Important History
- History of presenting illness
o Last menstrual period
o Menses frequency, regularity, duration, volume of flow,
any blood clot, flooding
o Intermenstrual and post-coital bleeding
o Since when?
o Abdominal mass: rapidly increasing in size?, compressive
sx
- Associated symptoms
o Symptoms of anemia
o Pain (abdominal, pelvic, dyspareunia)
o Dysmenorrhea
o Vaginal discharge; colour, odour, amount
o Abdominal and bladder symptoms
o Symptoms of bleeding tendency
o Symptoms of endocrine disorder
o Affect toward daily activities
- Gynae hx
o Current contraception
o History of sexually transmitted infections (STIs)
o PAP smear history
- Obs hx
o The number of pregnancy and mode of delivery; previous
caesarean section
- PMH: Liver disease, Thyroid disease, Anemia
- Drug: Blood thinner, OCP
- FH: Malignancy, endocrine disorder, coagulopathy
- Social: Tobacco, alcohol, and drug uses; occupation; impact of
symptoms on quality of life, Concern?
Physical Examination
- General – cachexia, pallor, hirsutism, insulin resistance
signs
- Vital signs, BMI
- Signs of endocrine disorders
o Examination of the thyroid for enlargement or
tenderness
o Excessive or abnormal hair growth patterns,
clitoromegaly, acne that could indicate
hyperandrogenism
o Moon facies, abnormal fat distribution, striae that could
indicate Cushing's
- Signs of coagulopathies; bruising or petechiae
- Abdominal exam to palpate for any pelvic or abdominal
masses
o (Site, Size (gravid uterus), Tenderness, Margin,
Surface, Consistency, Mobility, Get below or not)Complete examination by:
- Speculum examination: Lesion at the external genitalia,
growth or lesion in the vagina, cervical growth or discharge,
prolapse fibroid / polyp.
- Bimanual : Differentiate between uterine or ovarian
mass,adnexal mass, POD tenderness
- Digital Rectal Examination: to look for any PR bleed
Script presentation (Althea’s) & Discussion
Uterine:
My patient is young/elderly conscious and alert. She is lying comfortably with one
pillow, she had small body frame and hydration status is fair. She is not tachypnic
with respiratory rate of 20 breath/min. She is pale with clinical Hb of about
8g/dl. There is/no evidence of cachexic or jaundice. There is/no evidence of
lymphanedopathy. On hand examination, the CRT is less than 2 secs, palmar pallor,
and the pulse rate is 90 beats/min regular rhythm, good volume.
On inspection, there is well healed transverse suprapubic scar/midline
infraumbilical scar measuring 15cm, with no evidence of incisional hernia. The
lower part of the abdomen is slightly distended. There is no dilated vein or visible
peristalsis noted.
On palpation, the abdomen is soft and non tender. There is mass palpable at
suprapubic area measuring 7x5cm located centrally and extending to the right.
The mass can get above but cannot get below and it mobile right to left but
cannot move up and down. The mass is about 16 week gravid uterus. There is no
inguinal node felt. The liver and spleen are not palpable and kidneys are not
ballotable.
On percussion, the shifting dullness is negative suggestive of no ascites. On
auscultation, the bowel sound is heard and it is normal. There is no bruit heard.
I would like to complete my examination by performing speculum examination and
bimanual examination to assess the vulva, vagina, cervix, uterus adnexa and the
mass- to determine the origin of the mass either from uterus or ovary
Ovarian:
On general examination, patient is comfortable not in pain, cachexic, pale and
jaundiced. There is cervical lymphadenopathy (left Virchow node)
The abdomen is mildly distended, the umbilicus is centrally located and inverted.
There was no dilated vein or visible peristalsis.
