Gynae presentations - 2) Menorrhagia/HMB Flashcards
(55 cards)
1
Q
Define HMB/menorrhagia
A
- Blood loss >80ml/period;
- in practice it is diagnosed based on patient’s perception of blood loss, sanitary products used, and effect on QoL
2
Q
What are the causes of menorrhagia (HMB)?
A
Structural: PALM
- Polyps - endometrial
- Adenomyosis
- Fibroids (Leiomyoma)
- Malignancies:
- Endometrial cancer - younger patients
- Cervical cancer
Hormonal:
- Dysfunctional uterine bleeding
Infection:
- Pelvic inflammatory disease
Systemic:
- Thyroid disease
- Haemostatic disorders
- Anticoagulant therapy
3
Q
What does PID and malignancies (cervical, endometrial & ovarian) usually present with alongside menorrhagia (HMB)?
A
Irregular bleeding
4
Q
What are fibroids?
A
Benign tumours of uterine smooth muscle (leiomyomas)
5
Q
How are fibroids classified/
A
According to location wrt to uterine wall:
- Intramural (most common): confined to myometrium
- Submucosal: underneath the endometrium; protrudes into uterine cavity
-
Subserosal: protrudes into serosal (outer) surface of the uterus
- May be pedunculated
- Cervical: located within the cervix
6
Q
What is the aetiology of fibroids?
A
They are oestrogen-dependent benign tumours
- Enlarge during pregnancy and in response to the hyperoestrogenic state, and shrink after menopause when oestrogen production ceases
- Exact cause is unknown
They undergo degenerative change, usually when they outgrow their blood supply
7
Q
What are the types of degenerative change that fibroids can undergo?
A
- There are 3 forms of degeneration:
- Red: haemorrhage and necrosis occurs within the fibroid, often in pregnancy
- Hyaline: asymptomatic softening and liquefaction of the fibroid
-
Cystic: asymptomatic central necrosis leaving cystic spaces at the centre
- Degenerative changes can initiate calcium deposition → calcification
8
Q
RFs for fibroids?
A
- obesity,
- early menarche,
- age in 40s,
- FHx,
- African-American
9
Q
Symptoms of fibroids?
A
- Vast majority are small and asymptomatic
-
Menorrhagia
- Usually due to submucosal fibroids
- Dysmenorrhoea
-
Pelvic mass, pressure, abdominal distension/bloating
- Fibroids are usually multiple and can substantially increase the size of the uterus
-
May have bulk effects on adjacent structures:
- Subfertility (mechanical distortion of uterine tubes/uterine cavity)
- Urinary symptoms, constipation
10
Q
Signs of fibroids O/E?
A
- Abdo: palpable mass in pelvis
- Bimanual: enlarged, firm, non-tender uterus
11
Q
Ix for fibroids?
A
- FBC (if HMB)
-
TAUSS (pelvic)
- Mainstay of diagnosis
- TAUSS detects larger intramural and subserosal fibroids
-
TVUSS
- Mainstay of diagnosis
- TVUSS detects submucosal and small intramural fibroids
-
Hysteroscopy
- Can detect submucosal fibroids
- Used to plan subsequent treatment or for actual treatment
12
Q
What is the Mx of fibroids, if fertility is wished to be preserved?
A
Choice of Tx is determined by the PC and patient’s wishes for menstrual function and fertility
-
1<u>st</u> line: Medical therapies (3-6 months)
-
GnRH agonists e.g., leuprorelin
- Induces low oestrogen (menopausal) state → amenorrhoea → fibroid shrinkage
- Only used prior to surgery (myomectomy/hysterectomy)
-
Antiprogesteronese.g., mifepristone
- Shrinks fibroid
- SEs: vasomotor symptoms, risk of endometrial hyperplasia
-
IUDe.g., Levonorgestrel
- 1st line for fibroids <3mm + no uterine distortion
-
NSAIDs
- Reduces HMB, also treats dysmenorrhoea and pelvic pain
-
Tranexamic acid
- Reduces HMB & cause necrosis of fibroids
-
GnRH agonists e.g., leuprorelin
-
1<u>st</u> line: Surgery
-
Myomectomy
- Can be laparoscopic/abdo/hysteroscopic
- But hysteroscopic → increased recurrence of fibroids, especially when multiple
- ST risks: infection, bleeding, other organ injury, emergency hysterectomy due to bleeding
- LT risks: uterine rupture during subsequent pregnancies, recurrence of fibroids
-
Myomectomy
13
Q
What is the Mx of fibroids, if fertility is not wished to be preserved?
