i and/or non-gynaecologic referrals

2.Chronic pain management and

multidisciplinary support

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Figure 8. Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines for treatment of

endometriosis

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GY13 Gynaecology Toronto Notes 2023

Treatment

• surgical confirmation of disease is NOT required prior to starting medical management.

Asymptomatic endometriosis does not require treatment.Management depends on certainty of the

diagnosis,severity ofsymptoms,extent of disease, desire for future fertility, and impact to Gl/GU

systems(e.g.intestinal obstruction)

• medical

NSAlDs (e.g. naproxen sodium -Anaprox*).Avoid selective COX-2 inhibitors(celecoxib,

rofecoxib, valdecoxib) in those who are attempting conception assome studies indicate these

drugs can prevent or delay ovulation

• 1st line

cyclic/continuous estrogen-progestin (OCP)

progestin (1M medroxyprogesterone (Depo-Provera*) or oral dienogest (Visanne’))

. Mirena'lUS

• 2nd line

GnRH agonist (e.g.leuprolide (Lupron*)):suppresses pituitary glands

- side effects:hot flashes, vaginal dryness,reduced libido

- use >6 mo:include add-back progestin or estrogen to prevent decreased BMD,

reduce vasomotor side effects

danazol (Danocrine*): weak androgen

- side effects: weight gain, fluid retention, acne, hirsutism, voice change (not

commonly used due to side effects)

• surgical

conservative laparoscopy using laser, electrocautery ± laparotomy

ablation/resection of implants,lysis of adhesions,ovarian cystectomy of endometriomas

definitive:hysterectomy ± bilateral salpingo-oophorectomy

best time to become pregnant is immediately after conservative surgery

if patient is not planning to become pregnant postoperatively,suppress ovulation medically to

prevent recurrence (not proven)

• above treatments are for the pain, not for the infertility associated with endometriosis, which usually

involvessurgery + assisted reproductive technologies.Also, management for endometriomas is

surgical for symptomatic and expanding masses, but this can decrease ovarian reserve,so if it is

asymptomatic and small (<5 cm), then no surgery is necessary

Adenomyosis E®

•synonym: “endometriosis interna” (uterine wall may be diffusely involved)

Epidemiology

•15% of females >35 y/o;found in 20-40% of hysterectomy specimens

•mean age at presentation: 40-50 y/o (older age group than seen in endometriosis)

•adenomyosis is a common histologic finding in asymptomatic patients

Clinical Features

•often asymptomatic

•heavy menstrual bleeding,secondary dysmenorrhea, pelvic discomfort

•dyspareunia, dyschezia

•uterus symmetrically bulky, usually <14 cm

•Halban’

ssign:tender, softened uterus on premenstrual bimanual exam

Investigations

•clinical diagnosis

•U/S or MR1 can be helpful

•endometrial sampling to rule out other pathology

Treatment

•medical

• iron supplements for anemia

• analgesics, NSAlDs

. Mirena'1US

• CHC,medroxyprogesterone (Depo-Provera*) -limited evidence for efficacy

• GnRH agonists (e.g. leuprolide (Lupron * ))

danazol 100-200 mg PO once daily (trial x 4 mo)

•surgical

definitive: hysterectomy -treatment of choice in women who have completed childbearing

Adenomyosis

Extension of areas of endometrial glands

and stroma into the myometrium

Final diagnosis of adenomyosisis based

on pathologic findings, but predictably

identified on MRI

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Fibroids

Leiomyomata/Fibroids

Benign smooth muscle tumour ol the

uterus (most common gynaecological

tumour)

Epidemiology

• diagnosed in approximately 40-50% of premenopausal women >35 yr

• more common in Black women, where they are also larger and occur at earlier age

• common indication for majorsurgery in females

• minimal malignant potential (1 in 1000)

• typically regress after menopause

Pathogenesis

• estrogen stimulates monoclonalsmooth muscle proliferation

• progesterone stimulates production of proteins that inhibit apoptosis

• degenerative changes (occur when tumour outgrows blood supply)

fibroids can painfully degenerate, become calcified,develop sarcomatous component,or obtain

parasitic blood supply

Classification

• intramural: most common, grow within the muscular wall of the uterus

• submucosal:grow within myometrium, can grow into endometrial cavity

• subscrosal: grow from the serosa

• fibroids can also grow in the cervix and vagina

Submucosal leiomyomata are most

symptomatic (bleeding,infertility)

