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Hey, hi, everyone. Thanks for joining. Um, just waiting for to join. Um, she's having some tech issues and we'll probably wait until about five past just to give people a chance to join. Hello? Can you hear me? Oh, yes, I was working for you. I'll, I'll keep my camera off camera off my golf. My camera is not working. Exactly. But my mic is working. So at least one, it's better than the other way around to be fair. Yeah. Sorry. My wifi is playing up so I'm just going to swap to the hotspot, so I'll probably drop out for a sec. Ok. Are you fine to do the slides or do you want me to do them? Because they've, they've, um, I think you can present while it's loading. Do you think your wifi won't hold? But if it's fine then it's fine. Ok. I think we'll just give it another minute or so and then we can start. Ok. So we're going to make a start. Um Thank you for coming. Yeah. So thank you so much for coming. So, what we're going to be talking today is about gynecology in medical school. We've got about an hour. So it was going to always be a bit ambitious to cover everything you need to know about gynecology in medical school. So we're going to be covering a fair bit of what you need to know but just to start off with um oh sorry, I'm just the teaching things lead has just messaged hang on just checking if we are actually ok to start. Sorry about this. Mhm He's just messaging me. So this is teaching things. So me and Molly, we're both final year medical students at UCL. So we're a couple of the teaching things tutor. We run weekly tutorials, some for the fourth year, some for the fifth years, but it's open to everyone. So we're focusing on kind of the core presentations and the core conditions. Um me is open to everyone. Um It's really fun to have people from all over but just bear in mind. We are medical students. This is very much focused at kind of UCL and UK medical schools. Um but all the content has been reviewed by doctors and if you're interested in joining some more teaching things sessions, it's always based on the group chat, but you can see all of the events on medal as well. So back to the talk, we're going to go through today, lots of what you need to know about gynecology for medical school. So um for this talk, we're going to cover a few things which are on the screen now, um it's really helpful if when we ask questions, if you can put the answers in the chat, ask questions throughout. But it's also a lot nicer for us if we feel like we're speaking to some people rather than just at a screen. Um So Molly is going to start off by talking about the gynecological cancers. Um And then I'm going to talk about some benign gynecology. So, endometriosis, adenomyosis fibroids and pcs. Um So with that, I'm going to hand over to Molly. Thank you. Perfect. Um Hi, everyone. Yeah, I'm Molly. Sorry, my camera is not working. Um But we're gonna start with the gynecological cancers um cause it is if you can just go to the next slide. Yes, Molly. I can't hear you. You can't hear me. Can you hear me now? Yes. Yes, you are perfect. OK. Um I'll, I'll just start again. Um So I'm Molly. Um And yeah, I'm also a UCL medical student and we're gonna start by talking about the Gyne cancers. Um Can we go to the next slide? Perfect. Um OK, so we're just gonna start by talking about the basics of cervical cancer. Can anyone um I'm just gonna ask you some questions first and then we'll talk through it. So, can anyone put some risk factors in the chat of um people who are most at risk of um cervical cancer? Great. So HPV. Perfect any more? OK. Well, that's fine. So, yeah, so HPV is the, um, main one. so 99.7% of cervical cancers are, um HPV associated. Um, great. We're getting some more. So, yeah, smoking, um, is one and, um, also immuno, any reason that you're immunosuppressed. Um, for example, HIV, um, on HPV as well. Anyone who's not vaccinated with the HPV vaccine? Great. And, um, does anyone know, um, who gets vaccinated in the UK with the HPV vaccine? Yeah. So girls and boys age 12 to 13. Um it used to be just girls but it's now all 12 to 13 year olds. Um any, any other um groups. No. So that's the main one. But um often sexual health clinics it's given to um men who have sex with men who are under 45 or anyone who is deemed to be high risk in a sexual health clinic. Um If you're uh between 25 and 45 you get two doses, um six months and then two years apart. Um rather than just the one off dose that the girls and boys at 12 to 13 get um great. And ok, so if we just go to the next slide, see we'll just um consolidate that. Great. So I've just put all the information on the slide so you can always go through them afterwards in more detail if there's anything you want to go over a bit more thoroughly. Um but we've spoken about a lot of this. So just to highlight a few other points, um 70% of cervical cancers are squamous cell. Um It's the main thing to know about the pathology. And then in terms of the pathophysiology, um usually cervical cancer develops um over 10 to 20 years from cervical intraepithelial neoplasia, which we'll get to in a minute. Um But essentially at the cervix. So if you just have a look at the picture, um cervical cancer happens at the um due to squamous cell metaplasia first. Um So essentially with the cervix, you have squamous cells and then columnar cells and they meet at the squamous columnar junction, which is the S CJ on the picture and during puberty, um when the columnar cells meet the acidic vaginal fluid, um they transform into squamous cells and it's called squamous aplasia. And this area is called the transformation zone. And that's where the endocervix, the inner part where the columnar cells are and the ectocervix, the outer part and where the squamous cells are come together. And that's the transformation zone and that's where you get the abnormal cell changes. And just to clarify metaplasia is when you get one cell transforming into another. And um neoplasia is then the uncontrolled abnormal growth of cells. So, terminology in cervical cancer is quite important. Um just to