Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

MILINDU WICKRAMARACHCHI DYSPAREUNIACONTENT HISTORY TAKING EXAMINATION INVESTIGATIONS QUIZ 1 CONDITION A CONDITION B CONDITION C QUIZ 2DIFFERENTIALS SUPERFICIAL: - vaginitis - vulvodynia - atrophy - inadequate lubrication - Atrophic vaginitis - Vaginal candidiasis DEEP: - Pelvic Inflammatory Disease - Endometriosis A lot of other causes! Think VITAMINS CDEFHISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORYHPC - The location of the pain: superficial or deep? - Duration of the symptoms? - Nature of the pain (sharp, aching - PID, endometriosis, fibroids, adnexal pathology \\\ burning - atrophic vaginitis, vulvodynia, inadequate lubrication) - SOCRATES Associated symptoms: - Abnormal bleeding or discharge (fibroids, STIs) Systems enquiry: - Ca)el symptoms, abdominal distension (endometriosis, ovarianPMH - Menstrual history (duration, frequency, flow, LMP , men+men) - Contraception - PGHx (medical and surgical) - Other specific diseases e.g. migraine, prev. VTE, brCa, bleeding disorders) - Smear history! date and result of last test, ?treatment, ?HPV vaccineDHx - enzyme inducers? think liver metabolism e.g. St John’s Wort and COCP . - Antibiotics -> secondary vaginal thrush - HRT: duration, method, frequency, type - Other meds for gynae conditions e.g. GnRH analogues and tranexamic acidSHx - General social context - Smoking!!! Alcohol and recreational drug use - Diet and weight - obesity + PCOS, anorexia + oligomenorrhoea, - Occupationications?FHX - Familial history of Ca -> ovarian, endometrial and breast, link to BRCA gene - Bleeding disorders e.g. vW disease and menorrhagia - VTE history - can contraindicate COCPEXAMINA TION - Bimanual examination + speculum examination Specific features to look out for (non-exhaustive): - Female genital mutilation - Cervical motion tenderness and PID - Abnormal cervical discharge and STIs - Cervical massesQUIZ 1a A 32-year-old female presents to the gynecology clinic with complaints of recurrent pain during sexual intercourse over the past several months. She describes the pain as a deep, burning sensation that occurs with penetration. The patient reports no prior history of dyspareunia or sexually transmitted infections. Her menstrual cycles are regular, and she denies any urinary symptoms or abnormal vaginal discharge. On physical examination, there is no visible external genitalia abnormalities, and a pelvic exam reveals tenderness upon palpation of the posterior vaginal wall. No masses or lesions are noted. Speculum examination is unremarkable. The patient's Pap smear results are normal. What is the most likely cause? A) Vulvovaginal candidiasis B) Endometriosis C) PID D) Vaginismus E) Cervical dysplasiaQUIZ 1b A 30-year-old female presents to the gynecology clinic with a complaint of dyspareunia. She reports experiencing pain during sexual intercourse for the past three months, specifically localized to the vestibule. The pain is described as a burning sensation that occurs with initial penetration. The patient is in a monogamous relationship, and there is no history of sexually transmitted infections. Clinical history reveals no abnormalities in menstrual cycles, and she denies any pelvic pain unrelated to intercourse. On physical examination, there is tenderness upon touch at the vulvar vestibule, and a cotton swab test elicits reproducible pain. No visible lesions or abnormal discharge are noted. What is the most likely cause? A) Vulvovaginal candidasis B) Vulvar vestibulitis syndrome (VVS) C) PID D) Urethral diverticulum E) Cervical dysplasiaQUIZ 1c A 42-year-old woman presents to her gynecologist with complaints of heavy menstrual bleeding, pelvic pressure and deep dyspareunia. She reports increased menstrual flow over the past six months, leading to the use of double sanitary protection. The patient has no history of intermenstrual bleeding or postmenopausal bleeding. Her menstrual cycles are regular, and she denies any urinary symptoms. On physical examination, the uterus is enlarged, palpable above the pubic symphysis, and irregular in contour. There are no adnexal masses, and bimanual examination reveals the uterus to be non-tender. What is the most likely diagnosis? A) Adenomyosis B) Endometrial hyperplasia C) Ovarian cysts D) Uterine fibroids E) Cervical polypsENDOMETRIOSISWHA T IS IT? - Endometrial tissue outside the uterus - ‘Endometriomas’ - ‘Chocolate cysts’? - Should be differentiated from adenomyosis - endometrial tissue in the myometrium - ASRM staging guidelines, but NICE recommend a clear description of the lesioinsCAUSES/ RISK FACTORS - Exact cause not clear No clear genetic link, but possible: - Retrograde menstruation - Embryonic cells - Lymphatic system - MetaplasiaSYMPTOMS AND SIGNS - Cyclical abdomino-pelvic pain - Deep dyspareunia - Dysmenorrhoea - Infertility - Cyclical bleeding elsewhere e.g. urine and stools - Chronic non-cyclical pain - O/E: Endometrial tissue visible via speculum, fixed cervix on bimanual, tenderness in vagina, cervix and adnexaINVESTIGA TIONS - Ultrasound