Firecracker - Benign Gynaecology

Question 1

What five factors lead to endometrial proliferations by increasing estrogen levels?

Answer 1

• Patients with high levels of unopposed estrogen include:
  
  • obese patients
  • those using exogenous estrogen as medication
  • patietns with estrogen secreting tumours (Granulosa theca cell tuours)
  • patients with anovulatory cycles
  • patients with PCOS
    
    • Other risk facotrs include DM and HT possibly due to their association with obesity and PCOS.

Question 2

What is adenomyosis?

Answer 2

• Defined as islands of endometrial glans within myometrium
  
  • Patients present with severe menorrhagia and dysmenorrhea
  • Generally in women older than 40
  • Symmetrically enlarged ‘boggy’ uterus on bimanual examination, as compared to fibroid uterus which is ‘lumpy bumpy’
  • Endometrial biopsy may be performed to rule out other causes of abnormal bleeding (i.e. endometrial hyperplasia) but the only way to diagnose adenomyosis definitively is with microscopic examination of the myometrium following hysterectomy
  • Definitive treatment with hysterectomy which also gives definitive (pathologic diagnosis)

Question 3

How is Lichen sclerosis treated?

Answer 3

• Lichen sclerosis is an atrophic skin condition found on the vulva of the post-menopausal women
• The condition causes:
  
  • skin thinning
  • pruritis
  • contracture of the vaginal introitus
    
    • therefore painful sex
  • Has an association with increased risk of vulvar cancer
• Treatment:
  
  • Topical corticosteroid cream such as Clobetasol

Question 4

How is primary dysmenorrhea diagnosed?

Answer 4

• PD is idiopathic - it is menstrual pain in the absence of any hormonal or anatomic pathology
  
  • Usually presents before the age of 20 and will often decrease throughout a patient’s 20s and early 30s
  • Symptoms include:
    
    • Nausea
    • Vomiting
    • Headache
• The diagnosis is made based on history and the absence of an organic cause

Note that the pain from primary dysmenorrhea usually begins on the first or second day of the menstrual cycle whereas pain from endometriosis usually occurs 1-2 weeks before menstruation.

Question 5

What are some multiorgan system effects associated with toxic shock syndrome?

Answer 5

• Acute onset of high fevers greater than 102F
• Vomiting and diarrhea
• Sore throat
• Generalized macular rash

Patients in more severe cases can develop:

• hypotension secondary to shock
• respiratory distress
• desquamation of the palms and soles

The generalised rash associated with TSS is a diffuse erythema that starts on the trunk and spreads to the extremities which leads to erythemaof palms and soles. It resembles sunburn

Multiorgan system involvement is also associated with toxic shock syndrome and can include:

• GI symptoms including profuse diarrhea
• Pre-renal and intrinsic renal failure
• Hyponatremia, hypocalcemia and hypophosphatemia secondary to the renal failure
• Diffuse myalgia with elevated creatinine phosphokinase
• Confusion due to cerebral edema

Question 6

What is dysmenorrhea?

Answer 6

Pain and cramping during menstruation that interferes with normal activities and requires medication - it can be primary or secondary

Question 7

How does endometrial hyperplasia present?

Answer 7

• Presentation
  
  • Usually a patient experiences a long period of oligomenorrhea or amenorrhea followed by return of menses.
    
    • Recognizing this pattern is key to diagnosis and treatment
• Diagnosis
  
  • Made via an endometrial biopsy
• Treatment
  
  • Most hyperplasia can be treated with progesterone which causes decidualization of the endoemetrium
  • Forms of progesterone include Depo-Provera, the Mirena IUD, oral progesterone or topical progesterone
• A repeat endometrial biopsy is performed after 3 months of treatment

Atypical complex hyperplasia is the most severe form of hyperplasia and is a precursor to endometrial carcinoma in one third of untreated patients.

Therefore a hysterectomy should be performed in these patients

Question 8

What is the first choice of treatment in the management of fibroids?