properly understand the the background of it. So, yeah, in summary, you have the transformation zone where the squamous cells become the columnar cells and that's where you get um in normal, in a normal cervix, you get transformation um from columnar cells into squamous cells. Um but then this can develop into cervical cancer for a number of years if you're high risk and in the majority of cases, um if you haven't been able to clear HPV, um mo 80% of women have HPV in their lifetime, but most are able to clear it. And if you don't, then that's when you are at risk of developing uh of the cervix developing cervical cancer. Um I hope that makes sense. Just put any questions in the charts, we go along and I'll see them. OK. Next slide. Great. Yeah. So that's just a picture just to confirm where we're talking about um with the anatomy. Next slide and then the next one again. OK. So we'll just do a few questions as we go. So you're an F one on your GP placement. Um Next question, next slide, sorry. Um A 30 year old female has had her smear test at the GP practice. She has just received her results. Um So what information, so you're the F one looking at about to look at the results. What information do you see on the um uh result sheet? What will, what kind of thing will it tell you? Yeah, exactly. So whether HPV, positive or negative anything else? Yup. So inconclusive result. Yeah, that's um you can um that's definitely a result that you would get on after a smear test. Any other information I would give you? Yep, cell changes? Great. Um OK. If we could go to the next slide Z Yeah. So essentially it gives you two pieces of information whether you're uh whether the patient is HPV, positive or negative and whether there's any abnormal cells and in a smear test that's called dyskaryosis. Um great. And then if we could go to the next slide, is he ok? Um Does anyone know what would happen to this patient next? If those were the results, would she need other, any further investigations or not? Yeah, exactly. Exactly. So, um, if you will go through this bit more proper on another slide, but essentially if you're HPV positive, but you have no abnormal cells, you will get a smear test again in a year to check that you've cleared the HPV essentially. Um But we'll go through kind of what you do after each result. Um So, yeah, let's go to the next slide. Ok. Oh, I've already put the answers. Um ok. So this is another case. Um And yeah, essentially this is an something else you could see on a results um sheet. So you'll get the HPV result and then the cytology result um with the dyskaryosis, which is essentially talking about the any changes to the nucleus of the cervical cells. Um and it will either say mild, moderate or severe and it's only talking about how abnormal the nucleus is. Um just to be clear on that, cos there's a lot of terminology, as I said, and if there's any abnormal cells um with any dyskaryosis, you'll be referred for colposcopy and we'll talk about that next. OK. If we could go to the next slide, OK. So this is just summarizing what we've already talked about. So in the UK, the national program is um every three years, if you're between 25 and 49 and then every five years from 50 to 64 at 65 if you have an abnormal result, then you might get um other smear tests. But the main thing to remember is the national screening. Um And as I said, thesis is the abnormal nucleus smear tests. Don't tell you about cervical intraepithelial neoplasia. Some people get a bit confused with that. You can only tell sin um through Colposcopy. And I don't know if anyone's been to a Colposcopy clinic yet. Um But it's quite good to go and um see how they do it in real life. And it just makes so much more sense that you've seen it. Um But essentially, um what happens is that a speculum is inserted. Um And then you can essentially get a magnified view of the cervix, which will look something like the pictures they are quite zoomed in. But um obviously, but um and then the doctor will then apply acetic acid and if the um if it comes up with a white plaque on the cervix that shows abnormal cells. So, in the first picture, you can see that kind of white area is the acetic acid picking up abnormal cells. And then they'll also paint the cervix with lugs iodine um which is the opposite. So the abnormal cells, abnormal cells won't be stained. Um And um just in case anyone's interested, it's about um the um iodine being taken up by the glycogen and in um metaplastic cells or in columnar cells and there is no glycogen. So the iodine isn't taken up. Um I don't think that's, you know, super important, but it's quite helpful to help, remember it and then they'll also take a biopsy. Um And then as we talked about, I think a lot of you guys seem to know this, which is really good. But anything, any result that's HPV negative, you will just carry on in the normal screening pathway. So, every three years or five years depending on your age, um even if you've got abnormal cells cos if you're HPV negative, then nothing. It's very unlikely that anything's gonna progress. If you're HPV positive with normal cells, you'll have a repeat smear in 12 months and if you're still not cleared and the HPV, you will have colposcopy. And if you're HPV positive with abnormal cells, you will have a colposcopy which should be within um six weeks. So those are the three results that you need to know and that's very high yield for um SBA and M CQ questions. So if you're gonna know anything about cervical cancer, that would be the thing to know. Um next slide. OK. So the next question, so the patient attends her colposcopy appointment, she's received her result and it says that she is sin three. She is very worried and calls the GP to ask what this means and what will happen next? Can anyone put in the chart? What would happen for this patient? Yeah, exactly. So let's. So if we go to the next slide, I'll explain that. OK. So um sin is basically talking about how um much of the basal epithelium of the cervix is affected. Um So if you're sin one, a third of the basal epithelium is affected. Um sin 