Gynae disorders Flashcards

Question

What are endometrial polyps? Risk factors?

Answer 1

May be referred to as ‘uterine polyps’, originate from endometrium therefore not the same as fibroids (myometrium). Discrete outgrowths attached by a pedicle (move with the flow of the distention medium). Pedunculated (have elongated pedicle) or sessile (large flat base). o Pedunculated more common, and can protrude though cervix into vagina. - Single or multiple - Variable size (0.5-4cm). No cause known but appear to grow in response to circulating oestrogen Risk factors: obesity, hypertension, Hx of cervical polyps, tamoxifen, HRT. Use of IUS containing levonorgestrel in women taking tamoxifen may reduce incidence of polyps.

Answer 2

Often asymptomatic, but may cause irregular bleeding, IMB, menorrhagia, and PMB (bleeding from vessels of the polyps). If protrudes into vagina, may have dysmenorrhoea (pain). <40: Unlikely to be significant (may cause IMB but only removed if symptoms persist for >3 months). >40 + premenopausal: if diagnosed by USS or hysteroscopy, consider removal (endometrial hyperplasia most common abnormality, increases with age – can be present in the polyp tissue + removal of polyp usually resolves symptoms). Post-menopausal: removal mandatory (can be due to hyperplasia or malignancy) – can also be caused by tamoxifen treatment (~30% of those treated). They are benign in most cases but removal is necessary to exclude the remote possibility of malignancy.

Answer 3

On surface of cervical canal, almost all benign. Usually <1cm diameter. May be pedunculated + occasionally prolapse into vagina (may be mistaken for endometrial polyps or submucosal fibroids). Most common if menstruating women / previous pregnancy. Cause unknown, often associated with cervical inflammation, ?raised oestrogen or clogged cervical blood vessels. ~1% will show neoplastic change which may lead to cancer.

Answer 4

Symptoms: usually asymptomatic, can cause IMB, menorrhagia, PMB, leukorrhoea. Dx: may be found incidentally during routine smear - red / purple projections from cervical canal during pelvic exam, (usually bright red, spongy texture). Dx can be confirmed by biopsy. Tx: removal with forceps and cauterise base with silver nitrate sticks. Send polyp for histology – if endometrial origin will need TVUSS and referral for further Ix of endometrium (to ensure complete removal). 99% remain benign. After removal, they are unlikely to regrow.

Answer 5

Mucus filled cyst on surface of cervix, most often caused when stratified squamous epithelium of ectocervix grows over simple columnar epithelium of endocervix > tissue growth can block cervical crypts (subdermal pockets 2-10mm diameter) trapping cervical mucus inside crypts. Typically appear as firm bumps on surface of cervix – woman may notice (e.g. cap / diaphragm / fertility assessment) or may notice during pelvic exam. If unusual appearance, colposcopy will rule out other diagnoses. If blood vessels short, comma-like or corkscrew-shaped (and bleed on contact), cyst may be a rare mucin-producing carcinoma of cervix (MRI distinguishes cancer from Nabothian cyst). Tx not required, resolve on their own (cryotherapy possible but very rarely necessary).

Answer 6

Benign condition (sometimes incorrectly termed ‘erosion’): ‘raw’ area on cervix due to presence of columnar epithelium (glandular) on vaginal aspect of cervix. Can present with excessive clear odourless mucus-type discharge. Commonly develops under 3Ps: puberty, pill, pregnancy. If troublesome, predisposing factor can be stopped or cervix ablated if cytology is normal. Screen to exclude chlamydia + other STIs prior to Tx. If persistent ectropion, columnar epithelium undergoes metaplasia to a ‘stronger’ squamous epithelium. This transformation zone undergoes dyskaryosis + possible malignant change due to HPV infection (subject to screening by cytology). Sometimes the columnar glands in the transformation zone become sealed over forming small (2-10mm) mucus-filled cysts visible on ectocervix > ‘Nabothian follicles’ with no pathological significance. No treatment usually required.

Answer 7

Usually iatrogenic: Tx of pre-malignant disease using cone biopsy or loop diathermy. Recent increase in endometrial ablation has seen higher incidence, especially where internal os (isthmus) has been ablated  hematometra (blood collected within uterus, unable to be released through cervix) causes cyclical dysmenorrhoea with no associated menstrual bleeding. Treatment: surgical dilatation of cervix with hysteroscopic guidance (under LA). anaesthesia. Re-stenosis can occur and sometimes hysterectomy required to relieve pain.

Answer 8

Term used to describe infection and inflammation of the female pelvic organs (any part of higher reproductive system) including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix. Salpingitis sometimes used interchangeably but this is inflammation of fallopian tubes. 1. Chlamydia trachomatis – (most common cause) 2. Neisseria gonorrhoeae 3. Mycoplasma genitalium 4. Mycoplasma hominis

Answer 9

``` Young (16-24) Multiple partners Chlamydia / gonorrhoea (90% PID acquired sexually, and mostly due to chlamydia – 10% cases occur after childbirth particularly if forceps used) IUD insertion Previous PID Bacterial vaginosis ``` Note: everyone having IUD inserted should be screened for infection before insertion to reduce the risk of PID – IUD can introduce infection from lower tract > upper tract.

Answer 10

Often asymptomatic: lower abdominal pain (unilateral or bilateral), fever, deep dyspareunia, dysuria and menstrual irregularities may occur, vaginal or cervical discharge, cervical excitation. - Heavy blood loss suggests endometritis - Cervicitis: cervix appears red and will bleed easily - Nausea & vomiting suggests peritonitis! Perihepatitis (Fitz-Hugh Curtis Syndrome) in ~10% of cases – inflammation of liver capsule, secondary to PID. Characterised by RUQ pain and may be confused with cholecystitis.

Answer 11

Examination: cervical excitation, tenderness / peritonism and tenderness at fornices Diagnosis: suspect in any woman with lower abdo pain, consider in any women with unexplained irregular bleeding Investigations: • Screen for Chlamydia and Gonorrhoea (endocervical swab), most women have negative swabs – does not rule out PID. • Bloods / urine test • Pregnancy test • TVUSS • Laparoscopy e.g. to rule out appendicitis / suspected complication that can

Answer 12

Due to difficulty in making an accurate diagnosis, and potential complications of untreated PID, consensus guidelines recommend having a low threshold for Tx. If very unwell may have to admit for IV ceftriazone. 1. IV Ceftriaxone 1g + PO doxycycline 12 hourly + PO metronidazole 8 hourly (14 days) 2. PO ofloxacin 12 hourly + PO metronidazole 8 hourly 3. Cannot tolerate oral: IV Ceftriaxone 1g + IV clarithromycin 12 hourly + IV metronidazole 8 hourly o RCOG guidelines: in mild cases, IUDs may be left in. More recent BASHH guidelines suggest that the evidence is limited but that 'Removal of the IUD should be considered and may be associated with better short term clinical outcomes' o Avoid intercourse until patient and partner treated (also contact tracing as per STI)

Answer 13

* Infertility - the risk may be as high as 10-20% after a single episode * Abscess formation: (up to 15%), may cause severe pain and peritonitis, may rupture * Chronic pelvic pain * Ectopic pregnancy * Fitz-Hugh-Curtis syndrome * Chronic salpingitis > can cause fibrosis and adhesions (may occur if PID not treated promptly).

Gynae disorders Flashcards

(37 cards)