Answer 8

• Management of asymptomatic uterine fibroids involves monitoring the patient with ultrasound to detect abnormal growth
• Pharmacological treatment options are often the first choice in management of symptomatic uterine fibroids
• For patients with moderate pain associated with uterine fibroids:
  
  • NSAIDs and expectant management
• For patients with heavy bleeding associated with uterine fibroids, OCPs, medroxyprogesterone acetate, progestin implants or danazol may be used
• GnRH agnonists are used to decrease the size of the fibroids as well as decrease the vascularity
  
  • Recall a GnRH agonist such as Leuprolide acts as an antagonist when used in continuous fashion (decreased FSH and LH lead to decreased circulating estrogen)

Question 9

Briefly, what are the surgical options for treating fibroids?

Answer 9

• Surgical management is appropriate for patients who suffer severe symptoms, such as anemia from menorrhagia, or in patients who have become infertile due to fibroids and wish to maintain fertility.
  
  • Endometrium overlying fibroids is less well-perfused than endometrium overlying normal myometrium, and is unable to support a pregnancy.
• Myomectomy is the removal of one or more fibroids laproscopically, hysteroscopically, or abdominally. This procedure can improve fertility in patients with subendometrial fibroids.
• Hysterectomy is used to treat severe symptoms in patients with no desire to maintain fertility.
• Uterine artery embolization is another treatment available for patients with uterine fibroids, which involves selectively infarcting small fibroids. Note: uterine artery embolization carries a high likelihood of impaired fertility.

Question 10

What are the risk factors for the development of uterine fibroids?

Answer 10

Risk factors for uterine fibroid development include:

Nulliparity
African American heritage
Diet high in meat
Alcohol consumption
Family history

Question 11

What are fibroids?

Answer 11

• Fibroids or uterine leiomyomas or are benign growths of smooth muscle that are commonly found in the myometrium (smooth muscle layer deep to the endometrium) in reproductive age women
• They are classified:
  
  • Submucosal - just deep to the endoemtrium, affects the interior shape of the uterine cavity and cause heavy menses
  • Intramural - in the muscular wall of the uterus which is the most common type
  • Subserosal - just deep to the serosa on the exterior of the uterus. These can impinge on the uterus and other pelvic structures

Their growth is stimulated by estrogen and progesterone - as a result symptoms vary with the menstrual cycle, worsen rapidly during pregnancy and improve following menopause.

Question 12

Symptoms of endometriosis?

Answer 12

• Women in their 20s or 30s with endometriosis may present with infertility and three Ds
  
  • Dysmenorrhea (painful menses)
  • Dyspareunia (painful sexual intercourse)
  • Dyschezia (painful defecation)
• In addition to the three Ds, endometriosis may present with:
  
  • Pelvic pain
  • Possible infertility
  • Uterine or adnexal tenderness
  • Palpable adhesions on uterus or ovaries
• The most common site of endometriosis include:
  
  • Adnexa - ovaries being the most common
  • Rectouterine pouch of Douglas
  • Bowel, bladder and peritoneum

Question 13

What is hypomenorrhea?

Answer 13

Hypomenorrhea is regularly timed menses with light bleeding.

Common causes of hypomenorrhea include:

Hypogonadism (seen in anorexia, heavy exercising)
Contraception use
Asherman’s syndrome (intrauterine adhesions)

Question 14

What is a Bartholin’s cyst?

Answer 14

• A bartholin’s cyst occurs when outflow from the glands of Bartholin is obstructed.
  
  • Recall, the Bartholin ducts are mucus-secreting ducts that are located at 4 and 8’o’clock on the vaginal orifice
  • Small cysts can be treated witih Sitz baths whereas large, painful cysts should be incised and drained
  • To prevent reformation of a large abscess, a drain, such as Word Catheter, should be left in place after drainage
  • Antibiotic coverage of Neisseria gonorrhea and skin flora such as Staph.aureus should be administered

Question 15

What is secondary dysmenorrhea?

