Module 13 - Gynaecological problems Flashcards
How do you stage endometriosis?
Stage Description
1 Superficial lesions & filmy adhesions
2 Deep lesions at cul-de-sac
3 As above + ovarian endometriomas
4 As above + extensive adhesions
What is the prevalence of endometriosis in subfertile women?
Up to 50%
What is the prevalence of endometriosis?
3-10%
When is diagnostic laparoscopy recommended in the management of endometriosis?
Diagnostic laparoscopy is NO longer the gold standard for diagnosis of endometriosis
Perform it if:
1) Normal US scan or MRI scan
and/or
2) Medical treatments have been ineffective or inappropriate
What are the recommended medical treatment options for endometriosis-associated pain?
1st line:
- NSAIDs
- Combined hormonal contraceptives
- Progestogens
2nd line:
- GnRH agonists. If above are ineffective. Consider combined add-back therapy to prevent bone loss & hypoestrogenic sx
- GnRH antagonists
3rd line:
- Aromatase inhibitors. Give if pain is refractory to medical or surgery treatment. Can give alongside the above
What are the recommended surgical treatment options for endometriosis-associated pain?
- May consider excision instead of ablation of endometriosis
- Don’t perform LUNA (Laparoscopic Uterosacral Nerve Ablation)
- Can do PSN (Presacral Neurectomy) for midline pain as an adjunct to conventional surgery
PSN SEs - bleeding, urinary urgency, constipation, painless 1st stage of labour
- Offer post-op hormonal treatment to improve the immediate outcome of surgery and reduce chance of relapse/endometriosis-associated dysmenorrhoea:
1) Mirena IUS 52mg
OR
2) COCP for at least 18-24 months
What are the pregnancy-associated risks with endometriosis? (2 points)
1) 1st trimester miscarriage
2) Ectopic pregnancy
What is the risk of relapse of symptoms following excision or ablation of endometriotic lesions?
40-45%
How many women will require a 2nd operation following excision or ablation of endometriotic lesions?
50%
30% within 5 years
How many women will require 3 or more operations following excision or ablation of endometriotic lesions?
25%
What are the risk factors for endometriosis in adolescent women?
1) Positive family history
2) Obstructive genital malformation
3) Early menarche
4) Short menstrual cycles
Consider endometriosis in young women who miss school due to menstruation (cyclical absenteeism) or who use COCP for dysmenorrhoea
What are the medical treatments offered to adolescents with endometriosis?
1) COCP or progestogens - 1st line
2) NSAIDs - 2nd line
3) GnRH agonists with combined add-back therapy - if laparosocpy has confirmed endometriosis + hormonal treatment has failed. Give for up to 1 year
Discuss potential side effects and long-term health risks
If discussing cystectomy for ovarian endometriomas then discuss potential detrimental effects on ovarian reserve and future fertility
What is the medical management of post-menopausal women with endometriosis?
1) Aromatase inhibitors - especially if surgery isn’t feasible
2) Combined HRT - don’t give oestrogen-only HRT as it can be associated with an increased risk of malignant transformation
Even with women who have had a total hysterectomy + BSO (surgical menopause) - give combined HRT at least until the age of natural menopause
Endometriosis provides a slightly increased risk of which cancers? (3 points)
1) Ovarian
2) Breast
3) Thyroid
What proportion of postmenopausal bleeding is due to atrophic vaginitis/endometritis?
60-80%
What proportion of postmenopausal bleeding is due to exogenous oestrogens?
15-25%
What proportion of postmenopausal bleeding is due to endometrial hyperplasia?
5-15%
What proportion of postmenopausal bleeding is due to endometrial polyps?
2-12%
What proportion of women with endometrial cancer present with PMB?
90%
What is the risk of endometrial ca in women who are >80 years old presenting with PMB?
25%
What is the risk of underlying endometrial ca in women who are <50 years old?
1%
What is the risk of underlying endometrial ca in women who have PMB and are obese?
18%
What is the risk of underlying endometrial ca in women who have PMB and have diabetes?
