OGCO-E29 Guidelines for patients management in general gynaecology clinics Flashcards
What is the history taking for menstrual irregularity?
When is examination indicated for menstrual irregularity?
OGCO-E18 Protocal for initial management of patients on tamoxifen
What is done for exam of menstrual irregularity?
- BMI
- Pallor
- Abd mass
- Cervical lesion, local cause
- Uterus: size, irregularity, mobility
What are the ix done for menstrual irregularity?
- pregnancy test if indicated
- Take cervical smear when: due for cervical screening, cervix looks suspicious but no obvious lesion
- Indicatiosn for endometrial biopsy: presence of RF for endometrial pathology (e.g. obesity, PCOS, on tamoxifen, failed treatment, needs endometrial sampling). If age >40 and persistent IMB or irregular bleeding. If age <45 and regular heavy period can consider trial of hormoanl therapy without endometrial sampling)
- CBP if suspect anemia
- Iron status: fasted morning iron profile: beware of conditions like acute inflammatory disease, chronic illness, pregnancy and patients on combined pills may affect results
- Hb pattern
Indications for hysteroscopy +/-endometrial biopsy
* Suspect endometrial polyp/submucosal fibroid
* Irregular bleeding while on hormonal therapy for more than 3 months
* Endometrial aspirate failed/result inconclusive
Indication for USG examination: if structural abnormality suspected or examination inclusive or difficult
What are the parameters included in iron deficiency anemia?
Which is affected earliest and latest?
What is treatment of menstrual irregularity?
What is the follow up interval?
What is the mx algorithm for menstrual irregularity?
What is the history taking for post menopausal bleeding?
What is the Ix for postmenopausal bleeding?
- Cervical smear (if without regular screening)
- Endometrial aspiration for all patients
- Transvaginal USG for endometrial thickness(may skip if taking tamoxifen)
- Hysteroscopy if taking tamoxifen, endometrial thickness >4mm or recurrence or refractory
- symptoms despite given treatment for atrophic change
What is the Tx for atrophic vaginitis/endometritis?
local oestrogen cream Premarin cream 0.5 g qd for 2 weeks and 3 times weekly thereafter for 6 months
When to consider secondary dysmenorrhea?
- occur in first 6 months after menarche
- begin more than 2 years after menarche
- late onset after a history without previous dysmenorrhea
- pain during non-menstrual phases of the menstrual cycle
- associated with other symptoms e.g. menorrhagia, intermenstrual bleeding pelvic abnormality on physical examination
- little or no response to therapy with NSAID, OC pills or both
What is the Mx for dysmenorrhea?
When is follow up for dysmenorrhea?
4 months after the initiation/change of treatment
What is the history taking for abd pain?
What is the PE for abd pain?
- Abdominal examination and pelvic examination – focal tenderness or trigger points, mass, distortion, tethering or prolapse
- ?pain at ovarian point – junction of the upper and middle thirds of a line drawn between the umbilicus and the anterior superior iliac spine(typical of pelvic congestion syndrome)
- Sacroiliac joint or pubic symphysis tenderness is suggestive of musculoskeletal origin of pain
What are the Ix done for abd pain?
- msu to exclude urinary tract infection
- If suggestive of pelvic congestion syndrome – consider MRI for pelvic varices If no other symptom
- endocervical swabs for gonococcus, chlamydia pelvic ultrasonogram for pelvic pathology
- If all investigations negative and other causes of pain excluded but pain persisted for 6 months - consider laparoscopy (if therapeutic trial of hormonal therapy failed after 6 months) and/or MRI
- If all investigations and laparoscopy negative consider referral to clinical psychologist/ other specialist as appropriate
What is the Mx algorithm for abd pain?
What is the history taking and PE for uterine leiomyoma?
What Ix done for uterine leiomyoma?
- Complete blood picture
- Ultrasonogram as baseline
- Consider endometrial biopsy for heavy menstrual bleeding if >45 year old or with risk factors
- Subsequent ultrasound only if there is rapid increase in size or difficulty in assessing uterine size
- Diagnostic hysteroscopy to assess resectibiity if submucosal and <5cm
What is the different Tx options for uterine leiomyomas?
When to follw up uterine leiomyoma?
When to discharge from clinic?
Follow up in 6 months if stable
Refer to integrated clinic when heavy periods controlled by medical therapy or if uterine size >16 weeks and asymptomatic; while awaiting appointment at integrated clinic, patients should be followed up routinely.
Close case if asymptomatic and uterine size static (<16 weeks)
What is the history taking for adnexal mass in premenopausal women?
Bloating/fullness/pressure in the abdomen Urinary urgency ± frequency
Abdominal pain or low back pain Dysmenorrhoea
Appetite change
Family history of ovarian or breast cancer
What is the Ix for adnexal mass in premenopausal women?
- USG – preferably transvaginal
- CA125 – not needed as a routine; save serum before operation
- LDH, AFP, HCG – in women under 40 with complex ovarian mass
What is the treatment of adnexal mass in premenopausal women?
