

• 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

53
Q

Prognosis of ectopic pregnancy?

A

o If untreated, spontaneous abortion in 50% of cases

o Recurrence rate in 20%

54
Q

Complications of ectopic pregnancy?

A

o Tubal rupture
o Recurrent ectopic pregnancy
o Psychological effects

55
Q

How common is molar pregnancy?

A
  • Occurs in 1 per 1000 pregnancies.
  • After 1 molar pregnancy, the risk rises to 1%
  • 5% of complete moles turn malignant
56
Q

Classification of molar pregnancy?

A 
Premalignant
	Hydatiform mole (complete or partial)
Malignant
	Invasive mole
	Choriocarcinoma
	PSTT, ETT
57
Q

Pathology of molar pregnancy? What are the types of hydatiform mole?

A

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

58
Q

Pathology of invasive mole?

A

o Develops from complete mole and invades myometrium

59
Q

Pathology of chroriocarcinoma?

A

o Follow molar pregnancy commonly, but can follow pregnancy/ectopic/abortion
o Ability to spread locally and metastasise
o Secretes hCG

60
Q

Risk factors for molar pregnancy?

A
  • Age = >45 and <16
  • Ethnicity = higher in east Asia (esp. Korea and Japan)
  • Previous molar pregnancy = 10x higher risk of developing subsequent molar pregnancy
61
Q

Symptoms and signs in molar pregnancy?

A

• 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%)

62
Q

Investigations in molar pregnancy?

A

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.

63
Q

Management of hydatiform mole?

A

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

64
Q

Surveillance of hydatiform mole?

A

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

65
Q

Future pregnancy management after hydatiform mole?

A

 In future pregnancies, serum hCG measured at 6 and 10 weeks postpartum as possibility of choriocarcinoma

66
Q

When would you start chemotherapy in hydatiform mole?

A 
hCG levels rise, plateau or are still abnormal 6 months after surgical evacuation
Choriocarcinoma
Metastases
Heavy vaginal bleeding
Serum hCG >20000
67
Q

Chemotherapy given in hydatiform mole?

A

 Most are given methotrexate and folinic acid.

 Metastases from choriocarcinoma are seen in the lung, liver and brain

68
Q

Treatment of choriocarcinoma?

A

 3 specialist centres

 Chemotherapy based on methotrexate

69
Q

How common are fibroids?

A
  • 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
70
Q

Define uterine fibroid?

A

• 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
71
Q

Types of uterine fibroid?

A
  • 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

72
Q

What are endometrial polyps? Seen commonly when? Treatment?

A
  • 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
73
Q

Risk factors for fibroids?

A

o Obesity
o 3x more common in African-American women
o FHx of fibroids
o Early menarche

74
Q

Protective factors for fibroids?

A

o Exercise
o Increased parity
o Smoking

75
Q

Symptoms of uterine fibroids?

A 
•	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
76
Q

Signs of uterine fibroids?

A

o Palpable abdominal mass arising from pelvis
o Enlarged, often irregular, firm, non-tender uterus on bimanual pelvic examination
o Signs of anaemia

77
Q

What is red degeneration of fibroid in pregnancy?

A

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

78
Q

Investigations in fibroids?

A

• 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)

79
Q

Management of asymptomatic fibroids?

A

No treatment may be necessary

80
Q

Medical management of symptomatic fibroids?

A 
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
81
Q

Medical management prior to surgery?

A

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

82
Q

Surgical management of fibroids - indications?

A

 Excessively enlarged uterus
 Pressure symptoms
 Medical management not enough
 Fibroid is submucous and fertility reduced

83
Q

Surgical management of fibroids - options?

A

 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

84
Q

How common are ovarian cysts?

A
  • 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.
85
Q

Classification of ovarian cysts?

A 
o	Functional (25%)
o	Benign (70%)
Malignant (5%)
86
Q

Describe functional ovarian cysts?

A

 Enlarged or persistent follicular or corpus luteum cysts

 Considered normal <5cm, usually resolve over 2-3 cycles

87
Q

Name three types of benign ovarian cysts?

A

 Epithelial neoplastic cysts (serous cystadenoma, mucinous cystadenoma)
 Cystic tumours of germ cells (benign cystic teratoma, benign mature teratoma)
 Solid Tumours

88
Q

Describe epithelial neoplastic of benign ovarian cysts?

A
  • 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
89
Q

Describe cystic germ cell tumours of benign ovarian cysts?

A
  • Benign cystic – rarely malignant
  • Benign mature teratoma – may contain well-differentiated tissue (hair/teeth)
  • 20% bilateral and most common in young women
90
Q

Describe solid tumours of benign ovarian cysts?

A

• 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)

91
Q

Risk factors for ovarian cysts?

A

o Obesity
o Infertility
o Early menarche
o Tamoxifen therapy

92
Q

Symptoms of ovarian cysts?

A 
•	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)
93
Q

3 acute presentations of ovarian cyst?

A

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

94
Q

Investigations in ovarian cysts?

A 
•	Pregnancy Test
•	Bloods – FBC
•	Urinalysis
•	USS
o	Transvaginal preferable over transabdominal
95
Q

USS findings and follow up?

A

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

96
Q

Other investigations needed in ovarian cysts?

A
  • CT/MRI need if US not definitive
  • Diagnostic laparoscopy and FNA and cytology needed in some cases
  • Tumour Markers
97
Q

What tumour markers and when would you perform them in ovarian cysts?

A

o Ca125 – in women >40

o LDH, AFP and hCG – in women <40

98
Q

What is the RMI in ovarian cysts?

A
  • RMI = USS x Menopausal status x CA125

- RMI >200 – should have CT abdomen and pelvis

99
Q

Management of ovarian cysts if unstable, stable or acute pain?

A
  • Admit to hospital if acute, severe pain
  • If stable, urgent TVS
  • If unstable, urgent laparoscopy
100
Q

Management of ovarian cysts in premenopausal women? Monitoring?

A
  • 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
101
Q

Management of post-menopausal ovarian cysts? What is it dependent on?

A
  • 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.

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