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Common Gynaecology Conditions By Dr Anamika Banerjee (FY2) and Dr Akshaya Rajangam (ST1 Obstetrics and Gynaecology) University Hospitals of Leicester NHS Trust 20/03/24 BRITISH INDIAN MEDICAL @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS ASSOCIATION @BIMA BIMA Clinical and OSCE series The British Indian Medical Association (BIMA) - The British Indian Medical Association (BIMA) is a national non-profit organisation founded on developing a supportive network amongst students and doctors across the UK - Provides tutorial series, conference events, networking, careers talks, socials and more! - For more information follow us on social media and stay up to date with latest academic events by joining our mailing lists: BIMA Clinical and OSCE series: https://forms.gle/CidGvWAc9YY9WSSs8 BIMA Fundamentals of Medicine & Pathology series: https://forms.gle/KfAgeoX55GPAWqee8 BIMA Clinical and OSCE seriesTalk Outline Case based discussion on common gynaecology conditions - Acute gynaecology - Menorrhagia - PCOS - Post menopausal bleeding Q&A BIMA Clinical and OSCE seriesLearning Objectives By the end of this session, you should be able to: - Recognise common presentations of common and important gynaecological conditions - Understand key investigations and management for these conditions - Apply this knowledge to clinical cases in gynaecology BIMA Clinical and OSCE seriesBefore we begin…. How confident are you on gynaecology topics? BIMA Clinical and OSCE seriesCase 1 31 y/o female was brought in by ambulance to A&E with sudden onset severe right iliac fossa (RIF) pain. Observations: HR 110bpm, BP 126/81, RR 20, Sats 95% OA, T 37.0, Urine pregnancy test negative. On examination, she has a distended abdomen with palpable mass in RIF. What are your top differentials? BIMA Clinical and OSCE seriesDifferentials Obstetrics and Gynaecology: - Ovarian torsion - Ovarian Cyst accident - Tubo-ovarian abscess - Ectopic pregnancy GI - Appendicitis - Bowel perforation/ischaemia/obstruction/malrotation BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents ● Ovarian cysts can be classified as: ○ Simple vs complex ○ Benign vs malignant ○ Pre-menopause vs post menopause BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents Physiological and Simple cysts: ● functional/physiological ovarian cysts – cysts that develop as part of the menstrual cycle and are usually harmless and short-lived; these are the most common type ○ Follicular cyst ○ Corpus luteum cyst - Both would normally be <3cm ● Simple cyst - usually a large follicle >3cm that has continued to grow after an egg has been released; simple cysts are the most common cysts to occur before the menopause and most disappear within a few months BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents ● Simple cyst characteristics: ○ USS: Benign, fluid filled, thin-walled, unilocular, anechoic cyst, NO septations or nodules ○ Classification: ○ Small: <5cm ■ Asymptomatic, simple cyst <5cm typically do not require treatment and can self-resolve with time. ○ Medium 5-7cm ■ Watch and wait approach with follow up scan 1 year later ○ Large >7cm ■ Referral to gynaecology, MRI scan +/- surgery ● Higher risk of ovarian cyst accident/torsion +/- pathology https://www.rcog.org.uk/for-the-public/browse-our-patient- information/ovarian-cysts-before-the-menopause/ BIMA Clinical and OSCE series Ovarian Cysts, Torsion and Cyst Accidents pathological ovarian cysts – cysts that form as a result of abnormal cell growth; these are much less common ○ Benign: ■ Mature teratoma (dermoid cyst) ■ Endometrioma ‘Chocolate cyst’ ■ Serous cystadenoma ■ Mucinous cystadenoma ○ Malignant: ■ Immature teratoma ■ Germ cell tumour ■ Epithelial carcinoma (serous or mucinous cystadenocarcinoma) ■ Sex-cord tumour ■ Malignant metastasis e.g. breast or GI tract → ‘Krukenberg tumour’ 151926/diseases-and-conditions/ovarian-tumor-benignntent/1- BIMA Clinical and OSCE seriesImages from: https://radiology.world/ovarian-cyst-f-u-guideline/Ovarian Cysts, Torsion and Cyst Accidents ● Key Ultrasound factors: International Ovarian Tumour Analysis (IOTA) Rules BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents Clinical presentation of ovarian cysts: ● asymptomatic, incidental finding ● Abdominal swelling/bloating ● lower abdominal pain or pelvic pain ● painful periods, or a change in the pattern of your periods ● pain during sex (dyspareunia) ● Pressure symptoms: ○urinary frequency ○pain related to your bowels, difficulty emptying bowels ○Early satiety, a change in appetite or feeling full quickly ● difficulty in becoming pregnant which may be linked to endometriosis BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents Ovarian torsion = gynaecology surgical emergency - Acute, severe iliac fossa pain - May be intermittent if spontaneously de- torts and re-torts - Tenderness +/-guarding - Nausea, vomiting - Clinically unwell – fever, hypotension etc. - May be associated with PV bleed +/- intraabdominal bleeding Infographic from: https://pubs.rsna.org/doi/full/10.1148/rg.2021200122 BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents Ovarian cyst rupture - acute lower abdominal/iliac fossa pain + tenderness and guarding - peritonitis - Nausea and vomiting - PV bleed - Pyrexia - Hypotension, feeling faint - Referred pain to shoulder tip BIMA Clinical and OSCE series Ovarian Cysts, Torsion and Cyst Accidents Investigations Imaging 1) Transvaginal USS +/- abdominal USS Bedside: - examination: abdominal, pelvic – bimanual 2) MRI scan and speculum If gynae-oncology condition suspected, consider: - Urine pregnancy test, urine dip - Basic observations CT abdomen pelvis, PET-CT Bloods: - Routine baseline Management: bloods including - Gynaecology referral/Gynae-oncology MDT FBC, U&E, CRP, referral LFT - Watch and wait + f/u USS - G&S - Surgical removal: - Tumour markers: - Laparoscopic - Laparotomy - If malignant may also need: - Hormonal therapiesadiotherapy BIMA Clinical and OSCE seriesOvarian Cysts, Torsion and Cyst Accidents Further reading RCOG Green-top guidelines for ovarian cysts in post-menopausal women https://www.rcog.org.uk/guidance/browse-all-guidance/green-top- guidelines/ovarian-cysts-in-postmenopausal-women-green-top-guideline-no-34/ RCOG guidelines and information on ovarian cysts in pre-menopausal women https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian- masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/ BIMA Clinical and OSCE seriesCase 2 31 y/o female presents to her GP with 6 months history of heavy periods described as very heavy lasting at least 7-10 days, passing multiple clots, having to change pads every hour. Bleeding is associated with painful periods and bloating sensation with distended lower abdomen. Also noticed increase urinary frequency and some constipation. No previous pregnancies, not using contraception as trying to conceive, but unsuccessful. PMHx: migraines with aura, No significant FHx. Pregnancy test negative. What are your differentials? BIMA Clinical and OSCE seriesMenorrhagia Definitions: ● The average menstrual cycle has a blood loss for seven days of a cycle of between 21 and 35 days. ● The average menstrual blood loss is about 30-40 ml. ● Menorrhagia – excessive blood loss during menstruation ○ 80 mL or more and/or a duration of more than seven days. ● The National Institute for Health and Care Excellence (NICE) defines heavy menstrual loss as excessive blood loss that interferes with a woman's physical, social, emotional and/or quality of life. https://patient.info/doctor/menorrhagia BIMA Clinical and OSCE seriesCauses of Menorrhagia: Uterine: Iatrogenic/device related: - Dysfunctional uterine bleeding – MOST COMMON - Copper IUD - Fibroids - Anticoagulant medication - Adenomyosis - Endometrial polyps non-gynaecology causes: - Endometrial hyperplasia/cancer - Bleeding disorders e.g. - Von Willebrand disease Cervical: - Factor V Leiden - Haemophilia - Cervical polyps - Antithrombin III deficiency - Ectropion BIMA Clinical and OSCE seriesFibroids Uterine fibroids (leiomyomata) are benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue Types: ● Intramural (the majority). ● Submucosal: growing into the uterine cavity. They may be pedunculated and may protrude through the cervical os. ● Subserosal: growing outwards from the uterus - can be: ● Uterine ● Cervical Image from: https://www.nurselk.com/2016/11/fibroids.html ● Intraligamentous ● Pedunculated subserous (abdominal) BIMA