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Gynaecology101:PV bleedingandPVdischarge Becky Powell and Tabby Hanks GynaeHistoryT aking101:MOSC § Menstrual § Obstetric § Could they be pregnant? § Sexual § Signpost before jumping in:“These next questions will be quite personal – if you don’t feel comfortable you don’t have to answer” § Cervical § If they’re over 25 Demo:The2MinuteMOSC § Scenario § You’re an FY1 in GP § Ms Becky Blake has come in with a 1-day hx lower abdo pain § No bowel sx § Points to pain around pelvis § Take a gynae history to narrow down the differentials Gynaehistorytaking101 § Important extras: § Ask about Bladder and Bowels § Red flags never hurt:weight loss,fatigue § Sx of anemia § Esp with menorrhagia § Tiredness,dizziness,pale Gynaehistorytaking101:endinghx § Give differentials obv § Management § Speculum § Bimanual § Abdo exam (if indicated) § Pregnancy test § Urine Dip § Serum ß-HCG § USS § Abdo § Trans-vaginal We will cover: § Fibroids § Dysfunctional Uterine Bleeding PVBleeding: Conditions § Endometrial cancer § Endometriosis § PCOS Endometriosis § Endometrial tissue grows in inappropriate places e.g. in the muscle wall (adenomyosis), fallopian tubes, ovaries § This tissue still acts normally under hormonal control- thickening, breaking down and bleeding cyclically § Often young women- 10% of women of reproductive age globally § Very painful periods, pain can be throughout pelvis and often starts before menstruation § Can involve heavy periods § Also associated with pain before, during or after sex (dyspareunia) and subfertility § Laparoscopy is gold standard for diagnosis § Treatment- ibuprofen/ paracetamol, hormonal contraceptives, gonadotrophin-releasing hormone (GnRH) analogues, surgery- remove endo tissue or hysterectomy § >40y § Painful,heavy periods § May be palpable lump in abdomen Fibroids § Benign lump of muscle and fibrous tissue § Treatment for symptomatic relief and to improve fertility § They naturally shrink after menopause § Management § Contraceptives,TXA or NSAIDs for heavy bleeding § Injections of gonadotropin releasing hormone analogues (GnRHas)- reduces oestrogen production from pituitary § Ulipristal acetate- occasional use if moderate- severe symptoms § Hysteroscopic resection if fibroids are small § Myomectomy- remove fibroids § Hysterectomy- remove uterus § 35-45 y/o § Menstrual bleeding significantly increases in run up to menopause § Not necessarily associated with pain Dysfunctional § Harmless uterinebleeding § Reassurance § Rx § IUS § Tranexamic acid § Consider iron replacement therapyEndometrialcancer § Main features are post menopausal bleeding (PMB) or a change in intermenstrual bleeding (IMB) if pre menopause § Pain/change in discharge is less common § Most commonly occurs after menopause but 25% occurs before § Women over 55 with PMB should be referred via 2ww pathway § Risk factors § obesity § nulliparity § early menarche or late menopause § unopposed oestrogen.The addition of a progestogen to Endometrial oestrogen reduces this risk (e.g.In HRT). § diabetes mellitus cancer: § Tamoxifen (breast Ca treatment) § PCOS contd § hereditary non-polyposis colorectal carcinoma § Management § Total abdominal hysterectomy with bilateral salpingo- oophorectomy. § +/- Sentinel node biopsy or lymph node removal if indication the disease has spread PolycysticOvarian Syndrome § Symptoms often start late teens/ early 20s § Irregular/ infrequent periods (oligmenorrhoea) or no periods (amenorrhoea) § Excess androgens results in increased body/ facial hair (hirsutism) § Classifically associated with being overweight/ struggling to lose weight § Subfertility § May also suffer from acne and thinning hair on the head § Increased risk of T2DM (insulin insensitivity due to high circulating levels) and high cholesterolPolycysticOvarianSyndrome:contd § Caused by fluid filled sacs on the ovaries which alter hormone release. § Diagnosis can be made on having 