There is mass palpable at suprapubic area measuring 7x5cm located centrally and
extending to the right. The mass can get above and also can get below and it
mobile up and down but cannot move right and left. The mass is about 16 week
gravid uterus
The shifting dullness is positive suggestive of ascites
I would like to complete my examination with speculum examination and bimanual
examination in order to assess the origin of the mass
Investigation
Blood
- Urine pregnancy test
- Full blood count (Hb, WCC, platelet)
- Thyroid function test
- Coagulation profile
- FBC: anemia (lethargy)
- LFT: liver metastasis (For Mass)
- RP: compressive effect to ureters (obstruction / renal
failure)Imaging
- Transvaginal or/and transabdominal ultrasound:
(endometrial thickness, uterus size and shape, fibroids,
adenomyosis, ovarian anomalies)
o ET: premenopausal
▪ Menstrual phase 2-4mm
• Early proliferative phase 5-7mm
• Late proliferative phase 11mm
• Secretory phase 7-16mm
# so need to ask last menses before doing US to check
for ET (identify the phase)
Uterine Features Ovarian Features
● uterine size, shape
● Endometrial thickness (ET)
○ <4mm cancer less likely
ca
○ >4mm (rule out Ca-
require further
evaluation)
● uterine margin
(irregularity)
● any mass in uterus:
○ Size
○ multiple/single
○ solid/cystic
○ Hyperechoic/hypoechoic
● Presence of metastases
● Size >10cm
● Solid vs cystic nature
● Uniloculated vs Multiloculated
● Papillary projections (>3mm)
● Poorly defined margins
● Bilaterality
● Presence of free fluid
(Ascites)
● Extraovarian disease -
peritoneal thickening, omental
deposits
● Doppler - vascularized vs
avascular
- CT TAP: if suspect malignancy & to rule out metastasis
- Pipelle Hysteroscopy
o Endometrial biopsy
o Indication:
▪ PMB
▪ HMB >45 years old
▪ HMB with IMB
▪ Risk factor of endometrial pathology
Management
General: AUB
Medical Minimally Invasive Major Surgery
- Antifibrinolytics
- Progestins
- Estrogen +
progestins (OCP)
- GnRH agonists
- Anti-progestational
agents
- Intrauterine
device (IUD)
- Endometrial
ablation
- D&C
- Myomectomy
- Hysterectomy
1. I would like to manage this patient as inpatient/outpatient
2. Acute/immediate management
- ABC are secured & stable
- Insert 2 large bore branula to anticipate further bleeding
- Take blood for investigation
- Start fluid resuscitation if there is hypotensive due to blood loss
- Pain relief: analgesia
3. Observation
- BP/ pulse rate (tachycardia are signs of hypovolemic shock
secondary to blood loss
- Pad chart monitoring
- Input output chartFibroid
Non-hormonal - Tranexamic acid
- Mefenamic acid
- NSAIDs
Hormonal - OCP
- LNG IUS
- GnRH analogue
- Danazol
- SPRM
Surgical - Myomectomy
- Hysterectomy
Radiological - Uterine artery embolization
- High intensity focussed ultrasound
- Asymptomatic: reassurance & 6 monthly f/up
- HMB, anaemic, want to conceive: tranexamic acid + Fe
supplement
- Compressive sx want to conceive: GnRH agonist w/
myomectomy
- Subfertility want to conceive: fertility workup, if normal
offer myomectomy
Adenomyosis
- Medical
o Non hormonal: NSAIDs reduce severity of
dysmenorrhea & pelvic pain
o Hormonal
- Surgical
Hysterectomy The definitive treatment for adenomyosis
Only way to remove diffuse adenomyosis & preferred
way to remove focal adenomyoma except where future
pregnancy is desired
Uterine-
sparing
resection
Can be considered in women with extensive
adenomyosis who are actively pursuing pregnancy
Associated with improvement of pain and menorrhagia
and reduction in uterine volume
Can use hormonal agents, such as GnRH agonists and
the LNG IUD, to help prevent recurrence and control
symptoms
Risk: Uterine rupture in the following pregnancy
Endometrial Hyperplasia
W/o
atypia
Conservative
- Observation alone w/ f/up endometrial biopsy
- Informed the risk progressing to endometrial cancer is <5% over 20
years & majority of cases will regress spontaneously during f/up
- Lifestyle modification: Obesity (Weight reduction)
- Reassess HRT: change to less estrogen
Pharmaco
- Progestogens for minimum 6/12
o Oral: medroxyprogesterone 10-20mg/day or norethisterone
10-15mg/day
- LNG-IUS is 1st line as has higher ds regression & more favourable
bleeding profile, less side effects
Surgical: Hysterectomy
- Not 1st line as progestogen therapy induce histological and
symptomatic remission
- Indicated in those not wanting to preserve fertility when:
o Progression to atypical hyperplasia
o No histological regression despite 12 months treatment
o Relapse after completing progestogen treatmento Persistence bleeding sx
o Decline endometrial surveillance & compliance to medication
W/
atypia
Surgical
• TAHBSO: 1st line treatment
• Progression to cancer
Endo Ca
Stage I TAHBSO*
Stage II Wertheim/Radical hysterectomy (spread to
cervival)
Stage III Surgical debulking or radiotherapy first followed
by surgery
Stage IV Chemoradiotherapy
Discussion on Uterine Mass & HMB
1) how do you ix if it is leiyomyosarcoma?
