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Ciara McCaffrey cmccaffrey33@qub.ac.uk Gynaecology https://forms.office.com/e/cvgh4gBk7HContents • Amenorrhea • Period problems • Menopause and HRT • Gynae cancer • Urinary incontinence • Contraception • Early pregnancy • No period– amenorrhoea • Irregular, infrequent periods – oligomenorrhea • Heavyperiods – menorrhagia Period problems • Painfulperiods – dysmenorrhea • Ceasing of menstruation– menopauseTheMenstrualCycle Hormonesinvolvedinmenstrualcycle • Hormonesinvolved in menstrual cycle:FSH LH oestrogenand progesterone. • Cycle typically lasts28days. 1.Follicular – eggis inside developingfollicle. 2.Luteal (Always 14days)– corpus lutealleft inside the ovary • FSH– developsfollicles • LH – ovulation. Spikesjust beforeovulation and causes one ofthe follicles to reach the surface ofthe ovaryand releasethe ovum. • Ovulation happens 14daysbefore theend ofthe cycle. • Oestrogen(steroid sexhormone that actsto promotefemalesecondarysexual characteristics e.g., breast tissue,vulva, vagina and uterus. It alsostimulatesthe BV inuterus and developmentof endometrium.Itcausesthinning ofcervical mucus around ovulation sospermcan getinto uterus and gettoegg. • Progesteroneis a steroid sexhormone thatacts ontissuesthathave previously beenacted onbyestrogene.g., thickens and maintains endometriallining, thickens cervical mucus topreventthings going in and out, alsocauses a slight rise in thebodytemperature.Placentaproduces progesteronefrom 5-10 weeks pregnancy.Amenorrhoea • Primary • Neverhad menses • Secondary • No periodfor 3 months if had regular periods • No period for 6 months if had irregular periods PrimaryAmenorrhoea • Notstarting menstruation: • By13 with no otherevidenceof pubertaldevelopment • By15 with other signs of puberty • Pubertystarts age 8-14 in girls and 9- 15 in boys • BPM for female puberty • Breast buds • Pubichair • Menstruation(2years after starting) • 5TannerstagesofpubertyCausesofPrimaryAmenorrhoea Hypogonadism(lack of oestrogen and testosterone) Othercauses: •  LHandFSHotropichypogonadism • Congenitaladrenalhyperplasia • Androgeninsensitivitysyndrome • pituitarymus – notproducing enough GnRH to stimulate • Structuralpathologye.g., • Pituitary– not producing enough FSH and LH to stimulate gonads imperforatehymen,femalegenital • Hypopituitarism mutilation • Chronic conditions • Excessive exercise or dieting • Constitutional delay • Endocrine disorders • Kalman's syndrome • Hypergonadotropichypogonadism  LHandFSH • Problemwith ovaries • Pituitaryproduces lotsof gonadotropichormones (FSH LH) totry stimulate ovaries.Leadsto disruptionof negative feedbackcycle • Damage to the gonads (torsion, cancer, infections) • Congenital absence of ovaries • Turner’s syndrome Investigations: • Bloods, hormoneprofile, imaging (pituitary MRI, USS uterus, PV exam) Management: • Treat underlying cause Investigationsand • Constitutionaldelay– reassure treatmentof1° • Lowbodyweight– adviseweight gain • Managementofchronic health amenorrhoea conditions • Replace hormones where needede.g., hypogonadotropic causes • PulsatileGnRH e.g., Goserelin, leuprolide • COCPSecondaryAmenorrhoea HypothalamiccauseLHFSH Ovariancause LHFSH Ovarian Causes Uterine causes • PREGNANCY • Asherman’s syndrome • Menopause • Prematureovarianfailure Pituitarycauses • Tumours • PCOS • Sheenan syndrome • Hormonal contraception • Trauma Hypothalamic causes • Radiotherapy • Same as Primary amenorrhoea • Surgery • HyperprolactinaemiaInvestigationsand Managementof2° amenorrhoea Investigations • Pregnancytest,hormoneprofile,bloods,imaging Management • Treattheunderlyingcause • PCOS– giveCOCP(Dianette)for3monthsandthen1 weekbreakforwithdrawalbleed • Hypothalamicamenorrhoea-treatwithGnRH/COCP • PituitarycausestreatwithCOCP • Asherman’s– hysteroscopicadhesiolysis • If>12 monthsamenorrhoeicthinkaboutbone protection(DEXA scan, bisphosphonates,vitaminD, calciumsupplements)Oligomenorrhoea • Irregular menstruation • Extremes