Answer 15

Secondary dysmenorrhea is menstrual pain due to an underlying pathology, such as:

• Endometriosis
• Fibroids
• Adenomyosis
• PID
• Cervical stenosis

Question 16

How is the pain from primary dysmenorrhea differ from that of endometriosis?

Answer 16

• Primary dysmenorrhea is idiopathic menstrual pain that has no identifiable pathology
  
  • Primary dysmenorrhea usually presents before the age of 20 and will often decrease throughout a patient’s 20s and early 30s
  • Symptoms include nausea, vomiting and headache
  • The diagnosis is made based on history and absence of an organic cause
• Note that pain from primary dysmenorrhea usually begins on the first or seconday day of the menstrual cycle whereas pain from endometriosis usually occurs 1-2 weeks before menstruation.

Question 17

What are the clinical criteria required to make a diagnosis of toxic shock syndrome?

Answer 17

• The diagnosis of toxic shock syndrome is based on the clinical presentation, which must include:
  
  • Presence of high fevers greater than 38.9
  • Hypotension
  • Erythroderma and desquamation
  • Involvement of 3 organ systems
• Labs will show:
  
  • S.aureus in vaginal fluid cultures associated with tampon use
  • Thrombocytopenia
  • Increased ALT and AST
  • Increased BUN and creatinine

Question 18

What are the treatment options for uterine fibroids?

Answer 18

• Pharmacological treatment options are often the first choice in management of symptomatic uterine fibroids.
  
  • For patients with moderate pain associated with uterine fibroids, NSAIDS and expectant management may be appropriate.
  • For patients with heavy bleeding associated with uterine fibroids, OCPs, medroxyprogesterone acetate, progestin implants, or danazol may be used.
  • GnRH agonists are used to decrease the size of the fibroids, as well as decrease the vascularity. Recall, a GnRH agonist, such as Leuprolide, acts as an antagonist when used in continuous fashion (decreased FSH and LH lead to decreased circulating estrogen).
• Surgical management is appropriate for patients who suffer severe symptoms, such as anemia from menorrhagia, or in patients who have become infertile due to fibroids and wish to maintain fertility. Endometrium overlying fibroids is less well-perfused than endometrium overlying normal myometrium, and is unable to support a pregnancy.
  
  • Myomectomy is the removal of one or more fibroids laproscopically, hysteroscopically, or abdominally. This procedure can improve fertility in patients with subendometrial fibroids.
  • Hysterectomy is used to treat severe symptoms in patients with no desire to maintain fertility.
• Uterine artery embolization is another treatment available for patients with uterine fibroids, which involves selectively infarcting small fibroids. Note: uterine artery embolization carries a high likelihood of impaired fertility.

Question 19

What symptoms indicate a more severe case of toxic shock syndrome?

Answer 19

• Hypotension
• Respiratory distress
• Desquamation of palms and soles

Question 20

What symptoms are associated with uterine fibroids?

Answer 20

• Half of women with fibroids are asymptomatic. Those with symptoms may present with the following:
  
  • Abnormal uterine bleeding (menorrhagia, metrorrhagia) especially with submucosal fibroids
  • Pelvic pain from subserosal fibroids
  • Infarction (due to outgrowth of blood supply), resulting in degeneration, necrosis and pain
  • Impingement of pelvic structure, resulting in constipation, venous stasis, hydronephrosis and urinary retention
  • Infertility

Question 21

What are the most common sites of endoemetriosis?

Answer 21

• The most common site of endometriosis include:
  
  • Adnexa - ovaries being the most common
  • Rectouterine pouch of Douglas
  • Bowel, bladder and pertioneum

Question 22

What symptoms are associated with premenstrual syndrome and premenstrual dysphoric disorder?

