1
Q
Discuss abnormal uterine bleeding
1. Incidence (2)
2. Definitions:
-AUB
-HMB
-Normal duration of bleeding
-Normal frequency of bleeding
-Normal regularity in cycle
A
- Incidence
-1 in 20 women seek medical services for AUB
-3-30% of all women of reproductive age affected - AUB - bleeding that is abnormal in frequency, duration, amount, regularity or any unscheduled bleeding
- HMB - bleeding which is considered excessive by the women and interferes with her life
- Normal duration of bleeding <8 days
- Normal frequency of bleeding - between 24-38 day cycle
- Normal cycle variation - >9 days at extremes of reproductive age, >7 between 26-41yrs
2
Q
What are the causes of AUB
A
PALM COIEN
1. Polyps
2. Adenomyosis
3. Leiomyoma
4. Malignancy
5. Coagulopathy - VWD most common
6. Ovulatory
7. Iatrogenic
8. Endometrial - overactive fibrinolysis, higher levels of prostaglandins, adolescence
9. Not otherwise explained - isthomocele, AVM
3
Q
What are the investigations for AUB
A
- Bloods:
-FBC, coag screen if Hx suggests so
-Fe and TFT
-Hormone testing NO recommended - Cervical smear
- HVS + LVS to investigate infection
- TVUSS - best done in follicular phase
- Endometrial Bx - do if thickened ET, risk factors for hyperplasia, persistence of bleeding despite conservative measures
NB: MRI, Saline sonography, D&C not firstline investigations
4
Q
Discuss management of AUB
1. Considerations (4)
2. Non-hormonal
3. Hormonal
4. Surgery
A
- Considerations
-Pathology
-Co-morbidities
-Fertility desires
-Treatment preferences - Non-Hormonal
-TXA - reduces bleeding by 50%
-NSAIDS - reduces prostaglandin synthesis. Reduced blood loss by 25% - Hormonal
-Mirena:
AUB NOS, Primary endometrial, Fibroid <3cm, adenomyosis.
Decrease blood flow by 96% in first yr
-COCP - reduces menstural blood loss by 50%
-Progesterone
-GnRH - Surgical
-Hysteroscopy D&C, Myomectomy, polypectomy, ablation, hysterectomy
5
Q
Discuss endometrial ablation
-Indication
-Contra-indications
-Relative (8)
-Absolute (6)
A
- HMB.
-Best done within 5 yrs of menopause transition
-Most effect in women >45yrs - Relative contraindications
-Congenital uterine abnormalities
-Uterine cavity >10cm
-Risk of endometrial hyperplasia (on tamoxifen, Lynch, Cowden)
-Submucosal fibroids that distorts the cavity
-Adenomyosis
-Previous ablation
-Post menopausal
-Acutely retroverted or anteverted uterus - Absolute contraindications
-Fertility incomplete
-Pregnancy
-Active genital tract infection
-Weakened myometrium - classical CS or myomectomy
-Malignancy or endometrial hyperplasia
-Uterine cavity <4cm long or uterine cavity width <2.5cm
6
Q
What are the pre-operative requirements of endometrial ablation (7)
A
- USS in last 6 months
- Recent endometrial sampling, preferably prior to procedure or at very least at time of procedure
- Discuss contraception- poor pregnancy outcomes post ablation
- Informed consent
- Negative pregnancy test
7
Q
How is endometrial ablation undertaken
-Types of ablation
-Procedure for Novasure (7 steps)
A
- Types of ablation:
-First generation: roller ball, diathermy loop ablation
-Second generation: fluid filled ablation balloon, microwave ablation, impedence controlled ablation (Novasure) - Novasure procedure
-Hysteroscopy first to assess cavity
-Curettage to collect tissue
-Determine length of uterus
-Place novasure wand into the cavity and rotate for sizing of cavity
-Novasure uses bipolar radiofrequency electrical energy passed through a porous metal fabric to vaporise and coagulate the endometrium
-Radio frequency ablation terminates after 2 mins or when increasing tissue impedance is noted
-Hysteroscope check
8
Q
What are the success rates o endometrial ablation (3)
A
-Amenorrhoea at 1 yr - 37% at 2-5yrs 53%
-Patient satisfaction - 91% at 1 yr, 93% at 2-5 yrs
-Hysterectomy within 2-5yrs - 14%
9
Q
What are the complications of endometrial ablation (8)
A
- PATSS - Post ablation tubal sterilisation syndrome
-Pain 6-8% secondary to proximal tube swelling - Ectopic pregnancy if become pregnant 26%
- Crampy pain 38%
- Treatment failure 9%
- Thermal injury to adjacent tissue - 1:10,000
- Uterine perforation 0.3%
- Haemorrhage - 1.2%
- infection 1-2%
10
Q
Discuss endometrial polyps
-Cause
