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Gynaecology > Uterine disorders > Flashcards

Uterine disorders Flashcards

1
Q

fibroids epidemiology

A

incidence 20-40%

most common benign tumour in women

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2
Q

pathophysiology of fibroids

A

benign smooth muscle tumour arising from myometrium
intramural most common
submucosal
subserosal

growth stimulated by oestrogen

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3
Q

risk factors for developing fibroids

A 
obesity
early menarche
increasing age
FH
african-american
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4
Q

history of fibroids

A

pressure symptoms +/- abdominal distension
urinary frequency or chronic retention
heavy menstrual bleeding
subfertility
acute pelvic pain (rare), rapidly growing fibroid undergoes necrosis and haemorrhage. rarely, pedunculated fibroids can undergo torsion

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5
Q

examination of fibroids

A

solid mass or enlarged uterus may be palpable on abdominal or bimanual examination
uterus is usually non-tender

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6
Q

DD for uterine fibroids

A

endometrial polyp
ovarian tumours
leiomyosarcoma
adenomyosis

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7
Q

investigations in fibroids

A

pelvic ultrasound

MRI: rarely required, unless sarcoma is suspected

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8
Q

medical managment of fibroids

A

tranexamic or mefanemic acid
hormonal contraceptives
GnRH analogues
selective progesterone receptor modulators

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9
Q

hormonal contraceptives for fibroids

A

Useful to control menorrhagia

Includes the COCP, POP and Mirena IUS

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10
Q

GnRH analogues
Zolidex
fibroid management

A

Suppresses ovulation, inducing a temporary menopausal state.

Useful pre-operatively to reduce fibroid size and lower complications.

Can be used for 6 months only, due to the risk of osteoporosis

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11
Q

Selective progesterone receptor modulators in fibroids

fibroid management

A

Ulipristal/ esyma
Reduces size of fibroid and menorrhagia
Useful pre-operatively or as an alternative to surgery
Use of Ulipristal is restricted due to risk of severe liver injury

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12
Q

surgical management of fibroids

A

hysteroscopy and transcervical resection of fibroid
myomectomy
uterine artery embolization
hysterectomy

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13
Q

presentation of fibroids

A

Asymptomatic

Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom

Prolonged menstruation, lasting more than 7 days

Abdominal pain, worse during menstruation

Bloating or feeling full in the abdomen

Urinary or bowel symptoms due to pelvic pressure or fullness

Deep dyspareunia (pain during intercourse)

Reduced fertility

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14
Q

initial investigation in submucosal fibroids presenting with heavy menstrual bleeding

A

hysteroscopy

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15
Q

initial investigation for larger fibroids

A

pelvic USS

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16
Q

<3cm fibroid medical mx

A

Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus

Symptomatic management with NSAIDs and tranexamic acid

Combined oral contraceptive

Cyclical oral progestogens

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17
Q

<3cm fibroid surgical mx

A

Endometrial ablation

Resection of submucosal fibroids during hysteroscopy

Hysterectomy

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18
Q

> 3cm fibroid medical mx

A

gynae referral
Symptomatic management with NSAIDs and tranexamic acid

Mirena coil – depending on the size and shape of the fibroids and uterus

Combined oral contraceptive

Cyclical oral progestogens

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19
Q

> 3cm fibroid surgical mx

A

Uterine artery embolisation

Myomectomy

Hysterectomy

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20
Q

GnRH agonists for fibroids

A

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.

They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.

Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

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21
Q

uterine artery embolization for fibroids

A

Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists.

The radiologist inserts a catheter into an artery, usually the femoral artery.

This catheter is passed through to the uterine artery under X-ray guidance.

Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.

This starves the fibroid of oxygen and causes it to shrink.

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22
Q

myomectomy surgical mx for fibroids

A

Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery).

Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.

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23
Q

endometrial ablation surgical management for fibroids

A

Endometrial ablation can be used to destroy the endometrium.

Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation.

This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.

24
Q

hysterectomy surgical mx fibroids

A

Hysterectomy involves removing the uterus and fibroids.

Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach.

The ovaries may be removed or left depending on patient preference, risks and benefits.

25
Q

complications of fibroids

A

Heavy menstrual bleeding, often with iron deficiency anaemia

Reduced fertility

Pregnancy complications, such as miscarriages, premature labour and obstructive delivery

Constipation

Urinary outflow obstruction and urinary tract infections

Red degeneration of the fibroid

Torsion of the fibroid, usually affecting pedunculated fibroids

Malignant change to a leiomyosarcoma is very rare (<1%)

26
Q

red degeneration of fibroids

A

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.

Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.

27
Q

endometriosis epidemiology

A

25-40 age

28
Q

endometriosis definition

A

chronic condition in which endometrial tissue is located at sites other than uterine cavity

29
Q

sites of endometriosis

A 
ovaries
pouch of Douglas
uterosacral ligaments 
pelvic peritoneum
bladder
umbilicus and lungs
30
Q

what are chocolate cysts?