Clinical and OSCE seriesFibroids Risk Factors - Oestrogen exposure: early menarche, late menopause, nulliparity - FHx - 1st degree relative - Obesity - Afro-Caribbean origin Protective Factors - Multiparity - ?smoking BIMA Clinical and OSCE seriesFibroids Symptoms: Signs ● Palpable abdominal mass arising ● Can be asymptomatic from the pelvis. ● Heavy menstrual bleeding - often prolonged ● Enlarged, often irregular, firm, non- ● Abnormal uterine bleeding e.g. IMB tender uterus palpable on bimanual ● Pain pelvic examination. ● Pressure symptoms: ● Signs of anaemia due to ○ Bloating ○ Early satiety menorrhagia ○ Urinary frequency ○ constipation Red degeneration of Fibroid: ● Fertility: Outgrows blood supply → degeneration ○ Submucosal fibroids that distort uterine cavity may impair fertility - e.g. recurrent miscarriagesevere abdominal pain Often associated with nausea, vomiting, fevers, clinically unwell. BIMA Clinical and OSCE seriesFibroids Investigations: Bedside: history and examination, urine pregnancy test! Bloods: FBC – anaemia, clotting screen G&S hCG Others for differentials - e.g. infection markers (WCC, CRP), Ca-125 etc Imaging Transvaginal USS MRI pelvis BIMA Clinical and OSCE seriesFibroids Interventional Management - Uterine artery embolisation Conservative: - MRI guided transcutaneous focussed Ultrasound lifestyle, diet + exercise Surgery: is indicated when: Medical ● There is excessively enlarged uterine size. - NSAIDS e.g. ibuprofen, mefenamic acid ● Pressure symptoms are present. - Antifibrinolytic agents e.g. tranexamic acid ● Medical management is not sufficient to control - Hormone: COCP, Progesterone, LNG- IUS symptoms. (Mirena Coil) ● The fibroid is submucous and fertility is reduced. - GnRH analogue - Ryeqo - relugolix + estradiol + norethisterone (GnRH receptor antagonist) - Myomectomy - Ulipristal acetate - intermittent management only - Management of anaemia: iron replacement, - Hysteroscopic or laparoscopic approach blood transfusion - Total hysterectomy BIMA Clinical and OSCE seriesFibroids further reading NICE CKS Fibroids https://cks.nice.org.uk/topics/fibroids/ RCOG Guidelines on uterine artery embolization for management of fibroids https://www.rcog.org.uk/guidance/browse-all-guidance/other-guidelines-and- reports/uterine-artery-embolisation-in-the-management-of-fibroids/ Patient.info Fibroids https://patient.info/doctor/fibroids-pro BIMA Clinical and OSCE seriesCase 3 59 y/o female presented to GP with 2 weeks history of abnormal PV bleeding. She reached menopause age 51, using SSRI for menopausal symptoms. Has 2 children with normal SVD, no miscarriage/TOP. PMHx: Breast cancer - on tamoxifen, hypertension, hypercholesterolaemia. O/E active PV bleeding and blood at cervix, no obvious cervical/vulvo-vaginal abnormality. What are your differentials? BIMA Clinical and OSCE seriesDifferentials: Post Menopausal Bleeding - Endometrial cancer - Endometrial hyperplasia - Vaginal atrophy - MOST COMMON - Hormone therapy induced - Perimenopausal: - Cervical ectropion - Polyps (cervical/endometrial) - Other: - Cervical cancer - Vulvo-vaginal pathology - Infections e.g. STI, endometritis BIMA Clinical and OSCE seriesEndometrial Hyperplasia and Cancer Endometrial hyperplasia: aberrant increase in endometrial epithelial cells - Hyperplasia without atypia (no abnormal cells on histology) - Hyperplasia with atypia (abnormal cells present → higher risk of malignancy) Endometrial cancer: - Typically ‘carcinoma’ - epithelial cell Type 1 - ~ 80% cases Type 2 ~ 10% cases ● Endometrioid, mucinous, secretory ● Serous and clear cell carcinoma adenocarcinoma ● YOUNGER age ● OLDER, post-menopausal ● OESTROGEN DEPENDENT ● Less oestrogen dependent ● Can arise from hyperplasia with atypia ● Atrophic endometrium ● Usually Lower grade cancer ● Higher grade cancer BIMA Clinical and OSCE seriesEndometrial hyperplasia and cancer Clinical presentation: Investigations ● Can be asymptomatic Bloods: FBC, CRP, U&E, LFT, TFT, consider G&S, iron ● Abnormal uterine bleeding e.g. PMB, studies etc. PCB, IMB, menorrhagia Hormone profile ● May have associated systemic features: ○ FLAWS Imaging ■ Fever, lethargy, loss of Transvaginal USS appetite, weight loss, night sweats Endometrial thickness - >4mm in