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%)
What is the chance of malignant change of fibroids to a leiomyosarcoma?
<1%
What is the name of a malignant fibroid?
A leiomyosarcoma
What is the use of GnRH agonists in fibroid management?
May be used to reduce size of fibroids before surgery
Mechanism of GnRH reducing the size of fibroids?
- Induce a menopause-like state and reduce amount of oestrogen maintaining the fibroid
- Only used short-term to shrink fibroid before myomectomy
What is a myomectomy?
A myomectomy is surgery to remove fibroids via laparoscopic (keyhole) or laparotomy (open surgery).
But a myomectomy is not suitable for all types of fibroid.
When would a myomectomy be considered over a hysterectomy?
It may be considered as an alternative to a hysterectomy if you’d still like to have children.
Give some surgical management options for larger fibroids
o Uterine arty embolisation
o Myomectomy
o Hysterectomy
How does uterine artery embolisation treat fibroids?
o Catheter inserted into artery (usually femoral) and passed through to uterine artery under Xray guidance
o Particles injected that cause blockage in arterial supply to fibroid
o This starves fibroid of oxygen and causes it to shrink
What type of drug is goserelin and leuprolein
GnRH agonists
What is the only fibroid treatment known to improve fertility?
Myomectomy
Give some surgical options for smaller fibroids with heavy menstrual bleeding
o Endometrial ablation
o Resection of submucosal fibroids during hysteroscopy
o Hysterectomy
What is a hysterectomy?
Removing uterus and fibroids - ovaries may be removed or left dependent on patient preference, risks, and benefits
What is red degeneration of fibroids?
Refers to ischaemia, infarction, and necrosis of the fibroid caused by a disrupt to the blood supply
Who is red degeneration of fibroids more likely to occur in?
Larger fibroids (>5cm) during 2nd or 3rd trimester of pregnancy
Why is red degeneration of fibroids more likely to occur in pregnant women?
o May occur as fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
o May also occur due to kinking in blood vessels as uterus changes shape and expands during pregnancy
Presentation of red degeneration of fibroids?
o Severe abdominal pain
o Low-grade fever
o Tachycardia
o Vomiting
Management of red degeneration of fibroids?
Supportive – rest, fluids, and analgesia
Clinical case:
A pregnant woman with history of fibroids presents with severe abdominal pain and a low-grade fever. What is the most likely diagnosis?
Red degeneration of fibroids
What is endometriosis?
Ectopic endometrial tissue outside the uterus
What is a lump of endometrial tissue outside the uterus called?
An endometrioma
What are endometriomas in the ovaries often called ?
Chocolate cysts
What is the cause of pelvic pain in endometriosis?
o Cells of endometrial tissue outside uterus respond to hormones
o During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body –> causes irritation and inflammation
Describe the pain in endometriosis
Cyclical - can be dull, heavy, or burning pain that occurs during menstruation
What causes blood or urine in stools in endometriosis
from deposits of endometriosis in bladder or bowel
What causes adhesions in endometriosis?
o Caused by localised bleeding and inflammation
o Inflammation causes damage and development of scar tissue that can bind organs together
Give some symptoms of endometriosis
o Can be asymptomatic
o Cyclical abdominal or pelvic pain
o Deep dyspareunia (pain on deep sexual intercourse)
o Dysmenorrhea (painful periods)
o Infertility
o Cyclical bleeding from other site e.g. haematuria
o Can also be urinary or bowel symptoms
Give some signs on examination during endometriosis
o Endometrial tissue visible in vagina on speculum exam, especially in posterior fornix
o Fixed cervix on bimanual exam
o Tenderness in vagina, cervix and adnexa
What is the gold standard for diagnosing abdominal and pelvic endometriosis?
Laparoscopic surgery
Give some investigation options for endometriosis
1) Pelvic US
2) Laparoscopy (need referral to gynaecologist)
What may a pelvic US reveal in endometriosis?
o May reveal large endometriomas and chocolate cysts
o Often unremarkable
What is the only way to definitively diagnosis endometriosis?
Biopsy of lesions during laparoscopy
What is the added benefit of laparoscopy for investigating endometriosis?
Added benefit of allowing surgeon to remove deposits of endometriosis and potentially improve symptoms
What staging system is used to stage endometriosis?
American Society of Reproductive Medicine (ASRM)
If deep lesions, with lesions on the ovaries and mild adhesions are found in endometriosis, what stage is this?
Stage 3
Describe stage 1 endometriosis
Small, superficial lesions
If deep and large lesions affecting ovaries with extensive lesions are found in endometriosis, what stage is this?
Stage 4
Describe stage 2 endometriosis
Mild, but deeper lesions than stage 1
What is the 1st line management of endometriosis before establishing a definitive diagnosis with laparoscopy?