2 out of 3: § Irregular/ infrequent periods § High levels testosterone on blood tests or physical signs of it § USS showing polycystic ovaries § Treatment § Lifestyle changes and weight loss if appropriate can improve symptoms § Contraceptive pill (mini pill) and IUS can be used to regulate periods and reduce chance of endometrial cancer. § Subfertility- weight loss if needed, then clomenifene first line, then metformin. Aim is to encourage ovulation. Next line is IVF § Most women with PCOS are able to get pregnant, but may need more support.CervicalCancer § High grade dyskaryosis cells on cervix § Most associated with HPV type 16 and 18 (vaccination at 12-13 in UK) § Cervical screening: § Brush takes cells from surface of cervix: screens for abnormal cell (looks at nuclei) § NOT histological (only biopsy is diagnostic as give histology) § If dyskaryosis present, test for HPV § Biopsy taken during colposcopy to test for cervical intra-epithelial neoplasia (CIN) § CIN = measure of dysplasia § graded 1-3 § CIN 3 is precancerous and needs treating via LETZ Symptoms: § PMB,IMB,post coital § Discharge + § Pelvic pain § Dyspareunia Risk Factors: CervicalCancer: § Smoking § HIV Contd § COCP >5 years § High gravidity § FHx cervical cancer § Exposure to diethylstilbestrol ante-natally (only in women born before 1971) § Columnar cells inside cervix migrate to outside of cervix (instead of stratified squamous) Cervical § Red ring around cervix § Not cancer Ectropion § Symptoms § discharge ++ § Abnormal bleeding § Dyspareunia/post coital bleeding § Causes: § COCP § Red = ectropion § White = CIN (on testing - doesn’t look like this day to day) § Spontaneously resolves – only treat if symptomatic § Treatment = cauterisation of the ectropion in colposcopy PVBleeding: Presentations § Periods § 5 main presentations: § Heavy § Post menopausal § Painful § Between periods § Irregular § Other § Painful § After sex § Pregnancy (miscarriage,placenta praevia,placental abruption) § Causes = POLICEMAN Heavy § Polyps § Ovarian dysfunction Bleeding § Leiomyoma § Iatrogenic § Coagulopathy § Endometrial process § Malignancy § Adenomyosis § Not yet classified § Is it period – menorrhagia § Ddx: § Endometriosis Heavy § Fibroids § PCOS § Dysfunctional uterine bleeding Bleeding § Painful? § SOCRATES § Anemia sx § Hx bleeding disorders? § Differentials: Post § Endometrial hyperplasia/Cancer § Atrophic vaginitis § HRT related bleeding Menopausal § Clotting disorder § Cervical cancer Bleeding § Full menopause hx § When did periods change § LMP § Any changes to period before menopause? § HRT?What kind? Progesterone cover? § MOSC:new sexual partners,up to date smear,gravidity § Smoking hx:protective against endometrial cs § Systems Review § Weight loss - metastatic Post § Bloating - ovarian § Prolapse (dragging sensation) – maybe be a source of bleeding Menopausal § Nose bleeds – clotting disorder § Haematuria/PR bleed – misdiagnosed § PV discharge/pain/itching – STI/trauma Bleeding § Always refer on 2WW § TVUSS,bimanual and speculum § FIGO staging § If lining of uterus >4mm then suspicious § Endometrial hyperplasia v cancer = presence of atypical cells § Hyperplasia treated with mirena coil or oral progesterone § Fibroids Painful § Endometriosis § Period cramps § SOCRATES as with any pain history § Particularly important points: § When is the pain e.g.cyclical § Associated symptoms § Sexual health history may be appropriate § Age is often helpful § Irregular periods = PCOS § Bleeding irregularly = intermenstrual (next slide) Irregular § How long are cycles? How long are periods? § How long have they been irregular (forever or recent change) § DDx – can narrow down w MOSC § PCOS § Near menarche/menopause § Post pregnancy § HRT/contraception § System review § High BMI § Acne § Depression § Hirsuitism § Fertility issues § DDX Inter - § Cervical cancer/ectropion § Trauma to vagina (eg post coital) § Contraception related bleeding menstrual § “spotting” § Key Questions Bleeding § How much,how often (liner/pad/tampon) § What colour § Assoc sx:Related to penetrative sex? Pain? § HPV jab? § FHx cervical cancer § Management § Speculum § SmearBleeding Not to Miss Benign Non-gynae One to watch The rest Heavy Miscarriage/haemorrhage Menorrhagia Clotting disorder Painful ie Dysfunctional endometriosis, uterine fibroids bleeding PMB Endo cancer HRT related Clotting disorder Endo - bleeding hyperplasia Post- Cervical Cancer Vaginal trauma n/a Cervical - coital ectropion Irregular PCOS Early/late in n/a - - menstrual life Painful Ectopic/pregnancy Endometriosis IBD/IBS/GI issue - PID related coinciding with period PVBleedingSummaryPVDischarge Physiological • Can vary with menstrual cycle • Can change in pregnancy Red Flags: Discharge • Odorous • Unusual color DDX • STIs • Bacterial/fungal infections § Candida aka thrush § “cottage cheese”– white,lumpy discharge § Itching,soreness § 150mg fluconazole one off § 500mg clotrimazole pessary § 1-2% clotrimazole cream externally § In pregnant women DON’T give fluconazole Thrush § Discharge § “Fishy”,foul smelling § Greyish-white and thin and watery § No pain,no soreness or itching § One of the most common causes of abnormal discharge § Caused by a change in balance of bacteria in the vaginal flora and pH change (more alkaline) § Not an STI,but can be triggered during sex Bacterial § Partner notification/ treatment not required. V aginosis § Also worth ruling out STIs during investigation § If left untreated,the patient will be more susceptible to infections e.g.chlamydia § Treatment is metronidazole/ clindamycin either oral, gels or creams § Can also get OTC treatments such as Candestan § Symptoms § Vulval pain/itching § Dysuria § Painful sex § Discharge § Unusual colored § “fishy”smell § May be thinner/greater in volume § Frothy § Causes vaginitis T richomonas § Less common,so usually diagnosed by GUM clinics under microscope § pH is raised § Treatment:metronidazole § Sexually transmitted,so partner needs notifying and treating,abstain until both treated. § Most common STI in the UK § In women 80% asymptomatic (50% in men) § Symptoms if present: § Discharge - smelly,yellow/ green/ white § PCB,IMB § Abdo pain Chlamydia § Dysuria § If untreated may cause infertility (<20%),PID (<16%),ectopic pregnancy § Notify and treat partner,abstain until treated – reinfection <30% § Treatment with doxycycline and azithromycin § Less common than chlamydia,found more in urban areas § 50% women and 10% men are asymptomatic § Symptoms include: § Cervical/ urethral discharge – thick yellow or green § Dysuria § PCB,IMB Gonorrhoea § Abdominal pain § Deep dyspareunia § Epididymitis in men § There is lots of antibiotic resistance so it must be referred to GUM,not treated in primary care.Usu cephalosporin. § STI- notify and treat partner,abstain.Condition Discharge Smell Symptoms Risk Factors Thrush White/creamy,lumpy nil Itching,soreness, Recent abx course redness Bacterial Grey,watery Fishy/foul None,just smell Unprotected sex,multiple Vaginosis partners.Douching. Trichomonas Yellow/green/grey/ Fishy Pain,itching, Unprotected sex,multiple partners clear dyspareunia Chlamydia Green/yellow Foul None or PCB,ICB, Unprotected sex,multiple partners dysuria,abdo pain Gonorrhoea Green/yellow Foul None or PCB, Unprotected sex,multiple partners ICB,dysuria,abdop ain Herpes nil nil Itching,pain Unprotected sex,esp with partner Blisters/vesicles on known to have cold sores vulva PVDischargeSummary § A 32-year-old woman with polycystic ovarian syndrome is struggling to conceive.She and her partner have been trying for 18 months,with no success.On examination,there is hirsutism and she has a BMI of 24 kg/m². What is the most appropriate management option for this SBAs patient? A. IVF B. Metformin C. Clomifene D. Weight reduction Answer: § A 32-year-old woman with polycystic ovarian syndrome is struggling to conceive.She and her partner have