- Rapidly increasing in size (clinical)
- MRI
2) How to do bimanual examination? – use to confirm the
origin of mass
- My left hand is place on the abdomen to hold the mass. My
right index and middle finger will be placed inside the vagina,
touching the cervix. I will push the mass towards the
xiphisternum. If the cervix move away from my right fingers,
most likely the mass is uterine in origin and my ddx is ovarian
mass which has adhere to uterus.
- If the cervix remain static, most likely the mass is from
ovary and my ddx is a pedunculated uterine fibroid
3) How to differentiate ovarian & uterine mass?
Uterine mass Ovarian mass
• Center
• Arising from suprapubic
• Unable to get below the mass
• Center or side
• Able to get below the
mass
4) Common side effect of danazol?
- androgenic effect
5) Mechanism of Uterine artery embolization?
- Embolization of both uterine arteries under radiological
guidance
- injection of polyvinyl alcohol particles into uterine artery n
branches that supply fibroid & reducing the blood supply
- can reduce intra-op bleeding
- periop cx: infection, bleeding, hematoma at femoral artery,
allergy
- Uncertain subsequent reproductive fx
- Post-embolization: fever, pain, n&v
6) How to do bimanual examination?7) Fibroid Vs Adenomyosis
Discussion on Endometrial cancer
1) Premalignant lesion = endometrial hyperplasia (simple,
complex and atypia)
2) Management of simple and complex endo hyperplasia
- Progesterone therapy 3 month → repeat hysteroscopy and
biopsy → if regress, continued therapy for 3-6 month and
surveillance TVS → if persistent, high dose depo-povera for
3 months or hysterectomy
3) Management of atypia endo hyperplasia
- Hysterectomy because higher risk to dev endo CA. If pt
refused or unfit, give high dose progesterone, endo sampling
6 monthly and long term surveillance
4) How to manage endometrial cancer?
- Explore risk factor
- TVS finding > 4mm (abnormal in postmenopausal woman) → do
pipelle (endometrial biopsy) → confirmed CA, do staging for
management and prognosis (MRI pelvis for T and N, CT TAP
for M)
5) How many type of endometrial CA?
- Type I = endometrioid adenocarcinoma, due to estrogen
(endometrioid and mucinous tumor)
- Type II = serous papillary cancer, not related to estrogen
associated with atrophic endometrium (serous and clear cell
tumor)
6) What type of ovarian tumor that can cause PMB and
development of endometrial CA?
- Estrogen secreting tumor which is granulosa-thecal tumor (a
sex cord stromal tumor)
Discussion on Ovarian Mass
1) What is your diagnosis?
- young pt = ovarian cyst, endometrioma, teratoma,
hydrosalpinx, pyosalpinx, tubo-ovarian abscess
- elderly pt = ovarian cancer
2) What is tumor marker you want to do?
- CA-125 = epithelial ovarian CA (serous)
- CA 19-9 = epithelial ovarian CA (mucinous)
- Inhibin = granulosa cell tumors
- hCG = choriocarcinoma, dysgerminoma
- AFP = yolk sac tumor, teratoma
3) Difference b/w ascites and ovarian mass?
Ascites Ovarian cyst
• Resonant
anteriorly &
dullness in flanks
• Fluid thrill positive
• Shifting dullness
positive
• Dullness anteriorly &
resonant in flanks
• Fluid thrill positive
• Shifting dullnes
negative4) Benign Vs malignant Ovarian mass?