ofreproductiveage • PCOS • Physiologicalstress • Medicationse.g., progesterone contraceptives,antipsychotics, antidepressants • Hormonal imbalancese.g., thyroid, Cushing’s, high prolactin ROTTERDAMCRITERIA(2/3fordx) Oligoovulationoranovulation,presentsas irregularor absentperiods Hyperandrogenism(hirsutismandacne) PCOS Polycysticovariesonultrasound(>12cysts inoneovaryorovarianvolumeofmore than10cm3) • Signs and symptoms Management • Oligo/amenorrhoea • Infertility:clomifene,ovariandrilling &weightloss– • Infertility OrlistatifBMI>30 • Obesity • Exercise&smokingcessation • Hirsutism • AntihypertensivemedicationsifHTN • Acne • StatinsifQRISK>10%/CVD • Hairlossinmalepattern • Mirenacoil,COCP,cyclicalprogestogenstoprevent • InsulinresistanceandT2DM endometrialhyperplasia.Dianette3 months(VTErisk) • Investigations • LH:FSHRatio Complications • Testosterone • CVD&HTN • Insulin • T2DM& obesity • TVUSS‘stringofpearls • Infertility appearance’ • Obstructivesleepapnoea • OGTTforT2DM • Depression&anxiety • Normal/  Oestrogen • Endometrialhyperplasiaandcancer Meig’ssyndrome:Triad of • Ovarian fibroma (benign) Ovarian cysts • Pleuraleffusion (exudative) • Cyst = fluid filled sac • Ascites • Sx: asymptomatic, pelvic pain or fullness,bloating, palpable mass • Premenopausal cysts most likely benign, postmenopausal more likelyto be malignant • Benign cysts: • Functional ovarian cysts due to fluctuating hormones of the menstrual cycle in premenopausal women • Follicular cyst (most common type of ovarian cyst overall) • Corpus luteum cyst • Benign germ cell tumour – dermoid cyst. Torsion more likelythan in other tumours. Raised AFP and BHcG • Benign epithelial tumours • Serous cystadenoma (more common and similar to most common type of ovarian cancer serouscarcinoma). Bilateral in 20% • Mucinous cystadenoma. Can become massive. Ifruptures can cause pseudomyxoma peritonei • Complex (e.g., multi-loculated) ovarian cysts should be biopsied to exclude malignancy • Complications: • Torsion (‘Whirlpool sign’, surgical emergency, risk of ischaemia) • Haemorrhage into cyst • Rupture with bleeding into peritoneum Investigations and management ofovarian Premenopausalcysts Nofurtherix cysts <5cm Postmenopausalcysts 6monthlyUSS+ RMI • Risk ofmalignancyindex (RMI): 5cm • Menopausalstatus Premenopausalcysts5- YearlyUSS 7cm • USS findings • CA125 Premenopausalcysts MRI/surgicalexploration >7cm Women<40ywithcomplex Tumourmarkers:LDH,AFP, ovarianmass bHCGforapossiblegerm celltumour Postmenopausalcyst RMI&redflagreferralif raised Investigations:pregnancytest, bimanualandspeculum exam, swabs,FBC, TSH,coag screen,TVUSSandif>4mm Menorrhagia thickhysteroscopywithendometrialbiopsy • Symptoms: >80mls (normal 40mls), self report,changing Management:doespatientneedongoing pads every 1-2 hours, period >7 contraception? days, flooding, clots • Causes: • No cause NO YES • TXA – • Extremes ofage 1. IUD antifibrinolytic, • Fibroids 2. COCP NO painrelief • Endometriosis 3. Progesterone • NSAIDs • PID injection/POP/ • Mefenamicacid • Copper coil implant – antifibrinolytic • Anticoagulants/bleeding disorders +painrelief (vWF) • Endometrial hyperplasia or cancer • PCOS • Endocrine disorders • Endometrialablation– balloon thermalablation • HysterectomyFibroids • Benign tumours of • Sx: menorrhagia, lower uterussmooth abdominal pain, bloating, muscle urinary/bowel sx, subfertility, • More commonin deep dyspareunia Afro-Caribbean • Dx: TVUSS women • Grow in response to • samef sx: Menorrhagia mx oestrogen • Grow during • fibroidst to shrink/remove • Get smaller after • GnRH agonists menopause • Surgery – myomectomy, • Submucosal is most hysterectomy commontype • Uterine artery embolisation REDDEGENERATION:ischemia,infarction& necrosisoffibroidduring 2/3trimesterofpregnancy.Fibroidoutgrowsbloodsupply/vessels kinked.Sx: severeabdopain,low-gradefever,tachycardia,vomiting.Mx issupportive(rest,fluids,analgesia) Dysmenorrhea Primary • Nounderlyingpelvicpathology • Usuallywithin1-2yearsaftermenarche • Cx: excessiveendometrialprostaglandinproduction • Sx:painstarts justbeforeorwithinafewhoursofthe periodstarting,suprapubiccrampsmayradiate tothe back ordownthelegs • Mx:1 NSAIDs– inhibitprostaglandinproduction,2 nd COCP Secondary • Underlyingpelvicpathology • Typicallydevelopsmanyyearsaftermenarche • Cx: endometriosis,adenomyosis,PID,IUS,fibroids • Sx:painusuallystarts 3-4days beforetheonsetofthe period • Mx:referraltoGynaecologyEndometriosis Adenomyosis • Ectopic endometrial tissue • Endometrial tissue within the myometrium • chronic non-cyclical as adhesions • Sx:painful periods, menorrhagia, form, deep dyspareunia, blood in dyspareunia, subfertility urine/stools during menstruation, subfertility • Ix &Dx: TVUSS • Endometriomas in the ovaries = • Mx: treat same as menorrhagia ‘chocolate cysts’ • GnRH agonists • Ix &Dx: pelvic USS, laparoscopic • Endometrialablation surgery • Uterine artery embolisation • Hysterectomy • Mx: NSAIDs forpain • agonists (induces pseudo menopause due tolow oestrogenlevels) • Surgery:laparoscopicsurgery, TAH+BSOMenopause • Ceasingofmenstruation • Retrospectivediagnosisafterno periodfor >12 monthsif>50y /24monthsif<50y • The ovariesstop producingeggs and thereforestopproducing oestrogen. LH& FSH,LH:FSH ratiooestrogen& progesterone • Prematureovarianinsufficiencyiswhenmenopause<40y • Postmenopausalincreasedrisk of CVD, OP ,prolapseandurinary incontinence Symptoms:hotflushes,moodchanges,irregularperiods,jointpain,vaginaldrynessand atrophy,reducedlibidoManagementofMenopause Non- hormonal Hormonal • Lifestyle advice: exercise, reduce • Vaginal oestrogen toimprove caffeine, balanced diet, reduce vaginal dryness alcohol and stopsmoking • Testosterone (gel/cream) to • CBT/SSRIsespvenlafaxine to improve libido help with mood • Hormone replacement therapy • Clonidine (alpha agonist) helps • Tibolone (synthetic hormone with vasomotor sx & hotflushes tablets) • Vaginal moisturisers help with vaginal dryness BestMOD:Oestrogen HormonereplacementtherapyHRT patch& progesteroneIUS • C/Is:undiagnosed abnormal PV bleeding, endometrial/breast ca, uncontrolled HTN, VTE, liver disease, recent angina/MI/stroke • MOD:patches, tablets, creams, coil • Benefits:relief ofsymptoms, reduced risk ofOP and IHD • Risks (norisks ifpremature menopause): increased risk ofbreast ca, VTE and stroke (notwith patch), ovarian ca(is used>5years), endometrial ca(not if given progesterone with uterus) • Side effects: • Oestrogen:breast tenderness, leg cramps,nausea,bloating • Progesterone:PMS • Bleeding: if cyclicalHRTLocalorsystemic symptoms? HRT doesn’t offer Local contraception. Stillneed TopicalHRT Systemic contraception (POP, IUD) for: • 2 yearsif<50y Dotheyhaveauterus? • 1 yearif >50y Avoiddepotinjectionin>45y(OP) Yes No AvoidCOCPin>50y(endo+ ovarianca) Period inlast 12m?strogen Only HRT Yes No Cyclical Continuous combinedHRT combined HRT Mirabegron has lessanticholinergic SEofanticholinergics:dry mouth & eyes, Urinaryincontinence urinary retention,constipation,postural effectsbut is C/I in uncontrolled HTN hypotension,cognitivedecline – monitor BP regularly CxandSx Investigations Management Stressincontinence Cx: Weakness of pelvic floor • History & examination Weightloss and sphincter muscles. • Abdominal 1. Pelvicfloor muscle exercises≥3 months Sx: leakage of urine when examination 2. Surgery– tensionfreevaginal tape, laughing, coughing, surprised, • Bimanual autologous sling, colposuspension weight bearing exercise examination to 3. Duloxetine(SNRI)is second lineif assesspelvic tone, surgerynot suitable Urge incontinence Cx:Overactive detrusor muscle Reducecaffeine,fluid intake,alcohol Sx: suddenly feel the urge to prolapse, pelvic 1. Bladderretrainingfor6weeks masses 2. Anticholinergicmedications e.g., pass urine and usually PU • Bladder diary ≥ 3 days oxybutynin,tolterodine,solfenacin before toilet, avoid • Uranalysis (to rule out UTI) 3. Mirabegron(B3-agonist) places/activities where no 4. Invasiveprocedures– Botox