General Gynecology and Minimally Invasive Surgery
Abnormal uterine bleeding is organised by PALM-COEIN: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia are structural; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not-yet-classified are non-structural. Fibroids cause heavy bleeding and bulk symptoms; treatment ranges from tranexamic acid and hormonal therapy to myomectomy, embolisation or hysterectomy.
Minimally invasive surgery questions test entry technique, contraindications and complications. Laparoscopy is relatively contraindicated in haemodynamic instability and suspected bowel obstruction; entry-related injury to bowel or vessels should be suspected when there is unexplained tachycardia or hypotension after laparoscopy. Hysteroscopy is the gold standard for intracavitary pathology.
An ectopic pregnancy must be excluded in any reproductive-age woman with pain, bleeding or syncope; methotrexate is suitable for a small, unruptured ectopic with low hCG and no fetal cardiac activity, and requires follow-up hCG monitoring. Ovarian torsion presents with sudden pain and requires prompt detorsion with ovarian preservation. Tubo-ovarian abscess is managed with antibiotics, with drainage for non-response.
Traps: interpreting a normal ultrasound as excluding ectopic pregnancy; using CA-125 to triage adnexal masses in premenopausal women; and forgetting VTE prophylaxis and pregnancy testing before surgery.
Rule of thumb: any woman of reproductive age with abdominal pain gets a pregnancy test before anything else.