Computer generated transcript

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

Gynaecological disordersContent • Endometriosis • Adenomyosis • Fibroids • Abnormal uterine bleeding • Amenorrhoea, Anovulation • PCOS • PID • Menopause • HRTEndometriosis • Endometrial-like tissue, outside of the uterus. • 10% of women of reproductive age • Aetiology - No clear aetiology yet • Retrograde menstruation • Genetics • Lymphatic spread • Coelomic metaplasia • Immune dysfunction • Endometriosis is associated with menstruation. • formation.al changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue • Oestrogen dependentEndometriosis • Most commonly • Pelvis • On the ovaries • Peritoneum • Uterosacral ligaments • Pouch of Douglas • Extra-pelvic deposits, are rare: • Bowel • Appendix • Pleural cavity • In the top 50 most painful chronic conditions as per the NHSEndometriosis cont. Risk Factors Signs & Symptoms Investigation • Early menarche • Varies based on severity, location of • Examination usually normal, but may lesions… have posterior fornix / adnexal • Late menopause tenderness, nodules or adnexal • Secondary and Deep Dysmenorrhoea • Nulliparity masses (endometrioma). • Dyspareunia • First degree relative with • The only reliable diagnostic test is endometriosis • Cyclical or Chronic pelvic pain laparoscopy. • Obstruction to vaginal outflow • Subfertility/infertility • Average 7.5 years from onset of symptoms till diagnosis made. • Cyclical rectal bleeding • TVUS excludes endometriomas, but • Painful defecation a negative TVUS doesn’t exclude endometriosis. • Cyclical haematuria • Ca 125 & MRI may be beneficial. • IBS-like symptoms (bloating, diarrhoea, constipation, lower back pain) • Catamenial pneumothorax (rare) • Asymptomatic !Endometriosis Management Management depends on the nature and severity of symptoms and the need for future fertility. 1. Medical • Suppress symptoms (pain), doesn’t reduce recurrence of symptoms once treatment has stopped. Works by inducing pseudo-pregnancy or pseudo- menopause state. • COCP, Medroxyprogesterone acetate , GnRH agonist 2. Mirena IUS • Effective even after three years of use. 3. Surgical – Best if trying to conceive. • Excision of severe and deeply infiltrating lesions, Ovarian cystectomy (for endometriomas), Adhesiolysis, Bilateral oophorectomy with a hysterectomy (if indicated). Complications Infertility (tubal damage), Risk of Ectopic pregnancy, Adhesion formation, bowel obstruction and Increased risk of IBDAdenomyosis • Endometrial-like tissue invading the myometrium, causing inflammation, pain and the formation of adhesions. • S&S - Menorrhagia, Dysmenorrhoea, Chronic Pelvic pain, Dyspareunia, Enlarged boggy uterus and Infertility. • Most common in multiparous, at end of reproductive years • Investigations - TVUS, hysteroscopy or diagnostic laparoscopy, MRI • Tx • Mirena coil • Non hormonal – tranexamic acid, NSAIDs • Hormonal COCP, POP, GnRH agonist • Surgical – hysterectomy, endometrial ablation, uterine artery embolizationFibroids / Leiomyomas • Benign tumours – proliferation of smooth muscle cells and fibroblasts • Age 30- 50 • Most common benign uterine tumour in reproductive age • Regress after menopause typically • Types: Subserosal, intramural or submucosal • Signs and symptoms • Asymptomatic • Menorrhagia, dysmenorrhoea, Abdominal discomfort/bloating • Infertility, pressure symptoms (on bladder or bowel) • Irregularly enlarged uterusFibroids cont. • Investigations – Abdominal and Bimanual pelvic exam, USS (preferably TVUS), hysteroscopy, MRI • Treatment • Asymptomatic – monitor growth, safety net, No action • Mirena useful ( if no distortion of cavity) • Mefenamic and tranexamic acid, NSAIDs • COCP, POP, GnRH agonist (reduce size of fibroids, short term use pre surg.) • Surgery- Myomectomy, Ablation, Uterine