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ROAD TO FINALS EPISODE 4: GYNAECOLOGY Priyanka Iyer ST2 O&G Newham University Hospital 2 May 2024TOPICS 1. Abnormal vaginal bleeding: Menorrhagia, Fibroids, Post menopausal bleeding 2. Pelvic Pain – Ovarian Cyst Accident, PID and Endometriosis 3. Sexual health – Contraception, Vaginal discharge, STIs 4. Infertility – PCOS, OHSS 5. Ovarian pathology 6. Cervical Screening 7. Amenorrhoea – Primary and secondary 8. Urogynaecology – Incontinence, ProlapseABNORMAL VAGINAL BLEEDINGABNORMAL VAGINAL BLEEDING MCQ 1 Samantha is a 41-year-old woman who comes to see you with heavy menstrual bleeding that has been worsening over the last 12 months. Along with this, she has severe period pain which begins a few days before each cycle. Her periods are regular and she has a 29-day cycle. Samantha has not been sexually active over the past year and takes no regular medication. She has 2 teenage children who were both born by vaginal delivery with no complications. Abdominal examination suggests a bulky tender uterus and a speculum examination reveals a normal-looking cervix. You request a full blood count. What is the most appropriate next step? A - Arrange for levonorgestrel intrauterine system (LNG-IUS) insertion B - Arrange for outpatient hysteroscopy C - Refer urgently to gynaecology D - Request a transabdominal ultrasound E - Request a transvaginal ultrasoundABNORMAL VAGINAL BLEEDING MCQ 1 Samantha is a 41-year-old woman who comes to see you with heavy menstrual bleeding that has been worsening over the last 12 months. Along with this, she has severe period pain which begins a few days before each cycle. Her periods are regular and she has a 29-day cycle. Samantha has not been sexually active over the past year and takes no regular medication. She has 2 teenage children who were both born by vaginal delivery with no complications. Abdominal examination suggests a bulky tender uterus and a speculum examination reveals a normal-looking cervix. You request a full blood count. What is the most appropriate next step? A - Arrange for levonorgestrel intrauterine system (LNG-IUS) insertion B - Arrange for outpatient hysteroscopy C - Refer urgently to gynaecology D - Request a transabdominal ultrasound E - Request a transvaginal ultrasoundABNORMAL VAGINAL BLEEDING MCQ 2 A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management? A Tranexemic acid B NSAID C Norethisterone D IUS Mirena E COCPABNORMAL VAGINAL BLEEDING MCQ 2 A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management? A Tranexemic acid B NSAID C Norethisterone D IUS Mirena E COCPHEAVY MENSTRUAL BLEEDING • History – Nature of bleeding, Related symptoms (persistent IMB, pelvic pain +/- pressure symptoms), impact on QoL, other comorbidities or previous treatment • If HMB and no other symptoms à consider pharmacological without carrying out physical examination • Investigations: • FBC for all women, coagulation + TFTs only if appropriate •When to offer TVUS? – uterus palpable abdominally, pelvic mass palpable on examination or difficult examination in obese women, significant dysmenorrhoea •When to offer outpatient hysteroscopy? – depending on TVUS findings, persistent IMB and irregular bleeding, women who are obese or have PCOS, if taking tamoxifen, if previous unsuccessful treatment HEAVY MENSTRUAL BLEEDING • Subtle abnormalities of endometrial haemostasis or uterine prostaglandin levels • Most common causes: uterine fibroids (30%) and polyps (10%) • Pharmacological management: • Trying to conceive: Tranexamic acid + NSAIDs • Not trying to conceive: st • 1 line: Mirena IUS • 2 line: COCP , Cyclical oral progestogens • Surgical management options: •Hysteroscopic removal of fibroids or polyps – TCRF or TCRP • Endometrial ablation • Uterine artery embolisation • HysterectomyABNORMAL VAGINAL BLEEDING MCQ 3 You see a 40 year old lady with longstanding menorrhagia in the Gynaecology outpatients clinic. She has had 3 normal deliveries and no other comorbidities with a raised BMI of 35. She has