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Back and maybe disappeared just before. So, um just went very, very early. Well, yeah, we can get started. There's quite a lot in getting you maybe a little bit less. So hopefully we won't have to skip as much. Um So actually we don't need that slide. So the first one, can you guys read that? So it's really small. I'll put up a pole and then let me know if you can't see it and I can read it out. So I didn't know it would come up so small. Cool. Thank you. We've got a three way tie so far with A B and C mm change a little bit, still a little bit of a change. Um OK. So the answer is see they're in red this time. I don't know why. Um I don't know why I did that. Um So we'll find out in a second. It's the first, so inversion of Mirena coil is the first line for heavy menstrual bleeding if a patient wants contraception. Um Other things is CSP is not first line. The copper coil, actually, one of the main adverse effects is like the pain and bleeding that it causes um the po pa again, not first line and then the guy, the is a little bit drastic, you know, to have a major surgery um when it could be fixed with a coil nice. And then we're gonna go on to someone who doesn't want contraception nice. So most people have got this one. The answer is a um So again, uh Trimezol acid or NSAID S are like the, the good non hormone option. So is hormonal, the IUD is something just to kind of um in terms of terminology, IUD, it usually refers to copper coil I us usually refers to Mirena. So the system has like hormones in it. So if someone's saying IUD, it's usually the copper coil. Um for Brini is not a treatment for um heavy menstrual bleeding and ablation. It's kind of the second one after medical management. Cool. And then we'll just get this one cause in the interest of time. So heavy menstrual bleeding also called menorrhagia is like a rudimentary number of 80 mL lost during menstruation. But really, it's just based on what a patient is telling you what, how it's impacting their quality of life. And if they think it's heavy, um there's lots of different causes of heavy menstrual bleeding. They can be put into palm coin. Um palm is the structural um and the coin is the knot. So, polyps, adenomyosis, fibroids, malignancy, um coagulopathy, um ovulatory dysfunction, endometrial causes genic and then others like, not yet, not yet classified. Um because there's a lot we don't understand about um heavy menstrual bleeding and the little scars are ones that I'm going to cover in a little bit. So, in terms of what you want to do to investigate, um you want to examine them, do bloods, um, transvaginal ultrasound. Um You can consider um high vaginal swabs. Um and you might want to consider a hysteroscopy um if there's interventional bleeding or any concerns about pathology. Um So the management kind of a split into first, you want to exclude any underlying pathology, like endometriosis, anything like that. But then if you think it's dysfunctional uterine bleeding, which is the most common cause of heavy menstrual bleeding. And then you, it's split into whether they want or don't want contraception. So the first line, if they want contraception is the Mirena, then the combined oral contraceptive pill, then like something like norethisterone. Um they can also try the pop or the depo injection, but they also, they quite a lot of them is like the main side effect is um irregular bleeding. So that's why it's not a uh such a good option if they don't want any contraception and it's like further split into if they have pain or they don't have pain. So if they have pain, then they can get um mefenamic acid because it helps with the pain as well. And if not, then they can just get tranexamic because it can um help reduce the bleeding. If the treatment is not successful, there's severe symptoms or large fibroids and you want to um con refer to secondary care for an ablation or a hysterectomy. But again, you need to try these things first um, before referring them. Cool. So the next one we have is but fibroids. Ok. A little bit of a split mix here, but the correct answer is GNR H agonist. So for they should, they should stop the combined oral contraceptive pill four weeks before surgery anyway. Um And then the purpose of the GNRH agonist, which will go to the second end helps reduce the size of the fibroids on the short term just before surgery. So, fibroids are benign tumors um of the uterine muscle which are estrogen sensitive. Um They reflect a lot of um people in later um reproductive years and there's different types, um which are fairly self-explanatory depending on their location. So you can see that here in the picture. Um So they present often asymptomatically with or with heavy menstrual bleeding, um, prolonged menstruation, sometimes abdominal pain. Um There's a feeling of like bloating. Um but that's sort of due to the bulk related, like if it's a big fibroid, they can also get urinary and bowel symptoms, um, and pain during intercourse. Um Oh, I forgot about this. What do you feel? Um What might you feel an examination? Can you put it in the chat sorry, I