Answer 22

• Symptoms of premenstrual syndrome and premenstrual dysphoric disorder include:
  
  • Food cravings, weight gain
  • Headache
  • Abdominal or pelvic pain, abdominal bloating, change in bowel habits
  • Mood lability, depression, fatigue and irritability
  • Breast tenderness
  • Acne
  • 5-10% of women have severe symptoms that interfere with daily life
• Symptoms associated with PMS and PMDD precede menses and occur at similar poitns in each cycle
• If a patient suspected of having PMS or PMDD has mood symptoms throughout her entire menstrual cycle (rather than only the second half) , a psychiatric workup for the mood disorder should be initiated.

Question 23

What is menorrhagia?

Answer 23

Menorrhagia is normally timed menstrual cycles but with excessive bleeding.

Common causes of menorrhagia include:

uterine fibroids

adenomyosis

endometrial polups

(less commonly) endometrial hyperplasia and cancer

If a teenager suffers from menorrhagia, it is recommended that she can be checked for a bleeding disorder (ITP, vWD)

Question 24

What is metrorrhagia?

Answer 24

• Metrorrhagia is when a patient has regular cycles, but experiences bleeding between those cycles
• Causes of metrorrhagia include:
  
  • Cervical lesions
  • Endometrial polyps
  • Endometrial carcinoma

Question 25

What is menometrorrhagia?

Answer 25

• Menometrorrhagia is excessive bleeding (greater than 80 mL) at irregular intervals
• Common causes of menometrorrhagia include:
  
  • Fibroids
  • Adenomyosis
  • Endometrial polyps
  • Endomentrial hyperplasia
  • Endometrial cancer

Question 26

What is oligomenorrhea?

Answer 26

• Periods are more than 35 days apart
• Common causes are related to hormonal abnormalities, such as hyperprolactinemia and thyroid dysfunction

Question 27

What is dysfunctional uterine bleeding?

Answer 27

• Abnormal bleeding in which there is no identifiable pathologic cause for the abnormal bleeding
• The most common cause of dysfunctional uterine bleeding is anovulation.
• The ovaries produce estrogen, but without ovulation, there is no corpeus luteum, no progesterone production and continual estrogen stimulation of the endometrium
  
  • Without the progesterone production, the endometrium continues to grow under the influences of estrogen, until it outgrows its blood supply and is sloughed off at irregular times.

Question 28

What are some risk factors for endometriosis?

Answer 28

Endometriosis is the implantation and proliferation of ectopic non-neoplastic hormonally-responsive endometrial glands and stromal tissue outside of the uterus.

Endometriosis is thought to occur via different mechanisms, which include:

Retrograde menstruation
Vascular/lymphatic spread of endometrial tissue to the pelvic cavity
Iatrogenic spread of tissue (e.g., during a c-section)

Because endometriosis is hormone-responsive, the symptoms of endometriosis are cyclical and worsen leading up to menstruation.
The ectopic endometrial tissue undergoes menstrual-type bleeding which leads to blood-filled “chocolate cysts” in the ovaries and reddish-bluish-brown “powder-burn” serosal nodules.

Risk factors for endometriosis include:

Family history
Nulliparity (no history of childbirth)
Low BMI

Question 29

When considering endometriosis, what tests are useful for ruling out benign causes?

Answer 29

Biopsy of lesions in endometriosis shows endometrial tissue, which provides the definitive diagnosis.

When considering endometriosis, b-hCG and urinalysis are helpful in order to rule out the possibility of pregnancy or UTI.

CA-125 levels are frequently elevated in endometriosis, but it is not considered a highly sensitive or specific test.

The ultimate diagnostic tool in endometriosis is a laparoscopy, which in most cases will show “powder-burn” lesions and cysts. Observation of a lesion with laparascopy is considered satisfactory for diagnosis. Note: endometriosis is a histological diagnosis, so a biopsy provides the definitive diagnosis.

Question 30

What are premenstrual syndrome and premenstrual dysphoric disorder?