Large fibroids can cause distressing bulk

symptoms

The effect of pregnancy on fibroid siie

is variable

'Pedunculated iubserosal Clinical Features

• majority asymptomatic (60%), often discovered as incidental finding on pelvic exam or U/S (occur in

50% of ALL women)

• abnormal uterine bleeding (30%):dysmenorrhea, heavy menstrual bleeding

• pressure/bulk symptoms(20-50%)

pelvic pressure/heaviness

• increased abdominal girth

urinary'frequency and urgency

constipation, bloating (rare)

acute urinary retention (extremely rare, butsurgical emergency!)

• acute pelvic pain

fibroid degeneration

fibroid torsion (if pedunculated subserosal)

• infertility,recurrent pregnancy loss

• pregnancy complications (potential enlargement and Increased pain, obstructed labour,

malprcsentation, difficult cesarean delivery)

Investigations

• bimanual exam: uterus asymmetrically enlarged, usually mobile

• CBC:anemia (only found if associated with AUB/heavy menstrual bleeding)

• pelvic and/or transvaginal U/S: to confirm diagnosis and assesslocation of fibroids

• sonohvsterogram: useful for differentiating endometrial polyps from submucosal fibroids,for

assessing intracavitary growth or for assessing potential risks with fertility associated with the fibroid

(submucosal only)

• endometrial biopsy to rule out uterine cancer for abnormal uterine bleeding (especially if age >40 yr)

• occasionally MRI is used for preoperative planning (e.g.before myomectomy)

Treatment

• only ifsymptomatic (heavy menstrual bleeding, bulk symptoms), rapidly enlarging or intracavitary

• treat anemia if present

• conservative approach (watch and wait) if:

• symptoms absent or minimal

fibroids <6-8cm or stable In size

not submucosal (submucosal fibroids are more likely to be symptomatic)

currently pregnant due to increased risk of bleeding (follow-up U/S if symptoms progress)

• medical approach to treat AUB-L

antiprostaglandins (ibuprofen, other NSAIDs)

tranexamic acid (Cyklokapron*)

• CHC,1US,or Depo-Provera*

GnKH agonist:leuprolide (Lupron*)

often used for 3 mo preoperatively to increase Hb and reduce fibroid size

reduces bleeding,shrinks fibroids, and corrects anemia

can be used long-term to bridge to menopause in combination with add-back progestin or

estrogen

• interventional radiology approach: UAE occludes both uterine arteries,shrinks fibroids by 50% at 6

mo; improves heavy bleeding in 90% of patients within 1-2 mo; not an option in women considering

childbearing

higher risk ofsurgical re-intervention than with surgical approaches

bubskir usdl

Intramura

'

Cervical

Pedunculated

submucosal

g) Camilla Matuk ^

Figure 9. Possible anatomic

locations of uterine leiomyomata

Uterine Artery Embolization let Symptomatic

Uterine Fibroids

C ochrane OBSyst See 2014:12

^

0005073

Purpose:locompare outcomes of UAE to otter

medical orsurgical therapiesfor symptomatic uterine

fibroids.Primary outcomes were pabeotsatisfactirm

and live birth rate

Results:Seven RCTs with 793women were included.

There was noevidence ola difference in the primary

outcomes or risk of major com plications between the

interventions.UAE was associated with a higher risk

of minor complications and the need for adddional

surgical intervention within 2 yr

Conclusions: No significant differences m patent

satisfaction or major complications m UAE complied

losu rgrcal intervention.UAC is associated wrtk an

increased riskof surgical ri

-mterrenboa

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GY15 Gynaecology Toronto Notes 2023

• surgical approach

myomectomy (hysteroscopic, transabdominal, or laparoscopic)

hysteroscopic resection of fibroid and endometrial ablation for AUB-Lsm

• hysterectomy (see Hysterectomy, G

'

1

'

6)

• note: avoid operating on fibroids during pregnancy (due to vascularity and potential pregnancy

loss); expectant management is usually best

Contraception

• see Family Medicine, TM23

Table 7. Classification of Contraceptive Methods

Type Effectiveness (Perfect Use, Typical Use')

