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GYNAE CCA ROUND UP H U D A A B I D T H 5 Y E A R M E D I C A L S T U D E N T 1H I STO R Y ST R U C T U R E Menstrual hx- • How long is your cycle? Obstetric hx- • Is there a chance you could be pregnant? • How many days do you • Have you ever been pregnant before? How bleed? • When was the first day of many pregnancies? your most recent period? • If pregnant before, how was baby delivered? (counts as cycle day 1) • Were there any complications with the delivery? • Was your baby born full term or premature? Sexual hx- • Are you sexually active? Red flags- • Have you got a regular partner or casual partners? • Weight loss? • What is the gender of your partner? • Night sweats? • Do you use protection? • Recent fevers? • Are you on any contraception? • If at the age of cervical smears, ask for most recent one. What was the result?H E AV Y B L E E D I N G Clarify: • Where is the blood coming from? • How much blood? How often do they need to change tampons/pads? Are they completely soaked through? • How long are their periods? Any deviation from what their normal periods are like? Investigations: • Examination- Bimanual, speculum exam • Bloods- FBC (Hb important), LFTs, clotting screenD I F F E R E N T I A L S / T R E AT M E N T Differentials for menorrhagia: • Endometriosis/adenomyosis Treatment: • PID • If the patient wants contraception- 1st line is • Fibroids IUS (Mirena), COCP, cyclic progestogens • Hypothyroidism (noresthisterone) • Contraceptives (specifically copper coil) • If the patient doesn't want contraception- • Bleeding disorders (Von Willebrand disease) Tranexamic acid (if no pain and just heavy • Endometrial cancer/hyperplasia bleeding), Mefenamic acid (if pain and heavy • Dysfunctional uterine bleeding (no identifiable bleeding) cause)S P OT T I N G It is important to establish when the patient experiences spotting.There are three potential scenarios, and each have their own set of differentials that need to be considered: In between periods: Ovulation bleeds, contraception side effect, STI, implantation bleed from pregnancy, ectopic pregnancy, miscarriage Post coital (after sex): atrophic vaginitis, endometrial hyperplasia/cancer Postmenopausal: Endometrial cancer/hyperplasia, atrophic vaginitis Ix: • Exam- Bimanual examination, pelvic exam to feel for masses, speculum exam, swabs if concerns about potential STIs. • Pregnancy test • Cervical smear/colposcopy • Bloods- FBC, clotting profile • USSC E R V I C A L S M E A R S PAT H W AY Smears are offered to women from the ages of 25-64. • Every 3 years from 25-49 Management: • Then every 5 years until 64 Loop excision of transformation zone If referred for colposcopy these are the potential results you might have to explain: •borderline changes in squamous or endocervical cells. •low-grade dyskaryosis. •high-grade dyskaryosis (moderate). •high-grade dyskaryosis (severe). •invasive squamous cell carcinoma. •glandular neoplasia After smear, sample sent to lab for testing. Is there HPV? Yes No Cervical changes? Come back for smear in 3-5 years Ye No s Invited for further Come back for After 3 results like this, tests at colposcopy smear in 1 year invited to colposcopy for further testingC E R V I C A L E C T R O P I O N What is it? It is when the cervix is everted (the bit that is in the uterus flips and is now on the side of the cervix in the vagina instead). Potential risk factors? Increased levels of oestrogen (Contraception containing oestrogen, HRT) What are the symptoms? Abnormal vaginal bleeding, increased vaginal discharge What is the treatment? None C E R V I C A L P O LY P What is it? It is a benign growth on the cervix. Potential risk factors? Not very clear but more common in older women. What are the symptoms? Abnormal vaginal bleeding. What is the treatment? As there is a small risk of these polyps turning into cancers, they are removed when identified. C E R V I C A L C A N C E R What is it? It is a squamous cell carcinoma of the cervix. It happens after cervical intraepithelial neoplasia (when genetic changes happen to cells in the epithelium over time that eventually lead to a full transformation into cancer). Potential risk factors? Majority of cases are caused by chronic HPV infections (speifically 16,18,33). Other risk factors include; smoking, HIV, lots of sexual partners, COCP What are the symptoms? Abnormal vaginal bleeding, increased vaginal discharge What is the treatment? Treatment depends on the classification of the cancer (FIGO classifications).They include chemotherapy, radiotherapy and hysterectomy with removal of the cervix.I R R E G U L A R P E R I O D S Differentials for oligomenorrhea: Obvious/physiological- Pregnant, Contraception, Breastfeeding, perimenopausal, recently menarche Take good history, this saves you the extra thinking More differentials- Hyper/hypothyroidism, PCOS, hypogonadotropic hypogonadism, hyperprolactinaemia, premature ovarian insufficiency Investigations: Physical exam- Pelvic Pregnancy test (urine hcg) Bloods- FBC, serum hcg USS MRI headP C O S Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women. There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, increase in androgens and insulin resistance. Women with polycystic ovarian syndrome present with some key features: •Oligomenorrhoea or amenorrhoea •Infertility •Obesity (in about 70% of patients with PCOS) •Hirsutism •Acne Women with PCOS are at risk of •Male pattern baldness •Acanthosis nigricans developing the following conditions: • Insulin resistance and diabetes • Cardiovascular disease • Endometrial hyperplasia and cancer P C O S D I AG N O S I S A N D T R E AT M E N T The Rotterdam criteria is something that is very easily tested in both ccas and progress.There are three components: •Oligoovulation or anovulation, presenting with irregular or absent menstrual periods •Hyperandrogenism, characterised by hirsutism and acne •Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3) Treatment involves Infertility: Hirsutism and acne: three components: • BMI reduction to • COCP (Co- <30 cyprindiol (Dianette)) Regulating • Clomifine and/or • Topical eflornithine can be ovulation: metformin.This used to treat facial hirsutism. • Lowering BMI to also helps with <30 reducing insulin • COCP used to help resistance regulate ovulationST I S Candidiasis Bacterial Trichomoniasis Chlamydia Gonorrhea vaginosis Cause Candidiasis Gardenerella Trichomonas Chlamydia Neisseria albicans vaginalis vaginalis trachomatis gonorrhoea Discharge White cottage Thin, grey Frothy, Mucopurulent Increased, change cheese yellow/green yellow,green Other Itching, Bad smell Vulval irritation, Dysuria, PV Dysuria, PV symptoms superficial pain pain on sex bleeding bleeding on sex, smell Investigations None Clue cells, + Strawberry NAAT- NAAT and whiff test (ew) cervix on exam, vulvovaginal MC+S? motile swabs trophozoites Management Oral fluconazole Oral Oral Oral Ceftriaxone metronidazole metronidazole doxycycline and azithromycin 1/5/2025 14QUESTIONS?C O N T R AC E P T I O N E X P L A N AT I O N It is important that you're able to still take a thorough but more concise history when being tested on contraceptive explanations.This is a likely station to come up as it is easily tested and there are lots of different devices/ medications that you can potentially get: • History- Age, PMHx, DHx, SHX, previous contraceptive use/ pregnancies. • What do you already know about contraception? • Do you have a particular preference? • Describing the contraception: How does it work? How do you take it/ use it? Missed pill rules What are the side effects? Pros vs Cons? • Suggest any alternatives if appropriate • Summarise and end the conversation/ thank patient for their time!C O N T R AC E P T I O N T Y P E S Barrier methods: Most common one is the condom. It is the only form of contraception that also protects against STIs, so always advise patients to use one even if they're on a different form of contraception. How it works- Prevents fertilisation Pros: • Used only during intercourse • Reduces STI transmission • Rare side effects from using (might cause an allergic reaction but non-latex versions available) Cons: • Can break, split, tear while using • May interrupt intercourse • Need to know correct technique for using them • Allergies to latex?Combined oral contraceptive pills: Combination pill of oestrogen and progesterone. Most common brand is Microgynon. How it works-Works by inhibiting ovulation and also creating a mucus plug to block entry of sperm into the uterus. Thins the lining of the uterus so that implantation doesn't occur/fails. Pros: • Doesn't interrupt intercourse • Can be stopped at short notice • Reduces risk of ovarian, endometrial and bowel cancer • Makes periods lighter, more regular, less painful Cons: • If forget to take the pill then effectiveness is reduced • Lots of side effects like headache, nausea, breast tenderness • Vomiting and diarrhoea can affect effectiveness • Increased risk of VTE/stroke • Increased risk of breast cancerProgesterone only contraceptive pills: Single hormone pill (also comes as an injection that I'll cover later) How does it work?- Prevents ovulation and creates a mucus plug to prevent fertilisation. Pros: Suitable for patients that can't take oestrogen Taken without breaks so don't have to remember to start/stop it Doesn't interrupt intercourse Cons: Can cause irregular bleeding, amenorrhoea, more frequent bleeding Protection affected if pill is forgotten (missed pill window is 3 hours) Vomiting and diarrhoea can affect effectiveness Certain drugs can affect effectivenessIUS Hormonal coil fitted inside uterus to stop pregnancy How does it work?