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OSCEAZY The Gynaecology Station Ravanth BaskaranTips for History Taking FIRST IMPRESSIONS PAUSES SUMMARISE Utilize WIPE – wash hands, Golden minute. Give patients Make use of summaries; they give introduce self, patient details, space to speak and reflect. you breathing space and highlight explain. gaps for further questioning OPEN TO CLOSED SHOWTIME! STRUCTURE Try to stick to the usual OSCEs are like a START WITH BROAD open history format – easier for performance – put question, then clarify points with closed questions. you and the examiner. But on your best show don’t be afraid to FOLLOW UP ON CUES Beginning The Gynaecology History PRESENTING COMPLAINT HISTORY of PC “Bleeding” Explore every symptom – timeframe and “Pain” symptom specific questions; SOCRATES “Periods” Systems review; general, gynae, gastro, “Subfertility” urological “Bloating/fullness” “Mass” PV bleeding: menorrhagia, intermenstrual, post-coital, post-menopausal Gynae systems PV discharge: volume, colour, smell? review: 4Ps Pain: pelvic, dyspareunia, dysmenorrhea Pregnancy: could they be pregnant? Additionally - MOSC MENSTRUAL Hx OBSTETRIC Hx st Gravity (pregnancies) and Parity (births over 1 day of LMP Menarche +/- Menopause ages 24 weeks regardless if born alive or not) Regular/irregular, cycle length MET: miscarriages, ectopics, terminations Duration of menses Some parts will be Children: number, ages, details of births, Character – quantify problems during previous pregnancies more/less relevant depending on PC – adapt accordingly! SEXUAL Hx - brief CONTRACEPTION + Partners: current and previous, ? CERVICAL SMEAR high risk encounters Contraception: current vs previous methods Intercourse: type, pain? Subfertility Cervical smears: date and result of lastRemaining of Gynaecology History PAST MEDICAL Hx DRUG Hx The usual Including HRT/hormones (inc. route), OTC Any previous abdominal surgery ?COCP/POP ALLERGIES Past Obstetric or Gynaecology history FAMILY Hx SOCIAL HISTORY Breast/bowel/ovarian cancer As PerSEXUAL HISTORYAKING Who, When, What, Where, How? PARTNERS SET THE SCENE… Sexual orientation (DON’T ASSUME!) Explain sensitive nature of Current partner(s) questions Sex in the last 3 months; STRESS CONFIDENTIALITY • Dates • M/F • Country of origin PC/HPC • Condom use • Type (oral/vaginal/anal) Explore every symptom: timeframe and specific questions Sexual health systems review: High risk for HIV; • MSM • Discharge (vaginal, urethral, rectal) • Sexual partner who: born abroad, • Dysuria • Swelling/growth/ulcer MSM, likely HIV +ve • PV bleeding + menstrual Hx (if female) • Paying for sex • ‘ChemSex’ • Pain • Needle sharing • Tattoos, piercings, • Blood transfusions, medical Tx The Remaining PAST MEDICAL Hx SOCIAL Hx Previous STIs/STI tests Alcohol HIV, HepB/C status (if known) Smoking Vaccination Hx (HepB) RECREATIONAL DRUGS (ChemSex, needle sharing) Living situation DRUG Hx Regular meds ALLERGIES Contraception and ADHERENCE Use of PrEP (if male)INTIMATE EXAMINATIONS SPECULUM and PVLOOK WIPE BE SYSTEMATIC For general inspection, LOOK at Always perform WIPE BE SYSTEMATIC and try to the patient and around the bed look slick for a good few moments WORDING RIGHT SIDE SHOWTIME! When talking in between the Examine from the patient’s PUT ON A examination, say ‘’there is no right side SHOW! evidence of….’’ rather than ‘’I am looking for …’ Equipment: • Gloves • Speculum Speculum Examination • Lubricant jelly • Paper towels • Light source CHAPERONE! MUST be offered Lock the door • Female genital mutilation (FGM) = procedures involving partial or POSITION INSPECT the vulva total removal of the external female genitalia, or other injury to Supine Ulcers the female genital organs for non- Modified lithotomy Abnormal PV discharge medical reasons. Cover for modesty Scarring • >140 million girls and women Atrophy worldwide (White) lesions/masses • Routinely ask if women attending FGM maternity, family planning, gynaecology, and urology clinics Prolapse • If <18, required to report to the police Speculum Examination Genital herpes Bartholin's cyst Candidiasis Images courtesy of Geeky Medics Vaginal prolapse Lichen sclerosis Speculum Examination SPECULUM INSERTION Warn the patient and confirm consent. If they consent to the continue; 1. Choose the relevant size of speculum – usually medium. 