A

endometriomas in the ovaries

31
Q

pathophysiology of endometriosis

A

retrograde menstruation
endometrial tissue is sensitive to oestrogen
symptoms depend on enstrual cycle
inflammation and scarring can lead to adhesions
symptoms reduced during pregnancy and menopause

32
Q

risk factors with endometriosis

A 
early menarche 
Family history of endometriosis
Short menstrual cycles
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in the uterus or fallopian tubes
33
Q

presentation of endometriosis

A 
cyclical abdominal or pelvic pain
deep dyspareunia
dysmenorrhea
cyclical bleeding from other sites, such as haematuria 
deposits in bladder/bowel can lead to blood in urine or stools, dyschezia
dysuria
reduced fertility
haemothorax from tissue in lungs
34
Q

examination findings in endometriosis

A

fixed, retroverted uterus

uterosacral ligament nodules

general tenderness

endometrial tissue visible in the vagina on speculum examination

tenderness in vagina, cervix and adnexa

35
Q

enlarged, tender and boggy uterus

A

adenomyosis

36
Q

endometriosis diagnosis

A

pelvic USS: large endometriomas and chocolate cysts

laparoscopy

37
Q

endometriosis staging

A

Stage 1: Small superficial lesions

Stage 2: Mild, but deeper lesions than stage 1

Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions

Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

38
Q

initial management for endometriosis

A

Establishing a diagnosis

Providing a clear explanation

Listening to the patient, establishing their ideas, concerns and expectations and building a partnership

Analgesia as required for pain (NSAIDs and paracetamol first line)

39
Q

hormonal management for endometriosis

A

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful

Progesterone only pill

Medroxyprogesterone acetate injection (e.g. Depo-Provera)

Nexplanon implant

Mirena coil

GnRH agonists

40
Q

surgical management for endometriosis

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)

Hysterectomy

41
Q

differentials for endometriosis

A

PID
ectopic pregnancy
fibroids
IBS

42
Q

diagnosis of endometriosis

A

laparoscopy: chocolate cysts, adhesions, peritoneal deposits

pelvic USS

43
Q

suppressing ovulation in endometriosis

A

Suppressing ovulation for 6-12 months can cause atrophy of the endometriosis lesions and therefore a reduction in symptoms.

A low dose combined oral contraceptive pill or norethisterone can be used. Injected hormones or intrauterine devices such as the Mirena coil can also be used. The Mirena has the benefit of containing a low dose of hormone.

44
Q

surgery for endometriosis

A

The surgical option is used if the endometriosis symptoms seriously affect the patient’s life. Surgery such as excision, fulgaration and laser ablation aim to completely remove the ectopic endometrial tissue in the peritoneum, uterine muscle and pouch of Douglas to reduce pain.

Relapses will almost certainly occur and surgery may have to be repeated. Ultimate management may be a hysterectomy and removal of the ovaries with subsequent replacement of hormones until the age of the menopause.

45
Q

adenomyosis

A

Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus.

This benign invasion of the middle layer of the uterine wall has been described as a variant of endometriosis – and although the conditions can occur together, they are distinct diagnoses.

46
Q

epidemiology of adenomyosis

A

Adenomyosis is found in up to 40% of hysterectomy specimens regardless of a previous history of pelvic pain and occurs most often in multiparous women at the end of their reproductive life

symptoms subside post-menopause

47
Q

pathophysiology of adenomyosis

A

endometrial stroma is allowed to communicate with the underlying myometrium after uterine damage

usually in posterior wall

48
Q

adenomyoma

A

When a collection of endometrial glands form grossly visible nodules

49
Q

risk factors for adenomyosis

A

high parity

uterine surgery, e.g. any endometrial curettage, endometrial ablation

previous C-section

hereditary occurrence has been reported

50
Q

symptoms of adenomyosis

A 
menorrhagia
dysmenorrhea
deep dyspareunia
irregular bleeding
progressive dysmenorrhea; cyclical-> daily pain
51
Q

signs of adenomyosis

A

symmetrically enlarged tender uterus may be palpable

52
Q

differential diagnosis of adenomyosis

A

Endometriosis

Fibroids

Endometrial hyperplasia/endometrial carcinoma

Endometrial polyps (not commonly associated with dysmenorrhoea)

Pelvic Inflammatory Disease (pelvic pain rather than cyclical pain/dysmenorrhoea)

Hypothyroidism and coagulation disorders (menorrhagia)

53
Q

investigations of adenomyosis

A

transvaginal USS

MRI

54
Q

hormone therapy adenomyosis

A

Combined oral contraceptives

Progestogens (oral or Intrauterine system e.g. Mirena)

Gonadotropin-releasing hormone agonists

Aromatase inhibitors

55
Q

non-hormonal treatments adenomyosis

A

hysterectomy
uterine artery embolisation

endometrial ablation and resection
laparoscopic excision

Gynaecology (10 decks)

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