- Prevents fertilisation and implantation as it contains progesterone. Pros: Lasts 3-5 years Suitable for people that cant take oestrogen Very effective in preventing pregnancy Doesn't interrupt intercourse More likely than the implant to reduce heavy menstruation Cons: Can make periods irregular, absent Can cause acne, headaches and breast tenderness Risk of uterine perforation/ infection with procedure to insert/remove (also it is painful despite what others might teach you) Can fall out of uterus If pregnancy occurs, more likely to be ectopicIUD: Copper coil fitted to stop pregnancy How does it work?: Copper makes uterus unhospitable environment for sperm.Acts as a spemicide preventing pregnancy. Pros: Lasts for 10 years Suitable for women that can't use hormonal contraception Very effective Doesn’t interrupt intercourse Effectiveness unaffected by medications Can be used as emergency contraception Cons: Can make periods heavier, longer and more painful Procedure can cause perforation/ infection and it's painful Can fall out of uterus If pregnancy occurs, more likely to be ectopicImplant: Depot injection: Plastic rod inserted in the arm that secretes progesterone Progesterone injection to prevent pregnancy How does it work?: Prevents ovulation How does it work?: Inhibits ovulation Pros: Pros: Good for those who can't take oestrogen Lasts for 3 years Don't need to remember to take it daily Suitable for those who can't use oestrogen Doesn't interrupt intercourse Very effective in preventing pregnancy Doesn’t interrupt intercourse Cons: May cause irregular periods, absent periods, more heavy bleeding Cons: Periods can become irregular, absent Patient needs to be ok with injections Can cause acne, headaches, breast tenderness Effectiveness reduced if injection is late Procedure to fit/remove carries risk of bruising and Can affect bone mineral density if used long term infection. Also, it hurts Certain drugs affect effectiveness 22Vasectomy: Female sterilisation: Prevents fertilisation Prevents fertilisation How does it work?: Cutting out a part of the vas Pros: deferens, so that sperm can't enter semen. Permanent contraception Doesn’t interrupt intercourse Pros: Doesn’t affect hormonal levels Permanent contraception Effectiveness unaffected by medications Doesn’t interrupt intercourse Less invasive and lower risk than female sterilisation Cons: Carries generic risks of surgery Cons: Women can experience pain afterwards Carries risks of surgery Difficult to reverse Pain Can still get pregnant Difficult to reverse If pregnancy occurs, more likely to be ectpoic Contraception should be used afterwards until confirmed that semen is sperm freeG U I D E L I N E S - G E E K Y M E D I C S Geeky medics has separate pages for each contraception and how to explain them. Also have a summary table that groups all the similar ones together. • Contraception counselling Finally, they have a summary page that talks • Separate pages for each about each one and their pros vs cons. contraception • Summary PDF Links for these are on this slide and at the end!G U I D E L I N E S - U K M E C 4 different categories. Summaries each contraceptive and when it is appropriate to use/ when it is completely contraindicated. Category 1- Good to use this contraception. Category 2- Benefit outweighs the risk of using this contraceptive method Category 3- Risk outweighs benefit. If used, it needs to be under specialist supervision/advice. Category 4- Unacceptable health risk if this contraceptive method is used.E M E R G E N C Y C O N T R AC E P T I O N Levonorgestrel Ulipristal IUD Inhibits ovulation Inhibits ovulation Spermicide,prevents implantation 3 days after UPSI 5 days after UPSI 5 days after UPSI or 5 days before ovulation Can restart long term contraception Long Term contraception can be Can be used as long term contraception immediately restarted 5 days after ulipristalM E N O PA U S E Amenorrhea for 12 months: Menopause Drop in oestrogen results in: • Change in periods: oligomenorrhea -> Contraindications to HRT: amenorrhea • Current/past breast cancer • Vasomotor symptoms: flushing, night sweats • Oestrogen sensitive cancers • Undiagnosed PV bleeding • Vaginal atrophy and dryness • Untreated endometrial • Anxiety and depression hyperplasia Management: • Lifestyle modifications: sleep, no stress, exercise • HRT: oral or transdermal • non-HRT: antidepressant, lubricants, therapy etcI N C O N T I N E N C E Stress Urge Leaking of urine when coughing, laughing, sneezing or Sudden and involuntary loss of urine associated with exercising urgency RF: childbirth, hysterectomy RF: recurrent UTI, high BMI, old age, smoking, caffeine Lifestyle: avoiding caffeine, fizzy and sugary drinks, as Lifestyle: avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake well as avoiding excessive fluid intake + pelvic floor exercises + pelvic floor exercises Pelvic floor muscle retraining Bladder retaining Surgical management Medical: anticholinergics (Oxybutynin, Tolterodine, Medical: Duloxetine Fesoterodine, Solifenacin) Surgical management available 28QUESTIONS?R E F E R E N C E S • Geeky medics- https://geekymedics.com/category/communication-skills/information- giving/contraceptive-counselling/ • Zero to finals- https://zerotofinals.com/obgyn/ • Passmed text book • UKMEC guidelines- https://www.fsrh.org/Public/Documents/ukmec-2016-summary- sheets.aspx • UKMEC- summary table- https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ukmec-summary- september-2019.pdfT H A N K YO U F O R L I ST E N I N G !