2. Apply some LUBRICANT jelly to the speculum. 3. Use your LEFT HAND (index and thumb) to separate the labia. 4. Gently insert the speculum SIDEWAYS, with blades closed and angled downwards. 5. Once inserted, ROTATE THE SPECULUM BACK 90° so that the handle is facing upwards. 6. Open the speculum blades until the cervix can be visualised effectively. 7. Tighten the locking nut to fix the blades of the speculum in position. 8. INSPECT THE CERVIX: cervical os, masses, ulceration, abnormal discharge Images courtesy of Geeky Medics Speculum Examination SPECULUM REMOVAL 1. With NON-DOMINANT hand, hold the blades of the speculum open. 2. Loosen the locking nut with your DOMINANT HAND. 3. Gently remove the speculum whilst slowly closing the blades – remember to simultaneously inspect the walls of the vagina. 4. Explain that the examination is over. 5. Re-cover the patient with the sheet, give the patient privacy to get dressed. (provide paper towels for the patient to clean themselves) Image courtesy of Geeky Medics 6. Dispose of the used equipment into a clinical waste bin. Further assessments/investigations • Urinalysis: including β-HCG. • Vaginal/endocervical swabs • Complete abdominal examination • Ultrasound abdomen and pelvis • HPV testing: Equipment: • Gloves Vaginal Examination • Lubricant jelly • Paper towels CHAPERONE, POSITION, Same as speculum INSPECT VULVA THE EXAMINATION 1. LUBRICATE the gloved index and middle fingers of your DOMINANT hand. 2. Separate the labia using the thumb and index finger of your NON-DOMINANT hand. 3. Gently INSERT the lubricated fingers of your dominant hand into the vagina. 4. Make sure your PALM FACING LATERALLY and then ROTATE 90 DEGREES so that your palm is facing upwards. Images courtesy of Geeky Medics 5. Cervix – position, consistency, cervical motion tenderness? 6. Fornices Vaginal Examination PALPATE UTERUS BIMANUALLY palpate the uterus: 1. Place your non-dominant hand just above the pubis symphysis. 2. Place two fingers into the posterior fornix. 3. Push upwards with the internal fingers and palpate the lower abdomen with your non-dominant hand. 4. You should be able to feel the uterus between your hands. Assess; - Size: ~ orange-sized is average Image courtesy of Geeky Medics - Shape - Surface characteristics: smooth/nodular. - TendernessCommon Presentations • Amenorrhoea • Irregular or Heavy Menstruation • Pelvic Pain and Dysmenorrhoea Presenting • Post-Coital Bleeding Complaints • Intermenstrual Bleeding • Vaginal Discharge • Vaginal PruritisPrimary Amenorrhoea = NEVER DEVELOPED PERIODS Abnormal function of hypothalamus or pituitary gland • Low FSH and LH • Damage, constitutional delay, hypopituitarism, endocrine disorders, Kallman syndrome Abnormal function of gonads • High FSH and LH = STARTED PERIODS BUT NOW STOPPED Pregnancy • Damage, Turner’s, absent ovaries VS Menopause Imperforate hymen/structural pathology Physiological stress PCOS Medications Premature ovarian insufficiency syndrome Thyroid hormone abnormality Excess prolactin (e.g. prolactinoma) Cushing’s sydnrome Secondary amenorrhoea AssessmentofAmenorrhoea Detailed history: health, development, family Hx, diet and lifestyle Detailed history and examination to assess for potential causes Intimate examination: look for structural/congenital causes Initial Hormonal blood tests: investigation: • βHCG (pregnancy is the most common cause!) • FBC and