Answer 30

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are syndromes seen in women with normal, functioning ovaries. They precede menses, occurring in the second half of the menstrual cycle, and are characterized by multiple pain, mood, and autonomic symptoms. PMDD is characterized by more severe mood symptoms, the diagnosis of which is made using criteria in the DSM-V.

More severe symptoms are associated with family history.

Question 31

What is the prevalence of uterine leiomyomas in women of reproductive age?

Answer 31

Uterine leiomyomas, or fibroids, are benign growths of smooth muscle that are commonly found in the myometrium (smooth muscle layer deep to the endometrium) in reproductive-age women.

Fibroids are classified based on the following locations:

Submucosal: just deep to the endometrium, affects the interior shape of the uterine cavity and cause heavy menses.
Intramural: in the muscular wall of the uterus, which is the most common type
Subserosal: just deep to the serosa on the exterior of the uterus. These can impinge on the ureters and other pelvic structures.

Fibroid growth is stimulated by estrogen and progesterone. As a result, symptoms vary with the menstrual cycle, worsen rapidly during pregnancy, and improve following menopause.

It is important to remember that fibroids do not progress to leiomyosarcoma. Fibroids are differentiated from leiomyosarcoma with post-op pathology.

Fibroids are found in 50% of African American women and in 30% of all women in the US. The peak occurrence is between 20-40 years of age.
Risk factors for uterine fibroid development include:

Nulliparity
African American heritage
Diet high in meat
Alcohol consumption
Family history

Question 32

How does endoemetriosis present and what are its common sites?

Answer 32

Women in their 20s or 30s with endometriosis may present with infertility and the three D’s:

Dysmenorrhea (painful menses)
Dyspareunia (painful sexual intercourse)
Dyschezia (painful defecation)

In addition to the three D’s, endometriosis may present with:

Pelvic pain
Possible infertility
Uterine or adnexal tenderness
Palpable adhesions on uterus or ovaries

The most common site of endometriosis include

Adnexa - Ovaries being the most common
Rectouterine pouch of Douglas
Bowel, bladder, and peritoneum

Question 33

What tests should be ordered in a woman with abnormal bleeding characterised by heavier than normal bleeding?

Answer 33

• When evaluating a patient for abnormla uterine bleeding, first rule out other causes/locations of bleeding such as the rectum, vagina, urethra and cervix
  
  • The most common cause of vaginal bleeding in a postmenopausal woman is atrophic vaginitis, but endometrial cancer is ruled out first.
• It is also important to rule out other underlying disease states that can cause abnormal uterine bleeding:
  
  • PCOS
  • Thyroid disease
  • Coagulopathies
• If the patient is having heavy bleeding, you should order:
  
  • Pregnancy test
  • TSH levels
  • FBC
• If a woman over the age of 45 suffers from abnormal uterine bleeding, she needs an endometrial biopsy to rule out endometrial hyperplasia or cancer
• If a patient with long periods of oligomenorrhea is under 45 but obese, she should also undergo endometrial biopsy.
  
  • Remember that obesity leads to increased estrogen production, which is a risk factor for endometrial cancer
• A pelvic ultrasound can be used to check for polyps, fibroids and other lesions as the cause of the abnormal bleeding.

Question 34

What is important to note about fibroid progression?

Answer 34

Uterine leiomyomas, or fibroids, are benign growths of smooth muscle that are commonly found in the myometrium (smooth muscle layer deep to the endometrium) in reproductive-age women.

Fibroids are classified based on the following locations:

• Submucosal: just deep to the endometrium, affects the interior shape of the uterine cavity and cause heavy menses.
• Intramural: in the muscular wall of the uterus, which is the most common type
• Subserosal: just deep to the serosa on the exterior of the uterus. These can impinge on the ureters and other pelvic structures.

Fibroid growth is stimulated by estrogen and progesterone.

As a result, symptoms vary with the menstrual cycle, worsen rapidly during pregnancy, and improve following menopause.