- History of presenting illness
o Last menstrual period
o Menses frequency, regularity, duration, volume of flow,
any blood clot, flooding
o Intermenstrual and post-coital bleeding
o Since when?
o Abdominal mass: rapidly increasing in size?, compressive
sx
- Associated symptoms
o Symptoms of anemia
o Pain (abdominal, pelvic, dyspareunia)
o Dysmenorrhea
o Vaginal discharge; colour, odour, amount
o Abdominal and bladder symptoms
o Symptoms of bleeding tendency
o Symptoms of endocrine disorder
o Affect toward daily activities
- Gynae hx
o Current contraception
o History of sexually transmitted infections (STIs)
o PAP smear history
- Obs hx
o The number of pregnancy and mode of delivery; previous
caesarean section
- PMH: Liver disease, Thyroid disease, Anemia
- Drug: Blood thinner, OCP
- FH: Malignancy, endocrine disorder, coagulopathy
- Social: Tobacco, alcohol, and drug uses; occupation; impact of
symptoms on quality of life, Concern?
Physical Examination
- General – cachexia, pallor, hirsutism, insulin resistance
signs
- Vital signs, BMI
- Signs of endocrine disorders
o Examination of the thyroid for enlargement or
tenderness
o Excessive or abnormal hair growth patterns,
clitoromegaly, acne that could indicate
hyperandrogenism
o Moon facies, abnormal fat distribution, striae that could
indicate Cushing's
- Signs of coagulopathies; bruising or petechiae
- Abdominal exam to palpate for any pelvic or abdominal
masses
o (Site, Size (gravid uterus), Tenderness, Margin,
Surface, Consistency, Mobility, Get below or not)Complete examination by:
- Speculum examination: Lesion at the external genitalia,
growth or lesion in the vagina, cervical growth or discharge,
prolapse fibroid / polyp.
- Bimanual : Differentiate between uterine or ovarian
mass,adnexal mass, POD tenderness
- Digital Rectal Examination: to look for any PR bleed
Script presentation (Althea’s) & Discussion
Uterine:
My patient is young/elderly conscious and alert. She is lying comfortably with one
pillow, she had small body frame and hydration status is fair. She is not tachypnic
with respiratory rate of 20 breath/min. She is pale with clinical Hb of about
8g/dl. There is/no evidence of cachexic or jaundice. There is/no evidence of
lymphanedopathy. On hand examination, the CRT is less than 2 secs, palmar pallor,
and the pulse rate is 90 beats/min regular rhythm, good volume.
On inspection, there is well healed transverse suprapubic scar/midline
infraumbilical scar measuring 15cm, with no evidence of incisional hernia. The
lower part of the abdomen is slightly distended. There is no dilated vein or visible
peristalsis noted.
On palpation, the abdomen is soft and non tender. There is mass palpable at
suprapubic area measuring 7x5cm located centrally and extending to the right.
The mass can get above but cannot get below and it mobile right to left but
cannot move up and down. The mass is about 16 week gravid uterus. There is no
inguinal node felt. The liver and spleen are not palpable and kidneys are not
ballotable.
On percussion, the shifting dullness is negative suggestive of no ascites. On
auscultation, the bowel sound is heard and it is normal. There is no bruit heard.
I would like to complete my examination by performing speculum examination and
bimanual examination to assess the vulva, vagina, cervix, uterus adnexa and the
mass- to determine the origin of the mass either from uterus or ovary
Ovarian:
On general examination, patient is comfortable not in pain, cachexic, pale and
jaundiced. There is cervical lymphadenopathy (left Virchow node)
The abdomen is mildly distended, the umbilicus is centrally located and inverted.
There was no dilated vein or visible peristalsis.
