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GYNAECOLOGYPart2 Dr Nina Cooper SpR Obstetrics & Gynaecology North West Thames DeaneryStructureforToday: There is MORE INFORMATION on the slides than I can explain in 45 minutes, so I will share the slides with the committee. Session 1 • Gynaecological cancers • Urogynaecology 10 minute break Session 2 • Benign gynaecology • Reproductive medicine, subfertility and menopause care To be covered at a later date: early pregnancy, acute gynaecology and gynaecological emergenciesDISCLAIMER All questions have been written by myself and should not be copied, distributed or shared without prior permission. Every effort has been made for answers to be in line with national guidance, however you should follow guidance from your local medical school if any answer conflicts with your teaching.Session 3: BENIGNGYNAECOLOGYQuestion1 A 16 year old presents to her GP with absence of periods. She reports cylical lower abdominal pain however no bleeding. She has normal secondary sexual characteristics and normal growth. What is the most likely diagnosis? 1. Imperforate hymen 2. Asherman’s syndrome 3. Turner’s syndrome 4. Bicornuate uterus 5. Kallmann’s syndromeQuestion2 A 33 year old woman is referred to gynaecology outpatients with heavy menstrual periods. A bimanual examination reveals a mobile uterus at 20 week size. A diagnosis of fibroids is suspected. She is keen to fall pregnant so would like to avoid treatment for now. Which of the following statements is false regarding fibroids in pregnancy? 1. Women who have had breach of the cavity at myomectomy will require a caesarean section 2. Large fibroids in the upper uterine segment may cause obstructed labour 3. Women with submucosal fibroids are at higher risk of major obstetric haemorrhage 4. Fibroid degeneration may occur during pregnancy 5. Most women with fibroids will have an uncomplicated pregnancyQUESTION3 A 25 year old girl is referred from her GP to gynaecology outpatients with severe dysmenorrhoea. She has tried mefenamic acid. Bimanual reveals a fixed, immobile 10-week sized uterus. A pelvic ultrasound demonstrates a globular uterus. What is the most likely diagnosis? 1. Endometriosis 2. Complex atypical hyperplasia 3. Endometriosis with adenomyosis 4. Endometrial cancer 5. AdenomyosisQUESTION4 A 38 year old woman presents with mood disturbance during the week prior to her period. She reports increased tearfulness and irritability. Which of the following is not a treatment for premenstrual syndrome? 1. Evening primrose oil 2. Combined oral contraceptive pill 3. SSRI 4. CBT 5. Hysterectomy and bilateral salpingo-oophorectomyQuestion1 A 16 year old presents to her GP with absence of periods. She reports cylical lower abdominal pain however no bleeding. She has normal secondary sexual characteristics and normal growth. What is the most likely diagnosis? 1. Imperforate hymen 2. Asherman’s syndrome 3. Turner’s syndrome 4. Bicornuate uterus 5. Kallmann’s syndromeDISORDERSOFREPRODUCTIVEDEVELOPMENT Primary Amenorrhoea - when to suspect • Girls who have not established menstruation by the age of 13 years and have no secondary sexual characteristics (such as breast development). • Girls who have not established menstruation by the age of 15 years and have normal secondary sexual characteristics.HPGAxisHPGAxisQuestion2 A 33 year old woman is referred to gynaecology outpatients with heavy menstrual periods. A bimanual examination reveals a mobile uterus at 20 week size. A diagnosis of fibroids is suspected. She is keen to fall pregnant so would like to avoid treatment for now. Which of the following statements is false regarding fibroids in pregnancy? 