Physiological

Withdrawalicoitus interruptus

Rhythm

Method calendar/mucuslsymptothermal

Lactational amenorrhea

Counselling the Adolescent about

Contraception

More than 90% of adolescent

pregnancies are unintended,and "

50%

of all pregnancies occur within the

first 6 mo of initiating sexual activity:

in addition.85% of sexually active

women become pregnant within1yr

if no contraception is used and even

some of the least effective contraceptive

methods markedly decrease the risk of

pregnancy

96%.77%

76%

93% (first 6mo postpartum)

15%

Abstinence of all sexual activity 100%

Barrier Methods

Condom alone

Spermicide alone

Sponge

Parous

Multiparous

Diaphragm with spermicide

Female condom

Cenhcal cap

Parous

Nulliparous

98%.82%

82%.72%

80%.76%

91%.88%

94%.88%

95%.79%

If-..68%

91%.84%

Hormonal

Combined (Estrogen and Progesterone)

0CP 99.7%.92%

99.7%.92%

99.7%.92%

MuvaRing:

Iransdermal(Ortho Evra*

)

Progesterone-Only

Progestin-only injection (Depo-Provera-)

MiTena:

IUS

99.7%.97%

99.9%

Etonogestrel implant (NEXPLAN0NT ) 99%

Copper IUD 99.3%

Surgical

Tubal ligation

Vasectomy

99.65%

99.9%

Emergency Postcoital Contraception (EPC)

Ywpe:method

"Plan 8'

levonorgestrel only

Postcoital IUD

98%(within 24 h). decreases by 30% at 72 h

98% (within 24h).decreases by 70% at 72 h

99.9% (within 7 d)

Ella 99.9%(within7 d)

’EPediveress:percentage ot womenreporting no pregrancy after 1yr of use

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Hormonal Methods

Combined Oral Contraceptive Pills

• daily pill with a 4-7 d placebo or pill free break to allow for menstruation

• estrogen:suppresses 1SH and follicular development

• progestin:prevents LH surge,suppresses ovulation, thickens cervical mucus,decreases tubal motility,

decidualizes endometrium

• most contain low dose ethinyl estradiol (20-35 pg) plus progestin (norethindrone, norgestrel,

levonorgestrei,desogestrel, norgestimate, drospirenone)

• failure rate (0.3-8.0%) depending on compliance

• monophasic formulations have the same amount of progestin throughout cycle while triphasic

formulations have a varying amount of progestin throughout cycle

Transdermal (Ortho Evra 1)

• patch that is changed every week for 3 consecutive weeks then left off for a week to allow for

menstruation

• continuous release of 6 mg norelgestromin and 0.60 mg ethinyl estradiol into bloodstream

• applied to lower abdomen, back, upper arm, buttocks, NOT breasts

• as effective as OCP in preventing pregnancy (>99% with perfect use)

• may be less effective in women >90 kg

Contraceptive Ring (Nuva Ring;

)

• thin flexible plastic ring that is inserted into the vagina by the patient and left there for 3 wk then

removed for a week to allow for menstruation; releases etonogestrel 120 pg/d and estradiol 15 pg/d

• as effective as(KIP in preventing pregnancy (98%)

• side effects:vaginal infections/irritation, vaginal discharge

• associated with less breakthrough bleeding than other methods

Starting Hormonal Contraceptives

• thorough history and BP measurement (post-pandemic SOGC guidelines do not require BP reading

anymore to allow for virtual appointments)

• pelvic exam not required as ST1 screening can be done by urine, and pap smear screening does not

start until >25 yr

• can start at any time during cycle but ideally within 5 d of LMP

• follow-up visit 3 mo after hormonal contraceptives prescribed

• generally recommended to use back-up contraception for 7days, particularly if initiated >5 days front

LMP

Table 8. Combined Estrogen and Progestin Contraceptive Methods

Advantages Side Effects Contraindications

Highly effective

Reversible

Cycle regulation

Decreased dysmenorrhea andheavy menslrual Fluid retention,1

bloating/edema

Weight gain (rare)

