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Year 4 OBGYN > Uterine Pathology > Flashcards

Uterine Pathology Flashcards

1
Q

Fibroids are benign smooth muscle tumours of the Uterus. Describe the pathophysiology.

A

Growth is stimulated by oestrogen

Rarely become malignant

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2
Q

Describe the classification of Fibroids

A

Intramural: Most common, confined to myometrium
Submucosal: Develops underneath endometrium and protrudes into cavity
Subserosal: protrudes into and distends Serosal surface of Uterus

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3
Q

Give three risk factors for Fibroids

A

Obesity
Early Menarche
Increased Age

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4
Q

How do Fibroids present?

A

Most are asymptomatic
Pressure Symptoms
Heavy Menstrual Bleeding
Subfertility

Normally a non tender mass OE

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5
Q

What does acute pelvic pain on the background of Fibroids suggest?

A

Torsion

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6
Q

How are Fibroids normally imaged?

A

TV USS

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7
Q

Give three differentials for Fibroids

A

Endometrial Polyp
Ovarian Tumour
Leiomyosarcoma

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8
Q

When do Fibroids require management?

A

When symptomatic

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9
Q

Give three medical managements of Fibroids

A

Tranexamic Acid
Hormonal Contraceptives
GnRH Analogues (only used for 6 months due to Osteopenia risk - oestrogen deficient state causes regression)

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10
Q

State four possible surgical managements of Fibroids

A

Hysteroscopy and Transcervical Resection of Fibroid
Myectomy
Hysterectomy
Uterine Artery Embolisation

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11
Q

Define Endometriosis

A

Where Endometrial tissue is located at sites other than Uterine Cavity (such as Ovaries, PoD, Pelvic Peritoneum, Lungs)

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12
Q

Describe the pathophysiology of Endometriosis

A

Retrograde Menstruation - Endometrial cells travel backwards from Uterine Cavity through Fallopian tubes and deposit

Sensitive to Oestrogen so do bleed

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13
Q

Give four clinical features of Endometriosis

A

Dysmenorrhoea (Cyclical but constant if adhesions)
Dysuria
Dyspareunia
Subfertility

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14
Q

Describe the investigations for Endometriosis and what you would expect to find

A

Laparoscopy - Adhesions, Peritoneal Deposits, Chocolate Cysts

Pelvic USS

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15
Q

Describe the medical management of Endometriosis

A

If no symptoms - no treatment required

Pain: WHO analgesic ladder
Suppressing Ovulation: COCP/Mirena Coil (may cause regression)

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16
Q

Describe the surgical management of Endometriosis

A

Ablation/Excision (both may require repeated procedures)

Hysterectomy (+/- HRT)

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17
Q

Define Adenomyosis

A

Presence of functional endometrial tissue within the myometrium

A variant of endometriosis but they can occur together

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18
Q

Describe the pathophysiology of Adenomyosis

A

Endometrial stroma communicates with myometrium after Uterine Damage

Commonly in posterior wall

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19
Q

Give four causes of Adenomyosis

A

Childbirth
Caesarean Section
Pelvic Surgery
Surgical Management of Miscarriage

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20
Q

Give four clinical features of Adenomyosis

A

Menorrhagia
Deep Dyspareunia
Dysmenorrhoea (Cyclical worsening to Daily)
Irregular Bleeding

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21
Q

What three investigations can be done for Adenomyosis? What would they show?

A

MRI - endomyometrial junction zone thickened irregularly

Only definitive is histological examination post hysterectomy

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22
Q

Describe the short term management of Adenomyosis

A

Uterine Artery Embolisation

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23
Q

How can the symptoms of Adenomyosis be controlled?

A

NSAIDS

COCP/Mirena

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24
Q

What is the definitive management of Adenomyosis?