21%
What is the risk of underlying endometrial ca in women who have PMB, obesity and diabetes?
29%
How many pregnancies in >40 yr old women are unplanned?
20%
How many pregnancies in women >40 end in termination?
28%
What are the future pregnancy-related complications with UAE?
1) Higher rates of CS
2) Higher rates of PPH
What are the success rates with UAE vs surgery?
80-90% asymptomatic or significantly improved symptoms over the 1st year
Similar improvement in symptoms over 5 years vs surgery
1 in 3 women will require secondary intervention by 5 years
What percentage of women will require a hysterectomy following a UAE?
3%
What is the risk of malignancy with endometrial polyps?
3% risk of malignancy
What is the risk of atypia with endometrial polyps?
0.8%
What is the percentage risk of lichen sclerosus developing into squamous cell carcinoma?
<5%
What is the incidence of chronic pelvic pain following PID/tubo-ovarian abscess?
12% after one episode
30% after two episodes
67% after three or more episodes
What are the pregnancy rates for TOA following laparoscopy and drainage vs antibiotics alone?
30-60% pregnancy rate with laparosocpy + drainage
5-15% pregnancy rate with antibiotic Rx alone
Laparoscopy + drainage should be considered for any woman who desire future fertility
Subfertility is a known long-term complication of TOA
What are the poor prognostic factors with TOA?
1) Age >40
2) Smoker
3) TOA >5cm
4) High initial WCC
What proportion of hirsutism is caused by PCOS?
75%
What is the prevalence of hirsuitism?
10%
What proportion of women discontinue the copper coil within the first 5 years? What is the reason?
Up to 50% of women discontinue the IUCD within 5 years. Most commonly due to unacceptable vaginal bleeding and pain
A 33 year old patient has been referred to clinic due to the presence of an adnexal mass. An urgent transvaginal ultrasound is organised which shows a unilocular ovarian lesion demonstrating diffuse ground glass echogenicity. No papillary structures with blood flow are seen. What is the likely diagnosis?
ovarian endometrioma
Cyclical HRT inhibits ovulation in what proportion of women?
40%
What percentage of premature ovarian failure cases are idiopathic?
90%
What proportion of women are affected by premature ovarian failure?
1%
GnRH analogues reduce fibroid size by how much?
36% by 3 months (12 weeks)
What proportion of postmenopausal bleeding is due to endometrial carcinoma?
10%
What is the likelihood of bilateral dermoid cyst?
10%
A woman with primary amenorrhoea is diagnosed with complete androgen insensitivity syndrome 46XY. On ultrasound there is confirmation of bilateral inguinal hernias with her testes. What is the risk of malignancy by the time she reaches her fourth decade of life?
20%
Therefore orchidectomy is recommended laparoscopically after puberty
A 32 year old woman presents with subjective fever and lower abdominal pain. TVS pelvis reveals cogwheel sign. What is the likely pathology?
Tubo-ovarian abscess
A 35 year old woman presents with acute on chronic lower abdominal pain. TVS pelvis reveals ‘beads on a string’ sign. What is the likely pathology?
Chronic salpingitis/hydrosalpinx
A 26 year old woman presents with sudden onset lower abdominal pain. TVS pelvis reveals ‘whirlpool’ sign. What is the likely pathology?
Ovarian torsion
Elderly woman presents with itching and irritation of the vulva. On examination there are satellite lesions. What is the diagnosis?
Malignant melanoma
In cases of lichen sclerosis, What percentage of patients will not respond to treatment with topical steroids?
15-22%
A postmenopausal woman presented with slow onset of increasing facial acne and hirsutism that started initially 6 months back. On examination: she has male type baldness. What is the most likely diagnosis?
Ovarian hyperthecosis
Postmenpausal, slow onset, increasing facial acne, hirsuitism and male type baldness = ovarian hyperthecosis
Uterine didelphys is associated with renal agenesis in approximately how many cases?
25%
What is the most common benign pathological cyst in premenopausal women?
Dermoid cyst
Benign cystic teratoma
Which pathogen is most commonly isolated from surgical site infections in the UK?