post-menopause ○ Metastasis Invasive - Hysteroscopy +/- biopsy BIMA Clinical and OSCE seriesEndometrial Hyperplasia and cancer Management: Endometrial hyperplasia without atypia OR with atypia/early cancer but want fertility: - Progesterone only - Mirena IUS - Active surveillance Endometrial hyperplasia with atypia or cancer: - Hysterectomy +/- Bilateral salpingo-oopherectomy - Higher stages: - sentinel lymph node biopsy, lymph node resection, debulking surgery - radiotherapy/chemotherapy BIMA Clinical and OSCE seriesEndometrial hyperplasia/cancer Further reading RCOG Greentop Guidelines ● https://www.rcog.org.uk/guidance/browse-all-guidance/green-top- guidelines/management-of-endometrial-hyperplasia-green-top-guideline-no- 67/ BIMA Clinical and OSCE seriesCase 4 26 y/o female presented to her GP with concerns about facial hair. She has also noted increasing weight over the last 7 months. On questioning, she also reported irregular periods. She stopped taking COCP 1 year ago as has been trying to get pregnant, but with no success. What is your top differential? BIMA Clinical and OSCE seriesPolycystic Ovarian Syndrome (PCOS) Also known as: Stein-Leventhal syndrome Image from: https://www.frontiersin.org/journals/physiology/articles/10.3389/fphys.2016.00124/full BIMA Clinical and OSCE seriesPolycystic Ovarian Syndrome (PCOS) ● Cause – uncertain ● Endocrinopathy: ○ Increased androgen production by theca cells ○ PCOS associated with increased LH and insulin levels ■ Insulin resistance = common in PCOS  weight gain, affects androgen production, reduction of sex-hormone binding globulin production = more free testosterone ● Anovulatory cycles can lead to increase oestrogen and thickened endometrium  risk of endometrial hyperplasia + cancer BIMA Clinical and OSCE seriesPolycystic Ovarian Syndrome (PCOS) Two of the three following criteria are Clinical and/or biochemical signs of diagnostic of the condition, assuming other hyperandrogenism: causes have been excluded (Rotterdam - Hirsutism – abnormal, male-patterned criteria): hair growth on face and body • Polycystic ovaries (either 12 or more - Male-patterned balding, alopecia peripheral follicles or increased ovarian volume (greater than 10 cm ). Insulin resistance: - Obesity • Oligo-ovulation or anovulation. - Acanthosis nigricans • Oligomenorrhoea = <9 menstruations/year BIMA Clinical and OSCE seriesPolycystic Ovarian Syndrome (PCOS) Investigations: Bloods: Hormone profile: Total testosterone – normal or slightly raised Free testosterone – raised SHBG – normal/low – can calculate free androgen index LH and FSH, LH:FSH ratio increased (>2) Oestrogen Progesterone – 7 days before ovulation (based on cycle) Other bloods for differentials: Endocrine screen e.g. cortisol, TFT, prolactin, 17-hydroxyprogesterone, Fasting glucose, HbA1c Imaging TVUSS BIMA Clinical and OSCE seriesPolycystic Ovarian Syndrome (PCOS) Management Lifestyle: Are planning pregnancy: Weight loss, diet and exercise - Weight loss! Diet and exercise - Optimise control of cardiovascular risk factors Clomiphine – induce ovulation Medical Metformin Not planning pregnancy: Regulation of periods including to reduce risk of Invasive: Laparoscopic ovarian drilling endometrial hyperplasia: ● COCP with pill free interval to induce Referral to fertility specialists for other fertility treatment withdrawal bleeds ● Mirena IUS Metformin Weight loss assistance e.g. orlistatCauses of infertility Uterus - Congenital abnormality of the uterus e.g. bicronuate - Fibroids - Previous surgery → - scarring, ‘Asherman’s Syndrome’, - previous hysterectomy!!lation, Ovaries - Primary ovarian insufficiency - Secondary ovarian insufficiency → GnRH analogues, endocrinopathy - PCOS - Ovarian cysts (dysfunctional/ large) - oopherectomy Tubes - Tubo-ovarian abscess - Scaring/distortion → Previous ectopic pregnancy, PID, - Tubal ligation BIMA Clinical and OSCE seriesPCOS Further reading RCOG guidelines ● https://www.rcog.org.uk/guidance/browse-all-guidance/green-top- guidelines/long-term-consequences-of-polycystic-ovary-syndrome-green-top- guideline-no-33/ Patient.info ● https://patient.info/doctor/polycystic-ovary-syndrome-pro BIMA Clinical and OSCE seriesTHANK YOU FOR LISTENING ANY QUESTIONS BIMA Clinical and OSCE series