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GOSH > Gynaecology: Pelvic problems (exc PID) > Flashcards

Gynaecology: Pelvic problems (exc PID) Flashcards

1
Q

what is the difference between endometriosis and adenomyosis?

A

Endometriosis - ectopic location of endometrial tissue outside the uterine cavity

Adenomyosis - invasion of endometrial tissue into the myometrium

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2
Q

In whom is endometriosis most common?

A

Oestrogen dependent disease therefore most common in women during reproductive years –> regresses during menopause

Typically age 30-45 yo

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3
Q

What are the clinical features of endometriosis?

A
  1. Pain (cyclical or constant)
    - Dysuria
    - Deep dyspareunia (indicates uterosacral ligament involvement)
    - Dyschezia (painful passing of stools)
    - Dysmenorrhoea
  2. Infertility

Bi-Manual:

  1. Adnexal mass + tenderness
  2. Retroverted uterus
  3. Nodules at posterior fornix and recto-vaginal

Speculum:
1. Thickening behind uterus

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4
Q

What are the most common locations of endometriosis

A

can occur anywhere in pelvis but most commonly utero-sacral ligament and on or behind the ovaries

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5
Q

What features can be seen under Laporoscopy and biopsy?

A

NB: Laporoscopy and biopsy is the gold standard for diagnosis

  1. Powder burns (tiny white scars and brown spots)
  2. Endometrioma or Chocolate cyst
  3. Rectovaginal nodules
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6
Q

What is the main complication of endometriosis?

A

Infertility - 25%

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7
Q

Whats the treatment for endometriosis?

A
  1. Analgesia - NSAIDs ± Paracetamol
  2. Contraception (helps reduce retrograde mentrustation)
    - 1st line - COCP
    - 2nd line - GnRH analogue, implant, depot, mirena coil
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8
Q

What is a fibroid

A

Benign neoplasm (tumour) arising from the myometrium typically smooth muscle

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9
Q

In whom does it commonly occur

A

Women of reproductive age

NB: Fibroids are oestrogen (and possible progesterone) dependent

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10
Q

What are the main types of fibroids?

A
  1. Subserous - >50% of fibroid lies outside uterine contours
  2. Intramural - within myometrium
  3. Submucous - > 50% lies projects into the endometrial cavity
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11
Q

What is the clinical presentation of fibroids?

A

Symptoms:

  • often asymptomatic
  • dysmenorrhoea
  • menorrhagia
  • IMB or irregular bleeding
  • Pelvic pain
  • Infertility

Signs (abdo exam)
- Hard, irregular uterine mass

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12
Q

How can fibroids be diagnosed

A
  1. Clinical presentation and abdo examination
    - hard irregular masses felt in pelvis or abdomen
  2. 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
  3. MRI - if uncertain fibroid or cancer
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13
Q

What is the treatment for fibroids? (not HMB)

A
  1. GnRH analogues to shrink fibroids
  2. Surgery
    - myomectomy, resection at hysteroscopy
    - Hysterectomy
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14
Q

What are the symptoms and signs of ovarian cysts and who do they commonly occur in?

A 
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
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15
Q

What is the investigation to diagnose ovarian cysts?

A
  1. 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
  2. Blood markers - CA 125 (exclude ovarian cancer)
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16
Q

What is the treatment for pre-menopausal ovarian cysts?

A
  1. Expectatant - watch and wait, most cysts resolve spontaneously if young
  2. Analgesia for pain
  3. Repeats US in 6 wks
  4. 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
17
Q

What is the clinical presentation of a woman with ovarian torsion?

A
  1. U/L abdominal or pelvic pain
    - Deep seated
    - Colicky
    - Very sudden onset
  2. U/L adnexal mass + tenderness (upon bimanual examination)
  3. Nausea and vomiting
  4. Fever
18
Q

What is the investigations to be ordered for a patient with suspected ovarian torsion?

A
  1. FBC: Raised CRP and WCC
  2. USS and Doppler of pelvis
    - Free fluid
    - Adnexal mass
    - Reduced blood flow
19
Q

What is the treatment for ovarian torsion?

A
  1. URGENT Laprotomy (diagnostic and therapeutic)
    - Untiwst or remove adnexa
    - May preserve ovary or cause gangrenous necrosis
20
Q

What are the common risk factors of ovarian torsion?

A

Pregnancy (20%)

Ovarian cysts

21
Q

What is the most common type of ovarian cyst?

A

Follicular cyst

22
Q

What are the types of functional cysts?

A
  1. Follicular cyst - occurs during mensturation when the ovarian follicle fails to rupture and release an egg
  2. 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
  3. Theca luteal cyst - thecal layer which lines oveary proliferates in presence of excessive HCG
23
Q

What is the most common benign tumour in under 30yo? explain how it is diagnosed?

A

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
24
Q

What are the two types of epithelial cysts?

A

Serous cystadenoma - most common type of epithelial

Mucinous cystadenoma - if ruptures can cause pseudo-myxoma peritonei

25
Q

What are the common inflammatory cysts?

A

Endometrioma - a/w endometriosis, can present with chocolate brown discharge if chocolate cyst ruptures

Tubo-ovarian abscess - capsule of pus develops between the ovary and fallopian tubes, it it ruptures can cause sepsis

26
Q

Which cyst is a/w Meigs syndrome?

A

Fibroma

27
Q

Which cyst secretes oestrogen?

A

Thecoma

- therefore causes oestrogen related symptoms like PMB, breast tenderness and enlargement etc.

28
Q

What is the management for a post-menopausal cyst?

A

Low RMI < 25

  • Monitor USS and CA125 every 4 months for 1 year
  • if no change continue monitoring
  • if enlargement consider excision

Moder RMI 25-250
- Oophorectomy

High RMI > 250
- Refer to oncology

GOSH (14 decks)

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