Women’s health - Gynae Flashcards
What is an ectopic pregnancy
Ectopic pregnancy occurs when a fertilised egg implants outsideof the uterus, most commonly within the fallopian tube.
Sx of an ectopic pregnancy
PV bleeding
Abdominal pain (usually unilateral, iliac fossa)
Shoulder tip pain
Dizziness
SOMETIMES ASYMPTOMATIC
Ix for ectopic pregnancy
Usually diagnosed by transvaginal USS +/-bHCG
Scan signs of tubal ectopic:
Adnexal mass moving separately to the ovary (sliding sign)comprising
a gestational sac containing a yolk sac or fetal pole
OR a non-specific mass (empty gestational sac)
In 20% of cases apseudosac(fluid) may be seen within the uterine cavity - must check all over and not just uterus
HCG- A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review
Management of ectopic pregnancy
There are three options for terminating an ectopic pregnancy:
- Expectant management(awaiting natural termination)
- Medical management(methotrexate)
- Surgical management(salpingectomyorsalpingotomy)
CRITERIA FOR WHICH MANAGEMENT OPTION IS BELOW:
Expectant management criteria:
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1500 IU / l
Medical management criteria:
Criteria formethotrexateare the same as expectant management, except:
- HCG level must be < 5000 IU / l
- Confirmed absence of intrauterine pregnancy on ultrasound
Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management. This include those with:
- Pain
- Adnexal mass > 35mm
- Visible heartbeat
- HCG levels > 5000 IU / l
KEY - Ectopic pregnancy and
miscarriage: diagnosis and initial management.
A women presents with PV bleeding and pain at 10 weeks gestation. You perform an USS, what are the 3 possible things you might see on the scan and what would they mean for diagnosis.
Quering ectopic vs misscarriage vs viable pregnancy
- immediate management
- baseline HcG
- TV USS - to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
- Tubal ectopic - adnexal mass moving separately to the ovary, or a gestational sac contianing a yolk sac and fetal pole in one of the tubes
- Positive pregnancy test but no sign of pregnancy on ultrasound scan → pregnancy of unknown location. Track the Serum HcG (viable should double every 48, a rise of less than 63% indicates an ectopic, a fall indicates miscarriage)
- USS shows a possible pregnancy in the uterus - either viable or misscarriage. When afetal heartbeatis visible, the pregnancy is consideredviable. Afetal heartbeatis expected once thecrown-rump lengthis7mmor more.Afetal poleis expected once themean gestational sac diameteris25mmor more.
Sholder tip pain is a sign of what gynaecological pathology
Ruptured ectopic pregnancy -> blood causing diaphragmatic nerve irritation (referred pain to the C3) dermatome
Me - techcially also a cyst rupture - blood on diaphragm is all it means really.
What are the three types of miscarriage? How are they each diagnosed?
Miscarriage is the spontaneous termination of a pregnancy. In the UK, it is estimated that 1 in 5 pregnancies end in miscarriage.
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Usually present following an episode of PV bleeding.
Diagnosed on USS showing an empty uterus. If not previous IUP confirmed then usually require followup of with bHCG monitoring (>50% decrease 48 hours apart is indicative of early pregnancy loss)
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage.
Diagnosed on USS – usually see mixed echoes within the uterine cavity
If no previous IUP (intrauterine pregnancy) seen on USS, will require serial bHCG monitoring to ensure failing IUP.
Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred. Diagnosed on transvaginal USS - CRL (crown rump length) >7mm with no foetal heart activity
How is incomplete miscarriage managed?
There are two options for treating an incomplete miscarriage:
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
Retained products create a risk of infection. Consider patients condition – are there signs of infection? Does our patient need antibiotics?
Management of missed/delayed miscarriage
There are three options for managing a miscarriage:
- Expectant management (do nothing and await a spontaneous miscarriage for 1/2 weeks) - first line
- Medical management (misoprostol - prostaglandin analogue -> uterine contraction), only option if CRL is above 54mm
- Surgical management (manual or electrical vacuum aspiration) can only be used if CRL<54mm BELOW!
What is a Molar Pregnancy?
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.