There is mass palpable at suprapubic area measuring 7x5cm located centrally and
extending to the right. The mass can get above and also can get below and it
mobile up and down but cannot move right and left. The mass is about 16 week
gravid uterus
The shifting dullness is positive suggestive of ascites
I would like to complete my examination with speculum examination and bimanual
examination in order to assess the origin of the mass
Investigation
Blood
- Urine pregnancy test
- Full blood count (Hb, WCC, platelet)
- Thyroid function test
- Coagulation profile
- FBC: anemia (lethargy)
- LFT: liver metastasis (For Mass)
- RP: compressive effect to ureters (obstruction / renal
failure)Imaging
- Transvaginal or/and transabdominal ultrasound:
(endometrial thickness, uterus size and shape, fibroids,
adenomyosis, ovarian anomalies)
o ET: premenopausal
▪ Menstrual phase 2-4mm
• Early proliferative phase 5-7mm
• Late proliferative phase 11mm
• Secretory phase 7-16mm
# so need to ask last menses before doing US to check
for ET (identify the phase)
Uterine Features Ovarian Features
● uterine size, shape
● Endometrial thickness (ET)
○ <4mm cancer less likely
ca
○ >4mm (rule out Ca-
require further
evaluation)
● uterine margin
(irregularity)
● any mass in uterus:
○ Size
○ multiple/single
○ solid/cystic
○ Hyperechoic/hypoechoic
● Presence of metastases
● Size >10cm
● Solid vs cystic nature
● Uniloculated vs Multiloculated
● Papillary projections (>3mm)
● Poorly defined margins
● Bilaterality
● Presence of free fluid
(Ascites)
● Extraovarian disease -
peritoneal thickening, omental
deposits
● Doppler - vascularized vs
avascular
- CT TAP: if suspect malignancy & to rule out metastasis
- Pipelle Hysteroscopy
o Endometrial biopsy
o Indication:
▪ PMB
▪ HMB >45 years old
▪ HMB with IMB
▪ Risk factor of endometrial pathology
Management
General: AUB
Medical Minimally Invasive Major Surgery
- Antifibrinolytics
- Progestins
- Estrogen +
progestins (OCP)
- GnRH agonists
- Anti-progestational
agents
- Intrauterine
device (IUD)
- Endometrial
ablation
- D&C
- Myomectomy
- Hysterectomy
1. I would like to manage this patient as inpatient/outpatient
2. Acute/immediate management
- ABC are secured & stable
- Insert 2 large bore branula to anticipate further bleeding
- Take blood for investigation
- Start fluid resuscitation if there is hypotensive due to blood loss
- Pain relief: analgesia
3. Observation
- BP/ pulse rate (tachycardia are signs of hypovolemic shock
secondary to blood loss
- Pad chart monitoring
- Input output chartFibroid
Non-hormonal - Tranexamic acid
- Mefenamic acid
- NSAIDs
Hormonal - OCP
- LNG IUS
- GnRH analogue
- Danazol
- SPRM
Surgical - Myomectomy
- Hysterectomy
Radiological - Uterine artery embolization
- High intensity focussed ultrasound
- Asymptomatic: reassurance & 6 monthly f/up
- HMB, anaemic, want to conceive: tranexamic acid + Fe
supplement
- Compressive sx want to conceive: GnRH agonist w/
myomectomy
- Subfertility want to conceive: fertility workup, if normal
offer myomectomy
Adenomyosis
- Medical
o Non hormonal: NSAIDs reduce severity of
dysmenorrhea & pelvic pain
o Hormonal
- Surgical
Hysterectomy The definitive treatment for adenomyosis
Only way to remove diffuse adenomyosis & preferred
way to remove focal adenomyoma except where future
pregnancy is desired
Uterine-
sparing
resection
Can be considered in women with extensive
adenomyosis who are actively pursuing pregnancy
Associated with improvement of pain and menorrhagia
and reduction in uterine volume
Can use hormonal agents, such as GnRH agonists and
the LNG IUD, to help prevent recurrence and control
symptoms
Risk: Uterine rupture in the following pregnancy
Endometrial Hyperplasia
W/o
atypia
Conservative
- Observation alone w/ f/up endometrial biopsy
- Informed the risk progressing to endometrial cancer is <5% over 20
years & majority of cases will regress spontaneously during f/up
- Lifestyle modification: Obesity (Weight reduction)
- Reassess HRT: change to less estrogen
Pharmaco
- Progestogens for minimum 6/12
o Oral: medroxyprogesterone 10-20mg/day or norethisterone
10-15mg/day
- LNG-IUS is 1st line as has higher ds regression & more favourable
bleeding profile, less side effects
Surgical: Hysterectomy
- Not 1st line as progestogen therapy induce histological and
symptomatic remission
- Indicated in those not wanting to preserve fertility when:
o Progression to atypical hyperplasia
o No histological regression despite 12 months treatment
o Relapse after completing progestogen treatmento Persistence bleeding sx
o Decline endometrial surveillance & compliance to medication
W/
atypia
Surgical
• TAHBSO: 1st line treatment
• Progression to cancer
Endo Ca
Stage I TAHBSO*
Stage II Wertheim/Radical hysterectomy (spread to
cervival)
Stage III Surgical debulking or radiotherapy first followed
by surgery
Stage IV Chemoradiotherapy
Discussion on Uterine Mass & HMB
1) how do you ix if it is leiyomyosarcoma?