1. Women who have had breach of the cavity at myomectomy will require a caesarean section 2. Large fibroids in the upper uterine segment may cause obstructed labour 3. Women with submucosal fibroids are at higher risk of major obstetric haemorrhage 4. Fibroid degeneration may occur during pregnancy 5. Most women with fibroids will have an uncomplicated pregnancy FIBROIDS • In pregnancy – associated wth preterm labour, malpresentation, transverse lie, obstructive labour and PPH • Menorrhagia and dysmenorrhoea symptoms more related to site rather than size • Submucosal can lead to menorrhagia or IMB • Can impair fertility due to distortion of uterine cavity, prevention of implantation or obstruction of the tubal ostiaMANAGEMENTOFFIBROIDS None if asymptomatic Medical: • TXA, NSAIDs, progestogens (give norethisterone for 5/7 usually) • GnRH can be used to shrink prior to surgery but only for 6/12 as reduce BMD Surgical • Hysteroscopy: if small submucosal or polypoid • Myomectomy: open or laparoscopic - if wishing to preserve fertility. Any uterine incision can increase risk of uterine rupture during labour therefore should book for elective caesarean • Hysterectomy IR: uterine artery embolisation – can be considered in those wishing future pregnancy • Potential risk of reduced placental blood supply or uterine rupture due to relative myometrial ischaemiaQUESTION3 A 25 year old girl is referred from her GP to gynaecology outpatients with severe dysmenorrhoea. She has tried mefenamic acid. Bimanual reveals a fixed, immobile 10-week sized uterus. A pelvic ultrasound demonstrates a globular uterus. What is the most likely diagnosis? 1. Endometriosis 2. Complex atypical hyperplasia 3. Endometriosis with adenomyosis 4. Endometrial cancer 5. AdenomyosisENDOMETRIOSIS Presence of endometrial tissue outside of the uterus Symptoms: chronic pelvic pain, dysmenorrhea affecting quality of life, deep dyspareunia, cyclical GI symptoms, period-related urinary symptoms, infertility Ix: pelvic USS (ideally TV), consider MRI if suspicion of bladder/bowel involvement, diagnostic laparoscopy + stagingENDOMETRIOSISADENOMYOSIS https://www.nice.org.uk/guidance/ng73/r esources PHARMACOLOGICALMANAGEMENTOFENDOMETRIOSISSURGICALMANAGEMENTOFENDOMETRIOSIS • Laparoscopy +/- excision of endometrial deposits/endometriomas +/- adhesiolysis • Hysterectomy • https://www.nice.org.uk/guidance/ng73/resources/algorithm-for- diagnosing-and-managing-endometriosis-pdf-4595719645QUESTION4 A 38 year old woman presents with mood disturbance during the week prior to her period. She reports increased tearfulness and irritability. Which of the following is not a treatment for premenstrual syndrome? 1. Evening primrose oil 2. Combined oral contraceptive pill 3. SSRI 4. CBT 5. Hysterectomy and bilateral salpingo-oophorectomyPMS • Mood disturbance associated with luteal phase of menstrual cycle Symptoms • mood swings • feeling upset, anxious or irritable • tiredness or trouble sleeping • bloating or tummy pain • breast tenderness • headaches • spotty skin or greasy hair • changes in appetite and sex drivePMSSession 4: REPRODUCTIVEMEDICINE, SUBFERTILITYANDTHEMENOPAUSEQUESTION1 A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1. Polycystic ovaries 2. Physiological puberty 3. Polycystic ovarian syndrome 4. Virilising tumour 5. Pituitary adenomaQUESTION2 A 32 year old woman has been trying to conceive for 14 months. Bloods and imaging are normal. She has a history of chlamydia which was treated at the age of 24. What is the most likely cause of her subfertility? 1. Premature ovarian insufficiency 2. Tubal scarring 3. Congenital uterine structural anomaly 4. PCOS 5. IdiopathicQUESTION3 A 52 year old woman presents with a 1 year history of amenorrhoea, hot flushes and mood swings. What is the most likely pattern you would see on her bloods? 