A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
Medical vs surgical termination of pregnancy
A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:
Mifepristone (anti-progestogen) - halts the pregnancy and relaxes the cervix
Misoprostol (prostaglandin analogue) 1 – 2 day later - softens the cervix and stimulates uterine contraction
From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
mnemonic
mifepristONE - anti-progesterONE
misoPROSTol - PROSTaglandin analog
Surgical TOP:
- can be performed at any gestational age
- can be performed under local anaesthetic (+/- sedation) or general anaesthetic
- cervical priming is performed prior with misoprostol, mifepristone, osmotic dilatation
- up to 14 weeks - cervical dilatation + suction of the context
- 14-24 weeks - cervical dilatation + evacuation using forceps
Rhesus negative women with a gestational age of 10 weeks or above having a medical or surgical TOP should have anti-D prophylaxis.
Utrasound shows bunch of grapes sign/snowstorm appearance - what is the diagnosis and management?
Molar pregnancy
Management involves evacuation of the uterus to remove the mole. The products of conception need to be sent for histological examination to confirm a molar pregnancy (definitive diagnosis) . Patients should be referred to the gestational trophoblastic disease centre for management and follow up. The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.
What is an ovarian torsion
Occurs when the ovary, and sometimes the fallopian tube twists on its vascular and ligamentous supports
This blocks adequate blood flow to the ovary
Surgical emergency – much like testicular torsion, but much harder to spot
Most commonly seen in women of reproductive age, Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour (usually benign). It is also more likely to occur during pregnancy.
Sx of ovarian torsion
The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting.
nonspecific - basically very similar to ectopic, but no bleeding
Diagnosis and management of ovarian torsion
Pelvic ultrasound is the initial investigation. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary (enlarged ovary). Doppler studies may show a lack of blood flow.
The definitive diagnosis is made with laparoscopic surgery.
Management: surgical
Detorsion is preferred -> oophorectomy is required if ovary is necrotic
Cyst accident - three reasons what ovarian cysts can cause acute pelvic pain
Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women.
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Key! What are GnRH angonists? What is the mechanism of action?
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), are used to shut down production of male and female sex hormones. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy. They are also used for endometriosis and prostate cancer. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.
Basic mechanism:
GnRH analogues are act just like GnRH and are agonists of GnRH receptors in the anterior pituitary gland. This triggers the release of the gonadotrophins (LH and FSH).
GnRH analogues a very powerful stimulation of these receptors leading to a very large (more than normal) release of gonadotrophins (FSH and LH). However, overtime the anterioir pituitary becomes desensitised to the GnRH hormone leading to a reduction in the production in gonadotrophins and thus sex hormones - A HYPOGONATROPHIC HYPOGONADISM
Background :
The Hypothalamic-pituitary-gonadal axis
Hypothalamus produces GnRH.
In females:
GnRH stimulates the pituitary gland to produces LH/FSH
LH/FSH stimulate the development of ovarian follicles which secrete oestrogen. Oestrogen has a negative feedback effect on the hypothalamus and pituitary gland.
In Males:
LH released from the pitary gland stimulates the testicles to produce testosterone, which also has a negative feedback effect on the hypothalamus and pituitary gland.
GnRH analogues:
GnRH analogues are act just like GnRH and are agonists of GnRH receptors in the anterior pituitary gland. This triggers the release of the gonadotrophins (LH and FSH).
GnRH analogues a very powerful stimulation of these receptors leading to a very large (more than normal) release of gonadotrophins. This causes an initial flare of sex hormones oestrogen and testosterone lasting days-weeks, with worsened symptoms of prostate cancer or endometriosis.
SC or IM injections give a slow release of the medication, and give a continuous stimulation of the GnRH receptors. Overtime the anterioir pituitary becomes desensitised to the GnRH hormone leading to a reduction in the production in gonadotrophins and thus sex hormones - A HYPOGONATROPHIC HYPOGONADISM (Low gonadrophins leading to low production of sex hormones by the gonads). Overtime the effects of overstimulation wear off so the dose needs to be repeated.
GnRH
GnRH antagonists are more complex than agonists, and act through a completely different mechanism but overall both inhibit gonadotropin secretion. GnRH antagonists bind competitively to GnRH receptors, preventing the action of endogenous GnRH pulses on the pituitary. The secretion of gonadotropins is decreased within hours of antagonist administration and no flare-up effect occurs.
KEY Define Pelvic inflammatory disease? what are the symptoms? Management?
