General gynaecologist problems Flashcards
(44 cards)
What is Endometriosis?
- Presence of endometrial-like tissue outside the uterus
- Causes a chronic, inflammatory reaction
- Common (10-12%); predominantly in women of reproductive age – esp. nulliparous
- Oestrogen dependent – cyclic symptoms
- Adenomyosis = endometrial tissue within myometrium
What are Endometriomas?
• large, ovarian endometriotic cysts (endometriomas)
o Endometriomas – benign cysts form when endometrial tissue grow on the ovaries
o Typical endometriomas is that they are usually filled with a thick fluid of degenerated blood products = “chocolate cyst”
o Unlike functional ovarian cysts that arise as part of a woman’s normal monthly ovulatory cycle, endometriomas usually do not resolve on their own and therefore may require some form of medical or surgical intervention at some point
What does Endometriosis commonly affect?
• Pelvic organs and peritoneum most commonly affected
- Peritoneum
- Pouch of Douglas (POD) = recto-uterine pouch
- Ovary/tubes
- Ligaments
- Bladder
- Myometrium (adenomyosis)
• Extent: a few small lesions on otherwise normal pelvic organs, to large, ovarian endometriotic cysts (endometriomas)
o Endometriomas – benign cysts form when endometrial tissue grow on the ovaries
o Typical endometriomas is that they are usually filled with a thick fluid of degenerated blood products = “chocolate cyst”
o Unlike functional ovarian cysts that arise as part of a woman’s normal monthly ovulatory cycle, endometriomas usually do not resolve on their own and therefore may require some form of medical or surgical intervention at some point
• Extensive fibrosis and adhesion formation = marked distortion of pelvic anatomy
• Typically appears as superficial “powder-burn” or “gunshot” lesions, nodules or small cysts containing old haemorrhage
What are the clinical features of Endometriosis?
Symptoms:
• Dysmenorrhoea/cyclic pelvic pain
• Classic pain before, worse during, better after menses
• Deep dyspareunia
• Dyschezia (pain on defecation)
• Ovulation pain
• Urinary Sx
• Rectal/anal Sx
• Chronic pelvic pain
• Cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain
• Caesarean section/TOP history
• Chronic fatigue
Each of these symptoms can have other causes
A significant proportion of affected women are asymptomatic
Signs: • Tenderness • Endometriomas • Fixed retoverted uterus (adhesions) • Infertility (inflammation/adhesions)
On examination – most reliably detected when examination performed during menstruation
• Abdo: NAD
• Vulva/Vagina (v/v): NAD
• Cervix (Cx): NAD
• Uterus: fixed, retroverted (some people have this anyway as an anatomical variant), tender ++
• Retroverted uterus – tipped backwards, so it aims towards rectum instead of front of belly
• Adnexae: bilat tenderness ++
• Tender uterosacral ligaments
• Enlarged endometriosis
• More certain if:
• Deeply infiltrating nodules are palpated on uterosacral ligaments or in the pouch of Douglas and/or visible lesions are seen in the vagina/on cervix
What are the differentials of Endometriosis?
Establishing diagnosis on basis of symptoms alone can be difficult because the presentation is so variable and there is a considerable overlap with other conditions:
- Adenomyosis
- Chronic pelvic inflammatory disease
- Chronic pelvic pain
- Other causes of pelvic masses
- IBS
What are the investigations for Endometriosis?
- Visualisation of pelvis at laparoscopy + biopsy = “gold standard”
- Transvaginal USS – to exclude endometrioma
- MRI – for andenomyosis + peritoneal endometriosis (+ IVP)
- CA-125 levels may be elevated in endometriosis, but has no value as a diagnostic tool
What is the treatment for Endometriosis?
