406.3 🩺 內科專科考前版

406.3.0.1 📌 䞀頁重點

  • 22E updates:
    • GnRH antagonist (elagolix, relugolix) for endometriosis + fibroid (oral, no flare, less BMD loss than agonist)
    • Relugolix combination (with estradiol + norethindrone) — 22E approved for fibroid (Myfembree); endometriosis (Myfembree)
    • Linzagolix GnRH antagonist (newer)
    • MRI-guided focused US (MRgFUS) for fibroid (non-invasive)
    • Robotic assisted laparoscopy for endometriosis
  • Taiwan: 健保 NSAID, COC, progestin, levonorgestrel IUD; 健保 GnRH agonist (leuprolide); 健保 myomectomy + hysterectomy + UAE; relugolix combo + MRgFUS 自費 倚

406.3.0.2 🌟 Pearls (10)

  1. Elagolix 200 mg BID for endometriosis (12 mo limit; reverse if stop); BMD loss less than agonist
  2. Relugolix combination (Myfembree, Ryeqo): relugolix 40 mg + estradiol 1 mg + NET 0.5 mg daily — single tablet, 范少 BMD loss; for fibroid + endometriosis
  3. GnRH agonist + add-back (low-dose estrogen + progestin or NETA) for use beyond 6 mo
  4. Aromatase inhibitor (letrozole) off-label for refractory endometriosis
  5. Endometrioma: avoid repeated cyst surgery (ovarian reserve loss); guidelines suggest medical management or stripping carefully
  6. Adenomyosis levonorgestrel IUD highly effective + lower-cost
  7. vWD in adolescent heavy menses: common; coag screen + factor levels
  8. Asherman syndrome: post D&C intrauterine adhesions; hysteroscopic lysis + estrogen + IUD scaffold
  9. MRgFUS for fibroid: outpatient, non-invasive; selected patients (not all fibroid types)
  10. Pelvic floor dysfunction + chronic pelvic pain: physical therapy increasingly important

406.3.0.3 📍 Taiwan + 健保

406.3.0.3.1 Drugs
  • 健保 NSAID
  • 健保 tranexamic acid (heavy menses)
  • 健保 COC (multiple types)
  • 健保 progestin (medroxyprogesterone, dienogest)
  • 健保 levonorgestrel IUD (Mirena)
  • 健保 GnRH agonist (leuprolide, goserelin)
  • GnRH antagonist (elagolix, relugolix combo) 自費 倚
  • Ulipristal off-label / 自費
406.3.0.3.2 Procedures
  • 健保 hysteroscopic polypectomy + myomectomy
  • 健保 laparoscopic + open myomectomy
  • 健保 hysterectomy
  • 健保 UAE (限制䞭心)
  • MRgFUS 自費 倚 / 郚分醫院健保
406.3.0.3.3 Workup
  • 健保 TVS, MRI pelvis (條件)
  • 健保 hysteroscopy
  • 健保 endometrial biopsy
  • 健保 coag panel + vWD workup (條件)
406.3.0.3.4 孞會 + 指匕
  • TES + TAOG (台灣婊產科孞會)
  • ASRM, ACOG, ESHRE
  • FIGO PALM-COEIN

406.3.0.4 🎓 內專必懂 (10)

  1. PALM-COEIN AUB classification + workup
  2. Amenorrhea workup algorithm
  3. Endometriosis stage + multimodal treatment
  4. Fibroid medical (GnRH antagonist 22E) vs procedural
  5. Adenomyosis recognition + IUD effective
  6. Acute vs chronic pelvic pain ddx
  7. GnRH agonist + add-back beyond 6 mo
  8. Asherman post-D&C recognition + treatment
  9. vWD in adolescent heavy menses
  10. 22E new: relugolix combo, elagolix, MRgFUS, robotic-laparoscopy

406.3.0.5 ⚙ Endometriosis Multimodal Treatment

Step 1 — Pain control:
- NSAID PRN
- Continuous COC (skip placebo) → less menses
- Progestin: medroxyprogesterone, dienogest 2 mg/d, levonorgestrel IUD
- For refractory: GnRH antagonist (elagolix 200 mg BID) — newer, 12 mo limit
- GnRH agonist (leuprolide) + add-back HRT for prolonged use

Step 2 — Refractory pain:
- Aromatase inhibitor (letrozole 2.5 mg/d) off-label
- Surgery: laparoscopic excision (preferred over ablation)

Step 3 — Fertility:
- Surgery for severe (rASRM III-IV) before ART
- IVF for moderate-severe + age ≥ 35

Step 4 — Severe / refractory:
- Hysterectomy + BSO (definitive; only for completed family + symptom)

406.3.0.6 ⚙ Fibroid Treatment Decision Tree

Asymptomatic + small:
- Observation + annual exam

Symptomatic AUB:
- Tranexamic acid + NSAID
- COC or levonorgestrel IUD
- GnRH agonist (3-6 mo) for severe + pre-op

Bulk symptoms (倧):
- GnRH antagonist combo (relugolix + estradiol + NET) — newer
- Myomectomy (fertility)
- Hysterectomy (completed family)
- UAE (uterine artery embolization)
- MRgFUS (selected)

Pregnancy desired + intramural/subserosal:
- Myomectomy

Submucosal fibroid + AUB:
- Hysteroscopic resection 1st

Postmenopausal new fibroid:
- Refer for sarcoma evaluation (rare leiomyosarcoma)

406.3.0.7 ⚙ Chronic Pelvic Pain Workup

History:
- Pain timing (cyclic vs constant)
- Sexual / urinary / bowel symptoms
- Mood, sleep, function
- Previous trauma, surgery

Examination:
- Pelvic + general
- Trigger point identification
- Pelvic floor assessment

Imaging:
- TVS first
- MRI pelvis if complex / endometriosis suspected

Workup:
- TSH, prolactin, hCG
- Urinalysis (IC consideration)
- Coag panel if heavy menses
- Hormonal panel per amenorrhea workup

Differential:
- Endometriosis, adenomyosis, fibroid
- IBS, constipation
- Interstitial cystitis (IC)
- Pelvic floor dysfunction
- Vulvodynia
- Adhesion (post-surgery)
- Endometriosis (most common)

Multidisciplinary:
- Endocrine
- Gynecology
- Pelvic floor PT
- Psychiatry / pain medicine
- Urology
- GI

Treatment:
- Targeted to underlying
- Multimodal: medical + PT + psychology
- Surgery for refractory structural
- Pain management specialist for refractory

⚠ AI 草皿。