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EVERYTHING YOU NEED TO KNOW ABOUT GYNAECOLOGY IN MEDICAL SCHOOL Izzy and Molly Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats! OTS OF WHA T YOU NEED TO KNOW ABOUT GYNAECOLOGY IN MEDICAL SCHOOL Izzy and MollyWhat we’ll cover: Gynaecological Cancers ■ Cervical ■ Ovarian ■ Endometrial ■ Vaginal ■ Vulval Benign Gynaecology ■ Adenomyosisis ■ Fibroids ■ PCOSGynaecological Cancers Molly1 - Cervical CaBasics 1 - Cervical Cancer: Basics 70% squamous cell carcinoma Pathophysiology 15% adenocarcinoma Develops over 10-20y from CIN 15% mixed (cervical intraepithelial neoplasia) Usually at ‘transformation zone’ Risk factors ~ Columnar cells + acidic vaginal fluid = 1 HPV: 99.7% HPV associated. 80% women squamous cell metaplasia have HPV in their lifetime, most clear it. 2 Not had HPV vaccine HPV 16 and 18 inhibit p53 (tumour 3 Smoking suppression protein) in cervical 4 Immunosuppressed (e.g. HIV) epithelial cells 5 Multiple sexual partners HPV vaccination: Gardasil 9: 6, 11, 16, 18 + 5 other strains Who? 12-13yo // MSM <45y or high risk in sexual health clinic. 25-45y = 2 doses (6mo-2y apart) Immunosuppressed (given over 12mo) Cervical Cancer: Basics 70% squamous cell carcinoma Pathophysiology 15% adenocarcinoma Develops over 10-20y from CIN 15% mixed (cervical intraepithelial neoplasia) Usually at ‘transformation zone’ Risk factors ~ Columnar cells + acidic vaginal fluid = 1 HPV: 99.7% HPV associated. 80% women squamous cell metaplasia have HPV in their lifetime, most clear it) 2 Not had HPV vaccine HPV 16 and 18 inhibit p53 (tumour 3 Smoking suppression protein) in cervical 4 Immunosuppressed (e.g. HIV) epithelial cells 5 Multiple sexual partners HPV vaccination: Gardasil 9: 6, 11, 16, 18 + 5 other strains Who? 12-13yo // MSM <45y or high risk in sexual health clinic. 25-45y = 2 doses (6mo-2y apart) Immunosupprseed (given over 12mo)Case 1 (a) You are an FY1 on your GP placement….Case 1 (a) A 30 year old female has had her smear test at the GP practice. She has just received her results. ■ What would she see on her results?Case 1 (a) A 31 year old female has had her smear test at the GP practice. She has just received her results. ■ What would she see on her results? HPV POSITIVE NO ABNORMAL CELL CHANGESCase 1 (b) A 31 year old female has had her smear test at the GP practice. She has just received her results. ■ What would she see on her results? HPV POSITIVE NO ABNORMAL CELL CHANGES ■ What happens next?Case 1 (b) A 31 year old female, Anne-Marie Peters, has had her smear test at the GP practice. She has just received her results. ■ What would she see on her results? HPV : POSITIVE CYTOLOGY : MODERATE DYSKARYOSIS ■ What happens next? COLPOSCOPY REFERRAL CIN Cervical Intraepithelial Neoplasia (pre-cancerous) National Screening programme, “SMEAR TEST” for 25-64y Result Action ~ Every 3y (25-49y) ~ Every 5y (50-64y) Any HPV -ve Normal screening pathway Results: 1. HPV +/- HPV+ and NORMAL cells Repeat smear in 12 months 2. Cytology: mild/mod/severe dyskaryosis If not cleared → colposcopy Dyskaryosis = abnormal nucleus HPV+ and ABNORMAL cells Colposcopy <6 weeks **Can’t tell CIN from smear test** COLPOSCOPY ● Speculum inserted ● Colposcope: magnified view ● Acetic acid: white plaque on abnormal cells. ● abnormal cells: no stain on ● Biopsy 6 in 10 have abnormal cells at colposcopy.Case 1 (c) Miss Peters attends her colposcopy appointment. She has received her result today. Histology comes back as CIN3. She is very worried, and calls the GP surgery