A

Hysterectomy

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25
Q

Endometrial Cancer is the most common gynaecological cancer of the developed world. Describe the pathophysiology

A

Most commonly adenocarcinoma

Often preceded by Endometrial Hyperplasia

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26
Q

Give four risk factors for Endometrial Cancer

A

High Oestrogen Exposure
Age
Obesity
Genetic (Lynch)

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27
Q

Give three clinical features of Endometrial Cancer

A

Post Menopausal Bleeding (or intermenstrual if pre menopausal)
Abdominal pain
Weight Loss

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28
Q

Give three differentials for Endometrial Cancer

A

Vulval Atrophy
Cervical Cancer
Endometrial Hyperplasia

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29
Q

How is Endometrial Cancer investigated?

A

1) Transvaginal USS (of if high risk then skip to 2)
2) If thickness >4mm then referred for Hysteroscopy with Pipelle Biopsy
3) MRI/CT Staging if cancerous

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30
Q

Describe the FIGO staging of Endometrial Cancer

A

I- Confined to Uterine Body
II - May extend to cervix but not beyond uterus
III - Beyond Uterus but confined to Pelvis
IV - Bladder/Bowel/Distant Sites

31
Q

How is Endometrial Hyperplasia managed?

A

With Progesterones such as Mirena

Any sign of atypical features then full hysterectomy and bilateral salpingo-oophorectomy

32
Q

How is Stage 1 Endometrial Cancer managed?

A

Hysterectomy with Bilateral Oophorectomy

the most commons stage presentation and procedure

33
Q

How is Stage 2 Endometrial Cancer managed?

A

Radical Hysterectomy (including parts of the vagina and lymph node dissection)

34
Q

How is Stage 3 Endometrial Cancer managed?

A

Maximal Debulking

Chemoradiotherapy

35
Q

How is Stage 4 Endometrial Cancer managed?

A

Maximal Debulking

36
Q

Define Dysmenorrhoea

A

Pain associated with the onset of menstruation, can be Primary (no underlying pathology) or Secondary (underlying pathology)

37
Q

Describe the proposed pathophysiology of Primary Dysmenorrhoea

A

When the corpus luteum regresses there is a drop in progesterone and rise in PG

PGs cause myometrial contractions and spiral artery vasospasm

An exaggerated response of the above is thought to be the cause of the pain

38
Q

Give four clinical features of Dysmenorrhoea

A

Crampy abdominal pain
Radiating down anterior thighs
Lasting 48-72 hours
Dizziness and Nausea

39
Q

Give three causes of Secondary Dysmenorrhoea

A

Adenomyosis
Endometriosis
Adhesions (PID)

40
Q

How can a Primary Dysmenorrhoea be distinguished from Secondary?

A
  • Onset of secondary is normally a few days before starting period
  • Secondary typically starts many years after initial menarche
41
Q

How would you manage Dysmenorrhoea non pharmacologically?

A

TENS

Local application of heat

42
Q

How could you manage Dysmenorrhoea pharmacologically?

A

1) Mefanamic Acid (NSAID - PG antagonist - in theory reduces the physiological effects)
2) COCP

43
Q

What is Mittleshmerz?

A

Unilateral ovarian pain associated with ovulation, on around day 14 of cycle

44
Q

Define Primary Amenorrhoea

A
  • Failed to start periods by age of 16 but has secondary sexual characteristics
  • Failed to start periods by age of 14 but has no secondary sexual characteristics
45
Q

Define Secondary Amenorrhoea

A

Cessation of periods for>6m when previously started (pregnancy excluded)

46
Q

Give two Hypothalamic causes of Amenorrhoea

A

Eating disorders

Chronic illness

47
Q

Give four pituitary causes of Amenorrhoea

A

Sheehans Syndrome
Hyperprolactinaemia
Depot - Provera
Radiation

48
Q

Give an adrenal cause of Amenorrhoea

A

Late/Mild Congenital Adrenal Hyperplasia

49
Q

Give three Ovarian causes of Amenorrhoea

A

PCOS
Turners Syndrome
Primary Ovarian Failure

50
Q

Give three genital causes of Amenorrhoea

A

Imperforate Hymen
Ashermans Syndrome
MRKH

51
Q

Define Oligomenorrhoea

A

Less than 9 periods a year, or >35d between periods

52
Q

Give three causes of Oligomenorrhoea

A

Thyroid disease
PCOS
Medications (including anti epileptics)