forgot. Ok, don't worry, we'll just go on. So, you, you, you wanna do, um, abdominal palpation and bimanual examination? Oh, someone answered. Yeah, that's good. Well done. Um, and then you can feel a palpal mass and a large tense uterus. And then if a person comes with past medical history of fibroids with severe abdominal pain and a low grade fever, you want to think about red degeneration of the fibroids, which is a hemorrhage into the fibroid. Um And quite often happens during pregnancy, I've messed up these sides a bit. So for a fibroid, the first choice investigation is transvaginal ultrasound and you can consider his hysteroscopy. Um if there's like submucosal fibroids and heavy menstrual bleeding and they might need to have an MRI prior to surgical intervention. Um So if they're less than three centimeters, um the medical management is just the same as heavy menstrual bleeding like in the previous slides. Um There's also some surgical options if they're over three centimeters and they need to refer to Gynae. Um you can have NSAID S and tram acid for the symptoms or the Mirena, but sometimes if the uterus is like really distorted because of the fibroids, they might not be able to put one in. You can use um the C OCP. Um And then there's different surgical options like uterine artery embolization, myomectomy, um which is like um remove the fibroids or hysterectomy and then prior to the surgery as in our question, they used GNRH to shrink the size of the fibroid to make the surgery easier. Um Of course, next question. Cool. So a bit of a mix there between CD and E correct answer here is Ibuprofen to inhibit the prostaglandin synthesis. So a bit about just menorrhea. So there's primary and secondary. Um so it's, they both have low anterior pelvic pain and that's associated with periods, but the difference is primary, occurs within six months to two years of menarche. Whereas secondary um ha starts like many years after the men arch. So it's not associated with. So f um so primary is not associated with any pelvic pathology. Uh And the first line is nsaids or mefenamic acid and then the second line would be the, the C OCP. Um And I guess especially in this one that says if she's not, if she's not yet sexually active, then that's another reason to point to um ibuprofen. And then in terms of secondary dysmenorrhea, um it's, it's thought to be associated with pathology such as endometriosis, adenomyosis and sometimes even the copper coil can be a cause of it. So you should refer these people to secondary care for further investigation as to why they've suddenly got this new pain. So we're gonna go on to a little bit of S TI S. No. Cool. So most people got this right is chlamydia, the cheeky. But there is um for anyone who got herpes, it's, it says bacterium. Um So chlamydia is the most common bacterial um S TI and then we're gonna go on to another question on this and then we'll go on to some explanation. No. So most people have got this one right. It is a pelvic inflammatory disease. Probably quite easy because of uh I said we're going with the S TI S. Um But yeah, so, um pelvic inflammatory disease is most commonly caused by gonorrhea, chlamydia or mycoplasma. Risk factors are like having no barrier contraception, being young. Um multiple sexual partners, previous ST is previous P ID. Um and also having an IUD in because I guess it's like a foreign, you know, it's like if, if you have like a, a metal joint and it's like a more likely to have infection that's kind of similar, you know, you've got something foreign where um bacteria can kind of hold on to. Um and then symptoms are like pelvic and lower abdominal pain. Um abnormal discharge, bleeding fever, dysuria, like, you know, they can just be septic as well. Um You want to do um nucleic acid amplification test for gonorrhea and chlamydia and mycoplasma HIV test, syphilis test, um high, high vaginal swabs, um do a pregnancy test to rule out ectopic and then ACR P and E sr um this is just we ha I haven't, it's hard to go into everything. I've gone through some of like the, the S TI S thrush is not an S TI but um you know, just some of the different kind of infections that you can get. Um this is just like a super quick kind of um summary table. Um So I won't go through it but it'll be on the size afterwards. Um Other notes I think are useful for P I and S TI S and be familiar with like HIV management and syphilis management. I didn't include them here mostly because of time, but also they do come up like HIV comes up a lot in um infectious diseases. Um in that kind of topic of revision, um look at the guidelines for chlamydia and gonorrhea contact tracing. Um and it's useful for us if you can give advice on like safe sex and safeguarding. Um and then be familiar with what tests that they do on a standard gum visit um as well cause I definitely got a question about that in med school. OK. This is going back to second year. Nice. So most people are getting this one. The answer is anterior pituitary. Um I'm not gonna go into it. It's just kind of a little bit of a reminder that some of the kind of anatomy things can come up. Um in terms