Gynae - Uterine, Cervical, Vulvovaginal Disorders

Question 1

Chronic Pelvic Pain

Definition
Clinical Features
Differential Diagnoses
Investigations

Answer 1

1.) Definition - intermittent or constant pain >6 months in the lower abdomen or pelvis not exclusively due to menstruation, intercourse or pregnancy

2. ) Clinical Features
   - persistent lower abdominal pain
   - painful: periods, intercourse, defecation, urination
   - heavy periods, IMB, PCB, rectal bleeding, epistaxis
   - pelvic examination: NAD, thickened uterosacral ligaments, fixed retroverted uterus, uterine/ovarian enlargement, uterine or forniceal tenderness
3. ) Differential Diagnoses
   - endometriosis and adenomyosis, ovarian cysts
   - PID, pelvic adhesions, IBS/IBD, interstitial cystitis
   - MSK, nerve entrapment, social/psychological factors
4. ) Investigations
   - abdominal and pelvic examination, speculum
   - STI screening
   - imaging (TVUS, MRI laparoscopy): identify and assess adnexal masses, adenomyosis

Question 2

Differentials for Chronic Pelvic Pain

Adhesions
IBS and Interstitial Cystitis
MSK Pain and Nerve Entrapment

Answer 2

1. ) Adhesions - post-surgical complication
   - residual ovarian syndrome: preserved ovaries after a hysterectomy causing chronic pelvic pain
   - ovarian remnant syndrome: ovarian tissue left behind after an oophorectomy causing pelvic pain
   - treatment is GnRH analogues or surgical removal
2. ) IBS and Interstitial Cystitis
   - IBS will have other bowel symptoms
   - IC has other urinary sx: frequency, urgency, nocturia, pain worse with a full bladder
3. ) MSK Pain and Nerve Entrapment
   - source of MSK: pelvic joints, muscle damage to the pelvic floor or abdominal wall, pelvic organ prolapse
   - NE: highly localised, sharp, stabbing or aching pain
   - Tx: analgesia, physio, nerve modulation

Question 3

Endometriosis

Pathophysiology
Risk Factors
Clinical Features
Differential Diagnoses

Answer 3

1. ) Pathophysiology - endometrial tissue located at abnormal sites due to “retrograde menstruation”
   - locations: ovaries, pouch of Douglas, uterosacral ligaments, peritoneum, bladder, umbilicus and lungs
   - oestrogen dependent: sx are cyclical with periods, sx are therefore reduced in pregnancy and menopause
   - bleeding from ectopic tissue during menstruation, repeated inflammation can occur leading to adhesions
2. ) Risk Factors
   - early menarche, uterine/fallopian defects, FH
   - short menstrual cycles, HMB, long bleeding duration
3. ) Clinical Features
   - cyclical pelvic pain occurring during menstruation
   - constant pain in cases where adhesions have formed
   - other sx: dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficult, painful defecating), and subfertility
   - focal sx of bleeding at ectopic sites during periods: e.g. bloating (abdo), haemothorax (lungs)
   - bimanual: fixed, retroverted uterus, uterosacral ligament nodules, general tenderness
4. ) Differential Diagnoses
   - PID, ectopic pregnancy, fibroids, IBS

Question 4

Management of Endometriosis

Investigations
Medical Management
Surgical Management

Answer 4

1. ) Investigations
   - laparoscopy (gold): chocolate cysts, adhesions, peritoneal deposits, effective at differentiating from PID
   - pelvic USS: helps determine severity, done before surgery, can see “kissing ovaries”
2. ) Medical Management
   - NSAIDs and analgesia is the first-line management
   - suppressing ovulation: ↓oestrogen can cause atrophy of the lesion, using COCP, POP, or Mirena-IUS
   - danazol: suppresses gonadotropin release
3. ) Surgical Management - if severely affected QoL
   - excision, fulguration and laser ablation aim to completely remove the ectopic endometrial tissue
   - relapses often occur so may need to be repeated
   - definitive management: TAH + BSO w/ HRT until menopause

Question 5

Adenomyosis

Pathophysiology
Risk Factors
Clinical Features

Answer 5

1. ) Pathophysiology - the presence of functional endometrial tissue within the myometrium of the uterus
   - occurs when endometrial stroma communicates with the underlying myometrium after uterine damage due to pregnancy/childbirth, C-section, surgery (inc TOP)
   - invasion can be focal or diffuse, more common in the posterior wall of uterus, can find blood in myometrium
   - adenomyoma: a collection of endometrial glands that form grossly visible nodules in the myometrium
   - oestrogen dependent: sx are therefore reduced in pregnancy and menopause
2. ) Risk Factors
   - multiparity: often occurs towards menopause (40-60s)
   - any uterine surgery, C-section, FH
3. ) Clinical Features
   - HMB, irregular bleeding, deep dyspareunia
   - progressive dysmenorrhoea: cyclical –> daily
   - frequently occurs with fibroids
   - examination: symmetrically enlarged boggy (tender) uterus may be palpable