can reveal large endometriomas and chocolate cysts, although mostly unremarkable - be therapeutic simultaneously.aroscopic surgery, + biopsy. CanTREA TMENT - NSAIDs and paracetamol - Hormonal management e.g. COCP , progesterone-only pill, Depo-Provera, Nexplanon, Mirena, GnRH agonists - Laparoscopic surgery/hysterectomy - Lap may improve fertility, hormonal won’t - How do these treatments work?COMPLICA TIONS - Haematuria/haematochezia if endometriomas present in bowel/bladder - Adhesions - Infertility due to damage to fallopian tubes and ovaries pathophysiology unclear - General surgical complicationsCERVICAL CANCERWHA T IS CONDITION B? Cancer of the cervix: - Predominantly squamous cell carcinoma, then adeno-, then small cell - Strongly associated with HPV (16 and 18)CAUSES/ RISK FACTORS - Increased risk of catching HPV - Non-engagement with screening - Smoking - HIV - COCP >5yrs - Increased number of full-term pregnancies - FHx - Exposure to diethylstilbestrol during fetal developmentSYMPTOMS AND SIGNS ● Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) ● Vaginal discharge ● Pelvic pain ● Dyspareunia (pain or discomfort with sex) O/E: ● Ulceration, Inflammation, Bleeding, Visible tumour -> urgent cancer referral and colposcopySCREENING ● Every three years aged 25 – 49 ● Every five years aged 50 – 64 Initially screened for hrHPV - if negative, return to normal screening If positive, cytology should be reported. ● Inadequate sample – repeat the smear after at least three months ● HPV negative – continue routine screening ● HPV positive with normal cytology – repeat the HPV test after 12 months ● HPV positive with abnormal cytology – refer for colposcopyTREA TMENT Using FIGO staging: ● Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy ● Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy ● Stage 2B – 4A: Chemotherapy and radiotherapy ● Stage 4B: Combination of surgery, radiotherapy, chemotherapy and palliative care Pelvic exenteration in advanced cervical cancer - removing most or all of the pelvic organs - has significant implications on quality of life. - Bevacizumab - monoclonal antibody, in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. Targets VEGF-A, which is responsible for the development of new blood vesselsCOMPLICA TIONS - Complications associated with cancer - Minor vaginal bleeding - Dysuria - Pain - Renal failure - Blood clots - Bleeding - Fistula formationATROPHIC VAGINITISWHA T IS CONDITION C? - Dryness and atrophy of the vaginal mucosa - Related to a lack of oestrogen - ‘Genito-urinary syndrome of the menopause’CAUSES/ RISK FACTORS - Smoking, via effects on circulation and reduced oestrogen sensitivity - No vaginal births - No sexual activity -> sexual activity increases blood flow and elasticity of vaginal tissues - MenopauseSYMPTOMS AND SIGNS - Itching - Dryness - Dyspareunia (superficial) - Bleeding - Recurrent UTIs, stress incontinence, pelvic organ prolapseINVESTIGA TIONS Typically a clinical diagnosis O/E: - Pale mucosa - Thin skin with reduced folds - Erythema and inflammation - Sparse pubic hair - DrynessTREA TMENT - Symptomatic treatment with lubricants e.g. Sylk, Replens, YES Oestrogen ladder: - Cream (with applicator) - od tablets (estradiol) - Ring (replaced every 3 months) Contraindications: BrCa, angina, VTE - unclear if increases risk of endometrial Ca -> monitor annually to stop treatmentCOMPLICA TIONS - Vaginal infections - Recurrent urinary infectionsQUIZ 2a A 55-year-old postmenopausal woman presents to her GP with complaints of vaginal dryness, itching, and dyspareunia. She reports a gradual onset of symptoms over the past year, and her discomfort is impacting her quality of life. The patient has no history of estrogen-dependent malignancies or contraindications to hormone therapy. She has not used hormonal replacement therapy previously. On physical examination, there is thinning of the vaginal epithelium, pallor, and loss of rugae. The pelvic exam is otherwise unremarkable, with no visible lesions or masses. The pH of the vaginal secretions is elevated, consistent with atrophic vaginitis. What is the most appropriate first-line management? A) Topical corticosteroids B) Vaginal moisturisers C) Vaginal lubricants D) Systemic oestrogen therapy E) Topical oestrogen therapyQUIZ 2b Which of the following is NOT a risk factor for cervical cancer: A) Nulliparity B) Prolonged COCP use C) Non-engagement with screening D) Smoking E) HIVQUIZ 2c What is the gold standard diagnostic tool for endometriosis? A) Abdominal ultrasound B) Transvaginal ultrasound C) Blood tests D) Laparoscopy E) LaparotomySUMMARY HISTORY TAKING EXAMINATION INVESTIGATIONS QUIZ 1 ENDOMETRIOSIS CERVICAL CANCER ATROPHIC VAGINITIS QUIZ 2THANK YOU!REFERENCES https://www.ncbi.nlm.nih.gov/books/NBK562159/ https://geekymedics.com/gynaecology-history-taking/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478410/ https://zerotofinals.com/obgyn/gynaecology/endometriosis/ https://zerotofinals.com/obgyn/cancer/cervical/phicvaginitis/ https://geekymedics.com/bimanual-vaginal-examination/