53
Q

Name 5 bloods you would do for Amenorrhoea/Oligomenorrhoea

A 
FSH/LH
Oestrogen/Progesterone/Testosterone
Thyroid Function
Prolactin 
Hydroxylase enzymes (CAH)
54
Q

Other than bloods, name three investigations you would do for Oligo/Anovulation

A

Pregnancy Test!
Swabs/Smear
Transvaginal USS

55
Q

What is the Progesterone challenge test in Oligo/Anovulation

A

Giving 5-10d Progesterone to aim to induce a withdrawal bleed

Bleed - the problem was with ovulation (PCOS, Thyroid)

No bleed - the problem is with lack of oestrogen priming OR structural issue (imperforate hymen, hypopituitarism, hyperprolactinaemia)

56
Q

How would you manage Oligo/Anovulation?

A

COCP/POP

57
Q

How to Thyroid Abnormalities affect menstruation?

A

Hypothyroidism - by feedback increases TRH, which also acts to increase prolactin (inhibiting FSH and LH)

\it also reduces SHBG - increasing free circulating oestrogen and therefore causes menorrhagia

58
Q

Define Menorrhagia

A

Excess menstrual loss at a level enough to affect woman’s QoL

59
Q

Give four structural causes of Menorrhagia

A

PALM

Polyps
Adenomyosis
Leiomyoma (Fibroid)
Malignancy

60
Q

Give 5 non structural causes of Menorrhagia

A

COEIN

Coagulopathies
Ovarian Pathology
Endometrial Pathology
Iatrogenic
Not Specified
61
Q

Give 2 associated symptoms with Menorrhagia

A

Dizziness

Fatigue

62
Q

How is Menorrhagia investigated?

A

Bloods (FBC, Clotting, TFTs, Hormones)
Pregnancy Test!
Transvaginal USS
Swabs and smear where relevant

63
Q

How is Menorrhagia managed medically?

A

1) IUS (Mirena)
2) Tranexamic Acid or COCP
3) POP

64
Q

How is Menorrhagia managed surgically?

A

Endometrial Ablation

Hysterectomy (subtotal or total)

65
Q

Give 5 causes of Post Coital Bleeding

A 
Vaginal Atrophy
STIs
Polyps
Cervical Ectropian
Cervical Cancer
66
Q

Give 5 causes of Intermenstrual Bleeding

A 
Tamoxifen 
STIs
Pregnancy related
Missed Pill
Perimenopause
67
Q

Give 5 causes of Post Menopausal Bleeding

A 
Endometrial Hyperplasia
Endometrial Cancer
HRT
Vaginal Atrophy 
Cervical cancer
68
Q

Who should be on 2WW for Post Menopausal Bleeding?

A

Anyone over 55

For Transvaginal USS

69
Q

How would you manage PMB?

A

Treat underlying cause

Vaginal Atrophy - Topical Oestrogen, Lubrication, HRT
Endometrial Hyperplasia - Dilation and Curettage to remove excess tissue

70
Q

How would you investigate PCB?

A

Full Menstrual and Gynae History
PV Exam and Swabs
Pregnancy Test
Transvaginal USS

71
Q

When should you refer a patient with PCB?

A

Abnormal Cervix with Cancer Suspicion
Cervical Polyp that is not easily removed
Pelvic Mass/USS abnormality
Those at high risk of endometrial cancer

72
Q

Give 5 causes of Chronic Pelvic Pain

A 
Endometriosis
Adenomyosis
Adhesions
IBS
Interstitial Cystitis
MSK/nerve
73
Q

How is Chronic Pelvic Pain investigated?

A

STI screen
Transvaginal USS
Laparoscopy

Year 4 OBGYN (15 decks)

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