Obs + gynae

• Uterine fibroids are benign smooth muscle tumours of the uterus that are most commonly located in the myometrium Intramural (most common) located within the myometrium Subserosal beneath the serosa (outer lining of uterus)Submucosal in the endometrium causing more troublesome symptoms
• Fibroids are more prevalent in black women, though they can occur in other groups, becoming more common in later reproductive years
• The incidence of uterine fibroids increases with age and fibroids tend to shrink post-menopause
• Most fibroids are asymptomatic, often discovered incidentally during exams or imaging
• What is the likely diagnosis in a premenopausal woman with heavy menstrual bleeding, dysmenorrhea, and an irregularly enlarged uterus? Uterine fibroids
• Uterine fibroids can present with menorrhagia, pelvic pain & difficulty conceiving update 03/12/24 changed card to include difficulty conceiving
• On physical examination, uterine fibroids typically feel like a firm, irregular, & enlarged uterus that is painless
• What investigation is done for suspected uterine fibroids? Pelvic ultrasound Submucosal fibroids are offered outpatient hysteroscopy [© NICE [24 May 2021] . Heavy menstrual bleeding: assessment and management [NG88]. Available from https://www.nice.org.uk/guidance/ng88/chapter/Recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• What is the management of asymptomatic fibroids? No treatment necessary; advise reviewing Asymptomatic = do not treat Symptomatic = treat Menorrhagia mx (<3cm fibroids) = 1st-line: Levonorgestrel IUS if contraception is desired 2nd-line: NSAIDs + tranexamic acid if contraception denied Definitive mx = myomectomy → hysterectomy → uterine artery embolization Shrinking mx = GnRH agonists e.g. (goserelin acetate), typically pre-surgery. Ulipristal acetate = option for pre-menopausal, moderate to severe fibroids. Used with strict caution due to concerns about rare risk of severe livery...
• What is the treatment for menorrhagia in uterine fibroids if contraception is desired? Levonorgestrel IUS Asymptomatic = do not treat Symptomatic = treat Menorrhagia mx (<3cm fibroids) = 1st-line: Levonorgestrel IUS if contraception is desired 2nd-line: NSAIDs + tranexamic acid if contraception denied Definitive mx = myomectomy → hysterectomy → uterine artery embolization Shrinking mx = GnRH agonists e.g. (goserelin acetate), typically pre-surgery. Ulipristal acetate = option for pre-menopausal, moderate to severe fibroids. Used with strict caution due to concerns about rare risk ...
• What is the treatment for menorrhagia in uterine fibroids if contraception is undesired? NSAIDs + tranexamic acid Asymptomatic = do not treat Symptomatic = treat Menorrhagia mx (<3cm fibroids) = 1st-line: Levonorgestrel IUS if contraception is desired 2nd-line: NSAIDs + tranexamic acid if contraception denied Definitive mx = myomectomy → hysterectomy → uterine artery embolization Shrinking mx = GnRH agonists e.g. (goserelin acetate), typically pre-surgery. Ulipristal acetate = option for pre-menopausal, moderate to severe fibroids. Used with strict caution due to concerns about r...
• What is the definitive management in uterine fibroids? 1st line myomectomy → hysterectomy → uterine artery embolization Asymptomatic = do not treat Symptomatic = treat Menorrhagia mx (<3cm fibroids) = 1st-line: Levonorgestrel IUS if contraception is desired 2nd-line: NSAIDs + tranexamic acid if contraception denied Definitive mx = myomectomy → hysterectomy → uterine artery embolization Shrinking mx = GnRH agonists e.g. (goserelin acetate), typically pre-surgery. Ulipristal acetate = option for pre-menopausal, moderate to severe fibroids. Used with strict caution due to concerns ab...
• To reduce fibroid size (e.g. pre-surgery), medical management may involve GnRH agonists e.g. goserelin acetate Asymptomatic = do not treat Symptomatic = treat Menorrhagia mx (<3cm fibroids) = 1st-line: Levonorgestrel IUS if contraception is desired 2nd-line: NSAIDs + tranexamic acid if contraception denied Definitive mx = myomectomy → hysterectomy → uterine artery embolization Shrinking mx = GnRH agonists e.g. (goserelin acetate), typically pre-surgery. Ulipristal acetate = option for pre-menopausal, moderate to severe fibroids. Used with strict caution due to concerns about rare r...