It is important to remember that fibroids do not progress to leiomyosarcoma. Fibroids are differentiated from leiomyosarcoma with post-op pathology.
Fibroids are found in 50% of African American women and in 30% of all women in the US. The peak occurrence is between 20-40 years of age.

Risk factors for uterine fibroid development include:

• Nulliparity
• African American heritage
• Diet high in meat
• Alcohol consumption
• Family history

Question 35

When evaluating a patient for abnormal uterine bleeding, what anatomic locations need to be ruled out as the possible source of bleeding?

Answer 35

• When evaluating a patient for abnormal uterine bleeding, first rule out other causes/locations of bleeding, such as the rectum, vagina, urethra and cervix.

Question 36

What serum marker is frequently elevated in endometriosis?

Answer 36

Biopsy of lesions in endometriosis shows endometrial tissue, which provides the definitive diagnosis.

When considering endometriosis, b-hCG and urinalysis are helpful in order to rule out the possibility of pregnancy or UTI

CA-125 levels are frequently elevated in endometriosis, but it is not considered a highly sensitive or specific test

The ultimate diagnostic tool in endometriosis is a laparoscopy, which in most causes will show ‘powder-burn’ lesions and cysts.

Observation of a lesion with laparoscopy is considered satisfactory for diagnosis.

Note: endometriosis is a histological diagnosis, so a biopsy provides the definitive diagnosis.

Question 37

When is a hysterctomy indicated for the treatment of dysmenorrhea?

Answer 37

• First line treatment of primary dysmenorrhea includes NSAIDs
  
  • Celecoxib (COX-2 inhibitor) has also been shown to be effective
• Second line treatment includes OCPs to cause cessation of ovulation
• Rarely, a hysterectomy may be required in true primary dysmenorrhea.

Question 38

What are causes of menometrorrhagia?

Answer 38

Menometrorrhagia is excessive bleeding (>80 mL) at irregular intervals.

Common causes of menometrorrhagia include:

Fibroids
Adenomyosis
Endometrial polyps
Endometrial hyperplasia
Endometrial cancer

Question 39

What are surgical options for the treatment of fibroids?

Answer 39

• Surgical management is appropriate for patients who suffer severe symptoms, such as anemia from menorrhagia, or in patients who have become infertile due to fibroids and wish to maintain fertility.
• Endometrium overlying fibroids is less well-perfused than endometrium overlying normal myometrium, and is unable to support a pregnancy.
  
  • Myomectomy is the removal of one or more fibroids laproscopically, hysteroscopically, or abdominally. This procedure can improve fertility in patients with subendometrial fibroids.
  • Hysterectomy is used to treat severe symptoms in patients with no desire to maintain fertility.

Question 40

What are the conservative and medical options for the treatment of fibroids?

Answer 40

Management of asymptomatic uterine fibroids involves monitoring the patient with ultrasound to detect abnormal growth.

Pharmacological treatment options are often the first choice in management of symptomatic uterine fibroids.

For patients with moderate pain associated with uterine fibroids, NSAIDS and expectant management may be appropriate.

For patients with heavy bleeding associated with uterine fibroids, OCPs, medroxyprogesterone acetate, progestin implants, or danazol may be used.
GnRH agonists are used to decrease the size of the fibroids, as well as decrease the vascularity.

Recall, a GnRH agonist, such as Leuprolide, acts as an antagonist when used in continuous fashion (decreased FSH and LH lead to decreased circulating estrogen).

Question 41

Why is the pain associated with endometriosis cyclical?

Answer 41

Endometriosis is the implantation and proliferation of ectopic non-neoplastic hormonally-responsive endometrial glands and stromal tissue outside of the uterus.

Endometriosis is thought to occur via different mechanisms, which include:

• Retrograde menstruation
• Vascular/lymphatic spread of endometrial tissue to the pelvic cavity
• Iatrogenic spread of tissue (e.g., during a c-section)

Because endometriosis is hormone-responsive, the symptoms of endometriosis are cyclical and worsen leading up to menstruation.
The ectopic endometrial tissue undergoes menstrual-type bleeding which leads to blood-filled “chocolate cysts” in the ovaries and reddish-bluish-brown “powder-burn” serosal nodules.