Medical
• Analgesics – NSAIDs (symptom relief)
• Ovarian suppression (as endometriosis is oestrogen dependent) using either:
• COCP
• Progestogens
• Mirena IUS (endometrial +/- ovarian supp) – reduces pain
• GnRH analogues + HRT
• Danazol/gestrinone (androgens) – rarely used nowadays
Surgical
• Laparoscopic ablation of endometriotic spots – scissors, laser, or bipolar diathermy
• Laparoscopic resection of active lesions/scar tissue
• Dissection of adhesions + removal of endometriomas
• Endometrioma cyst drain + either strip with forceps/ablate
• Laparoscopic cystectomy/oophorectomy
• Hysterectomy + BSO – concerns re age and will need HRT
What is Acute Pelvic inflammatory disease?
Infections of organs of a woman’s reproductive system/ upper genital tract.
• Most common presenting complaint is sudden onset, acute constant lower abdominal or pelvic pain in association with fever in a sexually active woman
• Usually associated with STI and is treated with antibiotics
• 5% gynaecological referrals
• “A diagnosis of PID should be considered, and usually empirical antibiotic treatment offered, in any sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified.
• The risk of PID is highest in women aged under 25 not using barrier contraception and with a history of a new sexual partner.”
What are the causes of Acute Pelvic inflammatory disease?
• Usually affects young, poor, sexually active, nulliparous women, with multiple partners, not using contraception
• Most commonly caused by ascending infection from the endocervix (typically STI, but non-STI if complication of childbirth/miscarriage), may also occur from descending infection from organs such as appendix
• Also can be caused by instrumentation (e.g. coil insertion)
• Can cause –
- endometritis
- salpingitis
- parametritis (connective tissue around uterus)
- oophoritis (rare)
- tubo-ovarian abcess
- and/or pelvic peritonitis
• Almost never occurs in presence of a viable pregnancy!!!
Infection – frequently polymicrobial (green = always screened for)
• Chlamydia trachomatis - up to 60% (usually asymptomatic + Sx due to secondary infection)
• Neisseria gonorrhoeae 10-15% (acute presentation)
• Mycoplasma genitalium 15%
• Bacterial vaginosis-associated organisms (anaerobes)
• Other organisms (eg streptococci, staphylococci, haemophilis, enterics, E coli)
• Mycobacterium tuberculosis
Always treat as an STI
What are the clinical features of Acute Pelvic inflammatory disease?
Signs and symptoms – NB 60% asymptomatic = no Hx and present later with subfertility/menstrual problems
Symptoms – recent onset (usually <30 days)…
• Bilateral lower abdominal pain with deep dyspareunia = hallmark
• Abnormal vaginal bleeding (inc. IMB, PCB and menorrhagia) or discharge (often purulent)
• Secondary dysmenorrhoea
Signs
• If severe – tachycardia + high fever + signs of lower abdominal peritonism
• On bimanual – bilateral adnexal tenderness, cervical excitation (pain on moving cervix) + a mass (pelvic abscess)
What are the complications of Acute Pelvic inflammatory disease?
• Abscess (e.g. tubo-ovarian) or pyosalpinx
- Systemically unwell, palpable mass, lack of Rx response
- A large pelvic abscess that ruptures may be life-threatening
• Tubal obstruction or damage (12%)
• Subfertility
- 10% 1 episode, 20% 2 episodes, 40% 3 episodes
- Multiple episodes of PID or delayed treatment increase the risk of infertility. Don’t delay starting treatment
• Chronic dyspareunia and pelvic pain (18%)
• Chronic pelvic infection
• Ectopic pregnancy – 6x more likely
• Peri-hepatitis (Fitz Hugh Curtis syndrome)
- Especially related to Chlamydia. In women <30y, RUQ pain is highly suggestive of perihepatitis rather than cholecystitis
Overall, 25% of women with one episode of PID suffer subsequent pain, infertility or ectopic pregnancy
What do you tell patients with Acute Pelvic inflammatory disease?