accessto toilet, effectsQoL • Post void residual bladder augmentationcystoplastyestimulation, volume Mixed incontinence Combination of urge and • Urodynamic testing for: Address which of thetwo has themore stress.Must identify which of • Urge incontinence significant impactfirst twohaving more significant not responding to first impact – Urodynamic studies line meds • Difficulties urinating Overflow incontinence Chronic urinary retention • Urinary retention Overflowincontinenceis morecommonin resultsin an overflow of urine • Previous surgery menand rareinwomensoall womenwith and the incontinence occurs have urodynamictestingand specialist without the urge to pass urine. • Unclear diagnosis management. Cx:chronic urinary retention, • Not always required where diagnosis is anticholinergic meds, fibroids, possible based on pelvic tumours, neurological conditions. history and Sx: PUwithout the urge to examination pass urine. Pelvicorganprolapse • Descentofpelvicorgans intovagina • Types • Rectocele– rectum • Cystocele– bladder • Uterine • Vault– afterhysterectomy • Sx:feelingof‘something coming down’ inthevagina, dragging orheavysensationin pelvis worse onstraining, urinary/bowelsx, sexualdysfunction • Cx: weakness and lengtheningoftheligamentsand musclessurrounding theuterus,rectum and bladder.Obesityand child-birthRF • Ix: Sim’sspeculumUshaped,cough/beardown • Mx: • Conservative– weight loss, physiotherapy(pelvicfloorexercise),vaginal oestrogen cream,reducecaffeine • Vaginal pessary– change every4months • Surgery– avoid meshrepairs,recurrenceofprolapse common • GradesofUterine Prolapse:Theseverityofa uterineprolapse canbegradedusingthepelvic organprolapsequantification(POP-Q) system: • Grade0: Normal • Grade1: Thelowestpartis morethan 1cmabove theintroitus • Grade2: Thelowestpartis within 1cmof theintroitus(above orbelow) • Grade3: Thelowestpartis morethan 1cmbelowtheintroitus,butnot fullydescended • Grade4: Full descentwitheversionofthevagina • A prolapse extendingbeyondtheintroituscan bereferredtoas uterineprocidentia.LichenSclerosus • Chronic inflammatory autoimmune skincondition • Causes dystrophy of vulva,labia,perineum and perianalarea • Associated withother autoimmune conditions e.g., T1DM, vitiligo, alopecia, hypothyroid • Sx: itch or vulval pain, skintightness, superficial dyspareunia, erosions, fissures, shiny porcelain white patches of skin invulvalarea, Koebner phenomenon • Mx: biopsy, potent topicalsteroids, emollients • Cc: risk of SCC of vulvaCervicalectropion • Occurswhen the columnar epithelium of the endocervix has extended out to the ectocervix (stratified squamous epithelium) • The columnar epithelium is more fragile and prone to trauma so it causes: • Sx: • Postcoital bleeding • Dyspareunia • Increased vaginal discharge • Visible transformation zone on speculum examination • Cx: it is associated with higher oestrogen levels • COCP • Younger women • PregnancyGynaecancer • Vulval • Cervical • Endometrial • OvarianVulvalCancer • 90% SCC Vulval intraepithelial neoplasia (VIN) • RFs:age>75y, HPV (<50y), VIN, immunosuppression, HPV associated VIN DVIN (non-HPVassociated lichen sclerosus VIN) Lowgradesquamous intraepithelial • Associatedwith vulval • Sx: lump or ulcer onlabia lesion dystrophies e.g., lichen majora, inguinal • UVIN1(mostcommonformofVIN) sclerosis, vulvalatrophy lymphadenopathy, itch or • Caused by HPV 6+11 • Occurs in olderwomen irritation • Notneoplastic • More likelytobecome High gradesquamous intraepithelial cancerous • Ix &Mx:Red flag referral lesion 2ww • Caused by HPV 16, 18+ 33 • WLE removal andbiopsy • UVIN2and 3 • Sentinel lymphnodebiopsy • Youngerwomen, sexually active • Risk factor =smoking • CTAP • Chemo/RT/furthersurgery CervicalCancer • 80%are SCC • HPV type 16,18and33 • HPV vaccineage 12-13 • Risk factors:HPVinfection,notengagingwith screening, HIV,smoking, COCP>5y,multiparity • Sx:abnormalPVbleeding/discharge, pelvic pain,dyspareunia,detected onsmear, asymptomaticdetected onsmear • Ix:A