Infection of the female reproductive system:
Uterus (endometritis)
Fallopian tubes (salpingitis)
ovaries (oophoritis)
Causes
Bacterial infection, usually sexually transmitted e.g. chlamydia, gonorrhoea or mycoplasma
Often asymptomatic, but symptoms can include:
- pelvic pain
- Dyspareunia
- Dysuria
- IMB/PCB
- Change to vaginal discharge
Treatment
14 day course of antibiotics – IM ceftriaxone single dose plus PO metronidazole (to cover gardnerella) and doxycycline (to cover chlamydia and mycoplasma)
Avoid SI until patient and partner completed treatment
What is the cervical cancer screening program frequency (SMEAR TEST)
25-49 - every 3 years
50-64 - every 5 years
Red flag symptoms of uterine bleeding
ME: you made this from memory so could be wrong
- intermenstrual bleeding - cervical and other cancers
- post-coital bleeding - cervical and other cancers
- post-menopausal bleeding - particularly if there is a large gap between last menstrual period
- post-menopausal - anemia, haematuria, discharge
- weight loss
- note- intermenstrual and postcoital bleeding are also caused by STIs
differential diagnosis for menorrhagia - 4 KEY ONES
Menorrhagia refers to heavy menstrual bleeding (more than 80mls). The volume is rarely measured in practice and diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. This can be caused by:
- 50% - Dysfunctional uterine bleeding(no identifiable cause)
- Fibroids - typically present 40-50s, pressure symptoms (pain/bladder issues)
- Uterine cancer - high BMI is a risk
- Endometriosis and adenomyosis (endometrial cells within the myometrium)
- Contraceptives, particularly the copper coil
- medications - (Anticoagulants)
- Systemic disorders (coagulation disorders and hypothyroidism)
- perimenauapse - ususally less regular
KEY Ix for menorrhagia in primary care? secondary care?
GP:
- FBC (exclude anemia)
- Pelvic examinationwith aspeculumandbimanual- This is mainly to assess for fibroids, ascites and cancers.
Maybe:
- thyroid - only if other thyroid symptoms
- swabs if evidence of infection
- coagulation screen if periods have been heavy since menarche
Session Secondary care:
- transvaginal scan - endometrial thickness, fibroids, masses
- hysteroscopy and endometrial biopsy - gold standard
KEY Management of menorrhagia? Conservative, medical and surgical
- Start by excluding underlying pathology such as anaemia, fibroids, bleeding disorders and cancer → these should be managed initially
Conservative
- once anything coerncing is exlcuded the patient might be happy with simple reassurance
Medical:
- Mirena coil(first line) - give it to everybody!!!! thin the endometrium, helps with pain in endometriosis…
- hormonal treatment options: IUS (above), Combined oral contraceptive pill (not if older or high BMI) or Cyclical oral progestogens, such as norethisterone
- non-hormonal treatment: Tranexamic acid(when no associated pain antifibrinolytic – reduces bleeding), Mefenamic acid(when there is associated pain - NSAID – reduces bleeding and pain)
Surgical - large fibroids, severe symptoms
- fibroids - submucous (resection hysteroscopically), myomectomy (muscle wall - laparoscopically for younger)
- endometrial ablation - hysteroscopically
- hysterectomy.
ILA - Differentials for post-menaupausal bleeding
- endometrial cancer- top differential
- vulval masses or other signs of gynaecancers
benign
- endometrial polyps
- atrophic vaginitis - irritated on wiping
- bleeding because of coagulants
KEY - How is PCOS diagnosed
Rotterdam Criteria
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism (high male sex hormones), characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
TOM TIP: If you are going to remember one thing about polycystic ovarian syndrome, remember the triad of anovulation, hyperandrogenism and polycystic ovaries on ultrasound. The Rotterdam criteria are commonly tested in MCQs and asked by examiners in OSCEs. It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.
What is PCOS- 4 key features
Polycystic ovary syndrome (PCOS) is a common endocrine disorder, characterised by excess androgen production (male sex hormones) and the presence of multiple immature follicles (“cysts”) within the ovaries.
Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women. There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.
7 key symptoms of PCOS
Women with polycystic ovarian syndrome present with some key features:
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity (in about 70% of patients with PCOS)
- Hirsutism - only a few other things cause this!
- Acne
- Hair loss in a male pattern
- chronic pelvic pain
Low yield but good for understanding
Pathophysiology of PCOS - what two key hormonal abnormalities seen in PCOS
Think this is low yield but good for understanding
The aetiology of polycystic ovary syndrome is poorly understood, and is thought to be multifactorial in origin.
The two most common hormonal abnormalities present in PCOS are:
- Excess luteinising hormone (LH) – produced by the anterior pituitary gland in response to an increased GnRH pulse frequency.