-Histology
-Risk factor (5)
-Natural history
-Impact on fertility (3)
-Management options (3)
A
- Hyperplastic overgrowth of endometrial glands and stroma
- dilated endometrial glands embedded in markedly fibrous stroma
- Risk factors
-Tamoxifen, obesity, HRT, Lynch syndrome, PM - Natural history
-10% regression, less likely to regress if >1cm
-Progression to malignancy 5% - increased risk with age, Tamoxifen, if present with AUB - Impact on pregnancy
-Polypectomy can improve fertility rates
-Not associated with miscarriage rates
-No obstetric implications - Management
-Expectant with reimaging in 6 months if premenopausal, polyp <1.5cm, single polyp, aSx, not on tamoxifen
-Surgery - hysteroscopy + polypectomy / Resection (reduces recurrence as coagulation to base)
-If polyps recurrent consider mirena placement concurrently
11
Q
Discuss fibroids
-Definition
-Incidence
-Risk factors (6)
A
- Def: Benign, monoclonal tumours of the myometrium formed from smooth muscle and fibroblasts
- Most common pelvic tumour. 30% of women have
- Risk factors
-Increased estrogen exposure - early menarche, late menopause, PCOS, COC, Nulliparity, obestiy
-Race 2-3 x higher in Black women, genetics, DES exposure, Prior uterine infection, physical and sexual abuse
12
Q
How does FIGO classify fibroids (8)
A
Submucosal 0-2
0 - pedunculated intracavity
1 - <50% intramural
2 - >50% intramural
Intramural 3-4
3 - 100% intramural
4 - intramural
Subserosal 5-7
5 - >50% intramural
6 - <50% intramural
7 - Pedunculated subserosal
8 - Other - cervical etc
13
Q
How do fibroids present (5)
A
- 50% asx
- AUB
- Pain
- Pressure sx
- Infertility or obstetric complications
14
Q
What are the options for fibroid management (4)
A
- Conservative - if aSx, slow growing and small
-Consider growth monitoring annually - Medical - Less effective if fibroid >3cm
-TXA/NSAIDS - not very effective
-Mirena if fibroid <3cm and not submucosal
-COC effective. POP, Jadelle, Depo - not effective
-GnRH - only if other methods contra-indicated
-Use pre-surgery
-If>6/12 need HRT add-back
-SPRM - ulipristal - apoptosis within fibroid
-Mifepristone - reduction in size by 25-75% - Surgery
-Hysteroscopic resection if submucosal
-Myomectomy -10% recurrence, 17% require further surgery
-Use inconjunction with 3/12 GnRH inhibitor
-Myolysis - directed electrical current or laser
-Hysterectomy - IR
-UAE
NB: Hysterocscopy / myomectomy/ Myolysis if desiring infertility
15
Q
Discuss uterine artery embolization efficacy (3)
A
- Relief of pressure sx 60%
- Relief of AUB - 70-90%
- Relief of pain 80%
16
Q
How do fibroids impact pregnancy (9)
A
- Infertility or recurrent miscarriage (submucosal mainly, intramural likely but unclear if myomectomy improves fertility)
- PTL
- Malpresentation
- Obstructed labour
- PPH
- Difficult CS
- Puerperal infection
- Abruption
- FGR
17
Q
What are the complications associated with fibroids (5)
A
- Red degeneration
- Torsion
- Prolapse through cervix
- Infection - pyometra
- Malignancy 1-2:1000 undergo malignant transformation
18
Q
What are the optimal imaging techniques for evaluating fibroids (3) RANZCOG guidelines
A
- MRI
- Sonohysterography
- Hysteroscopy
19
Q
How should fibroids be managed in infertile couples (RANZCOG guidelines) - (7)
A
- Avoid medical management as delays fertility
- Avoid Ulipristal acetate
- Intramural fibroids - may impact fertility and miscarriage rate but insufficient evidence for intervention benefit
- Submucosal fibroids should be resected if undergoing ART
- Infertile women with symptomatic fibroids should have these resected
- Couples with multiple failed ART cycles should have IM fibroids resected
- UAE should only be done in research setting
20
Q
Discuss uterine artery embolisation:
-Procedure
-Complications (procedural (3), Early (4), Late (3)
-Outcomes and complications compared to surgery (7)
A
- Procedure:
-Place catheter into uterine arteries via common femoral artery
-Inject embolic particles until the flow through the artery becomes sluggish - Complications
Procedural - Groin haematoma, arterial thrombosis, pseudoaneurysm
Early - Embolisation syndrome - fever, nausea, pain, malaise - 4%, Vaginal discharge - 4%, Pelvic infection, expulsion of necrotic submucosal fibroid (requirement to retrieve these)
