Gynae - Menstrual conditions

Question 1

What is PCOS?

Answer 1

common endocrine disorder characterised by excess androgen production and presence of multiple immature, follicles (cysts) within the ovaries

Question 2

What is the pathophysiology of PCOS?

Answer 2

hormonal imbalance - excess androgens
insulin resistance - suppressing SHBG
increased androgen circulation + inhibiting ovulation

Question 3

what are some risk factors of developing PCOS?

Answer 3

• diabetes
• irregular menstruation
• family history of PCOS

Question 4

how might PCOS present?

Answer 4

• oligomenorrhoea
• infertility
• hirsutism & acne
• obesity
• chronic pelvic pain
• depression

Question 5

what are some clinical signs you may notice in PCOS?

Answer 5

O/E → acne, hirsutism, acanthosis nigricans, male pattern hair loss, obesity and hypertension

Question 6

What are some differentials for PCOS?

Answer 6

hypothyroidism
hyperprolactinaemia
cushings

Question 7

how is PCOS diagnosed?

Answer 7

Rotterdam criteria - 2/3
- oligo or anovulation
- clinical or biochemical signs of hypernandrogenism
- polycystic ovaries on imaging

Question 8

what investigations are carried out for PCOS?

Answer 8

pelvic USS - ovarian cysts
FSH, LH, TSH, SHBG, TSH, testosterone, prolactin
oral glucose tolerance

Question 9

how is PCOS managed?

Answer 9

COCP, dydrogesterone for endometrial protection
weight reduction
clomifene + metformin to induce ovulation for infertility
anti-androgens for hirsutism -> eflornithine
Acne mx

Question 10

What are fibroids and what types are there?

Answer 10

🩸 benign smooth muscle tumours of the uterus
- most common benign tumours in women - 20-40% incidence
- leimyoma

types - intramural, submucosal, subserosal

Question 11

what are some risk factors for fibroids?

Answer 11

obesity
early menarche
increasing age
family history
ethnicity - Americans

Question 12

how might fibroids present, when they are symptomatic?

Answer 12

pressure sx - urinary frequency, retention
abdo distention
menorrhagia
sub-fertility
acute pelvic pain

Question 13

what might you feel on examination of fibroids?

Answer 13

• solid mass or enlarged uterus may be palpable on abdominal or bimanual examination
  
  • uterus is usually non-tender
  • mobile

Question 14

what are some differentials for fibroids?

Answer 14

endometrial polyps
ovarian tumours
leiomyosarcoma
adenomyosis

Question 15

how might you investigate a fibroid?

Answer 15

• pelvic ultrasound
• MRI - if sarcoma suspected
• bloods if diagnosis uncertain, pre-op surgery ix

Question 16

how might you manage fibroids?

Answer 16

medication - tranexemic acid, COCP, GnRH analogue Zolidex, ulipristal to reduce size

surgical - hysteroscopy and transcervical resection, myomectomy, uterine artery embolisation , hysterectomy

Question 17

what are some complications of fibroids?

Answer 17

iron deficiency anaemia
compression of pelvic organs - recurrent UTI, incontinence, hydronephrosis, retention
sub fertility or infertility
degeneration
torsion

Question 18

what is endometriosis?

Answer 18

chronic condition where endometrial tissue is located at sites other than the uterine cavity - 2 million in UK suffer, 25 to 40 year olds

Question 19

what is the pathophysiology of endometriosis?

Answer 19

retrograde menstruation - endometrial cells travel backwards from uterine cavity, through fallopian tubes and deposit on pelvic organs

symptoms arise due to the ectopic tissue and their response to oestrogen

repeated inflammation + scarring → adhesions

Question 20

where is the ectopic endometrial tissue commonly found?

Answer 20

ovaries, pouch of Douglas, uterosacral ligaments, pelvic peritoneum, bladder, umbilicus and lungs

Question 21

what are some risk factors of developing endometriosis?

Answer 21

• early menarche
• family history
• short menstrual cycles
• long duration of menstrual bleeds
• heavy menstrual bleeds
• uterus or fallopian defects

Question 22

what is the presentation of endometriosis?

Answer 22

• cyclical pelvic pain
• constant painmay suggest adhesions
• dysmenorrhoea, deep dyspreunia, dysuria, dyschezia, subfertility
• focal sx of bleeding → haemothorax at time of menstruation

Question 23

what would the bimanual examination show for endometriosis?

