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Obs & Gynae > Uterus conditions > Flashcards

Uterus conditions Flashcards

1
Q

What is Dysfunctional uterine bleeding? RF? Presentation?

A
  • Symptomatic variation from normal menstruation in terms of regularity, frequency, volume, duration. Due to a hormonal imbalance.
  • It is a Dx of exclusion, excludes pregnancy, iatrogenic causes, systemic causes i.e. this dx is where there is no recognisable pathology

RF
- women at extreme reproductive age e.g. after puberty or before menopauses

Clinical features
- Menorrhagia + no pain, no irregular cycle, no IMB

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2
Q

Ix of Dysfunctional uterine bleeding (5)

A

(1. ) Bloods: FBC, TSH if clinically hypothyroid
(2. ) Pregnancy test
(3. ) Cervical smear if due
(4. ) STI screen

(5. ) TVUS +/- biopsy or hysteroscopy
- if >45y or failed medical Rx
- Look for: fibroids, polyps, endometrial thickness

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3
Q

Mx of Dysfunctional uterine bleeding

A

(1. ) Mirena coil (1st line)
(2. ) COCP (2nd line)
(3. ) Tranexamic acid
(4. ) NSAIDs (mefenamic acid) CI in peptic ulcer

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4
Q

What is Endometritis? RF?

A
  • Inflammation of uterus lining
  • Usually due to infection, where barriers are broke (vaginal pH, cervical mucus)
  • Common postpartum infection

Rf
- C-section (biggest RF), birth, miscarriage, TOP, hysteroscopy, STI, PID

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5
Q

Clinical features of Endometritis

A

Postpartum fever + abdo pain

  • suprapubic pain
  • fever
  • PV discharge
  • dyspareunia
  • dysuria

O/e

  • suprapubic tenderness
  • uterine tenderness
  • offensive PV discharge
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6
Q

IX + Mx of Endometritis

A

Ix

  • HVS
  • blood cultures if septic
  • MSU

Mx

  • 7d broad spectrum Abx (cefalexin + metronidazole)
  • Prophylactic abx in c-section
  • Remove IUCD if not responding to abx
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7
Q

What is a prolapse? RF? What are the different types?

A
  • Weakness of supporting structure allows pelvic organs to protrude within the vagina
  • RF: multiple pregnancies, prolonged labour, hysterectomy, trauma from instrumental delivery, lack of postnatal pelvic floor exercise, obesity, chronic cough, constipation.

Types

  1. Cystocele – bladder prolapses into vagina.
  2. Rectocele – rectum prolapse into vagina
  3. Enterocele – loop of intestine in pouch of douglas causes posterior wall to bulge into vagina
  4. Uterine prolapse – uterus descends into vagina
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8
Q

How is prolapse graded?

A

Grading of prolapse

  • 1st degree – prolapse is halfway down to introitus (vagina opening)
  • 2nd degree – lowest part of prolapse exceeds halfway to introitus upon straining
  • 3rd degree – lowest part of prolapse exceeds outside the vagina
  • 4th degree/procidentia – uterus is outside the vagina
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9
Q

Clinical features of prolapse

A

(1. ) Asyx
(2. ) Dragging sensation/discomfort - feeling of lump coming down
(3. ) Dyspareunia
(4. ) Back ache

(5. ) Cystocele syx: Urinary frequency, dysuria, incomplete bladder emptying, urinary retention
(6. ) Rectocele: constipation, difficulty with defecation

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10
Q

Ix for prolapse

A
  • Bimanual ex
  • Sim speculum with women on left lateral position: inspect anterior and posterior wall for atrophy + descent. With speculum able to visualise vaginal walls caving in.
  • Urodynamic if urinary incontinence
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11
Q

Mx for prolapse

A

(1. ) Conservative: (a.) Reduce intraabdominal pressures: Wt loss, smoking cessation, stop straining (b.) Inc muscle tone: exercise, physiotherapy
(2. ) Medical: pessary if unfit for surgery - it will affect sexual function, must be changed every 6m, can cause vaginal erosion/irritation but topical oestrogen can help.
(3. ) Surgical: mesh repair operation. If syx severe, sexually active, pessaries failed.

  • Lifestyle modifications
  • Pelvic floor exercises
  • Pessary + PV oestrogen
  • Surgery
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12
Q

What is Endometriosis? RF?

A
  • Endometrium tissue grows outside uterine cavity, usually ovaries, fallopian tubes, pouch of Douglas (between uterus + rectum), colon, bladder

RF:

  • Early menarche
  • Late menopause
  • Nulliparity
  • FH
  • Low BMI
  • Smoke
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13
Q

Clinical features of Endometriosis

A

(1. ) Cyclic dysmenorrhea worse prior and during period, affecting ADL + QoL
(2. ) Dyspareunia
(3. ) Subfertility
(4. ) May also have GI/urinary syx e.g. cyclic rectal bleeding

O/E Often normal h/e posterior fornix tenderness/nodule may be found

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14
Q

Investigations of Endometriosis

A

(1. ) TV USS (gynae referral)
- Often normal
- May identify ovarian endometrioma
- ‘Chocolate cyst’ = endometriotic cyst

(2.) Diagnostic laparoscopy (GOLD)

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15
Q

Management of Endometriosis

A

Depends on severity and future fertility

Medical

(1. ) 3m course of analgesia (1st line)
(2. ) Hormonal rx: COCP, or progesterone (medroxyprogesterone acetate/depo-provera), or GnRH agonist or Mirena

Surgical

(1. ) If fertility priority: excisions/ablation
(2. ) Hysterectomy

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16
Q

What is Adenomyosis? RF? Clinical features?