Decreasedbenign breast disease and ovarian Migraine,headaches

cyst development

Decreased risk of ovarian and endometrial

cancer

Increased cervical mucuswhich may lower

risk ofSTIs

Decreased PMS symptoms

Less acne

Osteoporosis protection (possibly)

Patient controlled

Estrogen-related

Nausea

Breast changes (tenderness,enlargement)

Absolute

4 wk postpartum(breastfeeding) or <21 d

postpartum (not breastfeeding)

Major surgery with prolonged immobilication

ttnown/suspectedpregnancy

Undiagnosed abnormal vaginalbleeding

Prior thromboembolic events,thromboembolic

disorders (FactorIf Leiden mutation;protein

bleeding|1ess anemia)

Thromboembolic events

Liver adenoma (rare)

Breakthrough bleeding (low estradiol levels) Cor S.or anbthrombin III deficiency),active

thrombophlebitis

Cerebrovascular or coronary artery disease

Estrogen-dependent tumours (breast,uterus)

Impaired liver function associatedwith acute

liver disease

Progestin-related

Amenorrhea!breakthrough bleeding

Headaches

Breast tenderness

Increased appetite

Decreased libido

Mood changes

Congenital hypertriglyceridemia

Smoker age>35 yr

Migraines with focal neurological symptoms

(eidudingaura)

Uncontrolled HTN

H1N

Acnefoilyskin*

Hirsutism*

Relative

'Androgenic side effects may beminimiced Migraines (non-local with aura <1h)

by prescribing formulations containing DM complicated by vascular disease

desogestrel,norgestimate.drospvenone.or SIE

cyprolerone acetate Controlled HI

Hyperlipidemia

*

Sickle cellanemia

Gallbladder disease r m

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Drug Interactions

' Risks

Rifampin,phenobarbital.phenytoin.griseofulvin.

primidone,andSt.John's wort can decrease

efficacy of CHC requiring use of back-up method

Ko evidence of fetal abnormalities if conceived

onOCP

No evidence that OCP is harmful to nursing infant

but may decrease milk production

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Table 9. Selected Examples of OCPs

Type Active Compounds

(estradiol and progestin

derivative)

Advantages Disadvantages

Missed Combined OCPs

Miss1pill in <24 h

• Take1 pil ASAP, and the next pill at

the usual time

Miss >1pill in a row in 1st wk

• Take1ptH ASAP, and continue taking

1 pttl daily until the end of the pack

• Use back up contraception for 7 d:

EPC may be necessary

Miss <3 pills in 2nd or 3rd wk of cycle

• Take 1 pi0 ASAP, and continue taking

1pdf daily until the end of the pack

• Do not take placebo (28-d packs) or

do not take a hormone free interval

(21-d packs)

• Start the next pack immediately after

finishing the previous one

• No need for back up contraception

Mss >3 pills during the 2nd or 3rd wk

• Take1pil ASAP, and continue taking

1pill daily until the end of the pack

• Do not take placebo (28-d packs) or

do not take a hormone free interval

(21-d packs)

• Start the next pack immediately after

finishing the previous one

• Use back up contraception for 7 d;

EPC may be necessary

S0KCaunOtt Opnon on Messed Hor monj!

Cnctuuptnv »r» hKorarwiidibwis.

jMcnosjottso

-tott.

Alesse 20|ig ethinyl estradiol and 0.5 mg Low dose (20 pg) OCP

Less estrogen side effects

Low-dose pills can often result in

breakthrough bleeding

If this persistsfor longer than 3

mo. patientshould be switched

to an OCP with higher estrogen

content

Unlike monophasic OCP. triphasic

OCPs can not be used for

continuous menstrual suppression

levonorgestrel

Tri-cytlen'

35 pg ethinyl estradiol and

0.180(0.215/0.250 mg

norgestimate

Triphasic oral contraceptive

(graduated levels of progesterone)

Low androgenic activity can help

with acne

Yasmin: and Yaz Yasmin-:30 pg ethinyl estradiol Decreased perception of cyclic

n 3mg drospirenone (a new weight gaivtiloating

progestin) Fewer PUSsymptoms

Yaz5: 20 pg ethinyl estradiol-3 Improved acne

mg drospirenone - 24/4-d pill (4 d

pill free interval)