Risk factors for endometriosis include:

• Family history
• Nulliparity (no history of childbirth)
• Low BMI

Question 42

How do you monitor response to treatment in patients being treated for endometrial hyperplasia?

Answer 42

Presentation: patient experiences a long period of oligomenorrhea or amenorrhea, followed by return of menses. Recognizing this pattern is key to diagnosis and treatment.

Diagnosis is made via an endometrial biopsy

Treatment: most hyperplasia can be treated with progesterone, which causes decidualization of the endometrium.
Forms of progesterone include Depo-Provera, the Mirena IUD, oral progesterone, or topical progesterone.

A repeat endomentrial biopsy is performed after 3 months of treatment.

Atypical complex hyperplasia is the most severe form of hyperplasia and is a precursor to Endometrial Carcinoma in one third of untreated patients.

Therefore, hysterectomy should be performed in these patients.

Question 43

What is associated with the more severe symptoms in premenstrual syndrome and premenstrual dysphoric disorder?

Answer 43

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are syndromes seen in women with normal, functioning ovaries.

They precede menses, occurring in the second half of the menstrual cycle, and are characterized by multiple pain, mood, and autonomic symptoms. PMDD is characterized by more severe mood symptoms, the diagnosis of which is made using criteria in the DSM-V.

More severe symptoms are associated with family history.

Question 44

What are some of the risk factors for endometriosis?

Answer 44

• Family history
• Nulliparity
• Low BMI

Question 45

What surgical treatments may be required in severe cases of endometriosis?

Answer 45

Severe cases of endometriosis may require hysterectomy, lysis of adhesions, or salpingo-oophorectomy.

Question 46

What is hypomenorrhea and what are its causes?

Answer 46

Hypomenorrhea is regularly timed menses with light bleeding.

Common causes of hypomenorrhea include:

Hypogonadism (seen in anorexia, heavy exercising)
Contraception use
Asherman’s syndrome (intrauterine adhesions)

Question 47

What is dysfunctional uterine bleeding?

Answer 47

Dysfunctional uterine bleeding is abnormal bleeding in which there is no identifiable pathologic cause for the abnormal bleeding.

The most common cause of dysfunctional uterine bleeding is anovulation. The ovaries produce estrogen, but without ovulation, there is no corpus luteum, no progesterone production, and continual estrogen stimulation of the endometrium.

Without the progesterone production, the endometrium continues to grow under the influence of estrogen, until it outgrows its blood supply and is sloughed off at irregular times.

Question 48

How is primary dysmenorrhea diagnosed?

Answer 48

Primary dysmenorrhea is idiopathic menstrual pain that has no identifiable pathology.

Primary dysmenorrhea usually presents before age 20 and will often decrease throughout a patient’s 20s and early 30s.

Symptoms include nausea, vomiting, and headache.

The diagnosis is made based on history and the absence of an organic cause.
Note that pain from primary dysmenorrhea usually begins on the first or second day of the menstrual cycle whereas pain from endometriosis usually occurs 1-2 weeks before menstruation.

Question 49

What should be done next if a patient suspected of having premenstrual syndrome or premenstrual dysphoric disorder have symptoms during their entire cycle?

Answer 49

Symptoms of premenstrual syndrome and premenstrual dysphoric disorder include:

Food cravings, weight gain
Headache
Abdominal or pelvic pain, abdominal bloating, change in bowel habits
Mood lability, depression, fatigue, irritability
Breast tenderness
Acne

​And 5-10% of women have severe symptoms that interfere with daily life

Symptoms associated with PMS and PMDD precede menses and occur at similar time points in each cycle.