to ask what this means andwhat will happen next? Result Action CIN1 Watch and Wait (usually regresses) Stop smoking CIN2 Consider LLETZ (large loop excision of transformation zone) CIN3 LLETZ CIN 1 = ⅓ of basal epithelium affected All need follow up TOC smear in GP @ 6 CIN 2 = ⅔ of basal epithelium affected months. CIN 3 = >⅔ of basal epithelium Dysplasia = abnormal cells. Cervical Cancer: Dx & Ix Sexually active female, 30-45y (peak incidence) Differentials Endometrial Cancer Unexplained abnormal bleeding: IMB, PCB, PMB (not on Ectropion HRT) Cervical polyp Dyspareunia vaginal discharge: blood stained, foul-smelling Fibroids Pelvic pain Endometriosis Weight loss STI, PID Advanced disease: GI, urinary sx Hormonal contraception History ● Smear hx, previous colposcopies ● Sexual hx, STIs ● PMHx immunosuppression ● Smoking hxgree relative Investigations GPExamination: abdo, speculum, bimanual Vaginal swab: STIs examination findingy if suggestive Sx or abnormal Gynae oncology MDT Staging: CTCAP, MRI pelvis, CT PET, EUA for biopsies = FIGO staging Cytology Cervical Cancer: Management Stage Action IA1 LLETZ (for fertility sparing) Microinvasive Simple hysterectomy (uterus, cervix) IA2-IB2 Radical hysterectomy (uterus, Early cervix, vagina, parametrium, pelvic lymph nodes) +/- bilateral salpingo-oophorectomy +/- adjuvant chemotherapy / radiotherapy IB3-IVA EBRT External beam Locally radiotherapy / brachytherapy / advanced chemotherapy IVB Chemotherapy Spread to distant organsCase 2 (a) A 76 year old female attends the GP surgery to see you. She complains of ~6 months of bloating, abdominal discomfort and loss of appetite. What would you want to know? What else would you ask her? 2 - Ovarian Cancer Pathology Investigations 1 Epithelial (85-90%) CA-125 if… 2 Germ cell tumour (<2%) ● >12x / month (~3x/week) 3 Stromal cell tumour (1%) ○ “Bloating”, abdominal distention ○ Early satiety, loss appetite ○ Pelvic/abdominal pain Risk factors ○ Urinary urgency / frequency Age (peaks 75-79y) ● Consider if… Obesityrous ○ >50y + sx in last 12mo suggesting IBS No breastfeeding ○ Abnormal bleeding, GI Sx, SOB FHx of breast or ovarian (BRCA1/2) Use of HRT 2WW for TVUSS if… Smoking ● CA-125 >35IU/ml ● Ascites or pelvic/abdominal mass on Other causes of raised CA-125? examination = cancer antigen 25 - protein from peritoneal endothelium - any kind of irritation/inflammation of peritoneum Malignancy : colorectal, pancreatic, endometrial, breGynae pathologies - cancers, fibroids, PID Infection: abscess, appendicitis GI pathologies - cancers, IBD, coeliac, Benign: fibroids, endometriosis, adenomyosis, ovarian diarrhoea, IBS, diverticular disease,d torsion/rupture/haemorrhage, pregnancy, PID constipation Urinary pathologies - cancers, UTI Ascites: liver cirrhosis, late stage HFOvarian Cancer: Management FIGO Stage Management IA-B Ovaries Chemotherapy (Platinum IC Ovaries + ascites based) II +pelvic involvement (fallopian Surgery tubes, pelvic tissues) E.g. TAH / BSO / lymph III +peritoneal mets outside the nodes / debulking / omentectomy / bowel pelvis or retroperitoneal lymphadenopathy resection IV Distant mets including liver parenchyma Case 3 (a) A 68 year old female attends the gynaecology department having been referred by her GP for a trans-vaginal ultrasound scan for suspected endometrial cancer. Her endometrium measures 6mm. What is the next appropriate investigation? 