Drospirenone has

antimineralocorticoid activity and

antiandrogenic effects

Hyperkalemia (rare,

contraindicated in renal and

adrenal insufficiency)

Check potassium if patient also

on ACEI. ARB. K-*-sparing diuretic,

heparin

PROGESTIN-ONLY METHOD

Progestin-Only Pill

• progestcrone-onlv pill taken daily with no pill free interval

• advantages: patient controlled, does not impact breast milk supply

• disadvantages: must take at exactly the same time every day so compliance can be challenging

Progesterone Intrauterine System (IUS)

• small device left inside uterus for a maximum of 5 yr

• Mirena IL'

S:52 pg lev onorgestrel - better for women with very heavy"

or painful periods, 20%

amenorrhea rate

• Kyleena IUS:19.5 pg levonorgestrel - best for people who want a light period every mo and are mainly

looking for birth control

• advantages:convenient,low hormone dose, minimalside effects, no effect on breast milk, quick

return to fertility once removed

• disadvantages:uncomfortable to put in, must be inserted and removed by a doctor, rarely can have

uterine perforation or IUS expulsion

• very- effective reversible contraception; more likely to be an ectopic pregnancy if conception occurs.

Lower absolute risk of ectopic pregnancy compared to other contraceptive methods

Irregular breakthrough bleeding often

occurs ui the first few mo after starting

OCP:usually resolves after three cycles

Progestin-only contraceptives must be

taken at the same time every day

Coatiaioas«Extended Cycle vs. Cyclic Use

of Coabiaed Hormonal Contraceptives lor

Contraception

Cochrane 03Systker 2014:)

Purpose Systematicmen of RCIs assessing (lie

eScecyeedsdeeSectsof cyclic administration

vs.titeded ose (oc-ger periods of acbve pills

and orshorter penods placebo) or continuous

use (a uterrupted active pdladministration) of

coaptation oral contraceptives (C0C).

Base its The r ta: -eve*

published in 2012

berried12 KCTs that.bmately showed no

ddfeterce tehreen groups with regards to efficacy

pregzaecy rated,safety,and compiiaice rates.

Contoneusor eiterded COCs were shown to reduce

menstrual symptoms (headaches, tiredness, bloating,

and nenstizai pan),baddition.11 of 12 studies

-ercmecls mrbar or rmproved bleeding patternswith

cottmsous or eiten ded cycles.

CoKhsiots: Itsrecently published updated

systesatc renew dettfieda further 4 RCIs,

hawever.resultsrtid not change.

Depo-Provera

• injectable depot medroxyprogesterone acetate 150 mg 1M every 12 wk (convenient dosing)

• advantages:suppresses ovulation, complete amenorrhea in 70% of women after 1 -2 yr of use, does not

affect breast milk,effective for dysmenorrhea

• disadvantages:breakthrough bleeding, iveight gain, decreased bone density (may be reversible),

restoration of fertility may take up to 1-2 yr

Nexplanotv

• 4 cm long 60 mg etonogestrel implant that is placed in the inner arm and lastsfor a maximum of 3 yr

• advantages:does not affect breast milk, do not have to putsomething in uterus, good bleeding and

pain control, no change in bone density, quick return to fertility once removed

• disadvantages:breakthrough bleeding,weight gain

Table 10. Progestin-Only Contraceptive Methods

Indications Mechanism of Action Side Effects Contraindications

Does not affect breast milk supply Progestin prevents IH surge

Women with contraindications

to combined OCP (e.g.

thromboembolic or myocardial

disease)

Women intolerant ot estrogenic

side effects of combined OCPs

Irregular menstrual bleeding

Weight gam

Headache

Breast tenderness

Mood changes

Functional ovarian cysts

Acne/oityskin

Hirsutism

Absolute

Current breast cancer

Known/suspected pregnancy

Undiagnosed vaginal bleeding

Benign or malignant liver tumours,

severe cirrhosis,or acute liver

disease

Thickening ol cervical mucus

Decreases tubal motility

Endometrial decidualization

Ovulation suppression - oral

progestins do notconsistently

suppress ovulation

compared to combined OCPs

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Intrauterine Device

Table 11. IUS Contraceptive Methods

Mechanism of Action Benefits of all IUS Risks of all IUS Side Effects Contraindications

