Dysmenorrhoea + PCOS

Question 1

what is dysmenorrhoea?

Answer 1

subjectively very painful periods

Question 2

causes of dysmenorrhoea?

Answer 2

Endometriosis!!!
adenomyosis
PID

Question 3

How many females in the UK suffer from dysmenorrhea?

Answer 3

1/10 females

Question 4

What is endometriosis?
what ages does it affect and mean age it affects?

Answer 4

Ectopic endometrial tissue (anywhere in the human body)

20-40 y/o
mean = 28 y/o

Question 5

Where can endometrial tissue spread to?

Answer 5

ovary
bladder
bowel (inc Douglas pouch)
abdomen
thorax

Question 6

what is a condition where there is endometrial tissue in the thorax called?
Sx?

Answer 6

thoracic endometriosis syndrome

Cyclical haemoptysis (during periods + periods are heavy and painful)
pulmonary nodules and chest pain

Question 7

What are the 3 theories of endometriosis?

Answer 7

Halbans
Sampson
Meyers

Question 8

what is halbans theory?

Answer 8

haematogenous + lymph spread

Question 9

What is Sampsons theory?

Answer 9

retrograde menstruation

Question 10

what is Meyers theory?

Answer 10

metaplasia

Question 11

RF for endometriosis?

Answer 11

Nulliparity
Autoimmune diseases
early menarche + late menopause (high oest)
family Hx
vaginal outflow obstruction

Question 12

Sx of endometriosis?

Answer 12

Dysmenorrhoea (only a couple days)
menorrhagia
sub fertility
deep dyspareunia (pain during sex)
+/- dysuria, dyschezia (painful poo), haemoptysis, fatigue, SOB

Question 13

Dx of endometriosis?

Answer 13

1st - TV USS

Bimanual - ADNEXAL MOTION TENDERNESS + FIXED RETROVERTED UTERUS (+ uterosacral nodules)

GS - Laparoscopy

Question 14

what is seen on the TV USS?

Answer 14

may see ovarian chocolate cysts

MC on LHS (67%) then RHS (33%)
commonly mucus cyst adenomes

Question 15

What is the staging for endometriosis?

Answer 15

staging 1-4
ASMR system
minimal, mild, moderate, severe
extent of endometriosis spread

Question 16

Tx for endometriosis?

Answer 16

1. NSAIDS (ibuprofen and refer to 2^ care, TXA + Mefenamic acid)
2. COCP, then specialist led GnRH analogue
3. Surgery
   Fertility saving = ablation
   Non fertility saving = hysterectomy with bilateral salpingooopherectomy

Question 17

what is adenomyosis?
what age does it affect and who?

Answer 17

endometrial invasion into the myometrium
35-45 y/o F with history of uterine surgery

Question 18

Rf for adenomyosis?

Answer 18

uterine surgery!!!!
oestrogen dependent (like endometriosis)

Question 19

what are the 3 types of adenomyosis?

Answer 19

Focal (one site)
Diffuse (throughput uterus)
Adenomyoma (benign focal mass but BIG like uterine fibroma)

Question 20

What are the symptoms for adenomyosis?

Answer 20

dysmenorrhoea + cyclical pain (around 2 weeks) - longer than endometriosis

deep dysparanunia

menorrhagia

subfertile

Question 21

Dx of adenomyosis?

Answer 21

Bimanual - BOGGY UTERUS
TV USS
GS = post excision biosy

Question 22

Tx for adenomyosis?
medical and surgical?

Answer 22

Medical = Refer
cocp
mefanamic acid
(or GnRH with 2^ specialist input)

Surgery =
Yes fertility = myomectomy
No fertile = hysterectomy with bilateral salpingooopherectomy

Question 23

How many females in the UK are affected by PCOS?

Answer 23

1/10 around 5-10%

Question 24

What is pcos?
what criteria do we follow?

Answer 24

2 out of 3 min of the ROTTERDAM CRITERIA

Hirsutism/high androgens

Menstrual changes (menorrhoea/oligomeorrhoea)

polycystic ovaries on TV USS

Question 25

RF for PCOS?

Answer 25

Fhx
OBESE
insulin resistance (t2dm)

Question 26

What is the pathology of PCOS starting from having no periods?

Answer 26

No period = no progesterone from the corpus luteum = high GnRH pulsatile

Results in high LH stimulation (high andorgenesis) but little/no FSH response (low follicle maturation)

High LH = High Oestrogen = High androgens promoting hirsutism + insulin resistance (high testosterone)

therefore high insulin produced (+ insulin increases LH + Decreases FSH + SHBG) = EVEN MOPRE ANDROGENS

Result = hirsutism, failed follicle maturation (menstrual disturbance = no ovulation) + insulin resistance

Question 27

sx of PCOS?

Answer 27

Hirsutism (acne, facial hair, male pattern balding, deep voice)
Mood swings
amenorrhoea/oligo
sub fertility
ancanthosis nigricans
periumbilical referred pain

Question 28

Dx for PCOS?
What criteria needs to be fulfilled?
what tests?

Answer 28

need 2 out of 3 for Rotterdam (can be clinical)
1. Evidence of hirsutism / high androgens (visual or high testosterone/prog)
2. Menstrual changes
3. TV USS polycystic

Bloods: FBC, U+E, TFT, LFT
Sex hormones = Test, oest, prog, SHBG
LH:FSH >2:1

TV USS

Question 29

What must be seen on the TV USS?

Answer 29

12 or more polycystic ovaries (arranged like beads on a string) with >10cm3 ovarian volume

Question 30

what is the Tx for non fertility planning?

Answer 30

Lose weight and increase exercise

COCP (low hirsutism), POP also usable (bleed period induced)

Consider metformin (increase peripheral insulin sensitivity)

Question 31

what is the Tx for fertility planning?

Answer 31

Clomifine (induces ovulation)

other :
spironolactone (blocks androgens) = high oestrogenic

Topical eflornothine (acne)

Question 32

Complications of PCOS

Answer 32

Infertility

metabolic syndrome, T2DM

*Endometrial hyperplasia and cancer (increased risk)

*obstructive sleep apnoea