ferritin for anaemia • LH and FSH and LH:FSH ratio – high LH:FSH indicates PCOS • U&E for CKD • Prolactin • Anti-TTG/ anti-EMA for coeliac disease • Thyroid function tests (TSH first then T3 and T4) Hormonal blood tests: • Testosterone • FSH and LH Dexamethasone suppression test – Cushing’s • Thyroid function tests Imaging: • Insulin-like GF 1– screen for GH deficiency • Pelvic ultrasound SECONDARY • Prolactin • Testosterone (raised in PCOS, AIS and CAH) Genetic testing PCOS = polycystic ovarian syndrome AIS = androgen insensitivity syndrome Imaging: CAH = congenital adrenal hyperplasia • XR wrist (bone age • Pelvic ultrasound Hyperthyroidism = usually • MRI brain (pituitary) PRIMARY Hypothyroidism = usually menorrhagia SpotDiagnosis Amenorrhoea 53 y/o female presents with amenorrhoea, hot flushes and reduced libido. LMP 10 months ago. Has abdominal pain Menopause and a regular sexual partner 27 year old female with high BMI presents with amenorrhoea/oligomenorrhoea, hirsutism, difficulty PCOS losing weight. 17year old female presents having failed to start periods. You note short stature, lack of Turner syndrome breast tissue. She has a mild learning disability 32 year-old female presents with amenorrhoea, central obesity, moon face and a buffalo hump. She has Cushing's syndrome recently been diagnosed with hypertensionMENOPAUSE TERMINOLOGY MENOPAUSE Point at which menstruation ceases POSTMENOPAUSE ≥ 12 months from final period PERIMENOPAUSE Time approaching menopause – irregular periods and vasomotor symptoms PREMATURE Menopause before 40y/o. Result of MENOPAUSE premature ovarian insufficiency MENOPAUSE PRESENTATION DIAGNOSIS MANAGEMENT Low oestrogen èsymptoms If > 45 and typical symptoms - 1. Contraception • Hot flushes CLINCAL DIAGNOSIS - 2 years after LMP if <50 • Emotional lability - 1 year after LMP if >50 • Irregular periods Do blood FSH level if… - NOT depot injection (bones) • Vaginal dryness and atrophy • <40 and suspect premature 2. Management of • Reduced libido menopause perimenopausal symptoms • 40-45 with menopausal Sx / 3. Management of health risks change in menstrual cycle - Osteoporosis FSH and LH ↑ - Cardiovascular and stroke Oestrogen and progesterone ↓ MANAGEMENT OF PERIMENOPAUSAL SYMPTOMS Step 1: local or systemic symptoms No treatment Conservative: regular exercise, sleep hygiene etc. - Local ètopical - Systemic èsystemic treatments Hormone replacement therapy (HRT) Step 2 : Does patient have a uterus? Tibolone - No èOestrogen-only - Yes èAdd progesterone (combined) Clonidine Step 3 : Have they had a period in the last Cognitive behavioural therapy (CBT) 12months? SSRIs e.g. fluoxetine - Perimenopausal ècyclical - Postmenopausal ècontinuous Testosterone (specialist) Vaginal moisturisers RISK VS BENEFIT (if <60, generally okay) Are there an absolute contraindications? (Alternative remedies)POLYCYSTIC OVARIAN SYNDROME (PCOS) TERMINOLOGY ANOVULATION Absence of ovulation OLIGOOCVULATION Irregular/infrequent ovulation HIRSUTISM Growth of thick, dark hair in a male pattern OLIGOMENORRHOEA Irregular/infrequent menstruation AMENORRHOEA Absence of menstruation HYPERANDROGENISM High levels of androgens èsecondary characteristics 1. Oligoovulation or anovulation AND (irregular/absent periods) ROTTERDAM 2. Hyperandrogenism AND CRITERIA (hirsutism and acne)(Clinical or Biochemical) 3. Polycystic ovaries on ultrasound Must have at least 2 for diagnosis to be madeering this criteria (many women have multiple small cysts) POLYCYSTIC OVARIAN SYNDROME (PCOS) • PRESENTATION INVESTIGATIONS MANAGEMENT • Oligomenorrhoea or General examination to look for Conservative: amenorrhoea Infertility • Weight loss, diet and exercise clinical signs • Obesity or difficulty losing Bloods (hormonal): • Smoking cessation weight (70%) • Manage hirsutism • Testosterone • Hirsutism • Sex hormone-binding globulin Medical: • Acne (SHBG) • Antihypertensives, statins • Hair loss in a male pattern • LH • Progesterone (endometrial Insulin resistance and diabetes • FSH hyperplasia) – Mirena = 1st • - Acanthosis nigricans • Prolactin • Orlistat (BMI > 30) Cardiovascular disease • TSH • Clomifene, Metformin and Depression and anxiety Oral glucose tolerance test (OGTT) letrozole (infertility) Obstructive sleep apnoea Pelvic US Surgical Sexual problems Transvaginal US (gold) • Laparascopic ovarian drilling ↑ LH and ↑ LH:FSH, string of pearls • IVF (infertility)HEAVY MENSTRUAL BLEEDING62 year-old nulliparous woman present with post- menopausal bleeding. She has a high BMI. Endometrial cancer 26 year-old female present with cyclical abdominal pain during menstruation and heavy menstrual bleeding. She Endometriosis has pain on deep penetration. 32 year old female presents with heavy Fibroids menstrual bleeding and a palpable abdominal mass 29 year old patient presents with post-coital bleeding. Her vaccination history is unclear. Cervical cancer There is cervical excitation on bimanual examination HEAVY MENSTRUAL BLEEDING (>80ML) DIFFERENTIALS INVESTIGATIONS MANAGEMENT Dysfunctional uterine bleeding Pelvic examination – speculum and Treat cause if known Extremes of reproductive age bimanual Is contraception is acceptable..? Fibroids FBC – anaemia If NO: Endometriosis and adenomyosis Outpatient hysteroscopy • Tranexamic acid if no pain PID Pelvic and transvaginal ultrasound • Mefenamic acid if pain Contraceptives (copper coil) Additional tests (if relevant): If YES: Anticoagulant medication • Swabs 1. Mirena coil (1 )t Bleeding disorders (VW) • Coagulation screen 2. COCP Endocrine disorders • Ferritin 3. Cyclical progestogens Endometrial hyperplasia • Thyroid function tests Endometrial cancer Secondary care options: 1. More about the bleeding – when, how much, how long for PCOS 2. Could they be pregnant/have an STI • Endometrial ablation 3. Plans for future pregnancies • Hysterectomy 4. Cervical screening status – may affect Mx decisions 5. Migraines +/- auraFIBROIDS Women's Health and Wellnessroids - NabtaHealth - FIBROIDS Abdominal and bimanual- palpable mass/enlarged firm uterus Hysteroscopy (for menorrhagia) Pelvic ultrasound (1 choice for larger, palpable) MRI – before surgical options <3cm >3cm Medical Mx = same as heavy menstrual bleeding (NICE 2018) All need referral to gynaecology • Mirena coil Primary care Medical options: • Symptomatic (NSAIDS, tranexamic acid) (same) • Combined oral contraceptives Surgical options: • Cyclical progestogens GnRH agonists may be used to shrink fibroids before surgery Surgical options: Referral • Uterine artery embolisation • Endometrial ablation • Myomectomy • Resection of submucosal fibroids during hysteroscopy • Hysterectomy • Hysterectomy Disrupted blood supply èischaemia, infarction and necrosis of the fibroid Usually for fibroids >5cm RED Pregnancy induced – rapidly enlarging fibroid (oestrgoen) outgrows its blood supply Presentation = SEVERE abdominal pain, low grad fever, tachycardia, DEGENERATION vomiting OF FIBROIDS Management = SUPPORTIVE (rest, fluids, analgesia) Look out for pregnant woman with history of fibroids presenting with sever abdominal pain and low-grade feverENDOMETRIOSIS From The Ultimate Guide to Endometriosis in Singapore (2021) - human ENDOMETRIOSIS PATHOPHYSIOLOGY CLINICAL FEATURES Ectopic endometrial tissue outside the uterus. • Cyclical, abdominal/pelvic pain that occurs during During menstruation, this tissue sheds its lining and menstruation • Deep dyspareunia bleeds (in the same manner as normal endometrium) • Dysmenorrhoea Blood causes irritation and inflammation of the • Infertility surrounding tissues • Cyclical bleeding from other sites e.g. haematuria • Non-gynae: dysuria, dyschezia MANAGEMENT DIAGNOSIS Conservative - explain diagnosis, listen to ICE, • Pelvic ultrasound – endometriomas and chocolate