Late - Ovarian insufficiency 3% if <40, 40% if >40, Failure of response 3%, reintervention - Outcomes compared to surgery
-No significant difference in patient satisfaction
-Similar intraoperative complications
-No difference in early or late major complication rates
-No difference in long term ovarian failure rates
-UAE - shorted time in hospital, shorter procedural time, shorter recovery time
-UAE increased minor complications, increased number of unplanned reviews, increased re-intervention rate
-Myomectomies better option for women wanting to achieve pregnancy
21
Q
Discuss UAE and reproduction
-Fertility
-Pregnancy
A
- Fertility
-Pregnancy rates lower and miscarriage rates higher in UAE vs myomectomy
-May impact ovarian reserve. AMH recovers if <40yrs by 3 months. Doesn’t if >40
-May decrease endometrial health and impact implantation
-May impact myometrial contractility - Pregnancy
-Increased CS, PPH and miscarriage rates when compared to untreated fibroids
22
Q
How should patients be counselled about uterine artery embolisation (5 points) RANZCOG guidelines
A
- Avoid UAE in young women if they are wishing to concieve
- Disclose possibility of missing malignancy and avoid if concern or risk factors for leiomyosarcoma
- Counsel patients about requiring hysteroscopic or laparoscopic retrieval
- Counsel patients about alternative options
- Counsel patients wanting to conceive that UAE impact on miscarriage and pregnancy are uncertain
23
Q
What is the cause / mechanism of PCOS
A
- Multifactorial with genetic component
-Likely autosomal dominant with low penetration and variable expressivity.
-Heritability 70%
-Likely environmental component - Key element is insulin resistance - seen in 50-70% of women with PCOS.
- Insulin resistance is likely due to abnormal post receptor signalling
- Insulin resistance results in hyperinsulinemia which results in:
-increased release of fatty acids
-Increased LH and decreased FSH release from pituitary
-Augments activity of LH on theca cells to induce more androgen production from ovary
-Stimulates the adrenal glands to produce more androgens
-Reduces SHBG which results in more free androgens - The increased androgens:
-Disrupt folliculogenesis resulting in multiple small follicles and increased follicular atresia
-Acts peripherally to cause signs of hyperandrogenism
24
Q
What is the criteria for the diagnosis of PCOS
-In Adults
-In Adolescence
A
Diagnosis is based on Rotterdam criteria
1. Oligomenorrhoea or anovulation (>35/28, <21/7 or <8/yr)
2. Clinical and/or biochemical signs of hyperanderogenism
-High free testosterone and total testosterone
3. Polycystic ovaries on USS
>12 follicles 2-9mm or ovary >10mL without CL, cysts, dominant follicle
4. PCOS is dx of exclusion. Need to r/o
->CAH, Androgen secreting tumour, Cushings, thyroid abnormalities, hyperprolactinemia central causes)
5. In Adolescents
-Oligo/Anovulation. Up to 90 day cycles in yr one tolerable
-3yrs post menarche can use adult def of oligomenorrhoea
-Biochemical hyperandrogenism. Mild acne and alopecia do not apply in adolescence
-USS not recommended in Dx if <8yrs post menarche
25
What is the incidence of PCOS (2) and how does it present (6)
1. Incidence
-Most common endocrine condition in women
-8-13% of women affected
-70% under diagnosed
2. Presentation
Heterogeneous condition with multiple presentations
Hyperandrogenism -70% hirsutism, Acne 30%, Alopecia 10%
Menstrual disturbance - 60-70%
Infertility - 70%
Truncal obesity - 35-50%
PCOS on USS - 30%
Acanthosis nigricans - 1-3%
26
What investigations should be ordered for PCOS
1. For Dx (2)
2. Post Dx (4)
3. To rule out other causes of symptoms/signs (8)
4. Considerations in testing
1. For Dx
-FSH, LH, E2, testosterone
-TV USS
2. Post Dx
-OGTT or HbA1c
-Lipids
-BMI and waist circumference
-Annual BP
3. To rule out other causes
-Prolactin
-TSH
-17 Hydroxy progesterone
-DHEAS - marks adrenal androgen production (Ltd use)
-Androstenedione - marker of ovarian androgen production (Ltd use)
-24hr urine cortisol - Cushings
4. Considerations
-Cannot test testosterone if on hormonal contraceptive. Need to have 3 month period off this.
