Pelvic Mass / Pain Flashcards
1
Q
PAINFUL PERIODS
history
A
- Pain – location, character, duration
- GI symptoms – nausea, vomiting, diarrhoea, constipation, pain associated to bowel opening
- Urinary symptoms – dysuria, frequency
- Menstrual history – age of menarche, typical cycle length and regularity, normal period duration and symptoms, tampons / pads (how many, how often change, use together, flooding), effects on school and other activities
- Treatment – have they tried NSAIDs etc, was it effective
- Medical history – surgery, family history (endometriosis)
- Sexual history – first intercourse, male/femal partners, route of intercourse, contraception, history of symptoms of STI, vaccination, pain or bleeding during sex
2
Q
PAINFUL PERIODS
examination
A
Abdominal examination • Palpable masses • Location of tenderness • Auscultate for bowel bounds • Previous scars
Pelvic examination
• Not in adolescent who has never been sexually active
• Only indicted if; sexually active and not responding to conventional treatment or organic pathology suspected
• Speculum examination
• Bimanual examination
• STI testing
3
Q
PRIMARY DYSMENORRHOEA
- age of presentation
- responds well to…
- concerning features
- making a diagnosis
A
- Presents in teenage years
- NSAIDs
- dyspareunia, post coital bleeding, vaginal discharge, menorrhagia, unilateral pain
- Diagnosis of exclusion
•Abdominal USS if; palpable abdominal mass, not responding to treatment
• Consider bloods to rule out: FBC, ferritin and iron studies, ESR, CRP
4
Q
causes of secondary dysmenorrhoea
A
Endometriosis
Adenomyosis
5
Q
OVARIAN CYST
- what is it
- who gets it
A
- Fluid filled sac in ovary. Small cysts nor concerning unless symptomatic, resolution usually seen on US after a few weeks (scan after 12 weeks)
Potentially malignant – RMI (risk of malignancy index) - Common in premenopausal women
6
Q
OVARIAN CANCER
- where does it derive from
- risk factors
- protective factors
- associated genes
A
- Derive from surface epithelial irritation during ovulation
- More ovulation = increased risk, nulliparity, early menarche, late menopause, HRT, smoking, obesity
- multiparity, combined contraceptives, breastfeeding
- BRCA1 +2 / HNCCP – lynch 2 syndrome
7
Q
OVARIAN CANCER
risk of malignancy index and how is it calculated
A
risk stratification tool in patients with suspected ovarian cancer
RMI = U X M X CA125
M = menopausal status (1=premenopausal / 3= post menopausal)
U = ultrasound score -mulilocular cyst, solid area, metastases, ascites, bilateral lesions - (1 feature = 1 point / 2 or more features = 3 points
8
Q
OVARIAN CYST
clinical features
A
- Incidental and asymptomatic – scanning for other reasons eg pregnancy
- Chronic pain – may develop secondary to pressure on bladder or bowel causing frequency of constipation – may manifest as dyspareunia or cyclical pain in patients with endometriosis
- Acute pain – bleeding into the cyst, rupture or torsion
- Bleeding per vagina
9
Q
OVARIAN CYST
classification
A
- Divided into non-neoplastic and neoplsastic
- Simple ovarian cyst only contains fluid
- Complex ovarian cyst can be irregular and can contain solid material, blood, or have septations or vascularity
- Non neoplastic – functional (follicular cyst <3cm / corpus luteal cyst <5cm) OR Pathological (endometrioma aka chocolate cysts / polycystic ovaries these contain more than 12 antral follicles or volume >10ml, ring of pearls sign, seen in PCOS / theca lutein cyst due to raised hCG such as molar pregnancy
- Benign neoplastic – epithelial (serous cystadenoma, mucinous cystadenoma, brenner tumour) / benign germ cell tumours (mature cystic teratoma) / sex cord stromal tumours (fibroma)
10
Q
OVARIAN CYST
management in premenopausal women
A
- CA125 doesn’t need to be undertaken when diagnosis of simple cyst has been made by US as it can be raised by anything irritating the peritoneum so there are many benign triggers.
- Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to possible germ cell tumours
- Rescan a cyst in 6 weeks
- If persistent or over 5cm consider laparascopic cystectomy or oophorectomy
11
Q
OVARIAN CYST
management in post menopausal women
A
- If low RMI <25 – follow up for 1 year with US and CA125 if less than 5cm
- Moderate RMI 25-250 – bilateral oophorectomy and if malignancy found staging required
- High RMI >250 – referral for staging laparotomy
12
Q
FIBROIDS
what are they
A
- Leiomyomas
- Benign smooth muscle tumours of uterus
- Most common benign tumours in women with estimated incidence of 20-40%
- Low risk of becoming malignant
13
Q
FIBROIDS
pathophysiology
A
- Arise from myometrium and classified according to position
- Intraluminal – common and confined to myometrium of the uterus
- Submucosal – develops immediately endometrium of uterus and protrudes into uterine cavity
- Subserousal – protrudes into and distorts serousal surface of uterus. They may be peuculated
- Growth stimulated by oestrogen
14
Q
FIBROIDS
risk factors
A
- Obesity
- Early menarche
- Increasing age
- Family history
- Ethnicity – African americans
15
Q
FIBROIDS
clinical features
A
- Pressure symptoms+/- abdominal distention – urinary frequency of chronic retention
- Heavy menstrual flow
- Subfertility – obstructive effect
- Acute pelvic pain – rare- may occur in pregnancy due to red degeneration
16
Q
FIBROIDS
examination and investigetions
A
Examination
• Solid mass or enlarged uterus
• Usually non tender
Investigations
• Imaging
• Pelvic ultrasound
• MRI
17
Q
FIBROIDS
management
A
- Tranexamic or mefenamic acid
- Hormonal contraceptives - COCP, POP, mirena IUS
- GnRH analogues - suppress ovulation including temporary menopause state, useful pre-operatively to reduce siz and lower complications / used for 6 month – risk of osteoporosis
- Selective progesterone receptor modulators (ulipristal/esmya) – reduce size and menorrhagia, useful preo-operatively or alternative to surgery
- Surgery – hysterectomy and transcervical resection of fibroid, myomectomy, uterine artery embolization, hysterectomy
