General Gynaecology GTG - PMS, Ovarian masses, chronic pelvic pain

Question 1

When do core menstrual disorders present?

Answer 1

Luteal phase and abate with menstration.

Question 2

What are the 5 subgroups of core menstrual disorders?

Answer 2

1) Pre-menstrual exacerbation of underlying disorder

2) Core menstral disorders

3) Progesterone induced PMS

4) PMD without menstruation

Question 3

To be considered core pre-menstrual disorder instead of PMS, what must the patient describe?

Answer 3

Severe symptoms, affect daily function, interfere with work/school/interpersonal relationships

Question 4

How many experience PMS?

Answer 4

4/10

Question 5

How to Dx PMD?

Answer 5

Symptom diary over 2 diaries, GnRH analogues can be considered for definitive Dx if diary inconclusive

Question 6

What are the 1st line Tx for PMD?

Answer 6

Exercise,
CBT,
Vitamin B6

Continuous or luteal SSRI (Day 15-28), low dose citalopram/esocitalopram 10mg

COCP (with drospirenon and short hormone free interval) cyclical or continuous

Question 7

What are the 2nd line treatments offered for PMD?

Answer 7

Estradiol patches (100micrograms) + microginosed progesterone (100mg or 200mg OD (D17-28) or LNG-IUS 52mg (20mcg/day)

High dose citalopram/esocitalopram 20mg - continuous or D15-28

Question 8

What are the 3rd line treatments offered for PMD?

Answer 8

GnRH analogues + add back therapy

(50-100 microginosed estradiol patch or 2-4 doses of estradiol gel combined) with microginosed progesterone 100mg/day (urtogestan) or tibalone 2.5mg

Question 9

What are 4th line treatments for PMD?

Answer 9

Surgical TX and HRT

Question 10

Which COCP should be used to treat PMS?

Answer 10

Drosprirenone containing COCs

Question 11

Why should micronised progesterone be used? What other route can it be given?

Answer 11

Less likely to reintroduce PMS like symptoms.
Vaginally

Question 12

What level is a normal CA125?

Answer 12

<35

Question 13

What ovarian cancers will it be raised in? Which will it not be raised in/

Answer 13

Raised epithelial ovarian cancer

Not primary mucinpous

Question 14

PM cyst <5cm - how many will
1) Disappear
2) Static
3) Enlarge

Answer 14

Disappear 52%
Static 28%
Enlarge 11%

Question 15

How to calculated RMI score?

Answer 15

USS 1 point for each:
Multilocular, solid area, mets, ascites & BL lesions

U=0 (0 points, U=1 (1point) U= 3 (2-5 points)

Menopause status
Premenopause = 1
Post menopause = 3

CA125

RMI U x M X Ca125

Question 16

Sensitivity and specificity off RMI score?

Answer 16

78% sensitive
87% specific

Question 17

What RMI score cut off is used for low risk/high risk malignancy?

Answer 17

200

Question 18

For low risk women, RMI < 200, when would you consider BSO?

Answer 18

Cysts with any of the features
- Symptomatic
- Non simple features
- >5cm
- Multilocular
- Bilateral

Question 19

For low risk women, RMI < 200, and no concerning features, when would you offer repeat assessment? What tests would you perform?

Answer 19

After 4-6 months
- CA125
- TVUS/TAUS

Question 20

At the follow up at 4-6 months, what you do if
1) Resolved
2) Persistent unchanged
3) Change in featues

Answer 20

1) Discharge
2) Repeat assessment 4-6 months
3) Consider intervention

If not resolved after 1 year can either discharge or intervene, decision individualised

Question 21

If RMI > 200 what tests should be requested?

Answer 21

CT abdomen
Refer Gynae MDT

Question 22

If MDT think high risk of ovarian malignancy?

Answer 22

Full staging procedure by trained gynae oncologist

Question 23

If MDT think low risk gynae malignancy?

Answer 23

TAH + BSO + omentectomy + peritoneal cytology by suitably trained gynaecologist

Question 24

If RMI < 200, what % of cysts will resolve by 3 months?

Answer 24

50%

Question 25

If cystectomy is required in PM women, what surgery should be performed?

Answer 25

Lap (if possible) BSO Remove through umbilical port without spill

Question 26

What is the sensitivity and specificity of the IOTA rules?

Answer 26

Sensitivity 98% Specificity 91%

Question 27

What are the B rules?

Answer 27

1. Unilocular 2. Solid component <7mm 3. Acoustic shadowing 4. Smooth multilocular cyst <100mm diameter 5. No blood flow on doppler

Question 28

What are the M rules

Answer 28

1. Irregular solid tumour 2. Ascites 3. 4+ papillary structures 4. Irregular multilocular cyst >100mm 5. Prominent blood flow on doppler

Question 29

What % of women will have surgery in their life for ovarian mass?

Answer 29

10%

Question 30

List 5 types of benign ovarian cyst

Answer 30

Functional Endometrioma Serous cyst adenoma Mucinous Cystadenoma Mature teratoma

Question 31

List benign non ovarian adnexal mass

Answer 31

Paratubal cyst Hydrosalpinges TOA Peritoneal pseudocyst Appendices abscess Diverticular abscess Pelvic kidney

Question 32

List malignant ovarian mass

Answer 32

Germ cell tumour Epithelial carcinoma Sex-cord tumour

Question 33

In Germ cell tumour, what tumour markers are raised?

Answer 33

A-FP bhCG LDH

Question 34

Should CA125 be measure to assess ovarian mass in premenopausal women

Answer 34

No, raised in multiple conditions Only raised 50% epithelial ovarian carcinoma

Question 35

Premenopausal cyst <50mm

Answer 35

No follow up

Question 36

Premenopausal cyst 50-70

Answer 36

yearly FU - USS

Question 37

Premenopausal cyst >70mm

Answer 37

Consider MRI or surgical intervention Always aim laparoscopic if possible

Question 38

Endometriomas over what size should be biopsied/removed?

Answer 38

>30mm, rule out rare cases of malignancy

Question 39

How common is chronic pelvic pain?

Answer 39

1 in 6

Question 40

What is definition of chronic pelvic pain?

Answer 40

Intermittent or constant pain for at least 6 months, not exclusively with menstruation/intercourse

Question 41

What criteria is used to Dx IBS?

Answer 41

ROME III criteria

Question 42

What does the ROME criteria ask?

Answer 42

Continuous or recurrent abdo pain/discomfort on at least 3 days/month with onset >6months with at least 2 - Improvement on defecation - Change in frequency of stool - Change in form of stool

Question 43

Incidence of nerve entrapment after 1 pfannestiel incision?

Answer 43

3.7% Sharp stabbing pain, exacerbated by particular movements

Question 44

When should CA125 for screening

Answer 44

>50yrs Bloating, early satiety, pelvic pain, urinary urgency/frequency, new IBS

Question 45

Tx for IBS

Answer 45

Antispasmodics - mebeverine hydrochloride