a background of a large fibroid uterus which is causing a significant impact on her quality of life. She has tried various conservative and What is the most appropriate management in this case? has completed her family. A. Arrange an outpatient hysteroscopy B. Further trial of tranexamic acid and NSAIDs C. Insertion of Mirena Coil D. Discuss surgical management for her fibroid uterus including hysterectomy E. Reassure her that her symptoms will get better after the menopauseABNORMAL VAGINAL BLEEDING MCQ 3 You see a 40 year old lady with longstanding menorrhagia in the Gynaecology outpatients clinic. She has had 3 normal deliveries and no other comorbidities with a raised BMI of 35. She has a background of a large fibroid uterus which is causing a significant impact on her quality of life. She has tried various conservative and What is the most appropriate management in this case? has completed her family. A. Arrange an outpatient hysteroscopy B. Further trial of tranexamic acid and NSAIDs C. Insertion of Mirena Coil D. Discuss surgical management for her fibroid uterus including hysterectomy E. Reassure her that her symptoms will get better after the menopauseFIBROIDS • Risk factors for fibroids: increasing reproductive age, Asian and Black women, obese, early menarche, 1 degree relative • Growth is oestrogen and progestrone dependent • Symptoms: Menorrhagia (submucosal), IMB (polypoid/submucosal), pressure effects (subserosal), subfertility (submucosal) Complications: Torsion of pedunculated fibroids, degeneration (red in pregnancy, hyaline or cystic, calcification), malignancy Features of malignancy: pain and rapid growth, growth in post menopausal, poor response to GnRH or ullipristal acetate MANAGEMENT OF FIBROIDS MEDICAL Mirena IUS - but limited efficacy in women with fibroids GnRH agonists - short term use (bone density loss), can use add back HRT, fibroids return to normal size once treatment stopped Ullipristal acetate (Mechanism?) - shrink fibroids, no SE of bone density loss or menopausal side effects, what bloods do you need to monitor? SURGICAL Hysteroscopy +TCRF Myomectomy Uterine Artery Embolisation HysterectomyWHAT’S NEW? RYEQO Ø Combination of Relugolix + Estradiol + Norethisterone acetate Ø NICE approved for treatment of moderate to severe symptoms of uterine fibroids in adults of reproductive age Ø Results suggest effectiveness in reducing menorrhagia Ø Additional benefits compared to GnRH analogues/surgert: Ø Non-surgical management Ø Taken orally Ø No restriction on treatment duration Ø Well tolerated Ø Uterus preservingGNRH AGONISTS VS ANTAGONISTSABNORMAL VAGINAL BLEEDING MCQ 4 A 67-year-old woman attends your GP surgery complaining of three episodes of postmenopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 five years. You perform an abdominal exam, which is unremarkable and a vaginal examination,for which is normal apart from some vaginal dryness. What is the investigation you are going to perform first? A USS Abdomen B TVUS C Smear test D Colposcopy E HysteroscopyABNORMAL VAGINAL BLEEDING MCQ 4 A 67-year-old woman attends your GP surgery complaining of three episodes of postmenopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 five years. You perform an abdominal exam, which is unremarkable and a vaginal examination,for which is normal apart from some vaginal dryness. What is the investigation you are going to perform first? A USS Abdomen B TVUS C Smear test D Colposcopy E Hysteroscopy POST MENOPAUSAL BLEEDING DIFFERENTIALS Others: • HRT • Tamoxifen • Vaginal/vulval cancerPOST MENOPAUSAL BLEEDING GUIDELINES >55 with PMB - TVUS within 2 weeks!!! - Normal ET is <4mm To diagnose Endometrial cancer - Hysteroscopy + Biopsy Need to Ix women on HRT who present with PMB to rule out Ca. Mx for other causes of PMB: Vaginal atrophy: topical oestrogens, lubricants, HRT Patient on HRT: different preparations can be used Endometrial hyperplasia: surveillanceypia: <5% risk of developing into cancer, manage with progesterone + - With atypia: Risk of progression, Hysterectomy + BSO in postmenopausal ENDOMETRIAL CANCER Risk Factors • Age • Obesity • Early menarche and late menopause • Nulliparity • PCOS • Oestrogen only HRT Protective: COCP & Smoking Treatment options: • Localised disease: TAH + BSO • Indications for radiotherapy: high risk/proven for extrauterine disease, inoperable or recurrence (vaginal vault), palliation for symptoms • Progestogen for frail + elderly womenPELVIC PAINPELVIC PAIN MCQ 1 A. IV Ceftriaxone and IV Doxycyline B. IV Ofloxacin and IV Metronidazole D. IV Clindamycin and Gentamicinidazole E. Oral Azathioprine and BenzylpenicillinPELVIC PAIN MCQ 1 A. IV Ceftriaxone and IV Doxycyline B. IV Ofloxacin and IV Metronidazole D. IV Clindamycin and Gentamicinidazole E. Oral Azathioprine and Benzylpenicillin PELVIC INFLAMMATORY DISEASE • Ascending infection from the cervix --> infection & inflammation of female pelvic organs • Risk factors: prior STI, recent new sexual partner, multiple partners, unprotected intercourse, history of PID – (known to happen in those who are not sexually active) • Most common organisms: Chlamydia and Gonorrhoea (only comprise 40% of PID), most infections are polymicrobial hence broad spectrum • Inflammation --> scarring, adhesions, partial or total obstruction of fallopian tubesPID MANAGEMENT Analgesics Antibiotics: Duration 14 days Mild PID: Levofloxacin PO + Metronidazole PO Severe (Pyrexia > 38, clinical signs of tubo-ovarian abscess, pelvic peritonitis): IV Ceftriaxone + Doxycycline PO + metronidazole PO Consider laparoscopy if no sig. improvement after 24 hours Pelvic abscess – lap or US drainage Treatment of sexual partner, Careful counselling – barrier contraception, partner tracing, advise to attend sexual health clinicCOMPLICATIONS OF PID Infertility Fitz Hugh Curtis Syndrome Abscess Chronic Pelvic Pain Ectopic Pregnancy Peritonitis Intestinal obstruction Disseminated infections (endocarditis, sepsis, meningitis)PELVIC PAIN MCQ 2 A 32-year-old woman presents with a history of painful, regular periods. Since stopping the combined oral contraceptive pill eight-months ago her periods are more painful and heavy. She is upset because she would like to conceive but the pain is limiting intercourse. She would like to know the cause of her symptoms. On examination, her abdomen is soft and non-tender with no masses, but a bimanual examination pelvic examination is limited due to pain. What is the gold standard diagnostic test for this woman? • CT • Laparoscopy • MRI • TVUS • CA -125PELVIC PAIN MCQ 2 A 32-year-old woman presents with a history of painful, regular periods. Since stopping the combined oral contraceptive pill eight-months ago her periods are more painful and heavy. She is upset because she would like to conceive but the pain is limiting intercourse. She would like to know the cause of her symptoms. On examination, her abdomen is soft and non-tender with no masses, but a bimanual examination pelvic examination is limited due to pain. What is the gold standard diagnostic test for this woman? • CT • Laparoscopy • MRI • TVUS • CA -125 DIFFERENTIALS FOR DYSMENORRHOEA Primary Dysmenorrhoea – very common, coincides with the start of menstruation, responds to NSAIDs or COCP (suppression of ovulation) onset of menstruation, deep dyspareunia/menorrhagia/ irregular menstruation common • PMS – 80% of women have premenstrual symptoms • Endometriosis •mildly enlarged + tender, TVUS + MRIum within myometrium, uterus • Fibroids • Pelvic Inflammatory disease •?Ovarian tumoursENDOMETRIOSIS Presence of endometrial tissue outside of the uterine cavity - responds to the hormonal fluctuation of the menstrual cycle 4 D’s of endometriosis: Dysmenorrhoea, Dyspareunia, Dyschezia, Dysuria O/E: Fixed retroverted uterus, pelvic tenderness, enlarged ovaries Ix: TVUS, Lap – gold standardENDOMETRIOSIS: MANAGEMENT + COMPLICATIONS Management: oestrogen to avoid osteoporosis, CVD, etc)nRH analogue to induce menopause (+ Add back Pain relief Surgery: Lap (it can grow back), resection, endometrioma cystectomy, TAH+BSO in refractory