1 Trans-abdominal USS 2 CT chest, abdo, pelvis 3 MRI pelvis 4 Chest XR 5 Pipelle Biopsy Case 3 (a) A 68 year old female attends the gynaecology department having been referred by her GP for a trans-vaginal ultrasound scan for suspected endometrial cancer. Her endometrium measures 6mm. What is the next appropriate investigation? 1 Trans-abdominal USS 2 CT chest, abdo, pelvis 3 MRI pelvis 4 Chest XR 5 Pipelle Biopsy 3 - Endometrial Cancer Pathology What to do? Adenocarcinoma (most common) History - presentation, RFs, differentials Endometrium stimulated by unopposed Examination - abdo, speculum, bimanual oestrogen (i.e. no protective progesterone) 2WW pathway? Post menopausal bleeding Presentation OR -good sensitivity, poor specificity (90% with >55y + vaginal discharge / thrombocytosis PMB do not have endometrial Ca) / haematuria / high serum glucose. >> TVUSS Vaginal discharge (clear, white) Abnormal uterine bleeding in >45y- e.g. IMB, If ET is >=4mm thick (or oligo, HMB, unscheduled on HRT >16mm in pre-menopausal)... Age - peaks 65-75y Need histology… Nulliparous ● 1st line - Pipelle biopsy No breastfeeding ● 2nd line - Hysteroscopy High BMInarche, late menopause Hormonal drugs - HRT (oestrogen only), tamoxifeThen…Gynae-oncology MDT PCOS ● Staging - CTAP, MRI Endometrial Cancer: Management FIGO Management Stag e I Uterine Total hysterectomy + BSO + peritoneal body washings II +cervix Radical hysterectomy (i.e. + parametrium + pelvic lns) + BSO +/- adjuvant radiotherapy III +pelvis Maximal de-bulking surgery +/- chemotherapy / radiotherapy IV +bladder, Stage III approach OR palliative bowel, distant mets Endometrial Hyperplasia? “Hyperplasia” = irregular proliferation, increased gland : stroma ratio→ thick endometrium “Atypia” = abnormal cells, pre-cancerous Presentation? AUB Diagnosis? Histology from Pipelle / Hysteroscopy EH with No atypical cells EH with Atypical cells 1 Reduce risk factors : weight, HRT, PCOS Total hysterectomy (risk of underlying Management 2 Progesterone : malignancy / cancer progression) ○ 1st line : LNG-IUS (5 years) ○ 2nd line : medroxyprogesterone +/- BSO if postmenopausal or to reduce 10-20mg/day or norethisterone risk of ovarian Ca in pre-menopausal 10-15mg/day (>6mo) women *weight up with fertility plans. 3 Individualised surveillance plan, e.g. minimum 2 -ve biopsies @ 6 monthly Individualised surveillance, e.g. -ve biopsies 3mo apart. intervals.Case 4: Vaginal / Vulval Cancer Urgent Suspected Cancer Referral, NICE Guidelines 2021 ● Vulval cancer — over 1000 new vulval cancers are diagnosed each year in the UK. A full time GP is likely to diagnose approximately one person with vulval cancer during their career. ○ Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration, or bleeding. ● Vaginal cancer — over 250 new vaginal cancers are diagnosed each year in the UK, meaning most GPs will not encounter a woman with the disease during their career. The 5-year survival varies considerably with stage. ○ Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina. Benign Gynaecology IzzyCore conditions ■ Endometriosis ■ Adenomyosis ■ Fibroids ■ PCOSCore conditions ■ Endometriosis - the growth of ectopic endometrial-like tissue outside the uterus. ■ Adenomyosis - the growth of endometrial tissue in the myometrium. ■ Fibroids - smooth muscle tumours of the uterus. ■ PCOS - a complex condition of ovarian dysfunction characterised by androgenic features, oligomennorhoea and hyperinsulinaemiaEndometriosis: T ypes ■ Superficial peritoneal ■ Ovarian endometriomas - chocolate cysts ■ Deep infiltrating endometriosis ■ AdhesionsEndometriosis: A T ypical CaseEndometriosis: A ‘T ypical’ Case ‘A 35-year-old woman presents to GP