Y4 Obstetrics and Gynaecology SA > 6 - Uterine Disorders > Flashcards

6 - Uterine Disorders Flashcards

(46 cards)

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1
Q

What are fibroids?

A
  • Tumours of the smooth muscle of the uterus “leiomyomas”
  • They are oestrogen sensitive
  • Most common in 40-60 year olds and black women
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2
Q

What are the different classes of fibroids?

A
  • Intramural: within the myometrium. As they grow, they change the shape and distort the uterus.
  • Subserosal: below the outer layer of the uterus. They grow outwards and can become very large, filling the abdominal cavity
  • Submucosal: below the lining of the uterus (the endometrium).
  • Pedunculated: on a stalk
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3
Q

which types of fibroid are the most common

A

intramural - within the myometrium

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4
Q

What are some risk factors for developing fibroids?

A

Pregnancy and POP is protective against them!!!

Anything raising oestrogen is a risk factor

  • Obesity
  • Early age of puberty
  • Increasing age
  • Black ethnicity
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5
Q

which ethnicity is a risk factor for fibroids??

A

AFRO CARRIBEAN

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6
Q

How may fibroids present?

A

Often asymptomatic or heavy menstrual bleeding

  • Prolonged menstruation, >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
  • Reduced fertility
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7
Q

What examinations and investigations are done to diagnose fibroids?

A

Exams

  • Abdominal
  • Bimanual: palpable pelvic mass with enlarged non-tender uterus

Investigations

  • 1st Line: Pelvic US (usually transvaginal over trans abdominal) for HMB
  • Pelvic MRI +/- hysteroscopy: if concern about intramucosal fibroids, malignancy or planning for surgery
  • FBC: anaemia
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8
Q

How are fibroids classified by their size?

A

<3cm = small

>3cm = large

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9
Q

How are small fibroids managed? (<3cm)

A

Treated same way as heavy menstrual bleeding

Medical

  • IUS Mirena Coil: 1st line as long as no distortion of uterus
  • Symptomatic management with tranexamic acid and NSAIDs
  • COCP
  • Cyclical oral progestogens

Surgical (if not controlled by medical)

  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy
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10
Q

How are fibroids >3cm managed?

A

Need referral to gynaecology for investigations and management!!!!!

Medical

  • Symptomatic management with NSAIDs and tranexamic acid
  • IUS Mirena coil – depending on size and shape of fibroids and uterus
  • Combined oral contraceptive
  • Cyclical oral progestogens

Surgical options:

  • Uterine artery embolisation
  • **Myomectomy - fancy word for fibroidectomy **
  • Hysterectomy
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11
Q

What medication can be given before myomectomy surgery for fibroids?

A

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap)

Induce menopause like state and lower oestrogen to stop maintenance of the fibroid and shrink it

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12
Q

When is surgical management used over medical management for fibroids?

A

If medical has not worked or significant pain and mass effect then myomectomy and hysterectomy considered

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13
Q

What is uterine artery embolisation?

A

Surgical option for large fibroids done by interventional radiologists

Catheter put through femoral artery and guided to uterine artery via x-ray. Particles are then injected to block arterial supply to fibroid

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14
Q

What are the following surgical techniques for fibroids:

  • Myomectomy
  • Endometrial ablation
  • Hysterectomy
A

Myomectomy: removing the fibroid via laparoscopic or laparotomy. Only treatment known to potentially improve fertility in patients with fibroids

Endometrial ablation: destroy endometrium usually done by Novosure. Cervix dilated and electrical mesh put on endometrium fro 60 seconds

Hysterectomy: removing uterus and fibroids, can leave ovaries or take them out depending on patient preference, risks and benefits. Can be done laparoscopically, laparotomy or vaginally

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15
Q

What are some of the complications of fibroids?

