Gynaecology: Fibroids, Endometriosis & Adenomyosis Flashcards
Define amenorrhoea
A lack of menstrual periods
1ary vs 2ary amenorrhoea?
1ary –> patient has never developed periods
2ary –> patient has previously had periods that then stopped
Define hypogonadism
Decreased functional activity of the gonads (ovaries or testes)
What hormones are low in hypogonadism?
Oestrogen and/or progesterone
Describe the hypothalamic-pituitary-ovarian axis pathway
- Hypothalamus produces GnRH at onset of puberty
- GnRH acts on pituitary gland, stimulating production of FSH and LH
- FSH and LH acts on ovaries to stimulate production of oestrogen and progesterone
1ary vs 2ary hypogonadism?
1ary –> refers to a condition of the ovaries (primary ovarian insufficiency/hypergonadotropic hypogonadism)
2ary –> refers to the failure of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Give 3 main causes of 1ary amenorrhoea
- Abnormal functioning of hypothalamus or pituitary (hypogonadotropic hypogonadism)
- Abnormal function of gonads (hypergonadotropic hypogonadism)
- Imperforate hymen or other structural pathology
What are the most 2 common causes of 2ary amenorrhoea?
- Pregnancy (most common)
- Menopause
What type of amenorrhoea can medications such as hormonal contraceptives cause?
2ary
What type of amenorrhoea can excessive prolactin (e.g. prolactinoma) cause?
2ary
What type of amenorrhoea can Cushing’s syndrome cause?
2ary
Define anovoluation
A lack of ovulation
What do irregular periods indicate?
Anovulation or irregular ovulation
Give some causes of irregular menstruation
Due to disruption of normal hormonal levels or ovarian pathology:
- Extremes of reproductive age (early periods or perimenopause)
- Polycystic ovarian syndrome
- Physiological stress
- Medications e.g. particularly progesterone only contraception, antidepressants, antipsychotics
- Hormonal imbalances e.g. thyroid, Cushing’s, high prolactin
Define intermenstrual bleeding
Bleeding that occurs between menstrual periods
Is intermenstrual bleeding a red flag?
Yes - consider cervical and other cancers.
Give some causes of intermenstrual bleeding
- Hormonal contraception
- Cervical ectropion, polyps or cancer
- STIs
- Endometrial polyps or cancer
- Vaginal pathology including cancers
- Pregnancy
- Ovulation can cause spotting in some women
- Medications e.g. SSRIs and anticoagulants
Define dysmenorrhoea
Painful periods
Give some causes of dysmenorrhoea
- Primary dysmenorrhea (no underlying pathology)
- Endometriosis or adenomyosis
- Fibroids
- Pelvic inflammatory disease
- Copper coil
- Cervical or ovarian cancer
Define menorrhagia
Heavy menstrual periods
Most common cause of menorrhagia?
Dysfunctional uterine bleeding (no identifiable cause)
Give some causes of menorrhagia
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- PID (infection)
- Contraceptives, especially copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes & hypothyroidism)
- Connective tissue disorder
- Endometrial hyperplasia or cancer
- Polycystic ovarian syndrome
Define postcoital bleeding
Bleeding after sex
Is postcoital bleeding a red flag?
Yes - consider cervical or other cancers BUT other causes are more common. Often no cause is found.
Give some causes of postcoital bleeding
- Cervical cancer, ectropion or infection
- Trauma
- Atrophic vaginitis
- Polyps
- Endometrial cancer
- Vaginal cancer
Give some causes of pelvic pain
- UTI
- Dysmenorrhea
- IBS
- Ovarian cysts
- Endometriosis
- PiD
- Ectopic pregnancy
- Appendicitis
- Mittelschmerz (cyclical pain during ovulation)
- Pelvic adhesions
- Ovarian torsion
- IBD
What may excessive, discoloured, or foul-smelling discharge indicate?
- Bacterial vaginosis
- Candidiasis (thrush)
- Chlamydia
- Gonorrhoea
- Trichomonas vaginalis
- Foreign body
- Cervical ectropion
- Polyps
- Malignancy
- Pregnancy
- Ovulation (cyclical)
- Hormonal contraception
Define pruritus vulvae
Itching of the vulva and vagina.
Causes of pruritus vulvae?
- Irritant e.g. soaps, detergents and barrier contraception
- Atrophic vaginitis
- Infections e.g. candidiasis (thrust) and public lice
- Skin conditions e.g. eczema
- Vulval malignancy
- Pregnancy-related vaginal discharge
- Urinary or faecal incontinence
- Stress
What are fibroids?
Benign tumours of the smooth muscle of the uterus
What are fibroids also called?
Uterine leimyomas
What % of women do fibroids affect?
40-60%
What hormone do fibroids grow in response to?
Oestrogen
Name the 4 types of fibroids
- Intramural
- Sebserosal
- Submucosal
- Pedunculated
Where are intramural fibroids located?
Within the myometrium (muscle of uterus)
What type of fibroid is on a stalk?
Pedunculated
What type of fibroid is just below the lining of uterus (endometrium)?
Submucosal
Where are subserosal fibroids located?
Just below outer layer of uterus
Which type of fibroids can grow outwards and become large, sometimes filling the abdominal cavity?
Subserosal
Fibroids are often asymptomatic. What is the most frequent presenting symptom?
Menorrhagia (heavy menstrual bleeding)
Give some other symptoms of fibroids
- Prolonged menstruation (>7 days)
- Abdominal pain, worse during menstruation
- Bloating or feeling full in abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
What may an abdominal and bimanual examination reveal with fibroids?
may reveal palpable pelvis mass or enlarged firm non-tender uterus
What is the 1st line investigation for submucosal fibroids presenting with heavy menstrual bleeding?
Hysteroscopy
What is hysteroscopy?
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix.
What is the 1st line investigation for fibroids?
TV US
When may MRI scanning be considered for fibroids?
may be considered before surgical options where more information is needed about size, shape, and blood supply of fibroids
What is the 1st line management for fibroids <3cm?
Management is the same as with heavy menstrual bleeding:
1st line –> Mirena coil (fibroid must be <3cm with no distortion of uterus)
Give some other management options for small fibroids <3cm
o Symptomatic management with NSAIDs and tranexamic acid
o COCP
o Cyclical oral progestogens
What is the management for fibroids >3cm?
Women need referral to gynaecology for investigation and management.
o Symptomatic management with NSAIDs and tranexamic acid
o Mirena coil – depending on size and shape of fibroids and uterus
o Cyclical oral progestogens
What is the management for fibroids >3cm?
Women need referral to gynaecology for investigation and management.
o Symptomatic management with NSAIDs and tranexamic acid
o Mirena coil – depending on size and shape of fibroids and uterus
o Cyclical oral progestogens
Give some complications of fibroids
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications e.g. miscarriages, premature labour, and obstructive delivery
- Constipation
- Urinary outflow obstruction and UTIs
- Red degeneration of fibroid
- Torsion of fibroid – usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)