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Abnormal bleeding in gynaecology, Unsuccessful hormonal manipulation -…
Abnormal bleeding in gynaecology
Polyps
Risk factor
Obesity
HPT
Tamoxifen
Subfertility
STI
Premenopausal & postmenopausal
multigravida
Clinical features
Irregular menses
HMB, IMB, PCB, PMB
Bloating
Dyspareunia
Investigation
lab
FBC
Iron Study
Renal Profile
Imaging
TVS
Hysteroscopy (EP)
Endometrial biopsy (EP)
histological examination
Management
asymptomatic
usually dont need any intervention (good follow-up)
symptomatic
polypectomy
hysteroscopic removal (thick stalk polyps)
punch biopsy forcep (small polyps)
curretage (EP)
Types
Endometrial
Origins from the endometrium which create abnormal protrusions of friable tissue into the endometrial cavity
Cervical
Ectocervical
Endocervical
complication
Increases the risk of miscarriage
Infertility
inflammation or infection
Fibroids
signs & symptoms
Heavy menstrual bleeding
bulk-related symptoms
dysmenorrhea
firm mass --> intramural
pressure symptioms
urinary frequency
tenesmus
dyspareunia if at cervix
subfertility if obstruct fallopian tube or distortion of endometrial cavity
risk factors
obesity
positive family history
Genetic predisposition
Nulliparity
smoking
PCOS
early menarche
race/ethniciity
physical examination
bimanual pelvic examination
-Helpful to follow changes in uterus over time and surgical planning
-Enlarged, mobile uterus with irregular contour is consistent with leiomyomatous uterus
Size, contour and mobility should be noted
speculum examination
-Cervical fibroids present as cervix enlargement
-Prolapsed submucosal fibroid visible at external cervical os.
abdominal examination
-Palpate pelvic-abdominal mass and adnexal mass. Large fibroid can be palpated
-Palpate level of uterine fundus
investigations
FBC --> anemia
Transvaginal ultrasound
hypoechoic / isoechoic / hyperechoic mass/ capsulated mass
calcification: echoegenic foci with shadowing
cystic areas of necrosis or degeneration
saline infusion sonography
identify submucosal lesion & intramucosal lesion
management
patient desiring fertility
patient not desiring fertility
hysteroscopic resection of submucosal fibroids
progestin releasing intrauterine device
hormonal
Malignancy
Endometrial carcinoma
Staging
FIGO staging of carcinoma of uterus
Clinical features
Post-menopausal bleeding
Heavy menstrual bleeding or intermenstrual bleeding (pre- menopausal women)
Abdominal pain
Urinary dysfunction
Bowel distrubances
Investigation & Treatment
Transvaginal ultrasound
if > 4mm
Endometrial biopsy
Hysteroscopy
Surgery (mainstay)
Total abdominal hysterectomy and removal of both Fallopian tubes and ovaries
Postoperative radiotherapy and chemotherapy
High dose oral or intrauterine progestins
Risk factor
History of endometrial hyperplasia
Hyperostrogenic states
Obesity
Diabetes mellitus
Treatment with tamoxifen
Hereditary predisposition (Lynch syndrome)
Nulliparity
Late menopause
Family history of endometrial cancer
Types
Type 1
Endometrioid adenocarcinomas
Type 2
High grade serous and clear cell carcinoma
Adenomyosis
Physical examination
uterus to be generally symmetrically enlarged & somewhat boggy & tender
tender upon bimanual palpation
Investigations
Lab investigations
Full blood count for anaemia
pt & aptt --> to rule out coagulopathy
Thyroid function test to test for TSH
imaging
Pelvic Ultrasound
uterine enlargement
increased vascularity in myometrium
hypoechoic myometrium
MRI
distorted endometrium junction
Clinical features
Severe menorrhagia
dysmenorrhea
dyspareunia
Coagulopathy
Clinical features
Easy bruising
Excessive bleeding from other sites
Excessive post-operation bleeding or after dental extraction
History of post-partum hemorrhage
signs & symptoms of anaemia
Investigations
Full blood count (FBC) : low Hb & platelet
Deranged PT / INR / aPTT
VWF and factor VIII levels : low
Fibrinogen level: low
Risk factors
Personal history of bleeding disorder such as Von Willebrand disease
Medications such as anticoagulant, antiplatelets
Family history of bleeding disorders
Acquired coagulation disorders such CLD and vitamin K deficiency
Managements
Antifibrinolytic medication : tranexamic acid
NSAIDs : mefenamic acid
Combined hormonal therapy : COCP
Polycystic ovarian syndrome
Risk factor
Obesity
Family history of PCOS (first degree relatives)
Clinical features
Menstrual irregularities
Signs of androgen excess
Obesity
Acanthosis nigricans
Elevated serum LH levels
Raised level of inuslin
Diagnosis
Rotterdam criteria (at least 2/3 of criteria)
Clinical or biochemical signs of hyperandrogenism
Oligomenorrhea/ amenorrhea
Polycystic ovary
Treatment
Lifestyle modification
Combined oral contraceptive pill
Cyclical oral progesterone
Clomiphene
Treatment for hyperandrogenism
Investigation
Serum LH (raised)
Serum total and free testosterone (raised)
Transabdominal ultrasound (string of pearls appearance)
Endometrial
abnormal proliferation of the endometrial glands
in an increased gland-to-stroma ratio
compared to normal proliferative endometrium.
Types
Without atypia
normal but abundant gland cell in compare to stroma
With atypia
presence of hyperchromatic, enlarged epithelial cells with increase in nuclear to cytoplasmic ration
Risk factor
Unopposed estrogen
hign BMI
PCOS
u/l estrogen secreting tumour
Tamoxifen therapy
systemic estrogen replacement therapy
Clinical features
HMB
PMB
IMB
Diagnosis
Pipelle
Diagnostic hysteroscopy
TVS
IX
same with endometrial ca
management
Iatrogenic
Clinical features
Anaemic symptoms
Timing of the bleeding coincides with timing of starting new medication
Investigations
Full blood count (FBC) : low hb
Risk factors
Use of contraception injection
IUD
Use of POP
Managements
Stop the medications immediately
Blood transfusion if needed
Unsuccessful hormonal manipulation