artery embolization and Hysterectomy • Complications • Compression of adjacent structures (bladder, bowel) • Subfertility / infertility • Pregnancy complications – Miscarriage, Fibroid vascular infarction (red degeneration) – Acute pain, Foetal malpresentation, Preterm labour, PPH. Usually managed conservatively during pregnancy.Abnormal Uterine Bleeding • Abnormal uterine bleeding, in the absence of pregnancy, genital tract pathology or systemic disease • Heavy menstrual bleeding most common symptom- 50% of women with HMB have no identifiable cause • Rule out all other ddx first ! (bleeding problems, thyroid, fibroids, PID, PCOS, endometriosis/adenomyosis, PREGNANCY…) so blood tests and TVUS as investigations • Tx • Non hormonal – Tranexemic acid, pain relief (paracetamol, NSAIDs (mefenamic acid) • Hormonal – Mirena, COCP , POP, long-acting progestogens (Depo Provera) • Surgical – hysterectomy curativeAbnormal Uterine Bleeding – FIGO classificationPercentage reduction of menstrual blood loss with medical therapies 0 IUS Placebo -25 Prostaglandin Synthetase Inhibitor Combined pill -50 High dose progestogen Tranexamicacid -75 Danazol -100 Amenorrhoea Primary – No menstruation by 15 Secondary – Cessation of y.o with normal secondary sexual menstruation for 3-6 months with characteristics, OR by 13 y o with previously normal menses OR 6- no secondary sexual 12 months with previous characteristics oligomenorrhoea • Gonadal dysgenesis (Turner, • Hypothalamic amenorrhoea 46XO) (stress, excessive exercise) • Congenital adrenal hyperplasia • PCOS • Imperforate hymen! • Premature ovarian failure • Congenital malformations of the • Hypothyroidism, thyrotoxicosis genital tract • Sheehan syndrome • Functional hypothalamic • Asherman’s syndrome amenorrhoea (e.g. anorexia) (intrauterine adhesions) • Exclude pregnancy! Common Causes of Secondary Amenorrhoea Oestradiol FSH LH Prolactin Testosterone Hyperprolactinaemia Low Normal Normal High Normal Low Low PCOS Normal,low, Normal Normal/high Normal Normal/ high Raised LH:FSH Slightly high moderately increased Free androgen index increased Premature ovarian Low High High Normal Normal /Low insufficiency Functional Low Normal/Low Normal/Low Normal/Low Normal/Low hypothalamic (weight loss,Stress,exercise) Data from: [Practice Committee of theAmerican Society for Reproductive Medicine, 2008; Gordon, 2017; Samperi, 2019; BMJ Best Practice, 2022b]Anovulation / Anovulatory Cycle • Menstrual cycle with no release of egg • May still have bleeding, but no progestin secretion from corpus luteum (as no ovulation occurs) → Persistent proliferative endometrium, unstable and prone to irregular & heavy bleeding • Infertility common symptom • Classification • Group I – Hypothalamic pituitary failure (hypothalamic amenorrhoea, or hypogonadotrophic hypogonadism) • Pulsatile GnRH or gonadotrophins + LH • Group II – Hypothalamic - pituitary – ovarian dysfunction (PCOS) – 80%, most common • Group III – Ovarian Failure • Menopausal symptoms, <40 y o • Idiopathic, post chemotherapy/radiotherapy, Post oophorectomy • Raised FSH (>30), Low Oestradiol – Treat as menopauseCauses of Anovulation • Primary ovarian failure • Premature ovarian failure • Genetics (Turner) or autoimmune • Medication - antiepileptics, antipsychotics, chemotherapy • Secondary hormonal disturbance • Contraceptives, Pregnancy • PCOS • Hyperprolactinoma • Kallman’s syndrome (hypogonadotrophic hypogonadism) • Underweight/overweight, stress and significant exercise • HypopituitarismPolycystic Ovary Syndrome • Most common endocrine disorder in women, 80% of all anovulatory subfertility • Hyperinsulinaemia → Reduced Sex Hormone Binding Globulin (SHBG) production in the liver → Increased unbound active testosterone. • Vicious Cycle → Insulin resistance → Weight gain + Excess body fat → Increase insulin secretion → Worsening PCOS • Increased androgen → Stops follicular development → Anovulation and menstrual disturbance • Increased LH pulse amplitude and frequency from pituitary → Increased LH:FSH ratio → Ovaries prefer synthesizing androgen rather than oestrogen • May still have increased oestrogen levels. • The follicular development arrests before maturation of ovulatory follicle. • So, there will be no ovulation, but oestrogen production continues. • As a result to continuous oestrogen exposure, unopposed by progestogen, the endometrium becomes hyperplastic. Polycystic Ovary Syndrome Investigations – Rotterdam Criteria >2 of : Management • Irregular / absent ovulations (irregular menstrual • Weight loss, COCP (co-cyprindiol), cyclical cycle) POP or Mirena– manage symptoms like • Clinical OR Biochemical signs of hirsutism, acne and regulate cycle hyperandrogenism (acne, hirsutism, increased • Metformin as off-label use total testosterone/ low SHBG) • Polycystic ovaries on USS (>12 antral follicles on • If trying to conceive – covered more in an ovary, or ovary volume >10 mL) Infertility • Clomifene +/- metformin, Letrozole, • PCOS can be diagnosed without having Gonadotrophins or pulsatile GnRH polycystic ovaries, and polycystic ovaries alone • Ovarian drilling- damage hormone producing do not diagnose PCOS cells in ovary with diathermy/laser • Assisted reproductionPelvic Inflammatory Disease • Infection of the upper genital tract, almost always due to STI • Causes endometritis, oophoritis, salpingitis, tubo-ovarian abscess, peritonitis • RF – young, early first coitus, multiple sexual partners, history of STI, recent instrumentation of uterus/disruption of cervical barrier • Most common causes: Chlamydia trachomatis, Neisseria gonorrhoeae • In older women, may have descending appendicitis, or Pathogen negative PID • S&S • Fever, dysuria, pelvic / lower abdominal pain, Deep dyspareunia, abnormal vaginal bleeding / discharge. • Fitz Hugh Curtis Syndrome - RUQ pain, as anterior abdominal wall/ diaphragm and anterior liver capsule adhere to each other causing peri-hepatitis • Adnexal tenderness • Infertility, increased risk of ectopic pregnancyPelvic Inflammatory Disease cont. • Investigations • Exclude pregnancy! • Vaginal swabs • FBC, WBC, ESR, CRP • HIV & syphilis • USS – esp if abscess or hydrosalpinx suspected • Gold standard is Diagnostic laparoscopy, but is not routinely done • Treatment • Pain relief • Consider removing any IUD • Consider admission if septic, acutely unwell.. • Start empirical tx until results of swabsPelvic Inflammatory Disease cont. • First line • Ceftriaxone 1g Single IM dose + Oral doxycycline 100 mg BD + Oral metronidazole 400 mg BD for 14 days • Oral ofloxacin (or levofloxacin) + oral metronidazole for 14 days • Mycoplasma +ve – Moxifloxacin, discuss with micro • Alternative to 1 line – Ceftriaxone + Oral azithromycin for 14 days • Advice for adherence and sexual abstinence • If HIV positive – refer to clinic • Abscess may need surgical draining • May need contact tracing • Review in 72 hrs and some may need test of cureMenopause • Permanent loss of menstruation due to loss of ovarian follicular activity. It is diagnosed clinically after 12 months of amenorrhoea (>50 yrs) or after 24 months (<50 yrs) • Mean age 51 yrs • In perimenopause oestrogen levels begin to decline and fluctuate – unpredictable periods, hot flashes, dry skin, night sweats, atrophic vaginitis, osteoporosis, joint pain, decline in sexual function, cognition… • Elevated FSH – should not be used for diagnosis unless atypical presentation • Management • Lifestyle changes – exercise, good sleep hygiene, reduce stress, weight loss, smoking cessation • CVD risk assessment and management, osteoporosis prevention, screening