A
  • Endometrial tissue grows inside muscle uterine wall.
  • Uterus thickens and enlarges so there is extra tissue that causes heavy + painful bleeding.
  • Complications = difficulty conceiving, miscarriage, premature labour.
  • RF = 40-50y (due to prolonged oestrogen exposure), uterine surgery

Clinical features

  • Menorrhagia
  • Dysmenorrhea
  • Pelvic pain
  • Dyspareunia
  • Infertility
17
Q

What would you find on ex and Ix? what would you do for mx of Adenomyosis?

A
  • bimanual ex: enlarged tender uterus, BOGGY womb i.e. squishy + big
  • TV USS: thickened muscular uterine wall

Mx

  • NSAIDS (mefanamic acid) or tranexamic acid
  • Hormone treatment (IUD, depo injections) if not looking to conceive
  • Hysterectomy
18
Q

What is Leiomyoma? RF? Complications with pregnancy?

A

(1. ) Fibroids (benign smooth muscle uterine tumours) that can be multiple, vary in size and type - intramural, submucosal, subserosal, peduncled. They are oestrogen dependent + enlarge during pregnancy, COCP and atrophy after menopause
(2. ) RF: 30-50y, afro-Caribbean, FH, obesity, early puberty

(3. ) Complications:
- Can cause fertility issues if interferes with implantations +/- distorts uterine cavity
- Red degeneration= infarction of fibroid during pregnancy this causes stabbing abdo pain + swelling. Rx = rest, hydration, simple analgesics

19
Q

Clinical features of Leiomyoma

A

(1. ) ASyx
(2. ) Menorrhagia
(3. ) Pelvic Pain
(4. ) Subfertility
(5. ) As they get bigger they can cause:
- Urinary syx: frequency, urgency, urinary incontinence.
- Hydronephrosis
- Bowel syx: constipation, bloating

Abdo + pelvic exam

  • Firm, enlarged, irregularly shaped non-tender uterus
  • Mass can be moved slightly from side-to-side.
  • Mass may be felt abdominally
20
Q

Ix of Leiomyoma

A

Dx should exclude more serious causes

  • MSU: if urinary syx present
  • Bloods: FBC - IDA
  • TA/TV USS
21
Q

Mx of Leiomyoma

A

No Rx if no syx, overtime they shrink
(1.) Menorrhagia syx: tranexamic acid, NSAIDs, progesterone.
If considering IUS/IUD consult specialist if uterine distorted
(2.) GnRH analogues (initiated by gynae), shrink fibroid
(3.) Myomectomy - if wanting to conceive
(4.) Uterine artery embolization
(5.) Hysterectomy

Refer

  • compressive syx
  • > 12cm
  • fertility issues
  • malignancy
22
Q

When is referral indicated for Leiomyoma

A

Referral
(1.) Compressive syx from large fibroids e.g. dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms

(2. ) Fertility or obstetric problems associated with fibroids.
(3. ) Fibroids which are palpable abdominally, or intracavity fibroids and/or whose uterine length is measured at USS, or hysteroscopy, >12 cm.

2ww Urgent referral

(1. ) Pt with ascites +/- pelvic/abdo mass
(2. ) Pt with a pelvic mass with any other features of cancer (such as unexplained bleeding, or wt loss)

23
Q

What is the most common gynae cancer?

A

endometrial adenocarcinomas

24
Q

9 RF and 2 protective factors for endometrial cancer

A

exposure to unoppossed oestrogen inc risk:

(1. ) Obesity, T2DM, HTN - inc peripheral oestrogen
(2. ) Nulliparity
(3. ) Early menarche
(4. ) Late menopause
(5. ) PCOS - due to low progesterone
(6. ) Oestrogen only HRT
(7. ) Breast cancer
(8. ) Tamoxifen
(9. ) HNPCC, lynch syndrome

Protective factors

(1. ) parity (due to progesterone from pregnancy)
(2. ) COCP

25
Q

Referral criteria for endometrial cancer

A

(1. ) >55y + PMB
(2. ) >55y with:
(a. ) unexplained PV discharge who: presenting first time OR have thrombocytosis OR haematuria
(b. ) visible haematuria and: low hb level OR thrombocytosis OR hi BGL

26
Q

Ix of endometrial ca

A

(1. ) TV USS: abnormal endometrial thickening
(2. ) Hysteroscopy + pipelle biopsy: confirms dx + for FIGO staging
(3. ) CT/MRI for staging when dx made

27
Q

Mx of endometrial ca

A

(1. ) Hysterectomy + bilateral salpingo-oophorectomy if ca limited to uterus
(2. ) Surgery, radio, chemo if spread outside uterus
(3. ) Progesterone therapy if old + frail, not suitable for surgery.

Obs & Gynae (8 decks)

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