Answer 23

• fixed, retroverted uterus
• tenderness in posterior fornix
• uterosacral ligament nodules
• general tenderness
  
  • enlarged, tender, boggy uterus = adenomyosis

Question 24

what are the differential diagnosis for endometriosis?

Answer 24

PID
ectopic pregnancy
fibroids
IBS

Question 25

how would endometriosis be investigated?

Answer 25

gold - laparoscopy shows chocolate cysts, adhesions, peritoneal deposit s pelvis USS - kissing ovaries

Question 26

how is endometriosis managed?

Answer 26

pain - NSAIDs ovulation - suppress for 6-12m with COCP, norethisterone, mirena coil surgery - excision, fulguration and laser ablation to remove ectopic tissue, hysterectomy

Question 27

what are the differences between cervical and endometrial polyps?

Answer 27

cervical - benign growths protruding from the inner surface of the cervix endometrial - small soft growths on the endometrium of uterus

Question 28

what is the pathophysiology of cervical polyps?

Answer 28

- focal hyperplasia of the columnar epithelium of the endocervix - chronic inflammation, abnormal response to oestrogen, localised congestion of cervical vasculature

Question 29

what is the pathophysiology of endometrial polyps?

Answer 29

overgrowth of tissue lining, no cause known

Question 30

what are some risk factors for endometrial polyps?

Answer 30

endometrial - obesity, tamoxifen use, hypertension, cervical polyps

Question 31

what is the presentation of cervical polyps?

Answer 31

asymptomatic abnormal vaginal bleeding increased vaginal discharge cervix blocked and may cause infertility o/e - polyphoid growths progesting though external os

Question 32

what is the presentation of endometrial polyps?

Answer 32

- asymptomatic - irregular menstrual bleeding - intermenstrual menstrual periods - menorrhagia - post-menopausal bleeds - infertility

Question 33

what are the investigations done for cervical polyps?

Answer 33

- histological examination after removal - triple swabs - if infection suspected, endocervical + high vaginal + vulvovaginal - cervical smear - rule out neoplasia (CIN) - USS of endometrial cavity if sx persists

Question 34

what investigations are done for endometrial polyps?

Answer 34

- pelvic exam - seen if protruding through cervix - pap smear - USS - hysteosalpingogram - dilation and curretage for biopsy - hysteroscopy

Question 35

how is cervical polyps managed?

Answer 35

- small - polypectomy with forceps in primary care setting + silver nitrate cautery - large - diathermy loop excision in colposcopy clinic, or under GA *<0.5% malignancy transformation risk

Question 36

what is the management of endometrial polyps?

Answer 36

- watch & wait - polyps small and not sx - medication - shrink polyp - removal - during hysteroscopy, curettage - hysterectomy?

Question 37

what are some complications of endometrial polyp removal?

Answer 37

- infection - haemorrhage - uterine perforation

Question 38

what is the physiology of the endometrial response to the menstrual cycle?

Answer 38

🩸 lining of uterus which changes during menstrual cycle in response to oestrogen release - after ovulation, progesterone levels increase and prepares uterus for implantation - with the lack of this progesterone levels drop and the endometrial lining is shed → menstruation

Question 39

what is the pathophysiology of endometrial hyperplasia?

Answer 39

- imbalance of hormones cause endometrial thickening and overgrowth - too much oestrogen etc - two types based on cell kind - simple (without atypia) - consists of normal cells, not cancerous - complex atypical endometrial hyperplasia - pre-cancerous and results form overgrowth of abnormal cells

Question 40

what are some risk factors for endometrial hyperplasia?

Answer 40

- menopause transition - family history of colon, ovarian and uterine cancer - diabetes - nullparity - PCOS - smoking - hormone therapy - early menarche and late menopause

Question 41

what is the presentation of endometrial hyperplasia?

Answer 41

- heavy menstrual bleeding - post-menopausal bleeds - menstrual cycles shorter than 21 days

Question 42

how is endometrial hyperplasia investigated?

Answer 42

- hormonal bloods - USS - transvaginal USS to see thickness of lining - biopsy - of uterus lining - hysteroscopy - abnormalities - dilation and curettage

Question 43

how is endometrial hyperplasia managed?

Answer 43

- progestin - orally, via injection, vaginal, IUD - for atleast 6m - stops further proliferation, prepares for shedding, opposes oestrogen - hysterectomy if atypical endometrial hyperplasia, no improvement after 12m, relapse, bleeding not stopping