Obs & Gynae 2

Question 1

What is adenomyosis?

Answer 1

Presence of endometrial tissue and its underlying stroma within the myometrium

Associated with endometriosis & fibroids

Question 2

Pathogenesis of adenomyosis

Answer 2

Cause unknown
Oestrogen dependent
Endometrium appears to grow into the myometrium
Causes myometrium to enlarge

Question 3

Clinical presentation of adenomyosis

Answer 3

• symptoms may be absent
• cyclical pain with menstruation
• heavy periods
• dysmenorrhoea
• dyspareunia
  o/e uterus mildly enlarged & tender

Question 4

Diagnosis of adenomyosis

Answer 4

Can be suspected on USS but diagnosed with MRI

Question 5

Treatment of adenomyosis

Answer 5

progesterone IUS or COCP (tricycle to reduce no of periods - decrease pain, decrease growth of adenomyosis)
NSAIDs for dysmenorrhoea

patients w/ severe symptoms that have completed family or failed other treatment options - hysterectomy

trial of GnRH analogue may determine if symptoms attributed to adenomyosis are likely to improve with hysterectomy

Question 6

Prognosis of adenomyosis

Answer 6

oestrogen dependent so menopause is a natural cure

does not ^ risk of cancer

Question 7

Location of fibroids

Answer 7

Intramural - in muscular layer - pain 
Submucosal - under endometrium 
Subserosal - under visceral peritoneum - don't get bleeding 
Pedunculated 
Intracavitary

Question 8

What are fibroids?

Answer 8

Benign smooth muscle uterine tumours of the myometrium

Question 9

Aetiology of fibroids

Answer 9

Prolonged unopposed effects of oestrogen - affects young women, low parity, early menarche
Fibroid growth is oestrogen & progesterone dependent

Question 10

Diagnosis of fibroids

Answer 10

USS - no, size, position
MRI - if need ^ accuracy - can differentiate from adenomyosis
hysteroscopy/transvaginal ultrasonography/HSG - assess distortion of uterine cavity - particularly if fertility is an issue
Hb concentration (may be ^ as fibroids can secrete erythropoietin, or decreased from bleeding)

Question 11

Clinical presentation of fibroids

Answer 11

• 50% asymptomatic
• heavy periods > anaemia
• dysmenorrhoea
• abdo pain
• infertility & miscarriage (submucosal, intra-mural)
  o/e - solid mass may be palpable

Question 12

Problems fibroids may cause in pregnancy

Answer 12

premature labour
malpresentations 
transverse lie 
PPH
obstructed labour (although most fibroids arise from body of uterus - dont obtsruct labour as they tend to rise away from the pelvis throughout pregnancy)

Question 13

Treatment of fibroids

Answer 13

• myomectomy (take away fibroid without taking uterus - preserves fertility)
• hysterectomy
• uterine artery embolisation
• GnRH analogues e.g. goserelin - 3-6m prior to surgery to shrink fibroid (not a long term option - demineralisation of bone)
• ulliprostol acetate - selective progesterone receptor modulator > 3-6m before surgery to shrink fibroids & induce amenorrhoea

Question 14

Fibroids are more common in…

Answer 14

^ age during reproductive years
Black & asian women 
obesity 
early menarche (before 11)
in women with affected 1st degree relative

Question 15

Complications of fibroids

Answer 15

• intracavitary fibroid - prevents woman getting pregnant, if she does - miscarries
• torsion if pedunculated fibroid
• degenerations - result of poor blood supply
  > red degeneration - particularly in pregnancy
• malignancy

Question 16

Definition of menopause

Answer 16

• cessation of menstruation

- dx 12m amenorrhoea (not on hormonal contraception)

Question 17

When is menopause premature? What might cause it?

Answer 17

<40

- surgical, infection, autoimmune, chemo, metabolic disease

Question 18

Investigations in menopause

Answer 18

usually none - clinical diagnosis
FSH if <45
- 2 levels >4 weeks apart, if both ^ can diagnose menopause

Question 19

Symptoms of menopause

Answer 19

Vasomotor: hot flushes, night sweats
Psychological: low mood, irritability
Urogenital: ^ frequency of micturition, urgency, nocturia, vaginal dryness due to vaginal atrophy - dyspareunia, itching, burning
Sexual difficulties: decreased interest in sex, decreased arousal
Joint and muscle pain

Question 20

HRT regimen for a woman with intact uterus

Answer 20

Perimenopausal: combined cyclical therapy
> mirena IUS can provide progesterone cover & acts as contraception if needed

Postmenopausal: continuous e.g. tibolone

Question 21

HRT regimen for a woman without uterus

Answer 21

Oestrogen only - oral or transdermal

Question 22

When is contraception needed post-menopause?

Answer 22

12m if >50

24m if <50

Question 23

Other treatments indicated in menopause

Answer 23

SSRI can be used to treat vasomotor sx if woman not keen on HRT
Osteoporosis - vit d, calcium, bisphosphonates
vaginal dryness - topical oestrogen, lubricants

Question 24

Risks associated with HRT

Answer 24

• breast cancer
• VTE
• CVD
• stroke

Question 25

Benefits associated with HRT

Answer 25

• relief of symptoms - vasomotor and urogenital, relief of sexual dysfunction
• BMD protection
• decreased risk of colorectal cancer

Question 26

Contraindications to HRT

Answer 26

• oestrogen dependent cancer
• past PE
• ^ LFT
• undiagnosed PV bleed
• pregnancy
• breast feeding
• phlebitis

Question 27

Side effects of HRT

Answer 27

• fluid retention
• breast tenderness
• nausea
• tenderness
• leg cramps
• mood swings
• acne