complaining of painful periods. The painshe experiences deep pain with sexual intercourse and pain whenioning, opening her bowels. On examination, you note a fixed, retroverted uterus.’Endometriosis: In Reality ■ There are roughly as many women living with endometriosis as there are women living with diabetes (~1 in 10) ■ The presentation is extremely variable ■ The severity of endometriosis does not correlate with the severity of symptoms ■ Can occur in conjunction with adenomyosis2 Patients “I can’t take the pain anymore. My periods have always been painful, but the pain is almost “Thanks for seeing me. I’ve been every day now. Ibuprofen does nothing and I’m struggling to trying to conceive now for two make it into university. Please years and it’s just not working. can you help me? My scans and blood tests are all absolutely fine, and my partner’s tests are clear too. I feel fine, I -Patient B, 26 just don’t know what’s going on. -Patient A, 34What questions do we ask?What questions do we ask? Symptoms Risk Factors Pain: Cycle: ■ Pre-menstrual and menstrual ■ Cycle duration pain ■ Bleeding duration ■ Dyspareunia, dysuria, dyschezia ■ Age at menarche Family Hx: GI ■ Diagnoses ■ Bloating ■ Symptoms ■ ‘IBS’ ■ Surgeries Fertility Heavy menstrual bleeding2 Patients “It’s a constant ache in my lower back that radiates down my legs. It gets really intense when I’m on - I can’t lie down and I’m really “Now you mention it, my periods nauseous and bloated. The bleeding is heavy too - I have to are pretty painful. Paracetamol wear a pad and a tampon and and ibuprofen takes the edge even then I leak. I sometimes get off, but I feel rough for a couple these stabbing pains while of days. It’s the same for every opening my bowels as well.” woman in my family though, so I’m used to it I guess.” -Patient B, 26 -Patient A, 34What do we do now?What do we do now? ■ Examination ■ Ultrasound ■ Referral or management in the GP?What do we do now? Examination ■ Ultrasound ■ Findings may include: ■ Findings may include: – Nothing – Nothing – Tenderness on palpation – Endometriotic cysts – Fixed organs – Nodules – Retroverted uterus – Retroverted uterus – Boggy, enlarged uterus – Enlarged uterus – Palpable endometriomas – Thickened myometriumWhen to refer? ■ Consider referring to a gynaecology service for a gynaecology opinion if: – The woman has severe, persistent, or recurrent symptoms of endometriosis. – The woman has pelvic signs of endometriosis. – Initial treatment is not effective, not tolerated, or contraindicated. – The diagnosis is unclear. ■ Refer to a specialist endometriosis service (endometriosis centre) if the woman has suspected or confirmed: – Deep endometriosis involving the bowel, bladder, or ureter. – Endometriosis outside the pelvic cavity. ■ DO NOT OFFER HORMONAL TREATMENT TO WOMEN ATTEMPTING TO CONCEIVEManagement Analgesia ■ Start with NSAIDs + paracetamol ■ Don’t forget adjuncts: TENS and heating pads Hormonal ■ COCP or mirena coil are ideal ■ DO NOT OFFER THE IUD ■ GnRH analogues are used in secondary care for symptom reduction as well as prior to and after surgery Surgical ■ Diagnostic laparoscopy +/- excision (superior to ablation) ■ Can offer mirena insertion during the laparoscopy ■ Hormonal treatment following surgery can reduce recurrence ■ Hysterectomies are last line, but can be curative for adenomyosisManagement Analgesia Pelvic floor physiotherapy can be incredibly helpful, but is not ■ Start with NSAIDs + paracetamol taught at medical school ■ Don’t forget adjuncts: TENS and heating