cases Complications: Ovarian failure post treatment Formation of adhesions Infertility PELVIC PAIN MCQ 3 A 33-year-old woman presents to the emergency department with worsening left-sided abdominal pain. She reports the pain started suddenly 5 hours ago and has been steadily getting worse. The pain started suddenly following intercourse. She is unsure about the date of her last menstrual period as she currently has the Mirena coil fitted. She denies any vaginal bleeding or discharge. Apart from the pain, she has no other symptoms and her observations are stable. Her lower abdomen is tender on palpation but there is no guarding or rigidity. Pelvic exam including bimanual exam is unremarkable. The Mirena coil threads are clearly visualised. Ultrasound shows free fluid in the pelvic cavity. Urinary pregnancy test is negative. What is the most likely diagnosis? • Adnexal torsion • Mittelschmerz • Ruptured ovarian cyst • Ruptured ectopic pregnancy • Appendicitis PELVIC PAIN MCQ 3 A 33-year-old woman presents to the emergency department with worsening left-sided abdominal pain. She reports the pain started suddenly 5 hours ago and has been steadily getting worse. The pain started suddenly following intercourse. She is unsure about the date of her last menstrual period as she currently has the Mirena coil fitted. She denies any vaginal bleeding or discharge. Apart from the pain, she has no other symptoms and her observations are stable. Her lower abdomen is tender on palpation but there is no guarding or rigidity. Pelvic exam including bimanual exam is unremarkable. The Mirena coil threads are clearly visualised. Ultrasound shows free fluid in the pelvic cavity. Urinary pregnancy test is negative. What is the most likely diagnosis? • Adnexal torsion • Mittelschmerz • Ruptured ovarian cyst • Ruptured ectopic pregnancy • AppendicitisPELVIC PAIN MCQ 4PELVIC PAIN MCQ 4 Answer: A OVARIAN CYST ACCIDENTS OVARIAN CYST RUPTURE : OVARIAN TORSION: Presentation: Presentation: • Acute abdo pain during exercise, intercourse • Acute abdo pain during exercise, intercourse • PV bleed • N&V • radiates to back, thigh, pelvis • Circulatory collapse +/- weakness, syncope • N&V • Fever (indicates a necrotic ovary) Ix: RULE OUT ECTOPIC!, USS – free fluid Mx: Ix: RULE OUT ECTOPIC!, USS Doppler – large oedematous ovary with impaired flow • If stable --> analgesia • Bleeding/unstable --> Laparoscopy Mx: Analgesia and LaparoscopySEXUAL HEALTHSEXUAL HEALTH MCQ 1SEXUAL HEALTH MCQ 1 Answer: BCONTRACEPTIONUKMEC 4 CRITERIA: Breastfeeding – up to 6 weeks postpartum Age > 35 and smoking > 15 cigarettes a day Uncontrolled hypertension History of stroke or ischaemic heart disease History of VTE or current VTE Breast cancer Severe liver cirrhosis SPECIAL CASES OF CONTRACEPTION POST-PARTUM EMERGENCY Not needed for 21 days Levonorgestrel: Up to 72 hours after POP & Depo-Provera : safe with Ulipristal (progesterone receptor breastfeeding and can be started at any modulator): up to 5 days after, caution in time severe asthma COCP: CI if breastfeeding <6 weeks Copper IUD: up to 5 days after or 5 days after estimated date of ovulation IUD/ IUS: inserted within 48 hours or after 4/52GUESS THE CONTRACEPTION o Which contraception is CI in a patient who has migraine with auras? o Which contraception do you have to take regularly without any breaks? o Which contraception results in a delay in fertility? o The most effective form of emergency contraception? o Which contraception can be useful for menorrhagia?GUESS THE CONTRACEPTION o Which contraception is CI in a patient who has migraine with auras? COCP o Which contraception do you have to take regularly without any breaks? POP o Which contraception results in a delay in fertility? Depo-Provera o The most effective form of emergency contraception? Copper coil o Which contraception can be useful for menorrhagia? Progesterone IUSSEXUAL HEALTH MCQ 2SEXUAL HEALTH MCQ 2 Answer: D TAKING A SEXUAL HISTORY – WHERE DO I BEGIN?? KEY SYMPTOMS: SEXUAL CONTACTS: • Abdominal/pelvic pain • Last sexual