Copper-Containing IUS

(Nova-T ):mild foreign body removal is very fast

reactionIn endometrium,toxic No estrogen (doesn't alfed

lo sperm and alters sperm motility breastfeeding,can use il

Return to baseline fertility after Insertion is uncomfortable

Must be inserted and removed by

a doctor

Infection (especially ilmultiple

smoker,hypertension,previous partners and withinlirsl10 d ol

insertion)

Uterine wall perforation on Insertion

(1/10000)

Expulsion (5% in the 1st yr,greatest

in the 1st mo)

Chance ol pregnancy very low, but if

piegnant,higher relative risk ol an

ectopic pregnancy or miscarriage

IUS do not protect agamstSlls’

Copper IUS:increased blood

loss and duration of menses,

dysmenorrhea,increased vaginal

discharge

Absolute

Both Copper andProgesterone IUS

Known or suspectedpregnancy

Undiagnosed genital Had bleeding

Acute or chronic PIP

lifestyle risk foi Slls

Known distorted uterinccavity

Immediately post-septic abortion

Progesterone IUS:spotting,

bloating,headache,acne,breast

tenderness,nausea.headaches,

ovarian cyst formation, vaginal

discharge,and/or mood changes.

Usually very mild.

Progcstcrone-Reteasing VII)

IUS (Mircna'

,Kylccna ): lasts Syr but can be removed

decidualiialion of endometrium before that it desired

and thickening ol cervical mucus: Can insert immediately alter

minimal effect on ovulation placental delivery and post

abortion

CopperIUS

Known allergy lo copper or Wilson's disease

Relative:

Both Copper andProgesterone IUS

Valvular heart disease

PMHx of PIP or edopic pregnancy

Presence of prosthesis

Abnormalities of uterine cavity

Intracavitary fibroids

Cervical stenosis

Immunosuppressed individuals (e.g.HIV)

Abnormalities of uterinecavity (excluding

distorted uterine cavity)

Copper IUS-Severe dysmenorrhea or heavy

menstrual bleeding

'Cervical swabs lor gonorrhea and chlamydia should be done prior loinsertion

Emergency Postcoital Contraception

Table 12. Emergency Postcoital Contraceptive (EPC) Methods

Method Mechanism of Action Side Effects Contraindications

HORMONAL

Yuzpe Method

Ovral5

2 tablets then repeat in12 h(100 pg ethinyl

estradiol 500 pglevonorgestrel)

Can substitute vnth any OCP as long as it contains100

pg ethinyl estradiol

2% overall risk of pregnancy

Used within 72 h olunprotected intercourse,limited

evidence of benefit up to 5 d

Efficacy decreased with lime

(e.g. less effective at 72 h than 24 h)

“PlanB '

"

Use within 72 ft of unprotected intercourse,can use

up to 5 d alter

750 pg levonorgestrel q12 h for 2 doses (can also take

2 doses together)

Creater efficacy (75-95%ilused within 24 h) and

better side effect profile than Yurpe method

No estrogen thus wry few conlraindications/side

effects (less nausea)

less eflectivc if >75 kg.not recommendedil>80 kg

Ulipristal (Ella )

30 mg P0 within 5 d ol unprotected intercourse

Unknown:theories include:

Suppresses ovulation or causes deficient luteal Irregular spotting

phase

Alters endometrium to prevent implantation

Affects spetm/ova transport

Nausea (due to estrogen:treat with Gravol '

) Pre-existing pregnancy (although not

teratogenic)

Caution in women with contraindications

to OCP (although no absolute

contraindications)

Samcasabovc Same as above Same as above but no caution in women

with contraindications lo OCP

Selective Progesterone Receptor Modulator

(SPRM) with primarily antiprogestin activity:

may delay ovulation by up to 5 d

Headache,hot Hashes, constipation.vertigo,

endometrial thickening

Same as above but no caution in women

with contraindications lo OCP

N0N-H0HM0NAI

Postcoital IUD(Copper)

Insert up to 7 dpostcoitus

Prevents implantation

1% failure rate

Can use (or short duration in higherrisk individuals

See fable 11 See table11 See labfe 11

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