been trying for 18 months,with no success.On examination,there is hirsutism and she has a BMI of 24 kg/m². What is the most appropriate management option for this patient? A. IVF SBAs B. Metformin C. Clomifene D. Weight reduction Answer:C- Clomifene Clomifene is first line for subfertility as this patient is not overweight.Metformin can also be used but isnt currently first line. § A 36 year old female presents with a curd-like white vaginal discharge.She also is complaining of pain during sex,which started recently.What is the most likely diagnosis? A. Pregnancy SBAs B. Bacterial vaginosis C. Physiological D. Candida (thrush) Answer: § A 36 year old female presents with a curd-like white vaginal discharge.She also is complaining of pain during sex,which started recently.What is the most likely diagnosis? A. Pregnancy B. Bacterial vaginosis C. Physiological SBAs D. Candida (thrush) Answer:D- Candida Vaginal discharge is a common presenting symptom and isn't always pathological,so it is important to consider being physiological as a differential.Curd like discharge with no fishy smell reported is most likely thrush. § A 25-year-old presents to the GP with cyclical pelvic pain and associated painful bowel movements.She has previously been seen by gynaecology for these symptoms which had improved with paracetamol and mefenamic acid initially,however,she states that the pain has returned and she would like to try an alternative treatment.She is not currently pregnant but she expresses a wish to try for a family sometime in the next couple of years. SBAs § Out of those listed below,what would be the next most appropriate management for this condition? A. Buscopan B. Combined oral contraceptive pill C. Opoid analgesia D. Referral for laparoscopic excision or ablation Answer: § A 25-year-old presents to the GP with cyclical pelvic pain and associated painful bowel movements.She has previously been seen by gynaecology for these symptoms which had improved with paracetamol and mefenamic acid initially,however,she states that the pain has returned and she would like to try an alternative treatment.She is not currently pregnant but she expresses a wish to try for a family sometime in the next couple of years. § Out of those listed below,what would be the next most appropriate management for this condition? SBAs A. Buscopan B. Combined oral contraceptive pill C. Opoid analgesia D. Referral for laparoscopic excision or ablation Answer:B- COC This history is suggestive of endometriosis.She should be re referred to gynaecology as symptoms have reoccured and the bowels may be involved.In the meantime the next line treatment which the GP can offer is hormonal contraception.In practice you would discuss which one suits the patient best, but in this case the best answer is the COC. CCATips Jump into practice – don’t try to cover all the content first Practice with different people to gain varied feedback Presentations > Conditions • Learning everything about a condition won’t teach you how to take a good history – cover all your bases and try to rule out things in your history Get used to asking“embarrassing”questions • Sexual history • Using terms like vagina and vulva comfortably§ Post menopausal bleeding § ICE § MOSC § Menstrual – menarche § Sexual – new partners? § Bleeding: § How much,how often,clots/pieces?,flooding,when did it start § Menopause: § When,LMP,HRT **unopposed oestrogen** CCAPrep– § Red Flags: § Systemic sx Focused § weight loss,fatigue,abdo lumps § Risk Factors: Gynaehx § unopposed oestrogen (COCP long term,fhx,HRT, nulliparity) § Other: § Bleeding disorders,PMH cancer, § Management: § 2WW clinic § TVUS;FBC,CRP,ESR;Speculum & BimanualCCAPrep– Focused GynaehxResources § ZERO TO FINALS – your best friend for F&C § <- This book for CCA prep § Ask to join sexual health clinics/midwife clinics on GP block § Use patient info leaflets § National Childbirth Trust (NCT) for birth counselling infoQuestions?