encounter – consensual? • Bleeding: PCB, IMB, PMB regular partner? type of sex? • Abnormal vaginal discharge – contraception? volume, colour, consistency, smell • Any other partners in the last 3 • Dyspareunia months? • Vulval skin changes + itching • HIV Risk assessment: previous • Systemic symptoms partners who were known to be HIV positive, recreational drugs, VAGINAL DISCHARGE COMMON CAUSES: • Physiological CONDITION KEY FEATURES • Candida Candida Cottage cheese discharge • Trichomonas vaginalis * Vulvitis • Bacterial Vaginosis Itchy Trichomonas Vaginalis Offensive, yellow/green, frothy discharge LESS COMMON CAUSES: Vulvovaginitis Strawberry cervix • Gonorrhoea Bacterial Vaginosis Offensive, thin, white/grey, fishy • Chlamydia - rarely odour, worse with intercourse • Ectropion • Foreign body • Cervical Cancer NON SEXUALLY TRANSMITTED INFECTIONS Bacterial Vaginosis • Loss of lactobacilli and increase in Candidiasis anaerobic and BV associated bacteria • Risk factors: pregnancy, • Amsel’s criteria: immunocompromised, diabetes, • Thin, white discharge antibiotics • Clue cells • Vaginal pH >4.5 • Cottage cheese discharge, itching, • Positive whiff test superficial dyspareunia and dysuria • Management: Oral metronidazole • Clotrimazole pessary or oral • Risks in pregnancy? fluconazole SEXUALLY TRANSMITTED INFECTIONS Chlamydia Gonorrhoea • Usually asymptomatic, can present • Altered vaginal discharge, IMB or PCB, with vaginal discharge, abdominal pain and dyspareunia inflammation of the urethra and • Complication: cervix and pelvic infection • Pelvic infection (can be silent) --> tu•al Single IM Ceftriaxone dose/ damage and infertility Single dose of Oral Cefixime + • Can precipitate reactive arthritis: Triad ofzithromycin urethritis, conjunctivitis and arthritis Disseminated Gonococcal Infection • Azithromycin (single dose) or Doxycycline (7 days)Sexually Transmitted Infections (Cont..) Genital Herpes: Trichomoniasis • Vaginal discharge, • Painful genital ulcers vulvovaginitis, strawberry • Oral aciclovir cervix, pH >4.5 • Elective C section if primary • Oral metronidazole for 5-7 infection after 28 weeks days pregnancy Syphilis: • Primary: chancre, lymphadenopathy • Secondary: rash, painless warty lesions • Tertiary: AR, tabes dorsalis, gummas • IM PenicillinSUMMARY SLIDE 1: INFECTION CLINICAL FEAUTURES TREATMENT Bacterial Offensive, thin, white/grey, fishy odour Oral Metronidazole Vaginosis [Amsel’s criteria] Candidiasis Cottage cheese discharge, Clotrimazole pessary, Vulvitis, Itchy Fluconazole Chlamydia Altered vaginal discharge, IMB/PCB, Single dose Azithromycin or abdo pain, dyspareunia, PID and Doxycycline for 7 days reactive arthritis Gonorrhoea Vaginal discharge, Inflammation of Single IM Ceftriaxone/ Single urethra and cervix, PID, Disseminated dose of Oral cefixime + Gonococcal Infection Azithromycin Trichomoniasis Offensive green vaginal discharge, Oral metronidazole for 5-7 vulvovaginitis, strawberry cervix, pH days >4.5SUMMARY SLIDE 2: INFECTION CLINICAL FEAUTURES TREATMENT Genital Herpes Painful genital ulcers Oral aciclovir Syphilis Primary: Painless genital ulcers + IM Benzylpenicillin Lymphadenopathy, Secondary: rash, painless warty lesions Tertiary: AR, tabes dorsalis, gummas Pelvic Inflammatory Bilateral lower abdominal pain, Oral Ofloxacin + Oral Disease fever, deep dyspareunia, vaginal Metronidazole discharge, cervical excitation OR IM cefotaxime + Oral Doxy + Oral MetroMANAGEMENT OF VAGINAL DISCHARGE whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis? A 30-year-old woman presents with an offensive 'fishy', thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5. A 27-year-old woman complains of an offensive 'musty', frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She negative diplococcus.uria, intermenstrual bleeding and dyspareunia. A swab shows a Gram-ANSWERS using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports not other symptoms of note. What is the most likely diagnosis? Candidiasis, Clotrimazole pessary, Oral fluconazole shows the pH to