22 3rd and then anything more than that is sin three. And um CIN is talking about dysplastic cells. So the actual cell is abnormal compared to sis where it's just the nucleus. Um And then depending on which grade um of CIN depends on the management. So if you're CIN one, you're watch and wait and advised to stop smoking because that increases your risk of cervical of progressing to cervical cancer. Um CIN two, you'd consider a lets and CIN three, you would um perform a lets um all patients will need a follow up smear in six months to ensure that all the abnormal cells have been adequately removed. Um And the diagram at the bottom is just um what happens during that procedure. Um And it kind of does what it says on the tin. Um I think that's all that's important to know about that. So if we go to the next slide, OK, I'm quite conscious about time. So I'm gonna try and speed through um this a little bit. Um But you'll have all the slides so you can read through it slower at another time. Um So, yeah, so that's thin and that's separate cervical cancer. So CIN um, can progress to become cervical cancer, but it's not actually cervical cancer. So in terms of cervical cancer, um, often it does present asymptomatically. Um, the peak incidence is, um, 30 to 45 year olds and if they are symptomatic, um, most commonly, um, you'll be looking out for any unexplained abnormal bleeding, often intermenstrual bleeding, post coital bleeding or post menopausal bleeding. Um And yeah, there's loads of causes for those things. Um, but cervical cancer should be one of your differentials. Um, then you need to take a good history of their sexual history, their smear history, um, smoking history, any family history, um, and then decide if they need any investigate, any further investigations. Um, it should be a two week wait for Colposcopy. Um, and you can look, there's a really good page on the nice guidelines with all the two week wait. Um, pathways. Um So, yeah, I think I'm gonna leave that slide there, but please feel free to have a look at it um later and then depending um the patient will then go to the Gyne Oncology MDT and they'll do more staging and imaging and based on the staging, we'll um decide which management the patient will get. Um So if the cancer is very small, you might be able to get away with doing a less procedure or a simple hysterectomy. If it's more extensive, the patient might need a radical hysterectomy, which essentially is the same as a simple hysterectomy. But you're also taking um, the vagina, the perimetrium and the pelvic lymph nodes as well. You might also take the um, fallopian tubes and the ovaries and that's called a bilateral salpingo oophorectomy. Um, and they may need um chemotherapy and radiotherapy as well. Um If the cancer is much more extensive, um, they may only be um eligible for radiotherapy and chemotherapy because surgery won't um, be able to remove um, the cancer. Um, which is why in cervical cancer it's usually more abnormal unless you've got quite extensive disease to have um gi and urinary symptoms because you need quite, um, a large cancer to kind of compress the ureters and cause urinary symptoms, et cetera. Ok. Next slide. Thank you. Ok. So another case. So in GP again, you're a, you see a 76 year old female, um, she complains of about six months of bloating, abdominal discomfort and loss of appetite. Um, what would you want to know? And what else would you ask her? Ok. Just for time's sake, we're gonna keep going. Oh, thank you. Um, urinary bowel symptoms were last night. So that's, that's perfect. Yep. So, your b, symptoms for cancer? Um, urinary and bowel. Exactly. Ok. Let's go to the next side. But, um, yeah, I'm just conscious of time so we'll keep going. So we'll talk about ovarian cancer. Um Next, but I just, with that question, just wanted to um kind of make the point that it's really important to be open minded with um kind of abdominal symptoms. Um because there's a very wide variety that it could be. So any abdominal symptoms always consider gyne pathologies, gastro pathologies and urinary pathologies and make sure you ask about each of those symptoms, um and keep ovarian cancer in the back of your mind because ovarian cancer presents very late because the symptoms are quite nonspecific. And also you don't become symptomatic till quite late on. Um So yeah, um just making the point about that, um, ovarian cancer is um usually an epithelial cancer in the majority of cases and main risk factors are age, um nulliparous, um, obesity, no breastfeeding, family history of breast or ovarian cancer because they're both BRCA related um use of HRT and smoking and essentially any kind of increase in your estrogen exposure. Um predisposes you more to ovarian cancer, which is why some of those are the risk factors. The main investigation to do in a GP setting is C A 125. And, um, I'll just talk about that bit cos I think it's easy just to know C A 1 to 5 but not really know what it is. So, essentially it's a protein from the peritoneal endothelium and any kind of irritation of the peritoneum can increase your ca 125. So any kind of I've listed them there, but anything that's gonna irritate the peritoneum. Um However, if the patient does have, if you just look to the blue box, um these symptoms, so bloating early satiety, any pelvic clot, abdominal pain and urinary urgency or frequency, um then you would do ac a 125 and if it's raised over 35 you then refer them for a transvaginal ultrasound scan. Um If you notice any ascites or pelvic abdominal mass on examination, you would just send them straight. Uh You would refer them straight on a on a two week wait pathway. You wouldn't need to wait for the C 125. Um But yeah, any nonspecific gi pelvic urinary symptoms that are quite persistent. Um Think of ovarian cancer. Great. Let's move to the next slide. Ok. And then the management of ovarian cancer again, depends on the staging. Most gynecological cancers um have Figo staging. You can just look it up. Um uh just online, but this is essentially what each one of them means. Um, so if it's stage one just affecting the