pads Hormonal ■ COCP or mirena coil are ideal ■ DO NOT OFFER THE IUD ■ GnRH analogues are used in secondary care for symptom reduction as well as prior to and after surgery Surgical ■ Diagnostic laparoscopy +/- excision (superior to ablation) ■ Can offer mirena insertion during the laparoscopy ■ Hormonal treatment following surgery can reduce recurrence ■ Hysterectomies are last line, but can be curative for adenomyosisSummary ■ Endometriosis and adenomyosis are a common cause of painful periods ■ Heavy menstrual bleeding should increase your suspicion of adenomyosis +/- endometriosis ■ Patient presentations are variable and diagnosis can be challenging as investigations are often negative ■ Historical lack of diagnosis and cultural factors mean women often normalise severe symptoms ■ Treatment encompasses analgesia, hormonal medications and surgery with consideration of fertilityFibroids/Uterine Leiomyomas Hi, thanks for seeing me. I’m here because my periods have got really heavy - I’m even having to wake up in the night to change my pad. The pain has got a little worse too. My friend was given a pill called something acid when hers got heavy - I was wondering if I could get some of that? -Patient C, 41What do we ask?Fibroids: Symptoms and Risk F actors ■ Most common: heavy menstrual bleeding ■ Dysmenorrhoea ■ Dyspareunia ■ Urinary: increased frequency, urgency, incontinence ■ Subfertility Risk Factors ■ Black women are more likely to be affected ■ Peak incidence: 40-50 years Other ■ Fertility - do they want to conceive? ■ Heavy bleeding - what else do we need to consider?What do we do now?Investigation ■ Examination – Palpable pelvic mass – Enlarged, non-tender uterus ■ Transvaginal ultrasoundInvestigation ■ Examination – Palpable pelvic mass – Enlarged, non-tender uterus ■ Transvaginal ultrasound ■ Consider FBCHow do we manage them?How do we manage them? ■ Refer to gynaecology if: – Treatment in GP fails – The fibroids are >3cm – Concerns about subfertility – The bleeding is severe – There are compressive symptomsHow do we manage them? ■ Symptomatic - NSAIDs and TXA ■ Mirena coil - if no distortion of the uterine cavity ■ COCP or POP ■ GnRH agonists - often used to decrease fibroid size before surgery ■ Surgical ■ Ablation ■ Resection during hysteroscopy ■ Myomectomy - only option if wanting to conceive afterwards ■ Uterine artery embolisation ■ HysterectomyBack to the patient Hi, again. I’ve been fine for ages but I’m 18 weeks pregnant now and I’m in agony. I’ve got these really intense period-like cramps and I feel really hot. I’m scared I’m losing the baby - please help me. -Patient C, 41What do we do now? ■ Observations ■ Examination ■ Emergency assessmentWhat do we do now? ■ Observations – Low-grade fever – Mild tachycardia ■ Examination – Pain on palpation with rebound tenderness – Palpable fibroid ■ Emergency assessment – You refer to the local obstetric centre who will perform an ultrasound while monitoring the fetusWhat’s happening?Red degeneration ■ High oestrogen levels in pregnancy cause rapid growth of existing fibroids ■ As the fibroid outgrows its blood supply, it becomes ischaemic and necrotic ■ Fibroid degeneration affects ~5% of pregnancies ■ Degenerating fibroids can become infected, leading to sepsisHow is it managed? ■ Depends on symptoms and signs of infection: – Conservative: management at home with paracetamol ■ Some patients may require admitting for closer observation +/- opiate analgesia ■ Should you give NSAIDs? ■ Surgical: – In severe cases, a myomectomy can