General gynaecology Flashcards
Heavy menstrual bleeding
History and examination
History:
Periods - frequency, length, regularity, IMB, pain, heaviness, symptoms of anaemia and impact on life
Discharge, bladder or bowel dysfunction
Other bleeding symptoms
G and P
Contraception, smears, previous STIs
Medical, surgical and psychiatric history
Family history
Medications and allergies
Social history - home, relationship, FV screen, occupation, substance use
Examination:
Obs
BMI
Conjunctivae, pallor
Abdomen - soft, pain, massess
Speculum - vulva, vagina, cervix, discharge, bleeding
Bimanual - uterine size, version, mobility, descent and suitability for TVH, massess, tender
Heavy menstrual bleeding
Differential diagnosis and
investigations
Differential diagnosis:
* Polyps
* Adenomyosis
* Leimyomata
* Malignancy/hyperplasia
* Coagulopathy - vWD, TTP
* Ovulatory dysfunction - PCOS, obesity, hypothryoidism
* Endometrial - infection
* Iatrogenic - CuICD, anticoagulation
* Not otherwise specified
Investigations:
- Hb
- Ferritin
- Coagulation screen, vWF if risks
- TFTs
- BhCG
- Vaginal swabs
- Cervical smear if due/cervix abnormal
- USS pelvis
- Pipelle biopsy
Heavy menstrual bleeding management
Fe replacement
Reverse cause if known and applicable
Give written information
NSAIDs
Mirena
COCP or progesterone - provera, norethisterone
TXA
NSAIDs
Endometrial ablation
Myomectomy
Uterine artery embolisation
Hysterectomy - TLH, TVH, TAH. Conserve ovaries
Von Willebrand‘s disease
- types
- diagnosis
- treatment
Three types:
1 - less of vWF (AD)
2 - present but not functioning (AD)
3 - severe reduction/absent (AR)
Diagnosis:
- Prolonged APTT
- Low vWF
- Low Factor VIII
- PFA-100 (screening tool)
Treatment:
- Haematology referral
- dDAVP
- Replacement from human derived factor VIII, cryo
- TXA
- Avoid aspirin and NSAIDs
- Hormonal control
- Topical - surigcel/gelfoam soaked in thrombin
- Factor VIIa - bypasses need for factor VIII
- Consider pregnancy implications
Mirena
- indications
- contraindications
- method of action
- risks
Indications:
- Contraception
- HMB
- Endometriosis
- Dysmenorrhoea
- Hyperplasia without atypia
- Stage 1A endometrial cancer and uterine preservation desired or poor surgical candidate
Contraindications
- Active infection
- Distorted uterine cavity
- Breast cancer (PR+)
Method of action:
Local release of 52mg levonorgrestrel over 5years, causes endometrial atrophy. Weak effect on ovarian function.
Risks:
Insertion - pain, bleeding, infection, perforation
Malposition/expulsion
Failure
Abnormal bleeding
Management of uterine fibroids
Assess:
* Number, location, size
* Type
Counsel:
* Bleeding, pressure symptoms, degeneration
* Pregnancy - may impact fertility (SM), malpresentation, IUGR, difficulty palping fundal height, abruption, needs for CS, PPH, red degeneration, torsion
Management:
* Medical - OCP, Mirena (not if cavity distorting), TXA, NSAIDs
* GnRH analogue - usually only pre-operative
* Hysteroscopic resection if submucosal
* Myomectomy - uterine preserving
* Uterine artery embolisation - Placement of an angiographic catheter into uterine arteries via common femoral artery injection of embolic particles until the flow becomes sluggish in both uterine arteries. Aims to reduce uterine blood flow by producing ischaemic injury causing necrosis and shrinking. 65% of women avoid hysterectomy. Possible complications: groin haematoma, arterial thrombosis. Vaginal discharge, infection, expulsion of necrotic fibroid and VTE. Embolisation syndrome - fever nausea pain and malaise.
* Hysterectomy
* MRI guided focused USS ablation - High frequency USS waves produce heat to denature proteins leading to cell death and shrinkage of fibroids. Quick recovery and very low morbidity.