1. Low FSH, high oestradiol 2. High FSH, low oestradiol 3. Low FSH, low oestradiol 4. High FSH, high oestradiol 5. Normal FSH, normal oestradiolQUESTION4 A 40 year old woman presents with a 2 year history of amenorrhoea. She complains of dyspareunia and hot flushes. What is the most likely diagnosis? 1. Menopause 2. Premature ovarian insufficiency 3. Turner’s syndrome 4. Hypothalamic hypogonadism 5. Pituitary hypogonadismQUESTION1 A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1. Polycystic ovaries 2. Physiological puberty 3. Polycystic ovarian syndrome 4. Virilising tumour 5. Pituitary adenomaQUESTION1 A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1. Polycystic ovaries 2. Physiological puberty 3. Polycystic ovarian syndrome 4. Virilising tumour 5. Pituitary adenomaPCOS Rotterdam criteria: • Oligo/anovulation (> 2 years) • Clinical or biochemical features of hyperandrogenism • Polycystic ovaries on ultrasound (> 12 in one ovary measuring 2-9 mm in diameter) Hyperoestrogenic state à conversion to androgens Associated with insulin resistancePCOS:Management Conservative: weight loss Medical: • Dianette COCP (androgenic symptoms) – contains cyproterone acetate (anti-androgenic) • Metformin Can manage symptoms e.g. laser therapy for excessive hair If desiring pregnancy: • Weight loss • Clomiphene (SERM) +- metformin • Induce ovulation if subfertility is an issue; used for up to 6 month • Laparoscopic ovarian drillingQUESTION2 A 32 year old woman has been trying to conceive for 14 months. Bloods and imaging are normal. She has a history of chlamydia which was treated at the age of 24. What is the most likely cause of her subfertility? 1. Premature ovarian insufficiency 2. Tubal scarring 3. Congenital uterine structural anomaly 4. PCOS 5. IdiopathicINVESTIGATINGSUBFERTILITY • Blood hormones: day 2-3 FSH, LH and oestradiol. AMH demonstrates ovarian reserve • STI screening • TVUS and antral follicle count • Tubal assessment (HYSTEROSALPINGOGRAM or LAP+DYE) • Semen analysis TREATINGSUBFERTILITY Ultimately depends on cause Cause Treatment Anovulation Ovulation induction (clomiphene) Laparoscopic ovarian drilling Male factor IUI if mild Donor insemination Tubal IVF Failed IUI/ovulation induction ICSI Lack off oocytes e.g. POI/Turner’s Donor egg syndrome Anatomical abnormality Surgical management e.g. adhesiolysis, myomectomyQUESTION3 A 52 year old woman presents with a 1 year history of amenorrhoea, hot flushes and mood swings. What is the most likely pattern you would see on her bloods? 1. Low FSH, high oestradiol 2. High FSH, low oestradiol 3. Low FSH, low oestradiol 4. High FSH, high oestradiol 5. Normal FSH, normal oestradiolQUESTION4 A 40 year old woman presents with a 2 year history of amenorrhoea. She complains of dyspareunia and hot flushes. What is the most likely diagnosis? 1. Menopause 2. Premature ovarian insufficiency 3. Turner’s syndrome 4. Hypothalamic hypogonadism 5. Pituitary hypogonadism MENOPAUSE Menopause: retrospective diagnosis, absence of menses for 12 months Premature ovarian insufficiency: before 42 years of age – can be idiopathic or iatrogenic e.g. chemotherapy, BSO • All women with POI require oestrogen replacement • Cannot give oestrogen without progesterone if a woman has a uterus in situ • Unopposed oestrogen à endometrial hyperplasia à cancer HRT can be given orally/transdermally/locally Atrophic vaginitis: vagifem topical oestrogen Cyclical or continuous HRT • Oestrogen: patch/pill/gel • Progesterone: mirena IUS, pill • Tend to give continuous to women who are definitely post-menopausal otherwise can cause erratic bleeding in perimenopausal womenhttps://forms.office.com/r/VYYRE1Wxmt END OF SESSION 2 ANYQUESTIONS?