smear test is offeredto all womenbetween the ages of25-64years • 25-49years:3-yearlyscreening • 50-64years:5-yearlyscreening • cervicalscreening cannotbe offeredto womenover 64(unlike breast screening, where patients can self-refer oncepast screening age) • Special situations • cervicalscreening inpregnancyis usuallydelayed until3 months post-partum unless missed screening orprevious abnormal smears • HIV+veannualscreening • If alesion/abnormalityis seen onthe cervix do nottake a smear – refer straight tocolposcopy.Smears are onlyforasymptomatic screening . CervicalcancerNI guidelines • Please be aware that as of Dec 23, the screeningprogramme in NI has switched to using HPV primary screening • Same as PassMed now • Specimens are now tested for the presenceof High risk HPV (HrHPV). Samples which test negative for HrHPV will not have cytology and these patients will be returned to routine recall. • If a sample testspositive forHrHPV then cytological examination is the next step to determine which samples contain abnormal cells. • Smears only allow you to see the see of dyskaryosis (pre-cancerous cell changes) of cells. • Individuals who test positive for HrHPV and for whom abnormal cellsare assessmentill be directly referredto the Colposcopy to enable clinical • Inormal (i.e. hrHPV +ve but cytologically normal) the testis repeated at 12 months • if the repeat testis now hrHPV -ve →returnto normal recall • if the repeat testis still hrHPV +ve and cytology stillnormal → further repeat test 12 months later: • If hrHPV -ve at 24 months →returnto normal recall • if hrHPV +ve at 24 months → colposcopy Aromataseisanenzymefoundinfat (adipose)tissue thatconvertsandrogenstooestrogen.After Endometrialcancer menopause,theactionofaromataseinfattissueis the primarysourceofoestrogen. • Mostcommongynae Sx: Referral criteria cancerinUK • PMB • Post menopausal bleedingclinic 2ww • 80%adenocarcinoma • Unexplainedvaginaldischarge >55y refer • IMB/PCB/HMB forTVUSS • Oestrogendependent • AbnormalPVdischarge • Visiblehaematuria+ raised platelets/ referfor TVUSSed glucose levels>55y Endometrialhyperplasia • Haematuria Precancerous RiskFactors Ix: Canbe atypical/without • Increasedage • <4mm post menopause)thickness (normal atypia • Increasedovulations • Early menopause • TVUSSle biopsyif>4mm/abnormalities on Treat withIUS/POP • Late menarche continuous • Nulliparity • OPhysteroscopy with endometrial biopsy • FIGO staging Protectivefactors • Exposetounopposed oestrogen Mx: • COCP • Obesity • IUS • PCOS • TAH+BSO/Radicalhysterectomy • Tamoxifen • RT/chemotherapy • Multiparity • HNPCC • Smoking • T2DM • Progesterone(palliative)Ovariancancer • Peak age 60 • Usuallycarries poor diagnosis as usuallylate Sx: Ix: diagnosis • Bloating • 90% areepithelial inorigin RMI index • distal endofthefallopiantube is oftenthe site • Early satiety / loss of oforiginofmany'ovarian'cancers appetite • Usuallymetastasize toparaaortic lymphnodes • Pelvic pain • CA125 • Serous cystadenoma most common subtype • Urinary frequency • USS findings Protective factors • Weight loss Fewer ovulations • Menopausalstatus • COCP • Abdo/pelvicmass • Ascites • Breastfeeding • Pregnancy • Diarrhoea Risk factors Mx: • latemenopause, nulliparitydine,earlymenarche, • Surgery • Age 60 • BRCA 1/2 • Chemotherapy • Smoking • Palliative • ObesityContraception • COCP • POP • Progesterone injection • Progesterone implant • IUS (Mirena coil) • IUD (copper coil) • EmergencycontraceptionCOCP Contraindications: MOA: Startingthepill • Stopsovulation • >50y • Startpill at any time • Smoke>15cig/day+ >35y • Thickenscervical • Ifday 1-5 – protectedimmediately • BMI>35 mucus • Otherwise use additional contraception for 7 days after starting • Migrainewithaura • Thinsendometrium • <21days postpartum • Breastfeeding Advantages: Howto take • >99% effectiveiftaken • Sametimeeveryday • CVD/AF/PAD correctly • HTN • Non-invasive • Conventionallytakenfor21days then stoppedfor7 – toinduceawithdrawal • VTE • Control