for cervical, breast and bowel cancer • Need for contraception for 2 yrs after LMP (<50) or for 1 yr (>50) until 55 yrs – NOT HRT! but HRT + POP • Non-HRT treatments – CBT, SSRIs/SNRIs, vaginal oestrogen creams to address symptoms • HRT- individualized choice Hormone Replacement Therapy • Transdermal, oral, topical can be used • General Rule: if has uterus add progestogen. If no uterus – oestrogen only can be given • Aim to prescribe the lowest dose for the shortest possible duration. • Vasomotor and mood symptoms : Oral or transdermal preparations • Urogenital symptoms: low-dose vaginal oestrogen first-line and continue treatment for as long as needed to relieve symptoms. Some women on systemic HRT may also benefit from additional low-dose vaginal oestrogen. • Consider transdermal rather than oral HRT for women at increased risk of VTE • Review in 3 months, then annually, unless new symptoms • Sudden change in menstrual pattern, intermenstrual bleeding, postcoital bleeding, or postmenopausal bleeding - 2-week referral if a gynaecological cancer is suspected. • SE : Nausea, breast tenderness, fluid retention, weight gain Hormone Replacement Therapy • Benefits • Decreases vasomotor and urogenital symptoms • Decreases risk of osteoporosis, fragility fractures and colorectal cancer • Risks • Increased risk of Breast & Ovarian cancer (endometrial if oestrogen alone), Increases risk of strokes, VTE and coronary heart disease • CI – Current/past breast Ca, any oestrogen sensitive Ca, undiagnosed vaginal bleed and untreated endometrial hyperplasia • Duration • Cyclical for perimenopausal ( still having menstrual periods) – regular predictable bleeds • Continuous for postmenopausal • Can be continued for 2-5 years, stop gradually! • Monitor any sudden change, new bleedings, treatment efficacy, comorbidities and contraindicationsImpact on risk of breast cancer Comparator + 4 - 4 + 4 + 5 + 3 + 24 - 7The risk lasted >10 years after ceasing MHT 58 studies (92-18)– 108,647 women developed Br Ca at mean age Of 65 years – 51% of those had MHT 5 years of HRT at age of 50 years – Ca incidence 50 to 69 1 in 50 –oestrogen and progestogen daily 1 in 70 – oestrogens and intermittent progestogens 1 in 200 oestrogen only If used for 10 years the risk is twice Lancet Aug 29’th 2019FeedbackResources • Collins, Sally, et al. Oxford Handbook of Obstetrics and Gynaecology. Oxford Oxford University Press -07-01, 2013, oxfordmedicine.com/view/10.1093/med/9780199698400.001.0001/med- 9780199698400. • Dr Colin Tidy. “Endometriosis.” Patient.info, 11 Mar. 2016, patient.info/doctor/endometriosis-pro. • Dr Mary Harding. “Menorrhagia.” Patient.info, 24 Feb. 2016, patient.info/doctor/menorrhagia. • “Fibroids.” NICE, cks.nice.org.uk/topics/fibroids/. • “Fibroids | Doctor.” Patient.info, patient.info/doctor/fibroids-pro. • “Infertility Management.” NICE, cks.nice.org.uk/topics/infertility/management/management/. • “Management of Endometriosis.” NICE CKS, cks.nice.org.uk/topics/endometriosis/management/management-of-endometriosis/. • “Menorrhagia.” NICE, Feb. 2024, cks.nice.org.uk/topics/menorrhagia-heavy-menstrual-bleeding/. • NICE. “Amenorrhoea.” NICE, Feb. 2022, cks.nice.org.uk/topics/amenorrhoea/. • “Dysmenorrhoea.” NICE CKS, cks.nice.org.uk/topics/dysmenorrhoea/. • “Menopause.” NICE, Sept. 2022, cks.nice.org.uk/topics/menopause/. • “Polycystic Ovary Syndrome.” NICE, Sept. 2018, cks.nice.org.uk/topics/polycystic-ovary-syndrome/. • “Scenario: Management of Pelvic Inflammatory Disease.” NICE, cks.nice.org.uk/topics/pelvic-inflammatory-disease/management/management/. • “Scenario: Managing Women with Menopause, Perimenopause, or Premature Ovarian Insufficiency.” NICE CKS, cks.nice.org.uk/topics/menopause/management/management-of-menopause- perimenopause-or-premature-ovarian-insufficiency/.