Hormonal management
Give some examples of hormonal management options for endometriosis
o COCP (can be used back to back without a pill-free period if helpful)
o Progesterone only pill
o Medroxyprogesterone acetate injection (e.g. Depo-Provera)
o Nexplanon implant
o Mirena coil
o GnRH agonists
Will hormonal treatment for endometriosis improve fertility?
No
Give 2 surgical options for endometriosis
- Laparoscopy surgery to excise or ablate endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy (?and bilateral salpingo-opherectomy)
Note - hysterectomy is final option
What is a salpingo-oopherectomy?
Surgery to remove fallopian tubes and ovaries (both if bilateral)
How can an oopherectomy help in endometriosis?
Removing ovaries induces menopause and this stops ectopic endometrial tissue responding to menstrual cycle
How does hormonal treatment help symptoms in endometriosis?
Hormones can treat cyclical pain by stopping ovulation and reducing endometrial thickening
How do GnRH agonists help symptoms in endometriosis?
GnRH agonists induce a menopause-like state, which shut down the ovaries temporarily
What are some side effects of GnRH agonists?
Menopause-like symptoms e.g. hot flushes, night sweats, risk of osteoporosis
Give some examples of GnRH agonists
Goserelin (Zoladex), leuprorelin (Prostap)
What is adenomyosis?
Endometrial tissue inside the myometrium (muscle layer of the uterus)
Who is adenomyosis more common in?
- Later reproductive years
- Multiparous women (had several pregnancies)
Prevalence of adenoymosis?
Occurs in approx 10% of women
Cause of adenomyosis?
Unknown - multiple factors are involved, including sex hormones, trauma and inflammation.
How is adenomyosis affected by the menopause?
The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.
Presentation of adenomyosis?
- Painful periods (dysmenorrhoea)
- Heavy periods (menorrhagia)
- Pain during intercourse (dyspareunia)
May also present with infertility or pregnancy-related complications
Around 1/3 are asymptomatic
What can an examination in adenomyosis demonstrate?
An enlarged and tender uterus
How will a uterus with adenomyosis feel compared to fibroids?
It will feel more soft than a uterus containing fibroids.
1st line investigation in adenomyosis?
Transvaginal US
What are 2 alternative investigations in adenomyosis where a transvaginal US is not suitable?
1) MRI
2) Transabdominal US
Gold standard diagnosis of adenomyosis?
Histological examination of the uterus after a hysterectomy (but obviously not usually a suitable way of establishing the diagnosis)
Management of adenomyosis?
Depends on symptoms, age and plans for pregnancy.
NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding.
When the woman does NOT want contraception, what treatment can be used during menstruation for symptomatic relief in adenomyosis when there is associated pain?
Mefenamic acid (NSAID - reduces bleeding and pain)
What class of drug is mefenamic acid?
NSAID
When the woman does NOT want contraception, what treatment can be used during menstruation for symptomatic relief in adenomyosis when there is NO associated pain?
Tranexamic acid (antifibrinolytic - reduces bleeding)
What class of drug is tranexamic acid?
Antifibrinolytic
When contraception is wanted/avaiable for the management of adenomyosis, what are the options?
1) Mirena coil –> 1st line
2) COCP
3) Cyclical oral progestogens
Progesterone only medications such as the pill, implant or depot injection may also be helpful.
Adenomyosis can affect pregnancies.
What are some potential complications?
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
Why do fibroids cause heavy periods?
A number of theories:
1) Uterine fibroids may press against the uterine lining, causing more bleeding than usual.
2) The uterus may not contract properly, which means it can’t stop the bleeding.
3) Fibroids may stimulate the growth of blood vessels, which contributes to heavier or irregular periods and spotting between periods.
4) Elevated levels prostaglandins may also contribute.
When does pain in endometriosis typically begin?
Days before bleeding
What may be noted on pelvic exam in endometriosis?
- reduced organ mobility
- tender nodularity in the posterior vaginal fornix
- visible vaginal endometriotic lesions
Is there a role for investigation in primary care (e.g. ultrasound) in endometriosis?
No - if the symptoms are significant the patient should be referred for a definitive diagnosis
What does management of endometriosis depend on?
Severity of symptoms - there is poor correlation between laparoscopic findings and severity of symptoms
1st line management of endometriosis?
NSAIDs and/or paracetamol for symptomatic relief
2nd line management of endometriosis?
If analgesia doesn’t help then hormonal treatments such as the COCP or progestogens e.g. medroxyprogesterone acetate should be tried
3rd line treatment for endometriosis (i.e. if analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority)?
Referral to 2ary care.
Treatments include:
1) GnRH agonists
2) Surgery
For women who are trying to conceive, what is the recommended surgical management for endometriosis?
Laparoscopic excision or ablation of endometriosis plus adhesiolysis (this has been shown to improve the chances of conception).
How can uterine fibroids lead to polycythaemia?
This is a rare feature.
Polycythaemia can occur 2ary to autonomous production of erythropoietin by fibroids.
How is a diagnosis of fibroids made?
Transvaginal US