of the anterior posterior pituitary and kind of the um the um the, the a like the axis that um can you should know for endo and for um for gynae as well with the FS H and LH just a useful reminder to have a brief look over that. So another question is how many days after conception would an over the counter pregnancy test be positive? Ok. Quite a mix. The answer is actually nine. So it'll be positive nine days after conception until 20 weeks gestation and for an over the counter pregnancy test and then it remains positive five days after miscarriage or fetal death. So just a useful kind of like one to keep in the back of your mind, you go back and one more question and then we'll go on to this explanation. OK. Again, a little bit mixed, but the correct answer here is a transvaginal ultrasound scan and we'll go into that in a sec. So, the thing that we're worried about here was an ectopic pregnancy. Um So which is a pregnancy implant outside of the uterus. Most commonly in the fallopian tube usually presents about 6 to 8 weeks gestation, but um can just present before a missed period. Um And it's really, it like it, if, if it ruptures, it can be really, really dangerous. Risk factors are previous ectopic P ID or Gyne surgery. Anything that makes the adhesions or anything like difficult for the egg to kind of get where it needs to go. Um Having a an IUD it doesn't increase your risk. Um I'm sure you guys have heard this before. It doesn't increase your overall risk but if you have an IUD and happen to get pregnant on it, you would then have an increased risk of it being in that topic. Um increased age in smoking as well. Um So you'd have lower abdominal right iliac left iliac fossa pain. Um and then tendons on palpation. Um You can have bleeding a missed period. You can have cervical motion, excitation and then later, you know, when things have ruptured, you could have shoulder tip pain because of the peritonitis. Um and you might be dizzy um or have syncope due to the blood loss and the internal bleeding um associated with um rupture. So you want to assess a patient, do a pregnancy test. If they're stable, then you, they should have a transvaginal ultrasound scan to look for the gestational sac outside the uterus and for an empty uterus. Um if they have um positive pregnancy test, but no evidence of pregnancy on the ultrasound, then you need to do serial um beta HCG S um And you do that every 48 hours. Um So the R as you can see in this table here suggests whether it's likely to be a miscarriage, an ectopic um or an injury, uterine pregnancy. So they come back to, you know, if they're stable and then they can't see anything on the scan. If it's too early or anything, then they'll come back to like the Gyne assessment unit to get these serial Beta HCG S until something can be done with like a management plan in terms of the management. Um, there's sort of three different, um, routes of management. Expectant, medical and surgical, um, expectant is really for people who are definitely gonna come back to, um, to have the, the, the beta HCG monitoring. Um, and so they need to agree to that, um, and it needs to, they need to be really stable, have a small size of um ectopic, not be ruptured, no heartbeat. They need to be asymptomatic. Um And they need to have um a beta HCG of less than 1000 for medical management, they use methotrexate. Um And again, this patient needs to be able to be followed up. Um And it's given as an im injection, which is teratogenic, which is how it um how it manages the ectopic pregnancy. Um And those people shouldn't get pregnant for three months afterwards. Um Again, you can see here the sort of um criteria that require um medical management. And then for surgical, the first sign is a salpingectomy. Um if they have no issues with um infertility. So that's a removal of the whole fallopian tube. Um And then the second line would be a th ingot toy if there are concerns surrounding um fertility. Um So that's just the removal of the pregnancy inside the tube. Um And the second line, you think it would be first line, but it's actually a second line because a lot of those people need um subsequent management um with a salpingectomy. So that's why they often go for that one first. But if there's risk of fertility then they'll infertility, then they'll first try and do a salpingotomy. Um And then remember to DD as we spoke about before and if there's a heartbeat, if they've got a high base of HDG, if they're unstable, they need surgical management. Um So, yeah, I'm not gonna do this purely because it's, I don't think it'll work very well with our chat function, but these are the different sort of, um, definitions for miscarriage. You've got early, um, late, threatened, incomplete, my inevitable uncomplete. Um, I would advise sort of knowing the presentations of these, knowing the management, um, of miscarriage, you know, um, medical, uh, you know, expectant, medical and surgical as well like ectopic. Um, and also being able to, um, maybe like if they show you a sort of speculum picture, you might be able to kind of, um, understand what that's showing in terms of like the