A
Choice of Tx is determined by the PC and patient’s wishes for menstrual function and fertility
Fertility not preserved; uterus preserved
-
1<u>st</u> line: Surgery
- Myomectomy
-
OR 1<u>st</u> line: Uterine artery embolisation
-
Uterine artery embolisation
- Embolisation of both uterine arteries under radiological guidance guidance → reduced blood supply to uterus → infarction and degradation of fibroids (50% reduction in size)
- Minimally invasive; avoids GA and surgery
- Reduces fertility but doesn’t eradicate risk
- ST risks: infection, bleeding, allergic reaction to contrast dye, PAIN, femoral artery puncture site haematoma, incomplete procedure, embolisation of other organs’ blood supply
- LT risks: vaginal discharge, expulsion of fibroid material, infection, may cause premature ovarian failure and infertility, 1/3 women need subsequent treatment within 5yrs
-
Uterine artery embolisation
- PLUS, Pre-op adjunct medical therapies (see above)
Fertility not preserved; uterus not preserved
-
1<u>st</u> line: Surgery
-
Hysterectomy
- May be laparoscopic/abdo/vaginal
- ST/LT risks: damage to urinary tract/bowel/vagina, risk of vaginal vault prolapse
-
Hysterectomy
-
OR 1<u>st</u> line: Uterine artery embolisation
- Uterine artery embolisation
- PLUS, Pre-op adjunct medical therapies (see above)
14
Q
What are the complications of fibroids?
A
- Recurrent growth
- Complications of treatment (e.g., infertility, infection)
-
Malignant/sarcomatous transformation
- 1 in 350
- Suspect in postmenopausal period or when size rapidly increases
-
Obstetric complications:
- Subfertility due to distortion of uterine tubes/cavity (removal can enhance fertility)
- Risk of miscarriage is not increased once pregnancy is established
- May enlarge in pregnancy → abnormal lie, obstruct vaginal delivery
- Red degeneration → may precipitate uterine contractions if severe
- PPH (due to inefficient uterine contraction)
15
Q
What is the prognosis of fibroids?
A
- Treatment is usually effective but may recur (unless hysterectomy)
16
Q
What is an endometrial polyp?
A
An abnormal, benign, growth of issue which projects from a mucous membrane
17
Q
Aetiology of endometrial polyp?
A
- Benign tumours that grow into the uterine cavity; usually endometrial but may be from submucosal glands
Aetiology is unknown
- Associated with high oestrogen, chronic inflammation, and atherosclerotic blood vessels
- Do not respond to normal hormonal changes (like normal endometrium) → unscheduled vaginal bleeding
18
Q
RFs and protective factors for endometrial polyps?
A
RFs:
- high oestrogen (e.g., obesity, PCOS, nulliparity, HRT, tamoxifen, late menopause) (causes endometrial proliferation, myometrial growth & motility, etc.)
- HTN
Protective factors:
- any method that increases progesterone levels (e.g. IUS) (prevents endometrial proliferation, etc.)
19
Q
What is adenomyosis
A
- Disorder in which endometrial glands and stroma are present within the myometrium (uterine musculature),
- → hypertrophy of the surrounding myometrium
20
Q
Epidemiology of adenomyosis?
A
20-35% of women
21
Q
RFs for adenomyosis?
A
- parity (previous pregnancy)
- endometriosis & fibroids
22
Q
Sx of adenomyosis?
A
- ⅓ are asymptomatic
- HMB/menorrhagia
- due to increased endometrial surface of the enlarged uterus
- dysmenorrhea
- due to bleeding and swelling of endometrial islands confined by myometrium
- ~ chronic pelvic pain
23
Q
What is seen O/E in adenomyosis?