be performed during pregnancyPCOS: Diagnostic Criteria 2 of: ■ Oligo/anovulation ■ Clinical and/or biochemical features of hyperandrogenism ■ Polycystic ovariesHyperandrogenism Clinical BiochemicalHyperandrogenism Clinical Biochemical ■ Hirsutism ■ Elevated free testosterone ■ Acne ■ Elevated LS: FSH - SBA sign ■ Androgenic alopecia ■ Insulin resistance - not formally part of the diagnostic criteria, but commonWho has PCOS? 1. A 24-year old obese patient with irregular periods and bilaterally enlarged ovaries on TVUS. 2. A 33-year old patient with absent periods and chest, upper lip and back hair. Her ovaries are normal on TVUS. 3. A 16-year old with irregular periods, acne and normal ovaries. Her periods started 9 months ago. 4. A 19-year-old with irregular periods and a ‘string-of-pearls’ appearance of her ovaries on TVUS. 5. A 28-year-old with absent periods, palpitations and normal ovaries.Who has PCOS? 1. A 24-year old obese patient with irregular periods and bilaterally enlarged ovaries on TVUS. 2. A 33-year old patient with absent periods and chest, upper lip and back hair. Her ovaries are normal on TVUS. 3. A 16-year old with irregular periods, acne and normal ovaries. Her periods started 9 months ago. 4. A 19-year-old with normal periods, a raised testosterone and a ‘string-of-pearls’ appearance of her ovaries on TVUS. 5. A 28-year-old with absent periods, palpitations and normal ovaries.Who has PCOS? 1. A 24-year old obese patient with irregular periods and bilaterally enlarged ovaries on TVUS. 2. A 33-year old patient with absent periods and chest, upper lip and back hair. Her ovaries are normal on TVUS. 3. A 16-year old with irregular periods, acne and normal ovaries. Her periods started 9 months ago. 4. A 19-year-old with normal periods, a raised testosterone and a ‘string-of-pearls’ appearance of her ovaries on TVUS. 5. A 28-year-old with absent periods, palpitations and normal ovaries. You can have PCOS without polycystic ovaries!Management ■ Symptoms ■ Weight/cardiovascular risk factors ■ Endometrial cancer ■ FertilityManagement ■ Symptoms ■ COCP can help with acne and hirsutism ■ Standard acne treatments are available ■ Topical eflornithine can aid with hirsutism if COCP is ineffective ■ Specialists may prescribe spironolactone and finasterideManagement ■ Weight/cardiovascular risk factors ■ Assess and manage risk factors independently ■ Remember: PCOS can make it more difficult to lose weightManagement ■ Endometrial cancer ■ Absent periods causes endometrial hyperplasia, which can lead to endometrial cancer ■ In patients with absent periods, endometrial tissue must be suppressedor withdrawal bleeds initiated – Suppression: mirena coil – Withdrawal bleeds: COCP or cyclical progesteronesManagement ■ Fertility ■ Should be done under specialist supervision ■ Advise weight reduction ■ Pharmacological: – Clomiphene - risk of multiple pregancies – Metformin – Letrozole – ■ Surgical: – Laparoscopic ovarian drilling ■ Once pregnant - screen for gestational diabetesGynaecology OSCE tips ■ Common history +/- examination stations ■ Try and examine patients not under general (don’t stop at the sign off!) ■ Emergency Gynaecology Units are fantastic places to practice clerking ■ Symptoms can be sensitive and distressing so make sure to establish a rapport and show empathy ■ Remember - management depends on fertility wishes, so explore this ■ Always explore impact of symptoms on daily life THANKS FOR W ATCHING! (for Molly and Izzy) and see you next week: Palliative Care & End of Life Medicine