• PID is the name given to inflammation of a woman’s reproductive organs: the womb (or uterus), fallopian tubes, ovaries and surrounding tissues
• In many women, PID is caused by an STI
• It is easy to treat, but untreated PID can cause serious problems
• Most women with PID can go on to become pregnant
NO SEX until they and their partner have completed treatment!!!!!!!
What are the investigations for Acute Pelvic inflammatory disease?
1. Pregnancy test – excludes ectopic pregnancy (unilateral pain)
2. NAAT from vulvovaginal swab for chlamydia, gonorrhoea and tirchomonas
3. Endocervical swabs for Chlamydia + gonorrhoea culture
4. Urine dipstick + MSU
5. Temperature – blood cultures if fever
6. Bloods for HIV + syphilis
7. Bloods – WCC (raised), CRP (raised), LFTs,
8. Specialist centre : microscopy for bacterial vaginosis, endocervical pus
Could consider:
9. Pelvic USS – excludes abscess/ovarian cyst (unilateral pain)
10. Laparoscopy + fimbrial biopsy and culture = ‘gold standard’ but not commonly performed
What is the treatment for Acute Pelvic inflammatory disease?
• Rest in severe disease. IV fluids if shocked
• Analgesia + Abx (outpatient):
Give effective treatment to cover chlamydia, gonorrhea, anaerobes and any other possible vaginal bacteria
• Parenteral cephalosporin: ceftriaxone 500 mg IM (with 1g PO azithromycin if chlamydia implicated), followed by
• Doxycycline 100mg bd PO 14 days PLUS
• Metronidazole 400mg bd PO 7-14 days
(or ofloxacin + metronidazole)
What covers what? cef – gonorrhoea, dox – chlamydia, met – anaerobes
If febrile = admit for IV therapy
NB This does not cover mycoplasma genitalium, which requires moxifloxacin
*Review at 24 hours if no improvement + perform laparoscopy
• Pelvic abscess (may not respond to Abx) = drainage under US-guidance/laparoscopy
• No sex until both they and their partner(s) have completed treatment and follow up (V. IMP FOR OSCE!!!)
What are the differentials of Acute Pelvic inflammatory disease?
Appendicitis, diverticulitis, UTI, IBS, ectopic pregnancy, endometriosis, ovarian cyst complications, ovarian torsion/rupture, functional pain (e.g. ovulation)
What is Chronic Pelvic inflammatory disease?
- Persisting infection – result of non-Rx or inadequate Rx of acute PID
- Dense pelvic adhesions + fallopian tubes may be obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx)
What are the clinical features of Chronic Pelvic inflammatory disease?
chronic pelvic pain/dysmenorrhea, deep dyspareunia, heavy + irregular menstruation, chronic vaginal discharge and subfertility
similar to endometriosis: abdominal + adnexal tenderness and fixed, retroverted uterus
What are the investigations for Chronic Pelvic inflammatory disease?
transvaginal US (fluid collections within fallopian tubes/surrounding adhesions), laparascopy (BEST DIAGNOSTIC TOOL), culture often –ve
What is the treatment for Chronic Pelvic inflammatory disease?
analgesics, Abx if infection evidence; if severe = adhesionolysis or sometimes salpingectomy
What is chronic pelvic pain “Functional pain”?
- Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
- DIAGNOSIS OF EXCLUSION (Sx, not a diagnosis)
- Chronic pelvic pain presents in primary care as frequently as migraine or low back pain affects 15% of adult women
What are the causes of Acute pelvic pain?
Gynaecological
- PID – e.g. salpingitis (more common post menses)
- Ectopic pregnancy – always do pregnancy test if any doubt re/ contraception; pain may be diffuse
- Ovarian cyst accident – gradual onset, exclusively unilateral dyspareunia and palpation pain
- Primary dysmenorrhea and Mittelschmerz
Non-gynaecological - GI • Appendicitis – N&V, no relation to menses • IBS/IBD • Strangulated hernia - Urological • UTI (may be indistinguishable from PID) • Calculi
What are the causes of chronic pelvic pain?