If a patient suspected of having PMS or PMDD has mood symptoms throughout her entire menstrual cycle (rather than only the second half), a psychiatric work-up for a mood disorder should be initiated.

Question 50

What is the major complication of endometriosis?

Answer 50

The major complication of endometriosis is infertility despite treatment, and may be responsible for up to 50% of cases of female infertility.

Question 51

What is endometriosis?

Answer 51

Endometriosis is the implantation and proliferation of ectopic non-neoplastic hormonally-responsive endometrial glands and stromal tissue outside of the uterus.

Endometriosis is thought to occur via different mechanisms, which include:

Retrograde menstruation
Vascular/lymphatic spread of endometrial tissue to the pelvic cavity
Iatrogenic spread of tissue (e.g., during a c-section)

Because endometriosis is hormone-responsive, the symptoms of endometriosis are cyclical and worsen leading up to menstruation.

The ectopic endometrial tissue undergoes menstrual-type bleeding which leads to blood-filled “chocolate cysts” in the ovaries and reddish-bluish-brown “powder-burn” serosal nodules.
Risk factors for endometriosis include:

Family history
Nulliparity (no history of childbirth)
Low BMI

Question 52

What symptoms are associated with uterine fibroids?

Answer 52

Half of women with fibroids are asymptomatic. Those with symptoms may present with the following:

Abnormal uterine bleeding (menorrhagia, metrorrhagia), especially with submucosal fibroids

Pelvic pain from subserosal fibroids

Infarction (due to outgrowth of blood supply), resulting in degeneration, necrosis, and pain

Impingement of pelvic structure, resulting in constipation, venous stasis, hydronephrosis, and urinary retention

Infertility

Question 53

What is unique about Atypical Complex Hyperplasia, and what is the treatment?

Answer 53

Presentation: patient experiences a long period of oligomenorrhea or amenorrhea, followed by return of menses. Recognizing this pattern is key to diagnosis and treatment.

Diagnosis is made via an endometrial biopsy

Treatment: most hyperplasia can be treated with progesterone, which causes decidualization of the endometrium.

Forms of progesterone include Depo-Provera, the Mirena IUD, oral progesterone, or topical progesterone.

A repeat endomentrial biopsy is performed after 3 months of treatment.

Atypical complex hyperplasia is the most severe form of hyperplasia and is a precursor to Endometrial Carcinoma in one third of untreated patients.

Therefore, hysterectomy should be performed in these patients.

Question 54

If a teenager suffers from menorrhagia, what should she be evaluated for?

Answer 54

If a teenager suffers from menorrhagia, it is recommended that she be checked for a bleeding disorder (ITP, vWD).

Question 55

What two manifestations of endometriosis are a result of the associated menstrual-type bleeding?

Answer 55

The ectopic endometrial tissue undergoes menstrual-type bleeding which leads to blood-filled “chocolate cysts” in the ovaries and reddish-bluish-brown “powder-burn” serosal nodules.

Question 56

What surgical treatment of endometriosis maintains fertility?

Answer 56

Laparoscopic ablation is a surgical method of treating endometriosis that may remove lesions while still maintaining fertility.

Question 57

When evaluating a patient for abnormal uterine bleeding, what underlying disease states need to be ruled out as the possible cause of the bleeding?

Answer 57

It is also important to rule out other underlying disease states that can cause abnormal uterine bleeding:

PCOS (polycystic ovarian syndrome)
Thyroid disease
Bleeding disorders

Question 58

What specific medications are used to treat endometrial hyperplasia?

Answer 58

Treatment: most hyperplasia can be treated with progesterone, which causes decidualization of the endometrium.

Forms of progesterone include Depo-Provera, the Mirena IUD, oral progesterone, or topical progesterone.

Question 59

What pharmacological agents can be used in endometriosis?

Answer 59

Pharmacological relief of symptoms may be achieved with:

NSAIDs
Oral contraceptives
Progestins (i.e. oral or IM medroxyprogesterone, megestrol)
Danazol
GnRH agonists