Enterobacterales - 30%
Followed by staph aureus 23%
What is the most common complication of PCOS?
Obstructive sleep apnoea
What is the incidence of hirsutism in most populations?
10%
What is the most common cause of hirsutism, and what proportion of does it make up?
PCOS
75% of cases
For menopausal patients with symptoms of low mood, the SSRIs Paroxetine and Fluoxetine should not be given alongside which medication?
Tamoxifen
Tamoxifen can interact with which medications sometimes used in the treatment of menopause?
Soy and St. John’s Wort
In women >45 years old how do you diagnose peri-menopause?
If experiencing vasomotor symptoms and/or irregular periods
In women >45 years old how do you diagnose menopause?
If >12 months amenorrhoea and not taking contraception
How do you diagnose peri-menopause or menopause in women <45 years old?
FSH tested on two occasions 4-6 weeks apart
Higher in menopause
What is the management of vasomotor symptoms in menopause?
1st line -
Combined HRT (oestrogen + progesterone) - women with a uterus
Oestrogen HRT - women without a uterus
2nd line -
SSRIs, SNRIs, Clonidine
Do not routinely offer HRT to women with a history of breast cancer
Do not give SSRIs (Fluoxetine or Paroxetine) to women taking Tamoxifen for breast cancer
What is the management of low mood in menopause?
HRT + CBT
Do not give SSRIs or SNRIs to treat low mood secondary to menopause
What is the management of low libido in menopause?
1st line -
HRT
2nd line -
HRT + testosterone
What are the recommended natural therapies to treat vasomotor symptoms in menopause?
1) Black cohosh
2) Soy - phytoestrogen, so has similar adverse effects
What proportion of women in the UK are affected by IBS?
10-15%
What proportion of patients with endometriosis will also have IBS?
40%
What is the management of IBS?
1) Dietary modification, anti-cholinergics, laxatives (avoid lactulose), anti-motility drugs (if diarrhoea present)
2) Tricyclic anti-depressants
3) SSRIs
4) Psychological intervention
AVOID: insolulable fibre, beans, fatty food, sugar subsitutes, chocolate, alcohol, caffeine
What is the main mechanism of action of ulipristal acetate?
SPRM (Selective progesterone receptor modulator)
Induces apoptosis of uterine fibroid cells and inhibits proliferation
What proportion of women will require a hysterectomy following endometrial ablation?
Up to 20%
When will most women require a hysterectomy following endometrial ablation?
Within the first two years
What is the main difference between laparoscopic and open myomectomy with regards to pregnancy?
The risk of uterine rupture is higher following laparoscopic than open myomectomy
How do you diagnose IBS?
Rome 3 criteria
Have to have abdominal pain/discomfort for at least 3 days a month for the past 3 months. Symptoms have to have been ongoing for at least 6 months prior to diagnosis
2/3 of the following:
- Abdo pain relieved by defecation
- Onset associated with change in frequency of stool
- Onset associated with change in appearance of stool
What are the risks associated with HRT? (6 points)
1) VTE - 2-3x increase with oral HRT
2) Stroke - no evidence that transdermal patches increase risk
3) Breast cancer - very small increase
4) Ovarian cancer
5) Endometrial cancer - use of cyclical orogestogen for at least 10 days per 28 day cycle reduces this risk
6) Gallbladder disease
What are the benefits of HRT?
1) Improve vasomotor symptoms
2) Improve mood
3) Improve bone mineral density/reduce risk of osteoporosis
4) Improve urinary symptoms
5) Improve vaginal dryness
6) Reduce risk of cardiovascular disease
7) Reduce colorectal cancer risk
What is the additional risk of breast cancer if using HRT for 5 years?
6 additional cases per 1,000 of breast ca if using HRT for 5 years
What are the values for T score for assessing bone mineral density?
Normal -1 to +1
Osteopaenia -1 to -2.5
Osteoporosis -2.5 to -3.0
Severe osteoporosis -3.0 and below
T score - compares your bone density to that of someone of the same sex who is 30 years old
Z score - compares your bone density to that of someone of the same sex and same age