A
24
Q
Epidemiology of endometrial polyps?
A
Common in women aged 40-50yo
25
Symptoms of endometrial polyps?
* Often asymptomatic
* Endometrial:
* **Intermenstrual bleeding** (usually spotting)
* **Irregular menstrual bleeding,**
* **HMB**
* **Vaginal discharge** (white/yellow mucus)
26
What is seen O/E in endometrial polyps?
* Usually unremarkable
* ~ Endometrial may prolapse through the cervix → may look like cervical polyp
27
Ix for ?endometrial polyp?
* **Speculum examination**
* *usually unremarkable*
* *~ Endometrial may prolapse through the cervix → may look like cervical polyp*
* **TVUSS**
* *Endometrial: endometrial thickening, hypoechoic protrusion from the endometrium*
* May use hysterosonography (saline injected into uterus) → clearer view during USS
* **Hysteroscopy**
* *Visualisation of polyp*
* **Histological examination of polyp after removal**
28
Mx of endometrial polyp?
_Symptomatic women:_
* **Polypectomy**
* Endometrial: polypectomy via hysteroscope; outpatient procedure +/- local anaesthesia
* Histological examination to exclude malignany
* **Medical management:**
* Can control bleeding with tranexamic acid, NSAIDs, COCP etc.
_Asymptomatic premenopausal women:_
* Management is based on risk of endometrial cancer
* **If high risk or subfertile → polypectomy**
_Asymptomatic postmenopausal women:_
* **Polypectomy** (as higher risk of endometrial cancer than premenopausal)
29
Complications and prognosis of endometrial polyp?
_Complications_:
* **Subfertility** (may block cervical canal, prevent implantation if multiple)
* **Recurrence** (10%)
* **1% risk malignant transformation** (endometrial/cervical cancer)
* **Complications of polypectomy**: bleeding, infection, uterine perforation (rare)
* Do not attempt to remove polyps that are not easily visible without Ix (i.e. from cervical canal)
_Excellent prognosis after removal_
30
What is endometrial cancer?
Carcinoma of the endometrium of the uterus
31
What are the types of endometrial cancer?
* adenocarcinoma - *90%*
* serous carcinoma,
* mucinous carcinoma,
* clear-cell carcinoma
* mixed
32
What is the aetiology of endometrial cancer (adenocarinoma)?
* **_Chronic oestrogen_** exposure unopposed by progesterone
* → **endometrial hyperplasia** (proliferation of endometrial glands)
* → further stimulation predisposes to **abnormalities of cellular/glandular architecture**
* → **_Endometrial hyperplasia with atypia_** (premalignant disease)
* → 25-50% risk of progression to endometrial cancer
* ~ → tumour spreads directly though myometrium to cervix and upper vagina
* ~ → lymphatic spread to pelvic/para-aortic nodes
33
How is endometrial hyperplasia seen histologically?
greater gland-to-stroma ratio than normal
34
What are the RFs for endometrial cancer?
* **unopposed oestrogen:**
* _Endogenous oestrogen:_
* early menarche,
* late menopause,
* nulliparity,
* PCOS (chronic anovulation),
* obesity,
* ovarian tumours (granulosa/theca cell)
* _Exogenous oestrogen:_
* oestrogen-only HRT,
* tamoxifen (oestrogen antagonist in breast but agonist in uterus)
* **FHx endometrial/ ovarian/breast/colon cancer (Lynch syndrome)**
35
What are the protective factors for endometrial cancer?
* **cyclical or continuous progesterone** e.g.,
* COCP
* POP
* **pregnancy**,
* **hysterectomy** (women with Lynch syndrome offered prophylactic hysterectomy)
36
What staging system is used for endometrial cancer?
FIGO staging
37
Describe each of the stages of endometrial cancer
**_Stages 1-4_**
* **Stage 1: lesions confined to uterus** *(75% patients present with stage 1)*
* 1A: \< 50% myometrial invasion
* 1B: \> 50% myometrial invasion
* **Stage 2: cervical invasion (but does not extend beyond uterus)**
* **Stage 3: local or regional spread**
* 3A: invades serosa of uterus or adnexae
* 3B: invades vagina and/or parametrium
* 3Ci: pelvic node involvement
* 3Cii: para-aortic node involvement
* **Stage 4: further spread**
* 4A: bowel or bladder
* 4B: distant metastases
38
What is the grading of each stage of endometrial cancer?
* **Grades 1-3** is also included for each stage,
* G1 being well-differentiated
* G3 being mostly abnormal cells
39
What is the epidemiology of endometrial cancer?
* **Most common gynae cancer**; lifetime risk 1%
* **Peak prevalence at 60yo; uncommon \<40yo**
40
What are the symptoms of endometrial cancer?
**_Pre_**_-menopausal:_
* **irregular/intermenstrual bleeding (IMB)**
* **menorrhagia (HMB)**
**_Post_**_-menopausal_
* **post-menopausal bleeding (PMB)**
**_Late**_ _**disease_** _(despite state of menopause):_
* **abdo pain,**
* **bladder/bowel disturbance (incl. haematuria),**
* **resp symptoms**
41
What is the Mx of Stage 1 endometrial cancer?
42
What is seen O/E in endometrial cancer?
* **often normal** unless advanced;
* _If advanced:_
* **bulky & fixed uterus,**
* **uterine mass,**
* **~ adnexal mass**
43
Ix for ?endometrial cancer?
**_In primary care:_**
* **Bloods**:
* **FBC** (anaemia),
* **U&Es** (renal involvement),
* **LFTs** (liver/bone involvement)
* **Bimanual exam**
* **Speculum exam**
**_In secondary care:_**
* **TVUSS**
* **Endometrial biopsy** (**+ ~ Hysteroscopy** - may be used to guide biopsy; not always performed)
* *essential for diagnosis*
* _If cannot tolerate biopsy_ → **hysteroscopy, dilatation & curettage**
44
What is the cut-off for endometrial thickness, in order for a biopsy to be indicated?
* \<4mm → no biopsy, no further Ix
* **≥4mm → biopsy +/- hysteroscopy**
45
What Ix are used to stage endometrial cancer, once the diagnosis has been confirmed by biopsy?
* CXR,
* MRI,
* CT CAP,
* PET CT
46
What are the different pathways and their eligibility criteria for TVUSS and further Ix?
* **_Rapid access clinic (2 week wait)_** → one-stop clinic for urgent Ix:
* REFER for those aged ≥ 55yrs, with PMB
* CONSIDER for those aged \<55yrs, with PMB
* **_Direct access USS (in primary care)_** to assess for endometrial cancer:
* **those aged ≥55yrs**, with:
* **unexplained symptoms of vaginal discharge** who:
* are presenting with these symptoms for 1st time _or_
* have thrombocytosis _or_
* report haematuria, _or_
* **visible haematuria** **AND**:
* low Hb _or_
* thrombocytosis, _or_
* high glucose
47
What is the Mx of Stage 2 endometrial cancer?
48
What is the Mx of Stage 3 endometrial cancer?
49
What is the Mx of Stage 4 endometrial cancer?
50
What is the Mx of endometrial hyperplasia with atypia (pre-malignant disease)?
51
Complications of endometrial cancer?
* Metastatic spread
* Complications of treatment
52
Complications of Surgery for endometrial cancer?
* infertility,
* bladder instability,
* lymphoedema,
* sexual dysfunction
53
Complications of radiotherapy for endometrial cancer?
* bladder/bowel fistulae (incontinence),
* vaginal stenosis
* vaginal atrophy
54
Complications of chemotherapy for endometrial cancer?
* nausea,
* hair loss,
* mouth ulcers,
* etc
55
Prognosis of endometrial cancer?
**Presents early so high survival rates**
* 5-year survival:
* **stage 1: 85%;** - *most cases present at this stage*
* stage 2: 70%;
* stage 3: 50%;
* stage 4: 25%