Gynaecological - Endometriosis/adenomyosis – pain that varies considerably over the menstrual cycle (hormonally driven) - Malignancy – esp. if post-menopausal (no oestrogen-related conditions) - Pelvic adhesions (e.g. chronic PID) - Fibroids - Cervical stenosis - Asherman’s syndrome - Dysmenorrhoea = common • 1° = No cause • 2° = underlying cause
Non-gynaecological
- GI
• Constipation – colicky pain, exacerbated by stress, L sided/posterior fornix
• IBS* (pain/cramps worse with food and better with defecation, bloating, diarrhoea, constipation)/IBD
• Hernias
- Urological
• Interstitial cystitis*
• Calculi
• Bladder pain syndrome – a chronic bladder health issue assoc. with pain and pressure in the bladder area
- Musculoskeletal
• Fibromyalgia – widespread pain especially in the shoulders, neck, and pelvic girdle. Characterized by tender points and a reduced pain threshold. Often shows cyclical exacerbations
- Psychological
• Depression
• Sleep disorders
• Hx of childhood and/or ongoing sexual/physical abuse
- Neurological
• Nerve entrapments – trapped in fascia/narrow foramen or in scar tissue after surgery; classically results in pain and/or dysfunction in nerve distribution
• Neuropathic pain – results from actual damage to the nerve (surgery, infection, or inflammation); classically described as shooting, stabbing, or burning
Other theories: ‘pelvic congestion syndrome’ – pelvic venous congestion said to cause chronic pain and ‘myofascial syndrome’ (pain originates in muscle trigger points or trapped nerves)
What are the investigations for chronic pelvic pain?
• Principles:
o Many women want an explanation for their pain
They may have a theory or a concern about the origin of the pain: this should be discussed in the initial consultation
o Allow enough time for history – address psychological/social issues
Often more than one component: physical (gynaecological and non-gynaecological), psychological, social factors
Discuss + explore multifactorial nature from the start
o May be associated with a Hx of sexual/physical abuse
o Just because no cause is found, doesn’t mean it does not exist
• History:
o Questions about pattern of pain and association with other problems: e.g. psychological, bladder, bowel symptoms, effect of movement and posture on the pain
o RED FLAGS – exclude Ca (weight loss, IMB/PCB, systemic Sx etc)
o Pain diary for 2-3 menstrual cycles
• Examination and Investigations: (as appropriate)
o Samples to screen for infection (chlamydia, gonorrhoea) if any suspicion of PID
o May have mild tachycardia and fever HR and temperature
o Transvaginal USS
o MRI
o Laparoscopy
*Women often have symptoms of irritable bowel syndrome or interstitial cystitis
• May be a primary cause or a component of chronic pelvic pain
What is the treatment for chronic pelvic pain?
- Appropriate analgesia – inc. amitriptyline or gabapentin
- If Sx suggestive of IBS = dietary change + trial of antispasmodics
- If cyclical pain = therapeutic trial of COCP or GnRH analogue + add-back HRT for 3-6mths
- Also consider progestogen IUS
- If pain unresolved after above = diagnostic laparoscopy (50% -ve, consider implications)
- Counselling and psychotherapy
- Referral to pain clinic or pain management programmes (relaxation therapy, sex therapy, diet and exercise)
- If infection detected = antibiotics
- If the history suggests to the patient and the doctor that there is a non-gynaecological component to the pain = referral to the relevant healthcare professional
What are Fibroids?
Benign Tumour. Non-cancerous growths that develop in or around the womb (uterus), the growths are made of muscles and fibrous tissue
• =lieomyomata
• Benign tumours of the myometrium
• Present in 25% of women
• More common approaching the menopause, in Afro-Caribbean women and those with a family history
• Less common in parous women (women who have children) and those who have taken the combine oral contraceptive pill/injectable progestogens