-USS in those who are <8yrs post menarche should be avoided
27
What are the typical biochemical findings in PCOS (8)
1. Raised free testosterones
2. Low SHBG
3. Raised LH/FSH ratio
4. Raised DHEAS and androstenedione
5. Raised LH
6. Increased oestrogen
7. Decreased progesterone
8. Mildly elevated prolactin
28
What are the key aims for PCOS management (6)
1. Correct hyperandrogenism
2. Restore menstrual function
3. Manage cosmetic symptoms
4. Restore fertility
5. Improve long term health
-Diabetes
-CVD
-Hyperlipidemia
-Endometrial protection
6. Manage mental health - Increased depression / anxiety
29
Discuss management for PCOS
-Lifestyle
-Cosmetic
-Pharmacological
-fertility
1. Lifestyle management
Interventions which result in weight loss
-5-10% weight loss will improve menstrual regulation and fertility
-Not required in BMI normal
Firstline diet and exercise with psychological support if required
In very obese women recalcitrant to first line = Bariatric surgery
2. Cosmetic
-For Hirsutism - bleaching, waxing, laser
-COCP with cyproterone - hirsutism and Acne
-Spironolactone or cryptoproterone actate for hirsutism takes 6-9 months to work. Are teratogenic - must be on contraception. Try if no improvement after 6/12 COCP
3. Pharmacological - not desiring fertility
-First line COCP - for hyperandrogenism, menstrual irregularity, endometrial protection. Consider contra-indication
-Second line - Progesterone only if contra-indicated to COCP. For menstrual irregularity and endometrial protection
-Metformin - off-label use. Not as effective as COCP
- Consider in high risk groups for diabetes in combo with POP or COCP
-Sht term improvement in insulin resistance, reduces androgen by 11%, may have modest impact on wt
4. Infertility
1. Lifestyle changes = first line
2. Ovulation induction
-Letrozole (first line) or clomiphene
-Metformin can be considered - less effective
-Ovarian drilling - improves ovulation and androgen normalisation in 60%
30
What are the long term health outcomes for women with PCOS (6)
1. Obesity
2. CVD
- manage modifiable risk factors.
-Annual GP reviews - to check for risk factors
-Insufficient evidence to commence of statin
3. Diabetes
-Increased risk of GDM (RR 2.0), T2DM, metabolic syndrome
-Assess glycemic status 1-3yrs. OGTT best
-HBA1c not validated in PCOS. Might miss T2DM
-OGTT between 24-28/40 weeks recommended
4. OSA - assess for symptoms and refer as appropriate
5. Endometrial hyperplasia and cancer
-2-6 fold increased risk of endometrial cancer
-Consider endometrial protection. May reduce risk if cycle >90 days
-Have a low threshold to investigate AUB / Thickened ET
-Routine screening with ET is not recommended
6. Psychological
- increased depression and anxiety - screen for PHQ and GADS7
-Increased psychosexual dysfunction and poor body image - screen for.