be > 4.5. Bacterial Vaginosis, Metronidazole, grey vaginal discharge. Testing the discharge A 27-year-old woman complains of an offensive 'musty', frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. Trichomoniasis, Metronidazole A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram-negative diplococcus. Gonorrhoea, IM CeftriaxoneINFERTILITYTAKING A FERTILITY HISTORY • How long have they been trying? • Intercourse: frequency, any pain? • Partners (consider each separately): age, occupation, BMI, previous children, smoking and alcohol, current medications & PMHx • Gynae historyAN APPROACH TO INFERTILITY In approaching infertility, there are five basic factors to examine: (1) ovulatory - PCOS (2) uterine - fibroids (3) tubal - PID (4) male factor (5) peritoneal factor – endometriosis Investigations: Male: semen analysis, Female: Mid-luteal progesterone, FSH & LH, HSG/Lap and dye to assess tubal patencyINFERTILITY: MCQ 1 Normal levels: - LH: 2 - 8 - FSH: 3 – 10 - Prolactin: 106-850 - T4 – 5.0 - 12.0 - TSH – 0.5 -5 - Oestradiol: 30 - 400INFERTILITY: MCQ 1 Normal levels: - LH: 2 - 8 - FSH: 3 – 10 - Prolactin: 106-850 - T4 – 5.0 - 12.0 - TSH – 0.5 -5 - Oestradiol: 30 - 400 Answer: D INFERTILITY MCQ 2 A 27-year-old woman who is struggling to conceive has the following hormone profile, taken on day 6 of her cycle: • LH:FSH Ratio = Raised • Testosterone: Mildly Raised A Amenorrhoea and infertility An ultrasound scan shows numerous peripheral ovarian B Amenorrhoea and pelvic pain follicles. C Oligomenorrhoea and facial hair Which single set of symptoms is she most likely to have? D Oligomenorrhoea and pelvic pain E Oligomenorrhoea and temporal headaches INFERTILITY MCQ 2 A 27-year-old woman who is struggling to conceive has the following hormone profile, taken on day 6 of her cycle: • LH:FSH Ratio = Raised • Testosterone: Mildly Raised A Amenorrhoea and infertility An ultrasound scan shows numerous peripheral ovarian B Amenorrhoea and pelvic pain follicles. C Oligomenorrhoea and facial hair Which single set of symptoms is she most likely to have? D Oligomenorrhoea and pelvic pain E Oligomenorrhoea and temporal headaches POLYCYSTIC OVARIAN SYNDROME FEATURES: Rotterdam Diagnostic Criteria (2003) for PCOS • Subfertility and infertility • Menstrual disturbances: oligomenorrhoea requires 2 out of 3 of the following for a diagnosis: and amenorrhoea • Clinical Hyperandrogenism (Ferriman-Gallwey • Hirsutism, acne Score of >8) OR Biochemical Hyperandrogenism • Obesity • Acanthosis nigricans (Elevated Total/Free Testosterone) • Oligomenorrhoea (Less than 6-9 Menses per year) or Oligo-Ovulation • Polycystic Ovaries on Ultrasound (> 12 Antral Follicles in one ovary or ovarian volume of > 10 cm3)MANAGEMENT OF PCOS •Treatment of Oligomenorrhoea: COCP (regulates menstruation and treats hirsutism) •Lifestyle Interventions: healthy and balanced diet, regular exercise, BMI 19-25 Why? improves acne and hair growth + regulates periods + improves fertility • Infertility: Ovulation Induction Drugs – mechanism? •diabetes + GDM, increased risk of endometrial caulatory cycles, X2 increased risk ofINFERTILITY MCQ 3 A 34-year-old woman attends clinic feeling generally unwell. Her abdomen has loose stools. She also feels dyspnoeic on exertion. On examination all observations are within normal range and there is generalised abdominal tenderness with no guarding. The patient is undergoing fertility treatment and the previous week was injected with gonadorelin analogue. Given the above history, which of the following is the most likely diagnosis? • Appendicitis • Ectopic pregnancy • Ovarian cyst rupture • Ovarian hyperstimulation syndrome • Ovarian torsionINFERTILITY MCQ 3 A 34-year-old woman attends clinic feeling generally unwell. Her abdomen has loose stools. She also feels dyspnoeic on exertion. On examination all observations are within normal range and there is generalised abdominal tenderness with no guarding. The patient is undergoing fertility treatment and the previous week was injected with gonadorelin