timing of periods bleedsimilartomenstruationevery • Breastcancer • Improvesacne • Liverdisease • HelpsHMB month • ReducesPMSsx • Butcantricycle–take three21-day • SLE packs back-to-back thenbreak • Enzymeinducingmedications • Reducesriskofovarian, uterine and coloncancer • Canbe runback-to-backcontinuously Disadvantages(SE): • Breast tenderness One missed pill 2 or more missed pills • Headache • Break throughbleeding • Take missedpill straight away. • Take most recent pill youmissed straight • Nausea • No protectionfromSTIs • Continue taking pack as normal. away • Moodchanges • User dependent • Emergency contraceptionifUPSIday 1-7of • IncreasedVTErisk & • Increasedrisk of cervical Emergency contraception not required cycle stroke, MI and breast ca • Omitpill free period ifday 15-24of cyclePOP Contraindications: Startingthepill Missedpills • Breastca • Can start at any time in cycle • Take themostrecentmissed • If day 1-5 – protected pillstraightaway(evenwith • Liverdisease immediately nextdose) • UndiagnosedabnormalPV • Otherwise use additional • If>3hrlatefortraditionalPOP bleeding • PAD contraception for 2 days after (or>12hrlateforDesogestrel) starting usecondomsfor2daysand MOA consideremergency Howto takethePOP: contraceptionifhadUPSIinthe • Thickenscervical mucus • Sametimeeveryday 2-3days beforemissedpill/ • Thinsendometrium • Nopillfreedays sincethemissedpill • Desogestrelstopsovulation Advantages: Disadvantages: • Noninvasive • 1/3getlighterperiods, 1/3get • >99%effectivewithperfectuse heavierperiods,1/3have no periods • Problemswithperiodsusually • Irregular periods improve • Moodchanges • NoSTIprotection • Safeduringbreastfeeding • Userdependent • Usefulis oestrogenC/I • Increasedrisk ofbreastca and ovarian cysts Progesteroneimplantandinjection MOA CIs Advantages Disadvantages Progesterone Stopsovulation Activebreast Longterm Progesteronesideeffects implant Thickenscervical cancer contraception NoSTIprotection mucus Severeliver Reversedeasily Smallprocedurerequired Thinsendometrium cirrhosis Periodslessheavyand Bruisingdownarmafter Livertumour painful procedure Effectiveforupto Safeinbreast feeding Damagetolocalstructures 3y Breastcancer– slight 99%effectivewith increasedrisk perfectuse Progesterone Stopsovulation Breastcancer Longacting Progesteronesideeffects injection Thickenscervical Severeliver Lesspainfulperiods NoSTIprotection mucus cirrhosis/tumour Usefulifoestrogen Weight gain Thinsendometrium Historyofsevere can’tbe taken Fertility–afterstopping arterialdisease Safeinbreastfeeding thereisa yeardelaybefore 99%effectivewith RFs forosteoporosis fertilityreturnstonormal perfectuse Unexplainedvaginal Osteoporosis bleeding Increasedriskofbreast cancerCoils MOA CIs Advantages Disadvantages IUS Thickenscervical PID/infection Non-userdependent Irregularbleeding (Mirena) mucus Immunosuppression Lighterperiods ProgesteroneSEs Thinsendometrium Unexplainedbleeding Easilyreversible NoSTIprotection Pelviccancer Localisedhormones Infection >99%effectivewith Uterinecavity (lowerSEprofile) Expulsion perfectuse distortion(e.g.,by Safeinbreastfeeding Damagetowomb fibroids) Noevidenceof Ectopic pregnancyif Replaceevery5y increasedcervical/ fallpregnant uterine/ovarian cancerrisk IUD Preventsspermfrom Wilson’sdisease Immediate Heavierbleeding (copper surviving PID/infection Easilyreversed NoSTIprotection coil) Changecervical Immunosuppression Noeffectonother Infection mucusconsistency Pregnancy medication Expulsion Unexplainedbleeding Safeinbreastfeeding Damagetowomb >99%effectivewith Pelviccancer Nohormones Ectopicpregnancyif perfectuse Uterinecavity fallpregnant distortion(e.g.,by Replaceevery5-10y fibroids) Contraceptionin older women • Afterlastperiodwomenrequirecontraception • For2yrsif<50y • For1yrif>50y • COCPcan be usedupto50yand may helptreat perimenopausalsx • Therefore,progesteroneonlycontraceptionbest option– thiscan act as theprogesteronepart ofHRT • Progesteroneinjection(i.e.,Depo-Provera)shouldbe stoppedbefore50yduetoriskofosteoporosis • Womenapproachingmenopausalage whoare amenorrhoeiconprogesteroneonlycontraception shouldcontinueuntileither: • FSH>55IU/Lontwotests taken6 weeksapart • 55yo SEofemergencycontraceptivepills: N+V, PVbleeding,headache, breast/pelvicpain Emergencycontraception Ifvomitwithin3hr,repeatdosewith domperidone/useIUD 1 lineCoppercoil 2 lineUlipristalacetate Levonorgestrel • Canbe insertedwithin 5daysof (EllaOne) • Takenwithin 72hofUPSI UPSI/within5daysofestimated • Takenwithin 120hofUPSI • Unlikelytobe effectiveafter date ofovulation • Unlikelytobe effectiveafter ovulationhasoccurred ovulationhasoccurred • Mosteffective • COCP/POPcanbestarted • Offerfirstline • Moreeffectivethan immediately aftertaking levonorgestrel levonorgestrel • Wait5daysbeforestaringCOCP • 1.5mgsingledose orPOPaftertaking • 3mgsingledoseinBMI>26/ • Givenas single30mgdose above70kg • Breastfeedingshouldbe • Notharmfulduring avoidedfor1weekaftertaking breastfeeding,howeveravoidfor • Avoidinpatientswithsevere 8hoursaftertakingdose uncontrolledasthma,<18y Earlypregnancy • Ectopic pregnancy • Miscarriage • Hyperemesisgravidarum • Molar pregnancy AntiD prophylaxistoallrhesus–veif Ectopicpregnancy bleeding.Pregtest3 weekspost procedure • A pregnancythat Presentation Investigations has implanted • Typicallypresentsaround6-8weeks outsidetheuterus gestation BhCGbloodtestpositive • Mostcommonsite • Missedperiod+positivepregnancy • Riseof>63%in48h=intrauterine pregnancy – ampullaof test fallopiantube • Lowerabdo/RIF/LIFpain • Riseof<63%in48h=ectopicpregnancy • Othersites–in • Vaginalbleeding TVUSS abdomen,ovary, • Cervicalmotiontenderness(pain • Blob/bagel/tubalringsign cervix whenmovingthecervixduringa • Movesseparatelytotheovary bimanualexamination) • Emptyuterus Management Expectant Medical-methotrexate Surgical Surgery Followupmustbe Followupmustbe Followupunlikely Laparoscopic possible possible Ruptured salpingectomy –firstline Unruptured Unruptured Adnexalmass>35mm Laparoscopic salpingotomy Adnexalmass<35mm Adnexalmass<35mm Visibleheartbeat – ifincreasedriskof Novisibleheartbeat Novisibleheartbeat Significantpain infertility Nosignificantpain Nosignificantpain hCG levels>5000IU/L hCG level<1500IU/L hCG level<5000IU/L Miscarriageisa spontaneous TVUSSfindings terminationofpregnancy CRL7mm= heartbeatshouldbe seen Miscarriage • Ifnot,repeatscanin1wtoconfirm Typeof Presentation miscarriage non-viablepregnancy Missed Nosymptomsassociatedwith Gestationalsacdiameter 25mm= fetal pregnancyloss • Early <12w poleshouldbe seen Threatened Vaginal bleedingwitha closed • Late>12-24 cervix.Fetusisstillviable • PVbleeding>24w • Ifnot,repeatscanin1wtoconfirm antepartum anembryonicpregnancy Inevitable Vaginal bleedingwithan open cervix hemorrhage Anembryonicpregnancy Incomplete Retainedproductsofconception • Deathoffetus Gestationalsac ispresentbutcontains (RPOC)aftermiscarriage >24w=stillbirth noembryo Complete NoRPOC Anti Dprophylaxis toallrhesus –ve if bleeding. Anembryonic Gestationalsac,noembryo Management Pregtest3weekspostprocedure Expectant Medical Surgical First line foMisoprostol Give misoprostolfirst to softencervix Incompletemiscarriage <6w Prostaglandin • Increasedriskofinfection Manualvacuum Electricvacuum • Medicalmanagement= analogue aspiration aspiration misoprostol First line for • Local anaesthetic • General • Surgical=vacuumaspirationand most>6w (if • Must be <10 weeks pain – EPAU) gestation anaesthesia curettage(ERPC) • EndometritisisacomplicationHyperemesisgravidarum Severe N&V plus: • N&V in first trimester is MxMildcases can be mxwithoral antiemeticsat home. • >5% weight loss than worse at8-12weeks before pregnancy • hCG produced by Admissionshouldbe consideredwhen: • Dehydration placenta causes • Electrolyte imbalance nausea • Unabletotolerateoralantiemeticsor keepdownanyfluids • Morethan5 %weightlosscompared Investigations: withpre-pregnancy Riskfactors • Observations MEWS • Ketonesarepresentintheurineona • Bloods urinedipstick(2+ ketonesontheurine (2Ms,2Fs): • Hydration assessment dipstickissignificant) • Multiplepregnancy • Weigh • Molarpregnancy • Othermedicalconditionsneedtreating • First pregnancy • Urinalysis thatrequiredadmission • Fat • Assessusing PUQE score Mxofmod-severe: • IV/IM antiemetics • IVfluids (saline with addedpotassium)Monitoring + correction of electrolyte abnormalities • Thromboprophylaxis • Thiamine supplementationMolarpregnancy A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. Complete mole Partial mole Presentation • 2 sperms fertilise 1 ovum • 2 sperms fertilise a normal • Hyperemesisgravidarum which contains no genetic ovum(containing genetic • PV bleeding material material) • Increased size ofuterus for • Sperms combinegenetic • Cell has 3 sets of dates material chromosomes • Abnormallyhigh hCG • No fetal material forms • Somefetal materialforms • Thyrotoxicosis(hCG can mimicTSH & stimulate the Investigations and management thyroid to produceexcess T3+T4) • TVUSS = snowstorm appearance • Suctionevacuationofuterus and send for histologyKeyfacts • Dayofovulation14daysbeforeendofmenstrualcycle • Checkifovulated-midlutealphaseprogesterone– 7days beforeendofcycle • Ifhxofbreast caavoidhormonalcontraception(usecoppercoil)andHRT • Ifhxofcervicalorendometrialca avoidIUS • Coilscanbe insertedwithin48hrofbirthor>4weeks.UKMEC3 48hr-4weeks • Fertilityreturns21days afterbirth– noneedforcontraceptionbeforethis • Recurrentmiscarriage≥3consecutive.Ix after≥3 1 trimester/ ≥12 trimesterd • Males produce anti-mullerian hormone and this leads to part of the sexual differentiation process – why males don't have uterus, vagina, cervix or fallopian tubes • endometriosis, fibroids25 (>35IU/L significant) – gynae cancer, pregnancy, liver disease, PID, adenomyosis, • abdominal pain that occurs midcycle (between days 7 and 24) in womenenign preovulatory lower • Post coital bleeding – red flag for consideration of cervical ca and others. Ddx: cervical ectropion, cervical ca, PID, trauma • Intermenstrual bleeding – red flag to consider ca esp cervical. Ddx: cervical ca, hormonal contraception, STI, PID, pregnancy, endometrial ca, cervical ectropion • Post menopausal bleeding – red flag referral for consideration of endometrial ca Gynaehistorytaking–4Ps • Pain • PV discharge General symptoms • Abdo pain • Changes, colour, o Weight loss, fatigue, skin • Pelvic pain consistency, smell, changes, night sweats, • Dyspareunia volume fever • PV bleeding o Abdominal distention, • Pregnancy early satiety • length, heaviness, pain, • LMP o Urinary PMS, regularity • Urine pregnancytest o Bowel • Intermenstrual bleeding • Gravidityand parity • Post-coital bleeding • Post-menopausalbleeding • Anaemiasymptoms/ hypothyroidism• Previousgynaehistory • Pastobstetric history • Menarche • Anypreviouspregnancies • Menopause– includingage of • Howmany? menopauseand menopausal • Howmanyyearssincelast symptoms pregnancy? • Smears, abnormalitiesand treatments • Howweretheydelivered? • Any complications? • Reproductiveplans • Anyfailed/terminatedpregnancies • Consideringhavingchildrenin the future/tryingto fallpregnant • Howmany,when,howwasit • Anygynae surgery managed,haveyoureceivedsupport etc.• Sexual history • Whoare youwith rightnow? • Is this youronlysexual partner? • Have you ever beenscreened for/ had an STI? • PMHx,Pastsurgicalhistory • FHx– gynae conditions, then general • Drug history • Include contraception – previous,current • Social history • Occupation,smoking, alcohol • Whodo you live athome with • ‘Wouldyou describe thisrelationshipas supportive’ • ‘Doyou feelsafe at home’ • ICE • Speculum Gynae Examinations • Bimanualexamination(PV) • Smears • SwabsSpeculumexaminationSmears&SwabsCounselling • COCP • POP • Progesterone injection • Progesterone implant • Mirena coil • Copper coil • Emergencycontraception • Menopause/HRT • Early pregnancy – breaking bad news? • Miscarriage • Ectopic pregnancy • Subfertility • Gynae cancer– smearresultshttps://forms.office.com/e/cvgh4gBk7H