Gynaecology: Conditions (Fibroids, PCOS, Endometriosis)

Question 1

What are Fibroids?

Answer 1

Benign smooth muscle tumours of the uterus

Question 2

How do uterine fibroids present?

Answer 2

Often asymptomatic.

Symptoms:

• Most common presentation is heavy and prolonged periods +/- symptoms of anaemia
• DO NOT generally cause IMB or PMB (this is because they are highly responsive to oestrogen therefore symptoms line up with cycle)
• Can cause fertility problems if in certain locations
• Can present as painful, especially if they become torted
• Occasionally they may present with mass effect, either as an abdominal mass or as or urinary frequency due to compression on the bladder

Question 3

How are Fibroids managed?

Answer 3

• If symptoms are minimal, no need for treatment
• Most common treatment is Myomectomy, removal of the fibroid. Can be done hysteroscopically, laparoscopically or open. (N.B: Some risk of hysterectomy due to bleeding, future pregnancies will need to be carefully managed and require elective CS to prevent uterine rupture)
• Can give GnRH analogues such as Goserelin for 3-6 months to shrink fibroid prior to surgery.
• For women who no longer wish to remain fertile, Uterine Artery Embolization (which avoids GA but ca be painful) and Hysterectomy are also options.

Question 4

What is endometriosis?

Answer 4

The presence of endometrial tissue outside the uterus.

Question 5

How does endometriosis present?

Answer 5

PAIN:

• Cyclical, as endometrial tissue responds to menstrual cycle
• Can become constant if adhesions form
• Severe dysmenorrhoea leading to time off work and school
• Deep dyspareunia
• Dysuria
• Dyschezia

Can also present as subfertility or asymptomatically

Question 6

What examination findings might you see in a woman with endometriosis?

Answer 6

Speculum: Rare you see anything, may see visible lesions in vagina or cervix.

BM Exam: Fixed retroverted uterus is a classic sign, may find adnexal tenderness or masses

Question 7

What is the gold standard for diagnosis of endometriosis?

Answer 7

Laparoscopy with biopsy (for histological confirmation).

Question 8

How is endometriosis managed?

Answer 8

Sort of depends on the issue (pain vs fertility).

To manage pain:

• Can treat empirically with COCP or progesterone w/o laparoscopic diagnosis
• NSAIDs are the most effective form of analgesia

To manage infertility OR if medical management fails, Surgery:

• Laparoscopy + ablation or excision
• Nodules in particular should be removed not drained as high chance of recurrence
• In mild-moderate cases surgery significantly improves chances of spontaneous pregnancy, in severe cases pregnancy is sadly unlikely.
• Last resort if symptoms are truly unmanageable is surgery.

Question 9

Post management (medical or surgical), what is a lingering concern for women with endometriosis?

Answer 9

Risk of developing Chronic Pain.

• High rates of relapse after stopping COCP
• Many patients with deep EM or adenomyosis will be left with chronic pain
• Potentially exacerbated by other MUS such as IBS, interstitial cystitis, fibromyalgia, neuropathic pain

Question 10

How should chronic pain in endometriosis be managed?

Answer 10

• Ideally refer to specialist centre w/ endometriosis nurse and chronic pain nurse
• Analgesia, Opiates are often required
• Gabapentin can also be effective
• Some women will request a hysterectomy, do not perform w/o trialling on GnRH analogue (pain relief predicts pain relief post hysterectomy