ovaries, um, you can just have chemotherapy. Um, if the cancer is more extensive, so involving the pelvis or peritoneum or the liver, um, they'll need surgery and ovarian cancer surgeries can be quite extensive depending on, um, how far the cancer has progressed. Um, and essentially the surgery just depends on how, um, on how far the the tumors progressed or metastasized too. Um Great. Let's, let's go on. Ok. Um So case three, a 68 year old female attends the gynecology department. Having been referred by her GP for a transvaginal ultrasound scan for suspected endometrial cancer. Her endometrium measures six millimeters. What is the next appropriate investigation? Anyone in the chart? Any ounces? Ok. So you've got a bit of a mix of answers. So you've got a few fives. Um, a one and then talking about hysteroscopy and biopsy. Yeah. Ok, great. So the answer to the question would be a papel biopsy. Um So if we could go to the next slide to just talk about that a bit more. Great. Sorry. Yeah. Um OK. So we'll just talk about endometrial cancer and then hopefully the reason that is the answer will make sense. So, yeah. So third cancer to discuss endometrial cancer, um usually an adenocarcinoma and it's stimulated. Um It's when the endometrium is stimulated by unopposed estrogen. Um You don't have the progesterone, protecting the endometrium. And that can put you at high risk of endometrial cancer, which is why again, things like being nulliparous, not breastfeeding, um early and late menopause, high BM I and hormonal drugs. Um and PCOS are risk factors because they all increase unopposed estrogen to the endometrium. The main presentation to remember is postmenopausal bleeding. Um 90% of people with postmenopausal bleeding don't have endometrial cancer. Um However, it's the best uh it's the most sensitive um symptom to look out for. But yeah, one in 10 people who then get put on the two week wait pathway won't actually have endometrial cancer. Um but they still need to be investigated. So you would do your history, you would ask about risk factors. Um do a full screen of symptoms for gi and urinary um pathologies and then do an abdominal examination speculum by manual exam and then would refer them on a two week wait pathway um for a transvaginal ultrasound. If the endometrial thickness is found to be more than four millimeters or over 16 millimeters in premenopausal women, um they will need histology. So that's either with a papel biopsy or a hysteroscopy. And then depending on the result of that, they would then be referred to the gyne oncology MDT for staging. Um If we just go to the next slide. So the picture on the left is a pall biopsy. That's what it looks like. And someone mentioned his hysteroscopy, which is the right. Um PAP is first line um hysteroscopy, you tend to need local anesthetic or general anesthetic. Um So if people aren't able to tolerate a PAP, they might have a hysteroscopy instead. Ok. Next slide and then endometrial management um is kind of similar to the others. But um again, depending on the stage, depends on the management. Um You'd start with a total hysterectomy, bilateral salpingo, oophorectomy and peritoneal washings that would extend to a radical hysterectomy with or without radiotherapy. Um, you would then at stage three, if there's pelvic involvement, need debulking surgery with or without chemo radiotherapy. And by the time the bladder and the bowel, any distant METS are involved, um, it may be palliative, um, or uh sort of palliative surgery or you might be able to debulk enough of the cancer for it to have therapeutic benefit. Um, but I guess it's just understanding the broad principles of management um, in the gyne cancers and yeah, feel free to look at it in more detail another time. Ok. I should go to the next slide. So I'm very conscious of time. Cos Izzy's got a lot of, um, great stuff to talk about as well. So we just on the end of my bit. So, um, last few things. So the first thing is talking about endometrial hyperplasia. Um, and you can have hyperplasia with or without atypia. So, hyperplasia is irregular proliferation. So you get a thick endometrium and then Ayia is about whether there's any abnormal cells involved. Um Often women who present who uh have postmenopausal bleeding. Once they have the biopsy, they may just have endometrial hyperplasia. So they'll go down that treatment pathway um because it's important to treat because of the risk of progression to endometrial cancer. Um If there are no atypical cells, essentially you reduce their risk factors, um give them progesterone. First line is the um intrauterine device and put them on a surveillance plan um with minimum of two negative biopsies at six monthly intervals. Um Oh, I think we've lost the slide um and see if we got the slides. Oh, not sure. I'll just keep talking about endometrial hyperplasia um while we get them back. Um So yes. So you want to give them progesterone if they don't have um if they don't have any atypical cells. Um And essentially, it's because they modify the proliferative effect of estrogen on the endometrium. Um If the patient does have atypical cells, they'll need a total hyster hysterectomy due to the risk of underlying progression. Um sorry, the risk of underlying malignancy um and cancer progression. And again, the um gynecologists would look at their um any their fertility plans and um kind of weigh up surgery with their fertility plans. Um And yeah, I think that's all we need to say about endometrial hyperplasia for now. Um brilliant. And then the last um main area of gyne oncology is vaginal and vulval cancers and these are very rare. Um but good to know about mainly for exam questions. Um And as you can see from the nice guidelines, the full time GP is unlikely to diagnose um a case of vaginal vulval cancer in their career. Um But the main things to look out for um to make sure that people are um being investigated properly as any unexplained vulval lump ulceration or bleeding, um, in the vulval area. And, um, in terms of vaginal cancer, any unexplained palpable mass in or at the entrance of the vagina. So, yeah, any