awesome, um, anything like that. So, yeah, sorry about that. Didn't work so well with this, but we'll just move on. Um, so yeah, we've done a bit of the management if it's, you want to discuss it sensitively, like provide emotional support. Um, if you, if it's less than six weeks, they don't need any investigations, um, because an ultrasound isn't gonna show anything and if the pregnancy is over six weeks and they can have a transvaginal ultrasound to rule out an ectopic and confirm the miscarriage. Um And you can see here, it's very small for me to see here, but there's expectant medical and surgical management depending on patient preference and how stable they are. Oh, yeah. And remember to look for um what would be tested for if a patient has a recurrent miscarriage and what the definition of recurrent miscarriages is because that does sometimes come up in exams. Cool. So, next question. OK, a little bit of a split one here. But you guys are kind of on the right idea. So this one most likely would be endometriosis. Um So I have to be honest, I haven't done a slight on adenomyosis just become just because it comes up less often. Um I've done endometriosis. Um So the exact cause and um HLG are kind of unclear but it's likely multifactorial, which means it's not gonna be examinable, but just understand that there's a lot of kind of ongoing research surrounding endometriosis. It presents with cy cyclical abdominal and pelvic pain, deep dys peria, infertility, cyclical bleeding. Um and depending on the severity, they can also have urinary and bowel symptoms. The gold standard um diagnosis is with a laparoscopic surgery within that surgery, they can diagnose it, but they can also some remove some of the endometriosis as well, um which can help um improve symptoms in terms of management it's quite difficult. Um, you just need to kind of listen to their concerns and explain the symptoms. Um, they can be given hormonal options, um, like the combined oral contraceptive or, um, or the surgical options that we discussed above as well. But I guess it again, it depends on where the patient is in terms of wanting contraception. Um, have they completed their family, that sort of stuff? But as long as you're aware that those are the kind of things that go on, you know, it's, it's quite a specialist topic. So I'd say that's mostly what you need just to be able to recognize it, know the gold standard for diagnosing. Um I know kind of a bit of the basics of the management. Cool. So now we're gonna go on to PCO S. Um I didn't have a question for it. Sorry. Um So, diagnosis for P CS is based on having two out of three of the following criteria. So, having Polycystic ovaries, which would be on an ultrasound scan, either having 12 or more peripheral follicles or an increased ovarian volume volume, which is over 10 centimeters cubed. They can have um oligo, so like less or just a ovulation. Um So like a regular period. Um and then they can have the clinical um or the biochemical signs of hyperandrogenism. Um You don't necessarily need to do blood test for it, you know, because you could, you could um diagnose it on the scan plus the symptoms. But um they would show an increased um LH and an increased um LH to FSH ratio. And then the main thing that you want to do is an ultrasound to show the characteristic ovaries that we discussed above in terms of management. Um Everyone should be given lifestyle advice which is like weight control and exercise and then kind of everything and d split into whether they want contraception or not. So if they are happy to have contraception, then you can use the combined oral contraceptive pill. Um, you can use that Metformin. Although I've seen um it's not to be started in primary care for anything except um, diabetes. So it's, it's, it's more likely like a specialist thing that they'd add, but just be aware that it can be sometimes used for P CS. Um And then they can use or the that to help with weight loss. But again, that would be something quite a lot more specialized. If they would like to become pregnant, then they can use clomiPHENE to help induce the ovulation to improve the chance of pregnancy, Metformin as well. And they can have um laparoscopic ovarian drilling. But again, uh you know, you're not gonna be doing that like for anyone. So as long as you're able to kind of know the first time management and know the kind of lifestyle, be able to diagnose it, that's mostly what you need for PCO S Cool next one we have is a lady with amenorrhea and an abdominal mass. Ok. This one's kind of see here, but actually the correct answer here is pregnancy. Um When I was doing this question, I remember actually from my M SA revision, I did click ovarian cancer. Um but we'll go through it in a second. But yeah, the most likely, you know, if you think amenorrhea, a palpable abdominal mass, that's just a pregnancy within the uterus. And so that is technically the most likely cause although you would get an abdominal mass with um ovarian cancer as well. I've got a few more questions to go first. Um And then we'll go on to some of the just questions surrounding gyne cancers. Ok. So a