analogue. Given the above history, which of the following is the most likely diagnosis? • Appendicitis • Ectopic pregnancy • Ovarian cyst rupture • Ovarian hyperstimulation syndrome • Ovarian torsion OVARIAN HYPERSTIMULATION SYNDROME • Potential side effects of ovulation induction (severe OHSS <1%) • Pathophysiology: • Ovarian enlargement with multiple cystic spaces --> increase in permeability of capiliaries --> fluid shift to extravascular space • Life threatening complications: • Hypovolaemic shock • Acute renal failure • Venous or arterial thromboembolism • Principles of management: fluid and electrolyte replacement, anti-coagulation therapy, abdominal ascitic paracemntesis OVARIAN PATHOLOGYMCQ 1 abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable next step ? • Prescribe Loperamide and Buscopan •Measure CA125 and refer her urgently to gynaecology •Perform CA125 and an ultrasound scan and only refer her urgently to gynaecology if these results return as abnormal •Refer her for an urgent abdominal/pelvic ultrasound scan •Measure oestrogen and progesterone levelsMCQ 1 abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable next step ? • Prescribe Loperamide and Buscopan •Measure CA125 and refer her urgently to gynaecology •Perform CA125 and an ultrasound scan and only refer her urgently to gynaecology if these results return as abnormal •Refer her for an urgent abdominal/pelvic ultrasound scan •Measure oestrogen and progesterone levels OVARIAN CANCER •Risk factors (related to the number of ovulations): BRCA 1 and 2, early menarche/late menopause, nulliparity •Protective factors: pill, pregnancy, lactattion •Vague clinical features (IBS like) •Ix:•Ca-125 (Can be raised in: Endometriosis, Menstruation, Benign ovarian cysts) •TVUSS •Spread: Directly within the pelvis and abdomen. Later - lymph (para-aortic) + blood borne •Malignant features on imaging: Rapid growth, ascites, advanced age, bilateral solid or septate, increased vacularity •Mx: Surgery + chemo CERVICAL SCREENINGPOST COITAL BLEEDING • Cervix more likely to bleed if not covered in healthy epithelium • Cervical causes: Polyps, cervicitis, ectropion, Cervical Ca • Vaginal causes: vaginitis – atrophic or infective, Carcinoma • Mx: • Speculum + smear • If polyp seen – avulsed and sent for histology • if smear normal à ectropion frozen with cryotherapyCERVICAL SCREENING: MCQ 1 recent cervical smear. On colposcopy she has aceto-white changes and a punchr biopsy followed by cold coagulation. Histology of the biopsy shows CIN II. When should she next be offered cervical screening? • 1 month • 6 weeks • 6 months • 12 months • Return to normal screening, every 3 yearsCERVICAL SCREENING: MCQ 1 recent cervical smear. On colposcopy she has aceto-white changes and a punchr biopsy followed by cold coagulation. Histology of the biopsy shows CIN II. When should she next be offered cervical screening? • 1 month • 6 weeks • 6 months • 12 months • Return to normal screening, every 3 years CERVICAL SCREENING Negative High Risk HPV Return to Normal recall (3 yearly if 25-50, 5 years if 50- 64) Positive High Risk HPV Sent for cytology Cytology result: Normal HPV -ve: Return to normal recall HPV +ve: repeat smear in 12 months (repeat at 24 and if still +ve then colposcopy) Cytology: Borderline or low grade If HPV -ve: return to normal call If HPV +ve: colposcopy Cytology: High grade dyskaryosis/CGIN Colposcopy Inadequate sample Repeat smear at 3 months and then colp if still inadequateCERVICAL SCREENING Colposcopy: CIN I Usually observe Colposcopy: CIN 2/3 Usually treat by LLETZ Treatment for CIN Follow up test of cure smear in 6 monthsAMENHORRHOEAAMENORRHOEA: MCQ 1AMENORRHOEA: MCQ 1 Answer: CAMENORRHOEA: MCQ 2 Normal levels: - LH: 2 - 8 - FSH: 3 – 10 - Prolactin: 106-850 - T4 – 5.0 - 12.0 - TSH – 0.5 -5 - Oestradiol: 30 - 400AMENORRHOEA: MCQ 2 Normal levels: - LH: 2 - 8 - FSH: 3 – 10 - Prolactin: 106-850 - T4 – 5.0 - 12.0 - TSH – 0.5 -5 - Oestradiol: 30 - 400 Answer: D AMENORRHOEA • Definitions: • Primary: menstruation has not started by 16 years (Delayed puberty: secondary sexual characteristics are not present by 14 years) • Secondary: previous normal menstruation, stops for 3 months or more • Oligomenorrhoea: menstruation every 35 days to 6 months Drugs causes for amenorrhoea: progestogens, GnRH analogues, antipsychoticsAPPROACH TO AMENORRHOEAUROGYNAECOLOGYUROGYNAECOLOGY: MCQ 1UROGYNAECOLOGY: MCQ 1 Answer: BUROGYNAECOLOGY: MCQ 2UROGYNAECOLOGY: MCQ 2 Answer: B HISTORY TAKING • or lifting things) and urge (leaking before reaching the toilet, spontaneous urge to pass urine) • Daytime frequency • Nocturia • Nocturnal enuresis • Urgency – detrusor overactivity, bladder conditions – interstitial cystitis • Bladder pain – occurs with bladder filling and relieved by emptying it, interstitial cystitis • Urethral pain • Dysuria • HaematuriaINVESTIGATION • Urine dipstick – infection, glycosuria, haematuria • Urinary diary – volume of fluid intake and micturition • Post micturition USS or catheterisation for chronic retention of urine • Urodynamic studies: useful to differentiate between stress and urge incontinence, before surgery for stress incontience or if OAB is not responding to medical therapy PRESENTATION AND RISK FACTORS STRESS OVERACTIVE BLADDER Clinical Features Involuntary leakage of urine on Urgency +/- urge incontinence effort or exertion, sneezing or Usually have frequency and coughing nocturia O/E – cystocele or urethrocele, O/E – often normal, might see leakage of urine with coughing incidenrtal cystocele Risk Factors Pregnancy and Vaginal Delivery Idiopathic – most cases – prolonged labour + forceps Neurological – MS orspinal cord Obesity & Age injury Prolapse commonly coexists Previous hysterectomy STRESS AND OVERACTIVE BLADDER: MX STRESS OAB 1 line Conservative: Conservative: - Pelvic floor muscle training for 3/12 by physio - Reducing fluid intake and caffeine drinks - Weight loss, smoking cessation, reduce fluid - Review drugs – diuretics and antipsychotics intake - Bladder training for 6 weeks nd 2 line Surgical: Medical: - Mid-urethral sling procedures: TVT and TOT - Anticholinergics – block muscarinic - Injectable periurethral bulking agents receptors, SE – dry mouth, urinary retention, - Colposuspension – rarely performed oxybutynin, solifenacin, tolterodine - Sympathomimetics – mirabegron rd 3 line Medical: Surgical: - Duloxetine – SNRI, enhances urethral sphincter - Botox injections – blocks neuromuscular activity via centrally mediated pathway transmission - Neuromodulation and sacral nerve stimulation UROGYNAECOLOGY: MCQ 3 A. Vaginal hysterectomy with anterior colporrhapy B. Vaginal hysterectomy alone C. Tension free vaginal tape D. Weight loss and pelvic floor exercises E. Insertion of pessary UROGYNAECOLOGY: MCQ 3 A. Vaginal hysterectomy with anterior colporrhapy B. Vaginal hysterectomy alone Answer: E C. Tension free vaginal tape D. Weight loss and pelvic floor exercises E. Insertion of pessary PELVIC ORGAN PROLAPSE • History: dragging sensation, sensation of lump worse at the end of the day or when standing up, severe prolapse – ulcerate/cause bleeding/interfere with intercourse, urinary and bowel symptoms • O/E – Abdo examination + Sim’s speculum, check for co-existing stress incontinence • Clinical diagnosis • Mx – only if significantly affecting quality of life • Conservative: weight reduction, smoking cessation, physio for mild-moderate degrees of prolapse • Pessaries • Surgical options MANAGEMENT OF PROLAPSE Pessaries: • Unwilling or unfit for surgery • vagina to stay behind pubic symphysis and TYPE OF PROLAPSE SURGICAL MANAGEMENT in front of sacrum UTERINE PROLAPSE Vaginal hysterectomy (but • monthsnd shelf pessary, changed every 6-9 women can represent with vaginal vault prolapse) • Post-menopausal: oestrogen replacement, topic oestrogen to prevent ulceration VAGINAL VAULT PROLAPSE Sacrocolpopexy • Complications: pain, urinary retention, Sacrospinous fixation infection, fall out ANTERIOR AND POSTERIOR Anterior and Posterior PROLAPSE ColporrhapySURGICAL PROCEDURESUSEFUL RESOURCES USEFUL O&G RESOURCES