unexplained masses or lumps in the vulval vaginal area need a two week, wait for a biopsy. Um, ok. I think that is everything I was going to say. Um, I think you can still hear me. I think it be. You hear me? Can you hear me? Izzy? No. Can anyone else see me? Ok. Is he typing Lizzy? Can you hear me? Hi. I'm sorry. My wifi has chosen a terrible moment. Can someone drop in the, if you can hear me? Yeah, I think we can hear Izzy, but I don't know if she can hear me, but that's fine. I'm finished. So Izzy can go. Hello? So I can't hear anything or see anything coming through on the chart. I'm not sure if you can hear me. I'm just reading that out of network. Ok. We're gonna want to send that everyone hear me. So that's great. Um There's a lag on the chat. Ok. I've just sent Izzy a message so just to say we can sort of hear her but it's quite uninterrupted. Um, hopefully her wi fi will sort out soon. Um, but if you have any questions about any of the gyne oncology stuff, then just put them in the chart. Um, sorry if that felt a bit rushed. Um, just quite conscious of time. Um, because Izzy's got um quite a lot to cover as well. I'm just gonna get the last slide up. Ok. Male. 10. Hey, II don't know if you can hear me. I'm just putting the slides up from my end so that it takes that off your computer. Oh, I don't know if you can hear me yet. No. Right. I think I might be back. Perfect. Right. I'm so sorry. It should be fine. Now my laptop time to die. Um, so I'm not sure how much I've got to do. Um, so I'm gonna be talking about no. Um, this term I hate but it's used very commonly and um the conditions they very much are benign but the symptoms can be really debilitating for the patients. Um, so I think there's often a perception among doctors also the wider public that the conditions they are very common. So they don't matter as much. Um, but it is really important to kind of bear the severity of some of my symptoms in mind. Um I, I'm a little bit glitchy, apologies for that, dropping anything in the chat if you need me to go back over it, but like that. So please. Perfect. So we're gonna talk about these four conditions. Um We're gonna start off with endometriosis and adenomyosis and we talk about fibroids and P CS. So, next slide, please. So I wanted to start by defining them just because it's really important. So, endometriosis is the growth of growth of ectopic endometrial like tissue outside of the uterus. Um It's not the kind of pass question definition of endometrial tissue outside of the uterus that leads every month. That's wrong. It's our update. We don't actually know what causes endometriosis. We used to think it was due to retrograde menstruation backwards. We now know that about 95% of women will experience that. So that's not the cause adenomyosis is like endometriosis, but it's the endometrial tissue within the myometrium, the muscular layer of uterus. Now, fibroids are smooth of tumors of the uterus, easy to remember. And PCS is a very complex condition of ovarian dysfunction um where you get androgenic features, irregular periods or nonexistent periods and metabolic features like high um the insulin resistance. The thing that unites all of these is we don't know much about them and we don't really know what causes them. Um And this is in part due to its complexity, but also due to a historic lack of research into these areas. And women's health has always been historically underfunded, but especially um the areas that have received funding traditionally are those that unfortunately affect male patients as well. So fertility, for example, has a disproportionate amount of research fund compared to things like for menopause about how common they are. So, on that note, next, likely. So starting with endometriosis, there are three types of endometriosis and it's really important to get your head around. So the most common type of endometriosis is now, this is really important because this type doesn't show up on imaging. So it's really common that women will, they'll come in with these really painful symptoms. They'll go for an ultrasound or an MRI nothing will come up. And if there's superficial endometrial cysts, that's why it doesn't show up. You do also get ovarian endometriomas. So it's also known as chocolate cysts. So, endometrial tissue filled cysts on the ovaries and the most severe form of endometriosis is deep infiltrating endometriosis. So these are nodules or that go at least five millimeters into the peritoneum. And we know that these cause significant pain. We don't know how much pain, superficial endometriosis and no variant endometriums caused. Now, you also get adhesions. Now, endometriosis itself can cause adhesions, but so can surgery for endometriosis. Um So that means it's challenging um to kind of work out whether or not you should operate for endometriosis because of this kind of risk benefit What about your team? So, next slide, please. So what do you think a typical case of endometriosis might look like a little bit lucky. Yeah, I can read them out. There's nothing at the moment I can't even hear. That's all I have to talk through. Um So next slide so often when you are like SBA and endometriosis, often, what you see is women in their thirties or forties l to the GP complaining of painful periods, pain starts two or three days before the onset of menstruation. And then they also experience symptoms like deep pain with sexual intercourse, which is called deep dyspareunia and dyschesia, which is pain when opening your bowels. Then on examination, you'll feel these like fixed, fixed organs, reduce il retroverted uterus. Now, neck like these. So that case certainly can happen. It's not uncommon, but you have to bear in mind with endometriosis. It's really common. There are about as many women living with endometriosis as there are women living with diabetes in the UK. That means the presentation is really variable and something else to consider is research has shown that the severity of kind of the spread of endometriosis. How severe it is at laparoscopy. It doesn't correlate with how severe symptoms