- Rapidly increasing in size (clinical)
- MRI
2) How to do bimanual examination? – use to confirm the
origin of mass
- My left hand is place on the abdomen to hold the mass. My
right index and middle finger will be placed inside the vagina,
touching the cervix. I will push the mass towards the
xiphisternum. If the cervix move away from my right fingers,
most likely the mass is uterine in origin and my ddx is ovarian
mass which has adhere to uterus.
- If the cervix remain static, most likely the mass is from
ovary and my ddx is a pedunculated uterine fibroid
3) How to differentiate ovarian & uterine mass?
Uterine mass Ovarian mass
• Center
• Arising from suprapubic
• Unable to get below the mass
• Center or side
• Able to get below the
mass
4) Common side effect of danazol?
- androgenic effect
5) Mechanism of Uterine artery embolization?
- Embolization of both uterine arteries under radiological
guidance
- injection of polyvinyl alcohol particles into uterine artery n
branches that supply fibroid & reducing the blood supply
- can reduce intra-op bleeding
- periop cx: infection, bleeding, hematoma at femoral artery,
allergy
- Uncertain subsequent reproductive fx
- Post-embolization: fever, pain, n&v
6) How to do bimanual examination?7) Fibroid Vs Adenomyosis
Discussion on Endometrial cancer
1) Premalignant lesion = endometrial hyperplasia (simple,
complex and atypia)
2) Management of simple and complex endo hyperplasia
- Progesterone therapy 3 month → repeat hysteroscopy and
biopsy → if regress, continued therapy for 3-6 month and
surveillance TVS → if persistent, high dose depo-povera for
3 months or hysterectomy
3) Management of atypia endo hyperplasia
- Hysterectomy because higher risk to dev endo CA. If pt
refused or unfit, give high dose progesterone, endo sampling
6 monthly and long term surveillance
4) How to manage endometrial cancer?
- Explore risk factor
- TVS finding > 4mm (abnormal in postmenopausal woman) → do
pipelle (endometrial biopsy) → confirmed CA, do staging for
management and prognosis (MRI pelvis for T and N, CT TAP
for M)
5) How many type of endometrial CA?
- Type I = endometrioid adenocarcinoma, due to estrogen
(endometrioid and mucinous tumor)
- Type II = serous papillary cancer, not related to estrogen
associated with atrophic endometrium (serous and clear cell
tumor)
6) What type of ovarian tumor that can cause PMB and
development of endometrial CA?
- Estrogen secreting tumor which is granulosa-thecal tumor (a
sex cord stromal tumor)
Discussion on Ovarian Mass
1) What is your diagnosis?
- young pt = ovarian cyst, endometrioma, teratoma,
hydrosalpinx, pyosalpinx, tubo-ovarian abscess
- elderly pt = ovarian cancer
2) What is tumor marker you want to do?
- CA-125 = epithelial ovarian CA (serous)
- CA 19-9 = epithelial ovarian CA (mucinous)
- Inhibin = granulosa cell tumors
- hCG = choriocarcinoma, dysgerminoma
- AFP = yolk sac tumor, teratoma
3) Difference b/w ascites and ovarian mass?
Ascites Ovarian cyst
• Resonant
anteriorly &
dullness in flanks
• Fluid thrill positive
• Shifting dullness
positive
• Dullness anteriorly &
resonant in flanks
• Fluid thrill positive
• Shifting dullnes
negative4) Benign Vs malignant Ovarian mass?
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