analgesia*, conception counselling and support (↑risk) Medical – hormonal options can be trialed cyst • Laparoscopic surgery = gold standard Surgical • Laparoscopic surgery to excise/ablate the ectopic • Can also be therapeutic tissue and remove adhesions (↑ fertility) • Hysterectomy • Ovarian cystectomy of endometriomas *NSAID and paracetamol = 1st Endometriosis Endometrial tissue outside of the uterus Pelvic/abdo pain and infertility May have bowel/urinary symptoms Dx = pelvic US and laparoscopic surgery Mx = see previous Endometrial tissue inside the myometrium VS More common if older and multiple pregnancies 1/3are asymptomatic Painful heavy periods Dx = transvaginal US is 1 line Mx = use heavy menstrual bleeding guidance AdenomyosisENDOMETRIAL CANCEREndometrial hyperplasia Pre-cancerous Sonohysterographic measurement of on ResearchGate. Available from:ic Figure - Most will return to normal over time asurement-of-endometrial-thickness-/Me a_fig2_279885187 [accessed 5 May, - <5% go on to cancer 2023] With atypia or without atypia Tx: progestogens Malignant VS - Will progress and metastasize if not treated 80% adenocarcinoma Oestrogen-dependant Endometrial cancer RISK FACTORS PRESENTATION INVESTIGATIONS UNOPPOSED OESTROGEN EXPOSURE • POST-MENOPAUSAL BLEEDING Examination (general, abdo, pelvic) - ↑Age • Post-coital bleeding USC PATHWAY - Early menarche, late menopause • Intermenstrual bleeding 1. Transvaginal ultrasound - No/few pregnancies • Abnormally heavy menstrual Endometrial thickness - Obesity <4mm is normal in PM bleeding - PCOS • Abnormal vaginal discharge 2. Pipelle biopsy - Tamoxifen • Anaemia (↑ blood loss) Highly sensitive 3. Hysteroscopy T2DM • Raised platelet count Hereditary non-polyposis colorectal • Visible haematuria (invasion of Endometrial biopsy for tissue cancer (HNPCC or Lynch syndrome) bladder) diagnosis MRI pelvis or CT TAP will be needed Post-menopausal bleeding is endometrial cancer until proven otherwise – always USC for staging pathway. Conservative: - Counsel on diagnosis and prognosis - Symptom management (?palliative care input) MANAGEMENT OF Early (stage 1or 2) ètotal abdominal hysterectomy and bilateral ENDOMETRIAL salpingoophorectomy (TAH + BSO) - Removal or the uterus, cervix, ovaries and fallopian tubes) CANCER chemotherapy/radiotherapylking laparotomy and Frail and unsuitable for surgery offer progesterone therapyCERVICAL CANCER RISK FACTORS PRESENTATION INVESTIGATIONS 1. Increased risk of contracting HPV Can be asymptomatic – picked up Screening programme • Early sexual activity incidentally on screening High-risk HPV and cytology • No HPV vaccine ABNORMAL VAGINAL BLEEDING • Inadequate èrepeat after 3 mo • Increased sexual partners • Post-coital bleeding • HPV - ve ècontinue with routine • Not using condoms screening • Intermenstrual bleeding 2. Late detection of precancerous Pelvic pain • HPV +ve with normal cytology è changes Dyspareunia repeat HPV after 12 mo B-symptoms • Non-engagement in screening • HPV +ve and abnormal cytology 3. Other (Unvaccinated against HPV) èrefer for colposcopy Smoking, HIV, COCP for >5 years Colposcopy Family Hx, multiparity • Staining Counselling stations • Punch or large loop excision of - Screening programme is important as women often do not have symptoms transformational zone (LLETZ) - HPV vaccine needs to be given before Staging child is sexually active to be effective • Extra imaging and also protects against genital warts CIN = cervical intraepthielial neoplasia è grading system for precancerous change CIN I : mild, 1/3 thickness of epithelium CIN II : moderate, 2/3 thickness of epithelium CIN III : severe, very likely to progress to cancer Conservative: - Counsel on diagnosis and prognosis - Symptom management (?palliative care input) CIN and early-stage 1A èLLETZ or cone biopsy MANAGEMENT Stage 1B-2A èRadical hysterectomy and removal of lymph