Question 6

Management of Adenomyosis

Investigations
Hormonal Management
Non-Hormonal Mangement

Answer 6

1. ) Investigations
   - MRI (gold): irregular thickening of the endo–myometrial junctional zone is the hallmark of adenomyosis
   - transvaginal USS: globular uterine configuration, poor definition of the endometrial-myometrial interface, myometrial anterior-posterior asymmetry, myometrial cysts, heterogeneous myometrial echotexture
   - definitive diagnosis: biopsy post-hysterectomy or a hysteroscopic biopsy
2. ) Hormonal Management - reduce the proliferation of the ectopic endometrial cells, cycle control, ↓bleeding
   - COCP, POP, Mirena-IUS
   - GnRH agonists, aromatase inhibitors
3. ) Non-Hormonal Mangement
   - pain: analgesia and NSAIDs
   - hysterectomy: only curative therapy
   - uterine artery embolisation: to preserve fertility, reduce blood supply to the adenomyosis –> shrinks
   - other: endometrial ablation/resection, laparoscopic excision and MRI-guided focused ultrasound

Question 7

Fibroids (Leiomyoma)

Pathophysiology
Risk Factors
Clinical Features
Differential Diagnosis

Answer 7

1. ) Pathophysiology - benign smooth muscle tumours arising from the myometrium of the uterus, their growth is thought to be stimulated by oestrogen
   - very rarely becomes malignant (0.1% risk)
   - classified via their position in the uterine wall
   - intramural (most common): confined to myometrium
   - submucosal: develops immediately underneath the endometrium and protrudes into the uterine cavity
   - subserosal: protrudes into and distort the serosal (outer) surface of the uterus, may be pedunculated
2. ) Risk Factors
   - obesity, early menarche, increasing age
   - FH: affected 1st-degree relative ↑risk by 2.5x
   - ethnicity: black people (3x more likely)
3. ) Clinical Features
   - majority are asymptomatic and fibroids are often discovered incidentally on pelvic or abdo examination
   - if they are symptomatic, they may have:
   - menorrhagia (HMB), may have abdo distension
   - pressure sx: inc frequency or urinary retention
   - subfertility: obstructive effect of the fibroid
   - acute pelvic pain is rare but may occur in pregnancy due to red degeneration where increased oestrogen levels cause excessive growth of the fibroid
   - if large enough, may undergo torsion
   - abdo/bimanual: a solid mass or enlarged uterus may be palpable, the uterus is usually non-tender
4. ) Differential Diagnosis
   - endometrial polyp, ovarian tumours, adenomyosis
   - leiomyosarcoma: malignancy of the myometrium

Question 8

Management of Fibroids

Investigations
Medical Management
Surgical

Answer 8

1. ) Investigations
   - imaging: pelvic USS, MRI (if a sarcoma is suspected)
   - blood tests are usually reserved where the diagnosis is unclear, or as a pre-op work-up if surgery is needed
2. ) Medical Management - if symptomatic (HMB), <3cm in size, and not distorting the uterine cavity
   - tranexamic or mefenamic acid: only for bleeding
   - hormonal contraceptives: inc COCP, POP, Mirena-IUS
   - GnRH analogues (Goserelin/Zolidex): suppresses ovulation, useful pre-op to ↓fibroid size and lower complications, used short term (6mths) due to side effects of menopausal sx and reduced bone density
   - SPRM (Ulipristal/Esmya): ↓size of the fibroid and menorrhagia, Ulipristal can cause severe liver injury
3. ) Surgical - for larger fibroids e.g. >3cm
   - hysteroscopy + transcervical resection of fibroid (TCRF): this is useful for submucosal fibroids
   - myomectomy: for women who want to remain fertile
   - uterine artery embolization (UAE): commonly causes pain and fever post-operatively
   - hysterectomy

Question 9

Ovarian Torsion

Pathophysiology
Risk Factors
Clinical Features
Management

Answer 9

1. ) Pathophysiology - partial or complete torsion of the ovary on it’s supporting ligaments
   - may in turn compromise the blood supply
   - adnexal torsion: If the fallopian tube is also involved
2. ) Risk Factors
   - ovarian mass: present in around 90% of cases
   - reproductive age, pregnancy
   - ovarian hyperstimulation syndrome
3. ) Clinical Features
   - sudden onset of deep-seated colicky abdominal pain
   - associated with vomiting and distress
   - fever in a minority (due to adnexal necrosis)
   - examination: adnexal tenderness
4. ) Management
   - TVUS: may show whirlpool sign or free fluid
   - laparoscopy: is diagnostic and therapeutic