lot of most people got this one. So this lady's got like heavy bleeding. So you would, you could get some um bleeding, you know, with the irritation in atrophic vaginitis, but it wouldn't be continuous and heavy like this fibroids, they're estrogen dependent. So, um it's not really a problem in postmenopausal uh resumption of menstruation. No. Um And then postmenopausal bleeding is an endometrial carcinoma until proven otherwise. That's like a key thing to reme remember and cervical carcinoma again, like it's in looking at this lady's age demographic is not as likely. Um Now one more question and then I go on to the uh explanation. Sorry. OK. A little bit of a mixed one. So for cervical cancer. Um One of the risks is um early first intercourse, which we'll go on to in a little second. So for cervical cancer, um, histologically, the most common type is um squamous cell carcinoma. It's mostly associated with um HPV 16 and, and 18. Risk factors are having like an increased risk of having HPV. So early sexual activity, which was in our question, muscle partners, not using condoms, um, poor engagement with screening, um smoking HIV, family history. Um and using the C OCP for over five years, it presents with um altered abnormal bleeding, um, abnormal discharge, pelvic pain, dyspareunia, um and it can be asymptomatic hence why um there's screening, so make sure you memorize the screening pathway, it could come up in a se. Um I was gonna say, I remember in my finals, I don't think, I don't think I heard of anyone getting anything S and G in finals, it was mostly like cardio rest gi M sk take with that what you will but you know, be prepared for anything and that could come up. But that's just what I, what I remember. Um So in terms of the screening pathway, I'm sure if you have past med, one of them, I didn't include it cause they're some of the most common questions that come up, but make sure that you're um you're happy with the screening for the screening ages and the times for Scotland specifically because I think, well, I'm not sure if they'd asked that just because it's different between Scotland, England and Wales. Um But make sure you're happy with like, what happens in the recall in terms of like, um depending on the HPV result. Um And then depending on um if they have C in and what stage and what the management would be. But again, it's quite specialized within colposcopy. So as long as you're able to understand that they're testing in the screening program for HPV, and then they look at the cells if they're HPV positive and make sure, you know that and make sure, you know, kind of like what happens with the screening um pro protocol in terms of if they have HPV and when they need to return for follow up screening, um I think that would be your best option. Cool. And then um endometrial cancer. Um So as we said before, in that question, um postmenopausal bleeding is cancerous until proven otherwise. So if you see anyone who has postmenopausal bleeding, even if it's a small amount, um you know, it, it, it's really important to rule it out. Um before then you treat for anything else. So it's mostly like the peak age of instance is 61. So it's mostly after menopause. So people who are obese, haven't had any Children, have a late menopause. Um have any family history of like breast ovarian or colon cancer um have used tamoxifen or unopposed HRT. Um And they have diabetes or PCOS, those are all risk factors. Um, so the most classic presentation is postmenopausal bleeding and pain would be a late symptom. Um, they're taken on the two week wait, obviously, um, from primary care, um, where they should be where, where the diagnosis is, um, from an endometrial sampling and like a curettage. Um And then they also, they also can, um, they'll measure like the thickness of the endometrium as well to see if they're concerned. And then the treatment sort of depends on the staging. Um but they could get hysterectomy, chemotherapy, radio, radiotherapy, et cetera. But I guess as long as you know, the, the investigation sort of the investigation pathway for postmenopausal bleeding um is really key, making sure that, you know, the risk factors and, and making sure that, you know, um like how it would be, would be diagnosed as key. You know, you're not gonna be making up plans for someone's um cancer treatment realistically, just as long as you're able to recognize it and know the initial plan. And lastly, we have ovarian. So the most common cause most common histologically is um epithelial. Um So they're commonly late diagnosed, which leads to poor prognosis. Um Some of the risk factors include having the BRCA one and two mutation, having many ovulations. So early menop early men are and late menopause which is increasing the number of um ovulations as well as another parity because that increases the number of ovulations you have as well. Presentation is often really vague. Um So you can have abdominal distention and bloating urinary symptoms, early satiety and diarrhea because they're vague, that leads to the poor prognosis because it's often diagnosed and when and the cancer is quite um heavily