-Offer psychological support
31
What is the definition of secondary amenorrhoea
1. Absence of menstruation for >3 months if previously regular cycles
2. Absence of menstruation for >6 months if previously irregular cycles
32
What are the causes of secondary amenorrhoea (8 categories)
1. Hypothalamus - 35%
-Functional - stress, wt los, low BMI, excess exercise
-Lesions -craniopharyngeioma, glioma
-Infiltrative disease - TB, sarcoidosis
-Head injury / radiation
-Chronic illness
2. Pituitary - 17%
-Hyperprolactinemia - almost always adenoma causes decreased GnRH release
-Sheenhan's syndrome - hypoxic insult to pituitary (after PPH)
-Trauma to pituitary stalk stopping dopamine control of prolactin = hyperprolactinemia
3. Ovarian - 40%
-PCOS 30%
-POI
4. Genital tract abnormalities 7%
-Asherman's syndrome
-Cervical stenosis
5. Adrenal
-Late onset CAH
-Virilising adrenal tumour
6. Drugs
-Progestogens / HRT
-Dopamine antagonists, metocloprimide
-Long term steroids
7. Chronic illness
-Chronic illness affecting HPO axis - renal/liver /thyroid disease. Diabetes, Cushing's
8. Physiological
-Pregnancy - most common cause
-Lactation
-Menopause
33
What investigations should be done to investigate secondary amenorrhoea
1. Bloods
FSH/LH
- Low/Low = hypogonadatrophic hypogonadism
-High in ovarian causes
-High LH/FSH ratio PCOS
Oestradiol
-Low in ovarian causes
-High where hyperandrogenism occurs as converts in peripheral tissue
Prolactin
-Hyperprolactinemia but can but raised for many other reasons
Thyroid function
Testosterone
-High in PCOS
DHEAS
-High in adrenal androgen secretion
SHBG
-Decreased in PCOS
17 hydroxyprogesterone
-High in late onset CAH
2. Imaging
-USS - PCOS / Adrenal masses
-MRI if suspecting prolactinoma / Tumour
3. Hysteroscopy if suspecting Ashermans
34
How should secondary amenorrhoea be managed
Management depends on cause
1. Hypothalamic
-Increase calories, decrease stress, decrease exercise
-GnRH if wanting fertility
-HRT
2. Pituitary
-Dopamine agonist - Carbergoline
-Transphenoidal transection if recalcitrant to medical management
3. Ovarian
-Management for PCOS
-Management for POI
4. Genital tract
-Hysteroscopic resection of adhesions
-Cervical dilitation
5. Adrenal
-Resection of androgen secreting tumour
-Hydrocortisone for CAH
6. Stop drugs contributing to issue
7. Optimise chronic disease management
35
What are the classifications of premenstrual syndrome (6)
PMS is an umbrella term for a range of disorders
1. Premenstrual syndrome
2. Premenstrual dysmorphic disorder
3. Premenstrual exaccerbation
-symptoms of an underlying disorder are worsened during luteal phase of cycle
4. Non-ovulatory PMD - due to follicular activity
5. Progesterone induced PMD - due to exogenous progesterone
6. PMD with absent menstruation (hysterectomy / Mirena)
36
What is the definition of premenstrual syndrome
1. Cyclical disorder with symptoms in the luteal phase
2. Includes physical and psychological symptoms
3. Timing and severity of sx support dx not type of sx
4. Must impact quality of life
37
What is the diagnostic criteria for premenstrual dysphoric disorder
-5 points
-11 symptoms
1. Must have 5 of 11 symptoms
2. One symptom must be mood
3. symptoms must be in luteal phase and abate when menstruation begins
4. Must be severe enough to disrupt daily function
5. Must be present during at least 2 consecutive cycles
Symptoms:
-Depression
-Anxiety
-Affect lability
-Anger or irritation
-Decreased interest in usual activities
-Difficulty concentrating
-Lack of energy, fatigue
-Change in appetite, cravings
-Change in sleep - hypersomnia or insomnia
-Feeling overwhelmed or out of control
-Physical symptoms: breast tenderness, headaches, joint or muscle aches, weight gain, bloating
38
Discuss premenstrual syndrome
-incidence
-aetiology
1. Incidence
-40% of women experience PMS
-2-5% have Premenstrual dysmorphic disorder
2. Aetiology (Theories)
-Sensitivity to progesterone
-Serotonin receptors are responsive to oestrogen and progesterone
-GABA levels are modulated by metabolites of progesterone
-Possible genetic component
39
Discuss premenstrual syndrome
-Diagnosis
-Management
1. Diagnosis
-Symptom diary over at least 2 consecutive cycles. Can use DRSS Questionnaire (Daily record of severity of symptoms)
-If diary inconclusive GnRH for 3 months with resolution of symptoms confirms diagnosis
-Need to rule out other causes. Examination and investigations should be normal
2. Management
-Holistic approach with MDT
-Aims to eliminate cyclical fluctuations, modify neurotransmitter response, improve coping strategies
-Conflicting evidence regarding efficacy of alternative therapies
-Calcium + vit D, exercise, chaste berry, saffron work
First line:
-Exercise, CBT (as effective as fluoxetine), Vit B6
-Low dose SSRI continuously or in luteal phase
-Continuous new generation COC (Drospiridone)
Second line
-Transdermal estrogen with micronised progesterone or LNG-IUS.
-Higher dose SSRI continuous or in luteal phase 60-70% sx improvement
Third line:
-GnRH analogues + add back HRT if >6 months or tibolone
Fourth line
-Surgery - if severe and recalcitrant to medical management and previous success with GnRH management. TH + BSO better as avoids need for progesterone in HRT.