A

Pregnancy-related

  • Infertility (distortion of uterine cavity)
  • Malpresentation
  • Placental abruption
  • Intrauterine growth restriction
  • Preterm labour
  • Miscarriages
  • Red degeneration

Non-Pregnancy related

  • Prolapsed fibroid
  • Malignant change (leiomyosarcoma very rare)
  • Anaemia from HMB
  • Urinary flow obstruction
  • Constipation
  • Torsion of fibroid (especially pedunculated)
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16
Q

What is red degeneration of fibroids?

A

Occurs during pregnancy

As fibroid rapidly enlarges it outgrows its blood supply and becomes ischaemic. Can also be due to kinking in blood vessels as uterus changes shape during pregnancy

Presentation: severe abdominal pain, low grade fever, tachycardia, vomiting

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17
Q

How is red degeneration of fibroids managed?

A
  • Rest
  • Fluids
  • Analgesia
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18
Q

What are some causes of severe abdominal pain in women with fibroids?

A
  • Red degeneration
  • Torsion of pedunculated fibroids
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19
Q

What is the typical patient with red degeneration of fibroids?

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A
  • Severe abdominal pain
  • Low grade fever
  • Known fibroids
  • Second trimester of pregnancy
20
Q

What are the commonest symptoms of fibroids?

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A
  • Menoraghia
  • Dysmennorhea
  • Asymptomatic
21
Q

What are some fibroid treatments that preserve fertility?

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A
  • Myomectomy
  • Uterine artery embolisation
22
Q

What is endometriosis?

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A

Ectopic endometrial tissue outside of the uterus

  • Adenomyosis: deposits of endometrial tissue in the myometrium of the uterus
  • Endometrioma: Cystic structures developing on the ovaries in endometriosis. They are frequently referred to as chocolate cysts due to the appearance of the contained, old and altered blood.
23
Q

What are some theories for the aetiology of endometriosis?

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A
  • Retrograde menstruation
  • Lymphatic spread of endometrial cells
  • Cell metaplasia outside uterus
  • Embryonic cells meant for endometrial tissue remain outside uterus during fetal development
24
Q

what is retrograde menstruation

Study These Flashcards
A

menstrual blood flows backwards into the pelvic cavity instead of out of the body
most of the blood is expelled out through the vagina just some isn’t.
this usually causes an increased risk of endometriosis or developing pelvic pain