are. So someone can have really, really minor endometriosis and really severe symptoms and vice versa. I I'm on my health. If I stop working much else I can do. Um, the other thing that is really important is it can occur in conjunction with alkalosis. So it will occur together. Um So that's something to remember when you're seeing a patient, when you. So next slide, please. So I wanted to consider kind of two patients. The first one patient a comes in, she's been trying to conceive for two years. She's not going anywhere. She's had scans, she's had blood tests, they all fine. Her, it's not her partner. She feels absolutely fine, just doesn't know what's going on. And then on the flip side, you have a university student who's in a lot of pain. She's always had painful periods, but she's now having chronic pelvic pain. Ibuprofen doesn't even touch it. She's not struggling to make it in university and she just wants some help with the pain, some exercises and I would keep the time and I'm just gonna talk through. Sorry. So, next, please. So when you're considering endos and adenomyosis, these are the kind of questions you want to be thinking about. So you're thinking about symptoms, first of all your pain symptoms. So you want to know about menstrual pain. What does it feel like? Is it kind of anterior? Um is it in the back radiating down the legs stopping her from going into work? How does the pain start before the bleeding starts? How long before it's normal for it to be a few hours before? But when it's days before that increases your ation of secondary dysmenorrhea. You want to ask if she's inhaling all of the time or most of the time. And then you need to think about dyspareunia, dysuria, and dyschesia say pain with sex urination and bowel movements. Whereas one doctor put it to me with endometriosis, nothing can come in, nothing can go out. So you need to think about those. You also want to think about gi symptoms. So a lot of endometriosis will experience quite severe bloating um or also IBS. So there are a lot of women will be diagnosed with IBS, like as actually gi symptoms related to endometriosis, ask about fertility. Two reasons is a symptom of endometriosis. Um But it is to consider um when you're thinking about how to manage them. Um So that's really ask and also want to make sure you're quantifying how heavy the bleeding is. Um because one of the presenting features of is this and then what else about risk factors? So, with endometriosis short cycles, um and a younger age period start to increase your suspicion of endometriosis and family history as well. So if they've got any diagnosis of endometriosis or abs and but if the things you have to remember it's historically really underdiagnosed. Um And so if there is history of family members with kind of hysterectomies in their thirties or really painful period, that increases your suspicion as well. Again, on that side, please. So we're revisiting these patients themselves. So, patient, a she actually goes well, young question. My periods have been really painful, but it's the same for every woman and her family and then patient expands it. So her period is this constant really bad ache in her lower back that radiates like gets really intense. She's really nauseous, nauseous. She's really bloated, really heavy bleeding and she has to wear a pad and tampon. She, the experiences this easier. So there's a quite a few typical patients that might come. So, next side, please. I'm next. So what do you want to do now? So you need to do an examination. You want to refer for ultrasound and you have to make a decision. You're gonna refer her to gynecology or are you going to manage the GP? So your next, please. So examination findings for endometriosis rhabdomys. So really commonly you're not gonna find anything, maybe just some tenderness, but that's quite nonspecific examination is quite uncomfortable with a lot of women. In more disease. You might see fixed organs, you could feel a retro. But remember that can be a normal finding. Um for adenomyosis you might feel is enlarged uterus. That's the typical finding. And if they're really large, you might even be able to palpitate some endometriums on ultrasound. Again, you're often going to see nothing and this is when you're referring ultrasound of your GP practice. They don't do the specialists, ultrasound that you will get in a guy looking for looking for cysts. It's just going to be looking at the visible organs. So nothing is really common. You might have see endometriotic cysts, you might see nodules or enlarged again and a thickened cases of a likely. So when do you back, you want to refer if they've got pelvic signs of meningosis? So, if you can feel it on examination, you need to refer if you've tried managing it and it's a really severe, it's really occurring. You need to refer if the initial treatment isn't effective, refer, you're not sure about the diagnosis. Refer specifically, you have to go to a specialist center. If there's deep endometriosis on the bowel bladder or ureter or if you suspect endometriosis outside of the pelvis. So the diaphragm is the most common. But there's cases of women having pneumothorax is on that area because of endometriosis really important. Whatever you do don't offer hormonal treatment to women who want to conceive. Um But also on the flip side, don't suggests just to treat the endometriosis because that's they'll still happen next. Sometimes always start with nsaids and paracetamol. Um But a very classic class. My question is when comes in with severe pain, you can feel endometriosis or a and then the correct answer is give ibuprofen, most of them will probably try at this point unless that's today. You do need to refer. Um Also you can then give codeine for acute attacks but try and paracetamol best. Don't forget, adjunct heating pads tens machines that it'll be really helpful in terms of your hormonal management. The combined pill of Mirena is chilly or ideal. The Mirena coil suppresses menstruation in most women. So that can be really beneficial, do not offer the copper IUD because the copper