• What is the prognosis of fibroids? Typically regress post-menopause [© NICE [24 May 2021] . Heavy menstrual bleeding: assessment and management [NG88]. Available from https://www.nice.org.uk/guidance/ng88/chapter/Recommendations All rights reserved. Subject to Notice of rightsNICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• Endometriosis is a chronic gynaecological condition characterised by the presence of endometrial-like tissue outside the uterus
• What is the most common presenting symptom in endometriosis? Chronic pelvic pain
• What are the common presenting symptoms of endometriosis? (5) chronic pelvic pain + Dysmenorrhoea, deep Dyspareunia, Dysuria & Dyschezia Pelvic pain can be cyclical or continuous
• Endometriosis often presents with dysmenorrhea and cyclic/continuous pelvic pain; it may also cause infertility When it is cyclical, it is often the week coming up to the period (the endometrial tissue gets bigger and then sheds)
• What investigation is done to diagnose endometriosis? Diagnostic laparoscopy [© NICE [06 September 2017] . Endometriosis: diagnosis and management [NG73]. Available from https://www.nice.org.uk/guidance/ng73/chapter/Recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• What is the management of endometrial-related pain? 1st line short trial of paracetamol and/or NSAIDs E.g. 3 months [© NICE [06 September 2017] . Endometriosis: diagnosis and management [NG73]. Available from https://www.nice.org.uk/guidance/ng73/chapter/Recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• Pregnant women at high risk of pre-eclampsia should take 75mg OD aspirin from 12 weeks gestation until birth High Risk: Hypertensive disease in past pregnancies CKD Autoimmune diseases e.g. APS, SLE T1DM or T2DM Chronic hypertension [© NICE [17 April 2023] Hypertension in pregnancy: diagnosis and management [NG133]. Available from https://www.nice.org.uk/guidance/ng133/chapter/Recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular revie...
• During pregnancy, blood pressure typically decreases during first & second trimesters of pregnancy
• Gestational hypertension = new-onset hypertension presenting after 20 weeks of gestation without significant proteinuria or other features of pre-eclampsia Pre-eclampsia = new-onset hypertension presenting after 20 weeks of gestation with significant proteinuria or other end-organ dysfunction
• Hypertension in pregnancy is > 140 mmHg systolic & > 90 mmHg diastolic
• HELLP syndrome is a severe variant of pre-eclampsia
• HELLP syndrome is characterised by Haemolysis, Elevated Liver Enzymes, and Low Platelets
• Chronic hypertension in pregnancy is pre-existing hypertension diagnosed before 20 weeks' gestation
• Menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity
• Menopause is diagnosed after 12 consecutive months without a menstrual period Nor using any hormonal contraception
• The average onset age for menopause is 51 years [https://thebms.org.uk/wp-content/uploads/2023/08/17-BMS-TfC-What-is-the-menopause-AUGUST2023-A.pdf]
• Perimenopause is the transitional phase preceding menopause, marked by hormonal fluctuations, irregular menstruation, ending 12 months after the final menstrual period
• Postmenopause is the stage of life that begins 12 months after a woman’s final menstrual period Cessation of ovarian hormone production & associated with long-term physiological changes
• Early menopause is the loss of ovarian follicular activity between the ages of 40 to 44 years [© NICE [07 November 2024] Menopause: identification and management [NG23]. Available from https://www.nice.org.uk/guidance/ng3/chapter/recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• Premature ovarian insufficiency (POI) is the loss of normal ovarian function before the age of 40 years old Needs 2 elevated FSH taken 4-6 weeks apart [© NICE [07 November 2024] Menopause: identification and management [NG23]. Available from https://www.nice.org.uk/guidance/ng3/chapter/recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/public...
• Use contraception until 12 months after the last period in women > 50 years
• Use contraception until 24 months after the last period in women < 50 years
• What is the likely diagnosis of a 53 year-old woman who presents with changes in menstrual cycle, then 14 months of amenorrhea with hot flushes and night sweats? Menopause
• How is menopause diagnosed? Clinically, FSH measurement is not recommended by NICE in healthy woman > 45 years [© NICE [07 November 2024] Menopause: identification and management [NG23]. Available from https://www.nice.org.uk/guidance/ng3/chapter/recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• How is premature ovarian insufficiency (POI) diagnosed? ↑ FSH levels on 2 blood samples; taken 4-6 weeks apart [© NICE [07 November 2024] Menopause: identification and management [NG23]. Available from https://www.nice.org.uk/guidance/ng3/chapter/recommendations All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• The median duration of menopausal symptoms last for 7.4 years(1) affecting ~85%(2) of women [Avis NE, Crawford SL, Greendale G, Bromberger JT, Everson-Rose SA, Gold EB, Hess R, Joffe H, Kravitz HM, Tepper PG, Thurston RC; Study of Women's Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015 Apr;175(4):531-9. doi: 10.1001/jamainternmed.2014.8063. PMID: 25686030; PMCID: PMC4433164.] [https://thebms.org.uk/wp-content/uploads/2023/08/17-BMS-TfC-What-is-the-menopause-AUGUST2023-A.pdf]