This stimulates ovarian production of androgens. - Insulin resistance – resulting in high levels of insulin secretion.
This suppresses hepatic production of sex hormone binding globulin (SHBG), resulting in higher levels of free circulating androgens.
Despite the high levels of LH, the increased circulating androgens suppress the LH surge (which is required for ovulation to occur). Follicles develop within the ovary, but are arrested at an early stage (due to the disturbed ovarian function) – and they remain visible as “cysts” within the ovary.
Early vs late miscarriage
Early miscarriage is before 12 weeks gestation.
Late miscarriage is between 12 and 24 weeks gestation.
Differential diagnosis for PCOS
Differential Diagnoses
There are a number of differential diagnoses to consider in cases of suspected polycystic ovary syndrome.
The alternative endocrine diagnoses include:
Hypothyroidism – obesity, hair loss and insulin resistance.
Hyperprolactinaemia – oligomenorhoea/amenorrhoea, acne and hirsutism.
Cushing’s disease – obesity, acne, hypertension, insulin resistance and depression.
KEY - Ix for PCOS
Hormonal blood tests typically show:
- LH- Raised luteinising hormone
- FSH -Raised LH to FSH ratio (high LH compared with FSH)
- testerone - raised
- also check prolactin, SHBG and TSH
TOM TIP: The key thing to remember for your exams is the raised LH, and the raised LH:FSH ratio.
Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either:
- 12 or more developing follicles in one ovary
- Ovarian volume of more than 10cm3 (even without visualisation of follicles)
OGTT for diagnosis of diabetes- the results are:
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
Management of PCOS - BIG BOI
Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions.
This is usually achieved through lifestyle modification, Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.
- antihypertensives and statins where required to help manage cardiovascular risk
Options for reducing the risk of endometrial hyperplasia and endometrial cancer are:
- Mirena coil for continuous endometrial protection
- Inducing a withdrawal bleed at least every 3 – 4 months with either:
- Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
- Combined oral contraceptive pill
Management of infertility:
- weightless -1st line - can store ovulation
- other options- IVF, clomifene, ovarian drilling
Management of acne:
- COCP - 1st line in PCOS,
- normal acne management - topical retinoids….
Management of Hirsutism:
- weightloss
- Dianette COCP (co-cyprindiol)- has antiandrogen effects
- Topical eflornithine
Background:
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
intentional double - a patient with string of pearls appearance on ultrasound, what is the diagnosis?
Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. A diagnosis of PCOS requires at least two of:
Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound
What is an ovarian cyst
A cyst is a fluid-filled sac.
Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women.
The vast majority of ovarian cysts in premenopausal women are benign.
Cysts in postmenopausal women are more concerning for malignancy and need further investigation.
Symptoms of ovarian cysts
Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.
Occasionally, ovarian cysts can cause vague symptoms of:
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
pathophysiology - Types of ovarian cyst- just name some common ones.
Functional Cysts
Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound. (I think this is because multiple follicles develop each cycle)
Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy.
Other Types of Ovarian Cysts:
Serous Cystadenoma
These are benign tumours of the epithelial cells.
Mucinous Cystadenoma
These are also benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.
Endometrioma
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
Dermoid Cysts / Germ Cell Tumours
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.
Sex Cord-Stromal Tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
Ix for ovarian cysts
USS is the Ix of choice
Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
ONLY DONE IF POST MENAUPAUSAL, CYST APPEARS ABNORMAL OR IS ABOVE 5CM:
CA125 is the tumour marker to remember for ovarian cancer. It contributes to the overall impression of whether an ovarian cyst is related to cancer and forms part of the risk of malignancy index (remember it is non specific and rises in endometriosis, adenomyosis, fibroids….)
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
KEY - Management of ovarian cysts
Simple ovarian cysts in premenopausal women can be managed based on their size:
- Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
- cysts above 5cm require follow up scan to see if they resolve. Peristant or large cysts (above 10cm) may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral.
What are fibroids? What promotes their growth?
Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas. They are very common, affecting 40-60% of women in later reproductive years.
They are oestrogen sensitive, meaning they grow in response to oestrogen.
4 types of fibroid
Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.
Presentation of fibroids
Fibroids are often asymptomatic. They can present in several ways, Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Other Sx:
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
Ix for fibroids
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. (basically I think the submucosal ones are the main ones that cause menorrhagia)
Pelvic ultrasound is the investigation of choice for larger fibroids.
MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.