nodes + CRT OF CERVICAL Stage 2B-4A èChemotherapy and radiotherapy Stage 4B ècombination of surgery, radiotherapy, chemotherapy and CANCER palliative care 5-year survival drops significantly with more advanced cancer - Stage 1A = 98% - Stage 4 = 15%OVARIAN CANCER RISK FACTORS PRESENTATION INVESTIGATIONS UNOPPOSED OESTROGEN EXPOSURE Can present with non-specific Refer directly on USC pathway if physical exam reveals: - ↑Age symptoms. Always have high index of - Early menarche, late menopause suspicion in older women - Ascites - No/few pregnancies - Abdominal bloating - Pelvic mass - Obesity - Early satiety - Abdominal mass - PCOS - Reduced appetite Carry out Ix in primary care if >50 - Tamoxifen - Pelvic pain and: T2DM - Urinary symptoms Any of symptoms to left Hereditary non-polyposis colorectal - Abdominal/pelvic mass Investigations: cancer (HNPCC or Lynch syndrome) - Ascites - Blood CA125 Risk of - B symptoms - Pelvic ultrasound malignancy - Menopausal status index (RMI) Biopsy generally involves surgery Secondary care: (laparoscopic or laparotomy) hence is - CT scan very invasive. RMI is designed to identify high risk people who should be further - (Histology) investigated - Paracentesis Conservative: - Counsel on diagnosis and prognosis - Symptom management (?palliative care input) Managed by a specialist gynaecology oncology MDT. MANAGEMENT Involves: - Combination of surgery and chemotherapy OF OVARIAN CANCER Cannot give neoadjuvant chemotherapy before surgery as don’t have a tissue diagnosis. removed and sent for histology.r a suspicious mass isOVARIAN TORSION OVARIAN TORSION PATHOPHYSIOLOGY PRESENTATION DIAGNOSIS Ovary twists in relation to its Sudden onset, severe, unilateral Pelvic ultrasound surroundings and blood supply pelvic pain - Transvaginal is ideal but - Constant/colicky transabdominal can be used if Usually due to an ovarian mass >5cm - Gets progressively worse TV not possible (cyst or tumour) - Associated with N&V - Whirlpool sign - Fever (less common) - Doppler – lack of blood flow Twisting èdisruption of blood supply èischaemia ènecrosis O/E: Definitive Dx = laparoscopic - Localised tenderness surgery SURGICAL EMERGENCY - May be a palpable mass Risk factors: ovarian mass, pregnancyInitially: A-E approach Emergency admission under gynaecology OVARIAN TORSION Analgesia Prepare the patient for surgery ACUTE MANAGEMENT - NBM - Consent REASSESS THE PATIENT IF ANY - Cannula etc. INTERVENTION IS PERFORMED Bloods: REVIEW INVESTIGATION RESULTS AS SOON AS THEY ARE - FBC, U&E, LFT, G&S, CRP, clotting AVAILABLE CALL FOR HELP EARLY USING SBAR Definitive management: laparoscopic surgery - Untwist the ovary and fix it in place (detorsion) - Remove the affected ovary if not salvageable (oophorectomy)SEXUALLY TRANSMITTED INFECTIONS (STI)Fishy-smelling discharge, strawberry cervix Trichomonas Gram-negative intracellular, often asymptomatic Chlamydia Gram negative diplococci, odourless Gonorrhoea green/yellow discharge Single painless ulcer èsystemic Sx Syphylis Multiple painful lesions, neuropathic Genital herpes pain, flu-like SxS T I s INVESTIGATIONS TREATMENT Speculum and abdominal examination Chlamydia èPO doxycycline 7 days (azithromycin/erythromycin) Charcoal swabs • Microscopy, culture and sensitivities Gonorrhoea èIM ceftriaxone one-off OR oral ciprofloxacin if sensitivities known • Chlamydia and gonorrhoea test (NAAT) Syphilis èIM benzathine benzylpenicillin • Vulvovaginal or high-vaginal one-off Blood tests: Trichomonas èmetronidazole • Syphilis and HIV Antibody testing: symptomatic managementvir and • Syphilis (T. palladium) HIV èHighly active anti-retrovirus Home-test kits therapy (HAART) + specialist input Pregnancy test (urine bHCG) Contact tracing and treating Advice about safe sex and contraception • Inflammation and infection of the organs of the pelvis. Cervical motion tenderness (excitation) is a