Dysmenorrhoea/pelvic pain management
MDT - pain specialist, physio, psychologist, dietician, social worker
Written information
Lifestyle modification - diet, exercise, sleep hygiene, reduce psychosocial stressors
Mindfulness, restorative yoga
NSAIDs
Hormonal suppression - OCP, Depo, Mirena
Neuropathic agents - gabapentin, nortriptyline, amitriptylline
(Laparoscopy for endometriosis)
You are performing a laparoscopy for a 14year old for pelvic pain. You note extensive superficial endometriosis on uterosacrals and posterior broad ligment. Outline your management steps
Document - photographs, descriptions
Escalate to suitably qualified/skilled senior/surgeon
Biopsy
Resection - now, planned later or later only if symptoms/fertility concern
Now - Butterfly peritoneal resection
Later - planned procedure with advanced laparoscopic surgeon, colorectal, ureteric stents
Mirena or other hormonal suppression
Follow up, MDT, pain team
Counsel re central sensitisation and fertility impacts
DES exposure
Risks, management
Women: 30% increase in breast cancer -> mammograms
Female fetus:
Breast cancer - mammorgams, breast exams
Clear cell ca of vagina and cervix
Cervical/vaginal dysplasia (large ectropions and large area of metaplasia) -> annual gynaecology review: general exam, colposcopy, HPV and smear co-test, bimanual. Experienced colposcopist.
Uterine malformations: Endometrial adhesions, hypoplastic uterus and cervix, preterm birth, miscarriage, ectopic.
Male fetus:
Testicular abnormality: epididymal cyst, hypogonadism, undescended testis. NOT cancer or infertility.
Secondary ammenorrhoea
Differential diagnosis, investigations
Differentials:
- Pregnancy
- Lactation
- Menopause
- POI
- Ashermann’s
- Hypothalamic (intensive exercise, weightloss)
- PCOS
- Sheehan’s syndrome
- Infection
- Drugs
Investigations:
- BhCG
- FSH, LH, oestradiol
- PRL
- Pelvic USS
- Hysterosalpingogram
- Hysteroscopy
Ashermann’s syndrome management
Hysterosopic resection
- Scissors
- May do concurrent laparoscopy to reduce perforation risk
Measure to prevent reformation
- Intrauterine balloon 7-10days
- IUCD
- Oestrogen to promote rapid re-epithelialisation
Counsel post op about recurrence, pregnancy complications incl accreta spectrum, PTB, PPH
Rudimentary uterine horn
Complications, management
Communicating or non-communicating
Complications:
Dysmenorrhoea
Endometriosis
Cornual ectopic pregnancy - rupture
Pregnancy: miscarriage, PTB, IUGR, malpresentation, CS birth
Management:
Surgical excision (laparoscopic hemi hysterectomy) +/- treatment of endeemtriosis
Consider endometrial ablaton, hysteroscopic resection (still risk of ectopic)
Scan for renal and skeletal anomalies - renal USS and XRs
Differentiation between PCOS, CAH, Androgen tumors of ovaries and adrenals
Testosterone, DHEAS, cortisol, 17-OHP
PCOS: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Congenital Adrenal hyperplasia: Testosterone increased or normal, DHEAS increased, Cortisol normal or decreased, 17-OH-progesterone increased.
Androgen producing tumour – adrenal: Testosterone increased, DHEAS increased, Cortisol increased, 17-OH-progesterone normal
Androgen producing tumour – ovarian: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Secondary amenorrhoea
Differential diagnosis and investigations
Pregnancy - BhCG
PCOS - USS, free androgens, SHBG, LH, FSH, mid luteal progesterone
Obesity
Hypothalamic or functional e.g. stress, excessive exercise, eatig disorder - history may suggest
Hyperprolactinaemia - PRL
Thyroid dysfunction - TSH
Sheehan’s syndrome - ask for PPH history
Medications
Chronic disease
Ashermann’s - USS, hysteroscopy, history may suggest
Cervical stenosis - suspect on history
POI - karyotype, autoantibody, FMR1 screen
Late onset CAH - 17OHP
Androgen tumor - ovarian or adrenal - DHEAS
Exogenous androgen
You suspect a patient has PCOS; what investigations would you perform to rule out other causes?
- BhCG
- FSH, LH, oestradiol, mid-luteal phase progesterone
- Testosterone, FAIS, SHBG +/- DHEAS
- Serum PRL, TFTs
- Pelvic USS
- 17-OH progesterone level (CAH)
- (Progestin withdrawal test if no other cause found ?intrauterine cause)
