Gynaecology: Pelvic problems (exc PID) Flashcards
what is the difference between endometriosis and adenomyosis?
Endometriosis - ectopic location of endometrial tissue outside the uterine cavity
Adenomyosis - invasion of endometrial tissue into the myometrium
In whom is endometriosis most common?
Oestrogen dependent disease therefore most common in women during reproductive years –> regresses during menopause
Typically age 30-45 yo
What are the clinical features of endometriosis?
- Pain (cyclical or constant)
- Dysuria
- Deep dyspareunia (indicates uterosacral ligament involvement)
- Dyschezia (painful passing of stools)
- Dysmenorrhoea - Infertility
Bi-Manual:
- Adnexal mass + tenderness
- Retroverted uterus
- Nodules at posterior fornix and recto-vaginal
Speculum:
1. Thickening behind uterus
What are the most common locations of endometriosis
can occur anywhere in pelvis but most commonly utero-sacral ligament and on or behind the ovaries
What features can be seen under Laporoscopy and biopsy?
NB: Laporoscopy and biopsy is the gold standard for diagnosis
- Powder burns (tiny white scars and brown spots)
- Endometrioma or Chocolate cyst
- Rectovaginal nodules
What is the main complication of endometriosis?
Infertility - 25%
Whats the treatment for endometriosis?
- Analgesia - NSAIDs ± Paracetamol
- Contraception (helps reduce retrograde mentrustation)
- 1st line - COCP
- 2nd line - GnRH analogue, implant, depot, mirena coil
What is a fibroid
Benign neoplasm (tumour) arising from the myometrium typically smooth muscle
In whom does it commonly occur
Women of reproductive age
NB: Fibroids are oestrogen (and possible progesterone) dependent
What are the main types of fibroids?
- Subserous - >50% of fibroid lies outside uterine contours
- Intramural - within myometrium
- Submucous - > 50% lies projects into the endometrial cavity
What is the clinical presentation of fibroids?
Symptoms:
- often asymptomatic
- dysmenorrhoea
- menorrhagia
- IMB or irregular bleeding
- Pelvic pain
- Infertility
Signs (abdo exam)
- Hard, irregular uterine mass
How can fibroids be diagnosed
- Clinical presentation and abdo examination
- hard irregular masses felt in pelvis or abdomen - TV/Abdo USS (diagnostic) - can differentiate between different types and size
- if > 4mm (post-menopausal) or >10mm (pre-manopausal) then refer for laparoscopy + pipeline biopsy - MRI - if uncertain fibroid or cancer
What is the treatment for fibroids? (not HMB)
- GnRH analogues to shrink fibroids
- Surgery
- myomectomy, resection at hysteroscopy
- Hysterectomy
What are the symptoms and signs of ovarian cysts and who do they commonly occur in?
1. Symptoms: Pain is either acute or chronic - Cyclical pain - Pelvic or abdominal which radiates to back Look for bleeding, torsion and rupture Dyspareunia Abnormal uterine bleeding
2. Signs: Pelvic, adnexal or abdominal mass - painful and tender - palpable PV discharge or bleeding Cervical excitation
What is the investigation to diagnose ovarian cysts?
- Abdominal or pelvic USS - visualise cyst
- calculate RMI (risk of malignancy index)
- if young < 35yo, simple or small < 5cm - r/v in 6 weeks
- if young, complex or large > 5cm - refer to gynaecologist
- if post-menopausal, regardless of size refer urgently to gynaecologist - Blood markers - CA 125 (exclude ovarian cancer)
What is the treatment for pre-menopausal ovarian cysts?
- Expectatant - watch and wait, most cysts resolve spontaneously if young
- Analgesia for pain
- Repeats US in 6 wks
- if cyst not regressed intervene
- < 5cm and simple = cyst fenestration and biopsy
- > 5cm and dermoid = laparo-cystectomy
- if found to look cancerous = abandon and refer to oncology
What is the clinical presentation of a woman with ovarian torsion?
- U/L abdominal or pelvic pain
- Deep seated
- Colicky
- Very sudden onset - U/L adnexal mass + tenderness (upon bimanual examination)
- Nausea and vomiting
- Fever
What is the investigations to be ordered for a patient with suspected ovarian torsion?
- FBC: Raised CRP and WCC
- USS and Doppler of pelvis
- Free fluid
- Adnexal mass
- Reduced blood flow
What is the treatment for ovarian torsion?
- URGENT Laprotomy (diagnostic and therapeutic)
- Untiwst or remove adnexa
- May preserve ovary or cause gangrenous necrosis
What are the common risk factors of ovarian torsion?
Pregnancy (20%)
Ovarian cysts
What is the most common type of ovarian cyst?
Follicular cyst
What are the types of functional cysts?
- Follicular cyst - occurs during mensturation when the ovarian follicle fails to rupture and release an egg
- Luteal cyst - occurs after ovulation when the corpus luteum fails to regress after 5-9 days and forms a cyst. If it ruptures it may cause intrapeirtoneal bleeding and bruising
- Theca luteal cyst - thecal layer which lines oveary proliferates in presence of excessive HCG
What is the most common benign tumour in under 30yo? explain how it is diagnosed?
Benign eratoma (dermoid cyst) - a benign neoplasm which develops from mesenchymal, ependymal and epithelial cells and can contain teeth hair etc.
- can present with torsion (acute onset pain, N+V)
- USS - shows whirlpool sign, Rakintoskys protuberance and multiple white shiny masses
What are the two types of epithelial cysts?
Serous cystadenoma - most common type of epithelial
Mucinous cystadenoma - if ruptures can cause pseudo-myxoma peritonei
