Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Learning about gynaecology and obstetrics (and most of medicine) is about understanding and organising thoughts, and not just about memorizing. To understand any condition, we need a framework on which to build. In order to do this logically, we have devised a series of headings to describe certain conditions.
Let us use endometriosis as an example
· Definition – This defines the condition. Endometriosis is when the endometrial tissue grows outside the uterine cavity.
· Incidence – Endometriosis most commonly presents in the third decade. It can be associated with subfertility. In comparison, if we were talking about endometrial cancer we would say that the incidence in the UK is 1 in 4,000 because all cases of cancer are recorded.
· Aetiology and pathogenesis – This explains the cause of the condition, and how the disease develops. In the case of endometriosis, theories include, retrograde menstruation and spread of endometrial cells, lymphatic dissemination of endometrial cells, spread through blood vessels, or local metaplasia. An immunological abnormality is necessary to allow the ectopic endometrium to proliferate. Pain may be caused by the endometriotic lesions “menstruating” into themselves, causing pressure or adhesions. Subfertility may be caused by adhesions or the release of prostaglandins interfering with gamete transport, fertilisation or implantation.
· Clinical Assessment
· History – The golden rule is always to take a thorough history first.
· Examination –
· Remember: Inspection/palpation/percussion/auscultation. It is important to examine the patient thoroughly.
· Inspection: There is little one would see on inspection – very rarely there can be endometriosis on the cervix or vagina.
· Palpation: In endometriosis, it is unlikely that anything can be felt on abdominal examination. On vaginal examination, one may feel nodules in the pouch of Douglas, a fixed retroverted uterus, or an ovarian cyst if there is an endometrioma.
Percussion and auscultation are not relevant.
· Investigations – whilst investigations can be helpful in reaching a diagnosis, they should be undertaken if the test result will influence patient management. Remember they are expensive and can be unpleasant, so only do those that are indicated. In endometriosis, an ultrasound may be helpful to detect possible endometriomata – with the characteristic “ground glass” appearance. Otherwise ultrasound is relatively unhelpful in managing endometriosis. A blood test measuring the Ca 125 hormone may be elevated. The ultimate gold standard investigation is laparoscopic inspection of the pelvis and biopsy of any suspicious lesions.
· Treatment
· Medical
· Hormonal – In endometriosis this could include combined hormonal contraception (CHC), progestogens, or hormones that switch off the pituitary FSH, and inhibit oestrogen production (GNRH analogues).
· Other medical – Analgesia may be used required.
· Surgical
· Minor – Laparoscopy. A diagnostic laparoscopy and biopsy is the only way to make a definitive diagnosis.
· Major – This would include major operative laparoscopic surgery or laparotomy, hysterectomy with or without oophorectomy. In endometriosis either laparoscopic or open surgery may involve bowel resection.
· Complications – Consider potential problems. Endometriosis may cause subfertility, fibroids may cause heavy menstrual bleeding.
· Prognosis – This describes the natural history of the disease, the chance of recurrence, and the possibility of deterioration.
The second check list is useful in organising one’s thoughts about any clinical situation. This is the “pathological shopping list”.
This gives a check list to ensure that all possible causes of a particular clinical situation are considered.
The “shopping list” consists of:
· Congenital
· Traumatic
· Inflammatory/Infective
· Vascular/Haematogenous
· Denegenerative
· Endocrine
· Neoplastic
· Benign
· Malignant
· Psychogenic
· Iatrogenic
· Toxic
In order to remember all the items on the shopping list the an acronym “C TIVDENPIT” could be used.
Let us now use this shopping list to identify all possible causes of heavy menstrual bleeding (HMB).
· Congenital – Any congenital abnormality that will increase the surface area of the uterine cavity will result in more endometrium being shed. This includes a bicornuate or septate uterus.
· Traumatic – The introduction of a foreign body, for example a copper intrauterine device (IUD)- could cause HMB.
· Inflammatory/Infective – Pelvic Inflammatory Disease would result in increased blood flow to the uterus, and may result in HMB.
· Vascular/Haematogenous – An abnormality of the coagulation system such as von Willebrand’s Disease could result in excessive menstrual bleeding. A vascular malformation is a rare potential cause of HMB.
· Denegenerative – The peri menopause reflects degeneration of the menstrual cycle and specifically loss of regular ovulation. Subsequent progesterone deficiency may result in heavy irregular bleeding.
· Endocrine – Dysfunction of the thyroid gland, particularly hypothyroidism can result in heavy bleeding.
· Neoplastic
o Benign – Fibroids (benign growth of fibromuscular tissue) are a common cause of heavy bleeding. Endometrial polyps may also cause troublesome bleeding.
o Malignant – Endometrial cancer should be excluded where risk factors exist.
· Psychogenic – The mind can have an effect on body systems, and it is possible that stress may cause HMB.
· Iatrogenic – This means due to medical intervention. HMB after the insertion of an IUD could be considered iatrogenic. Administration of hormones may also cause HMB.
· Toxic – There is no toxic cause of HMB.
By running through this pathological shopping list, a checklist is provided which provides a failsafe that no possible cause has been forgotten.