IUD one of the side effects is heavier under the painful periods. So you really need to avoid that GNRH analogs can be used but usually in secondary care for symptom reduction, but also prior and after surgery because they can help prevent recurrence, but also make surgery a bit safer. Now, surgical management, you can order a diagnostic laparoscopy with an excision. Ablation is still used, but it's not as good as excision is. So that's when you're cutting out the endometriosis, something else that can be quite useful is to offer to put in the migraine coil during microscopy. A lot of women are understanding to be very nervous about having a coil put in because it can be quite painful, especially with endometriosis and having it done under general after surgery. Um, if endometriosis is excised, hormonal treatment can help reduce currents and hysterectomies can be used. Um For endometriosis, the data is a little bit less clear but they can be cured of aosis and that's least um something that people kind of don't consider it's not taught in medical school, but it's really good pelvic floor physio, um with chronic pelvic pain. Um, a lot of women will develop things like to pelvic floor. So pelvic floor physios can be really, really helpful. So next, these so to summarize endometriosis, they're a really, really common cause of painful periods, heavy mental bleeding alongside endometriosis, and you should increase your suspicion of a patient presentations are really variable. Um And it can be challenging to diagnose because a lot of the initial investigations are negative. Um and then also historical lack of diagnosis means that women often normalize very severe symptoms. Um And so they won't come forward until they've been living with it for a very long time. And then for treatment, you need to take out analgesia hormones and surgery while considering the priorities to fertility. So next please. I'm sorry, I see that everyone. So please do drop any questions. Um ok. It is also called uterine leiomyomas. I didn't realize they in my basement. So our patient, she's 41. She says hi, thanks for seeing me and here because my periods have got really heavy. She's even having to wake up in the night to change her heart pains got a bit worse as well. My friend was given a pill type of acid and hers got headache. She was wondering if she could have some of that next week. Um So the symptoms by far, the most common is heavy menstrual bleeding. You can get some painful periods and some with results. So it's a really important differential for any of these symptoms. You can get bloating or a sense of abdominal fullness, especially fibroids are large and if the fibroids are really large, they can press on the bladder. So you get frequency urgency and incontinence, they can also impact. Now, in terms of risk factors, black women are more likely to be affected by fibroids and are most likely to come on between the age of 50. So and, and other things you need to consider when you take history, do they want to conceive again? If something change for management and then there's something else that you need to know when a patient presents with heavy bleeding. We want to find out if they've got any symptoms of anemia as well. So next, please. So what do you do now? So you need to do some investigations. So you want to do an examination um and you could feel a palpable pelvic mass. Um and you could feel an enlarged but a non tender risk fibroids don't tend to be tender. You also want to do a transvaginal ultrasound, really consider doing full to screen for and next. So how do you manage fibroids? So you want to refer to gynecology if treatment in g fails, fibroids are large three centimeters. And if there are concerns about subfertility, the bleeding is really are all there are compressive symptoms. So if you got these urinary symptoms, then you need to refer in those cases the next case. So if the patients are symptomatic you treat this with nsaids, pain relief and exam acid for he migraine coils are really useful for fibroids, but only if there's no distortion there is, it's not. You can also consider the mini pill or the combined pill. And if GNRH agonists again are often used to there. So when surgery is being considered, there's loads of different surgical options, we're not gonna go through all of them. The most important ones to consider though is ectomy because it's pretty much the only option if wants to conceive afterwards. Hysterectomy because that's completely curative at that point. Next, please. So then that's the patient. She's not 18 weeks pregnant and she's in a lot of pain. She's cramping, she feels really hot like she got a fever. She's, she's losing the baby. So what do we think this is? I think that. So what do you know? So you have to take these motivations. She, she's um, she's in the second trimester. You want to make sure that she's ok. But whenever you an acute person, you probably need an emergency as so next week. So on her observations, you the low grade fever with the mild tachycardia, but she is in a lot of pain. So that might make sense on examination. She's got a lot of pain on palpation and there's rebound tenderness and you can feel pal fibroid. So you prefer for an emergency assessment and he's gonna do an ultrasound while monitoring the fetus So have a think about what you think might be going on next, please. So this is regeneration of existing fibroids. So, estrogen levels go up in pregnancy. So the fibroids grow really fast, how it grows so fast and it outgrows its own blood supply. So the fibroid becomes ischemic, it becomes necrotic, so that becomes really painful. Um and it can create some stomach unwellness, tachycardia, low grade fever. Now, this affects the 5% of pregnancies. So, fibroids are common. So it's a really important thing about no fibroids don't tend to be people two on one, but the degenerated fibroids can become infected. So then when can become sepsis. So you need to monitor them quite quickly, please. So it's managed depending on symptoms and sometimes of infection. If they're really stable, then you can