25
What are some risk factors for endometriosis?
26
How may endometriosis present?
* **Cyclical abdominal or pelvic pain** * Deep dyspareunia * Dysmenorrhoea * Infertility * Cyclical bleeding from other sites e.g haematuria, blood in stool * Urinary and bowel symptoms
27
What is the pathophysiology of the following symptoms in endometriosis? * Cyclical abdominal/pelvic pain * Non-cyclical abdominal pain * Reduced fertility
**_Cyclical abdominal/pelvic pain_** Ectopic endometrial tissue responds to hormones and sheds it lining same as endometrium causing irritation and inflammation of tissues surrounding endometriosis. Can also bleed in urine and stools Burning, dull, heavy pain **_Non-cyclical abdominal pain_** Bleeding and inflammation leads to adhesions causing chronic non-cyclical pain that can be sharp, stabbing, pulling and associated with nausea **_Reduced**_ _**fertility_** Adhesions blocking release of eggs or changing shape of fallopian tubes obstructing route of egg to uterus Endometriomas in ovary may also damage eggs
28
What might you find on examination of a patient with endometriosis?
* Visible endometrial tissue in vagina or on speculum exam (posterior fornix) * Fixed cervix on bimanual exam * Tenderness in vagina, cervix and adnexa
29
How is endometriosis investigated and diagnosed?
**_1st Line_:** Transvaginal Pelvic US but often unremarkable. Can also do MRI **_Gold Standard:_** Laparoscopic Surgery with biopsy of lesions. Can also remove lesions during this surgery
30
How is endometriosis staged?
**American Society of Reproductive Medicine** * **Stage 1:** Small superficial lesions * **Stage 2:** Mild, but deeper lesions than stage 1 * **Stage 3**: Deeper lesions, with lesions on the ovaries and mild adhesions * **Stage 4:** Deep and large lesions affecting the ovaries with extensive adhesions
31
What are the different management options for endometriosis?
**_Initial_** * Establish a diagnosis and provide clear explanation * Listen to patient ICE and screen for anxiety/depression * Analgesia (Paracetamol and NSAIDs) **_Hormonal (not option if wanting to conceive)_** * COCP * IUS * POP * Medroxyprogesterone Acetate IM (Depo) * Implant * GnRH agonist (induce menopause!!) **_Surgical_** * **Laparoscopic surgery to excite or ablate tissues and do adhesiolysis**. Only way to improve fertility and symptoms * **Hysterectomy**
32
What is done before surgery for endometriosis and why?
3 months of GnRH agonists (they increase GnRH and so reduce oestrogen and cause a state of menopause - an absence of periods) 1. it can reduce the chances of this happening again 2. it thins the endometrium so it is easier to remove the tissue
33
What treatments can improve fertility chances in women with endometriosis?
* Excision or ablation of ectopic tissue * Adhesiolysis * Ovarian cystectomy with excision of the cyst wall if Endometriomas
34
What is the last resort option for endometriosis treatment?
Hysterectomy and Bilateral Salpingooopherectomy Not guaranteed to resolve symptoms and induces menopause
35
How do GnRH agonists help endometriosis? e.g goserelin (Zoladex)
Endometriosis improves in menopause as lack of hormones. GnRH agonists induce menopause like state by shutting down ovaries temporarily so can help pain **SE:** hot flushes, night sweats, risk of osteoporosis
36
What is the prognosis with endometriosis?
Improves after menopause entirely!!! Unless on HRT with oestrogen in Can have recurrence after surgeries to treat e.g ablation
37
What is adenomyosis and who does it typically affect?
**Endometrial tissue in myometrium** Usually in **later reproductive years** and have had **several pregnancies** Hormone dependent like endometriosis and fibroids so improves after menopause
38
How may adenomyosis present?
* Heavy periods * Painful periods * Pain during intercourse * Asymptomatic * May have fertility issues
39
What may you find on examination of a woman with adenomyosis?
Enlarged tender uterus Will be more soft than a uterus with fibroids
40
How is adenomyosis diagnosed?
**1st line**: Transvaginal US **2nd Line:** MRI or trans abdominal US **Gold Standard**: Histological exam after hysterectomy
41
How is adenomyosis treated?
Usually treated same way as HMB according to NICE **_No Contraception wanted:_** * Mefenamic acid (for pain) * Tranexamic acid (for bleeding - antifibrinolytic) **_Contraception wanted_** * IUS/Mirena (1st Line) * COCP * Cyclical progestogen **_Specialist Treatment_** * GnRH agonists * Endometrial ablation * Uterine artery embolisation * Hysterectomy
42
What issues can adenomyosis cause during pregnancy?
43
What is Asherman syndrome and some causes of this?
Adhesions form within the uterus * **_Following Dilatation and Curettage Procedure_** (e.g retained products of conception) * **After Uterine Surgery** * **Pelvic Infections** e.g STI
44
How may Asherman syndrome present?
* **Secondary amenorrhea:** due to uterus sealed off * **Significantly lighter periods** * **Dysmenorrhoea** * **Infertility**
45
How is Asherman's syndrome diagnosed and managed?
**_Dx_** * **Hysteroscopy (GOLD STANDARD)** as can dissect and treat adhesions whilst doing it * **Hysterosalpingography:** contrast x-ray * **Sonohysterography:** fluid and pelvic US * **MRI** **_Mx_** * Dissection of adhesions whilst performing hysteroscopy. High recurrence rate
46
when should a woman on the coop induce a bleed
very three months
Y4 Obstetrics and Gynaecology SA
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