progressed. Um But in terms of our first question that we had about the most likely cause of amenorrhea and ap abdomen, that would be pregnancy just because of kind of the, what's common is common. Um Thing that they always tell you and then initial testing is with the C A 125 tumor marker. Um And then they can do an ultrasound. Um and then they may need like a diagnostic laparotomy and the management is surgical. Um and with chemotherapy, but again, as long as you're able to recognize it, know the initial testing, that's what you need to know. Cool. Uh Next we have H OT OK. A bit mixed. Most people went for C which is the right answer. So well done. Um And we'll go through it again. But we, I have another question first. OK, slightly mixed. But most people going for the right answer, which is an SSRI so menopause is the permanent cessation of menstruation. Um and it usually happens at the average age in the UK is age 51. So if someone's perimenopausal, that's like the time leading up to the menopause and then postmenopausal um is when there's been no period for 12 months. If someone's aged over 45 then the diagnosis is clinical. Um, if someone is getting these symptoms, like before age 40 then they, but they would be diagnosed with premature ovarian insufficiency. Um, I haven't gone into like the specific management plan of that, but they would require investigation. So anyone with these symptoms age below 45 requires investigations with, uh, like LH FS H et cetera. Um But if they're age over 45 then it's sort of presumed that it's menopause cool. So the symptoms are like change in menstrual pattern and blood loss. Um, hot flushes, mood swings, they can get sort of joint pain and stiffness, vaginal dryness, um and loss of libido. And then in terms of management, you need to assess the symptoms, severity and like what symptom is causing them the most issues. Um So you can give them general lifestyle advice about sleeping exercise, healthy lifestyle, that sort of thing. But if they're having like the hot flushes are the most, um, like problematic, like the vasomotor vasomotor symptoms then and that's managed with an SSRI as you guys got in the question for vaginal dryness, you can use a lubricant as well. And then just in terms of some notes and important things to remember with HRT prescription. Um So if they have a uterus, then it needs to be combined estrogen and progesterone. Um just to protect the protect for the risk of endometrial hyperplasia. Um So that dual prescription can either be in the form of like a uh like estrogen progesterone tablet or if they have the Mirena coil in situ, then that's enough to protect them. Um If they're perimenopausal, then they should have a cyclical regimen which is like um where they'd have um bleeds. Um and if they're postmenopausal, then it can be continuous. Um So they wouldn't have bleeds. Um And if they ha if they're at high risk of um VT E for any reasons, um then they would use a transdermal option like an H RT patch. Um And then just make sure that you check kind of like the, well, the sort of classic contraindications. So anyone with like breast, previous breast cancer, cu current breast cancer, um anything like estrogen dependent, then they can't have H RT. Um it's like a, it's like a hard stop. Um So that, you know, that you'd have to manage their symptoms with SSR S or otherwise. Um and if they have any like undiagnosed, vaginal bleeding as well. But again, it's, it's quite like it is managed in GPA lot of the time, but it's quite a thing that, you know, even when I'm on GP right now, like a lot of people find quite tricky. So I think as long as, you know, this, as long as, you know, having to have the combined if they have a uterus. Um and having sort of this perimenopausal has cyclical and postmenopausal has continuous and that's mostly what you need to know. Cool. So I've actually smashed through Gyne, I think I panicked someone really quickly. Um, so that's the rest of the Gynae one done. Um, other topics that I didn't go through that might come up, um, is infertility. Um, the investigations are involved, um, ovarian torsion, um, and ovarian cysts and the presentation of that, um, investigations of amenorrhea might come up. Um, and also contraception is a big one to understand your M EC UK M AC criteria, what the most common, um, sort of like risks of having each type are and also what the most common sort of side effects like the downsides that people don't like if you're counseling someone on that. Um, and also be able to remember, um, emergency contraception. So either pi sterol or the live on a GRE or the copper coil and how long after each, um, unprotected sexual intercourse you can have those four. and then also a bit of the management of termination of pregnancy. I didn't include that either. Um, but yeah, so sorry, that was a little bit quicker. Um, if you guys have any questions and let me know or, yeah, I'd be grateful if you fill in the feedback form. But yeah, otherwise, best of luck with your exams, hope it goes well. Uh, just for everyone's potentially writing me questions or not. Um, because we finished a wee bit earlier.