sometimes manage them at home with paracetamol. However, a lot will require a ations or even open the analgesic. Now, can you give nsaids? Remember you want to avoid nsaids in pregnancy because of the impact on the doctor's arteriosis. So we don't have to give nsaids for right now. You can sometimes manage them surgically. Um You can actually do a my me during pregnancy, which is of course, very risky, but it can be unsuccessfully without aborting the fetus, which is I think really impressive because this is open during surgery. Say that please. Now, moving to P CS, this is the last one I'm gonna talk about. So P CS is the real classic question. Does this patient have PC or not? Um And we diagnose using the two of the following. So, anovulation which tends to, that is um infrequent or no ovulation which manifest as infrequent or no periods. You need clinical or well and biochemical features of hyper and or you need, you need two of the following. So next please. So what does hyperandrogenism mean? So clinical science be her so kind of excessive hair growth, it can be acne and it can be angiogenic alopecia. So this is her loss on a woman. So insulin resistance is also kind of a clinical sign, but it's not really formally part of the diagnostic criteria. So some point to bear in mind that acne is a hyperandrogenic sign but it's also very common. So I say that that acne isn't as strong a predictor as per is no biochemical and elevated free is the main one in SBA S. The classic one is you have an elevated LH to FSH ratio. Um The jury is a little out how useful this is clinically. Um But look out for this in your um this was an another question recently for next week. So I think about these five patients which of these has PT and I might try out function. Yeah, so I'll be in a minute and then I'll call the office. OK. So next piece me perfect. So in green are the ones that absolutely have to the breast. So a woman with obese woman with irregular period, bilaterally enlarged ovaries. So for cystic ovaries, large cysts or enlarged ovaries, both help patients with absent periods and her P CS 14 or even normal period test and a stroke appearance on ovaries. That's character polycystic as much as that when she has to. He definitely doesn't. He's a 28 year old with absent periods, pal palpitations and normal ovaries. She has one of the criteria. Um and this will be more characteristic of brain disease. It gets a little bit more complex as 23. She's got regular periods actually in normal ovaries. So she might make meet two of the criteria, but her periods only started nine months ago. So it's quite common to have regular periods for the first month and acne is really common in 16 year olds. So with this one, you might want a bit more of a senior opinion. Let's see. So this is a really important point. You can have Polycystic Ovary Syndrome without Polycystic ovaries. So in mind, next, please. So management, you need to think about four domains. So you need to manage the symptoms, you have to manage waiting, cardiovascular risk factors, you have to manage the risk of endometrial cancer and you have to manage. So next, please. So uh combined contraceptive pill that can really help her. Hopefully, you've also got some treatments available. Um can aid with her. Um You want to try the combined pill first and specialist can provide and please cardiovascular factors. You are all very aware of kind of cardiovascular factors at this point. So, managing cholesterol weight, if it's like anything like that, um, just something to bear in mind. Um, we always a weight for, but p make it hard to lose weight. So you have to be very careful that you're not reinforcing unhealthy eating habits. PCRs is much more common in women who are at a higher risk of eating disorders. So I have seen patients who are limiting themselves about 800 calories a day are struggling to lose weight and there's still be just exercise more and eat. You have to approach this very sensitively. That's please. Um endometrial cancer risk. So as Molly was saying earlier, if a some periods, then the endometrial tissue is just, it's not going to shed. So you have to either suppress the endometrial tissue or initiate with. So the best way of suppressing it is Mirena coil. If you want to induce withdrawal bleeds, then prescribe or to the pro. And so you've got a few options, what they were the next, please. And then for fertility management, uh the last bit on special vision because it's really complex. But the first thing we can do in GP is a weight reduction. Um even if 5 to 10% weight weight loss has really significant impact on fertility. There's a few drugs that you can try, I believe is the most effective but there is a risk of um and there's use of Metformin and that as well. Surgical management, you can do what I think might be the name of procedure in medicine, laparoscopic ovary injury, you draw holes in the ovaries to try and do some of these cysts and that could also improve fertility. Next, please. So the last thing I'll talk about, thank you for seeing me until the end. Just ask tips. So it's really common if a gynecology have history integrated with a station. Um I think the best practice for this is training patients, but while they're not on a general anesthetic, um people can be really awkward when they people. Um It's very easy just to stop that off, but try as many patients as you can emergency gynecology units to be the best places can be really sensitive. So really trying to start a wrap. Um And the last thing is remember, management and il wishes. So if you ask anything, make sure you're asking about about management. So next, please, thank you so much for watching. We run over and apologies for the issues with the internet. Uh Those left, please fill out the feedback form. Um It's really helpful for us, but it's also um is to do the teaching session. So we'd be really grateful. Um Next, next teaching session is palliative care again next week. So please bring um thank you so much for watching, please do any questions. Exactly. 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