kInfection spreads up through the cervix. examination finding. This is only found in PID and endometriosis. • Most commonly chlamydia trachomatis. Usually STIs but can be non-STI. • It is a significant cause of tubular infertility and chronic pelvic pain. • Present with abdo/pelvic pain, dyspareunia, abnormal PELVIC discharge/bleeding. May be systemically unwell/septic. • Investigations: screen for all STIs, inflammatory markers, INFLAMMATORY pregnancy test (similar presentation to ectopic!) DISEASE • Need referral for specialist management. • Antibiotic regime 1.A single dose of IM ceftriaxone 1g (cover gonorrhoea) 2.Doxycycline 100mg BD for 14 days (to cover chlamydia and Mycoplasma genitalium) 3.Metronidazole 400mg BD for 14 days (to cover anaerobes such as Gardnerella vaginalis) • (if systemically unwell, may require IV antibiotics in hospital)BACTERIAL VAGINOSIS AND CANDIDIASIS Bacterial vaginosis Overgrowth of bacteria in the vagina – Gardnerella vaginalis is most common (anaerobe) pH > 4.5 – disturbance of normal pH Risk factors: - Soaps, vaginal douching - Multiple sexual partners (not STI) - Recent antibiotics Vaginal infection with Candida family of yeast - Heavy periods Candida albicans is most common (opportunistic) Clear, thin, grey fishy discharge VS pH <4.5 –normal pH range ½ are asymptomatic; Risk factors: Clue cells on microscopy - Pregnancy - Poorly controlled diabetes - Immunosuppresssion - Broad-spectrum antibiotics Thick, white, scentless discharge Vulval and vaginal itching Usually treated empirically Candidiasis (thrush) BV/THRUSH Ix and Mx History and examination Vaginal pH – swab and pH paper Charcoal swab - microscopy Swab for NAAT – rule out other BV THRUSH METRONIDAZOLE ANTIFUNGAL Cream Tablets Pessary “Canesten Duo”INCONTINENCE TYPES OF INCONTINENCE Mixed Urge Stress Overflow Overactivity of detrusor muscle – Occurs when there is chronic urinary 3 canals through the female pelvic retention due to obstruction to the ‘overactive bladder’ floor: urethral, vaginal, rectal outflow of urine Suddenly need to pass urine, rush to Weakness of pelvic floor èlaxity of the toilet canals, organs poorly supported Incontinence occurs without urge to pass urine Impact on QoL – always worried Urine leaks at times of increased Causes: anticholinergics, fibroids, about access to the toilet, may avoid pressure on the bladder e.g. cough activities/places pelvic tumours, neurological conditionsASSESSMENT OF INCONTINENCE History and examination Modifiable lifestyle factors: Caffeine Bladder diary Alcohol Medications BMI Urine dipstick Non-modifiable factors: Multiple pregnancies Post-void residual bladder volume Large babies (on bladder scan) Increasing age Urodynamic testing INCONTINENCE MANAGEMENT Stress Urge • Conservative: Remember anticholinergic Conservative: side effects; - Bladder retraining • dry mouth/eyes, - Modifiable risk factors • urinary retention, • Medical: • constipation - Avoid excessive or resistricted • postural hypotension. fluid intake - Anticholinergic medication - Mirabegron a cognitiveso lead to - Supervised pelvic floor decline, memory • Surgical options: problems and worsening exercises (at least 3 months) of dementia, - Botox injections This is obviously Medical: problematic in older, more - Duloxetine - Percutaneous sacral nerve frail patients (who are often stimulation the ones affected by Surgical options incontinence). - Augmentation cystoplasty TAKE HOME MESSAGES Always think about pregnancy test in women of reproductive age; • even if the pregnancy isn’t causing/exacerbating the symptoms, it will affect choice of medications Transvaginal ultrasound is usually better than pelvic ultrasound for gynaecological issues Hormonal treatments are not without risk Always think about future pregnancy plans when offering management options in gynaePLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK