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Ok. Hi, everyone. Sorry, I've had some technical difficulties. Um I hope you guys can all hear me now. Um I hope you're having a good evening. My name is Joel. I'm one of the F ones in currently in the Northwest. Um I'm also the sing lead for Mind the Bleed. Um Hello. Uh Yes, this is recorded. Um So today, uh we're gonna cover high yield UK MLA topics uh for the gynecological disorders. Uh I'll try to answer all of your questions but if I can't, I'm, I'm sorry, in advance. Um If you guys need anything, you guys can just cut me off at any point. Uh I'll get started. This is a general overview of gyne disorders, of course. Um You'll need more in depth learning and practice, but I hope it's a good um general overview. Um So this is the content we're gonna be talking about today. Um focusing on endometriosis because it's a really high yield topic for um UK ML. Um We'll, we'll discuss as well, adenomyosis, fibrosis, uh abnormal uterine bleedings, amenorrhea, anova sa little bit on pid menopause and hormone replacement therapies. Uh So let's get into it. Uh I apologize for the slightly graphic, um, picture. Um, endometriosis always, always comes up in gyne, uh, exams. Uh, it's a very high yield topic and I think we should really focus on it as much as we can. So, um, endometriosis is very common. Uh, it affects about 10% of the population. I think it does affect more than that, but it's very underdiagnosed. Uh, it takes about seven years on average for a woman to get diagnosed from the onset of symptoms, which is crazy. Um You would know at least one woman with endometriosis in your life. That's a guarantee. Um So what is endometriosis? It's endometrial like tissues outside of the uterus. Um I it affects, as I said, 10% of the population of women. We don't have a clear etiology of it yet. Uh Some people say it might be retrograde menstruation, meaning endometrial cells going back from the fallopian tubes and out to the peritoneum and then just sticking everywhere. Um There's a lot of um shall we say? Sorry, apologies? Um Well, hypotheses, um a lot of these uh etiologies have been rejected and proven to be um untrue. We have also omic metaplasia, which is um that the cells of the lining of anything can transform and become endometrial cells. Um But that's also again, a hypothesis. Uh It's what we know for sure is that it's associated with menstruation and that hormonal changes cause the bleeding, chronic inflammation and because these are endometrial like tissues, they act again as endometrial cells. So when the woman has menstrual bleeding, they bleed as well. So you'd expect very, very bad symptoms. Um It's also estrogen dependent um as you may know. So, uh endometriosis can be classified into three different, let's say categories. We have peritoneal. So which are on the peritoneum wall itself, um just endometrial tissues, they, they look kind of blackish tarry on the cells um or on, on the endomet, the peritoneum from the inside. Uh they can also be ovarian. So you can have endometriomas or ovarian cysts that are cause also called chocolate cysts and more deeply infiltrating um endometriosis. And that could be literally anywhere. Um Some cases you can see on the bowels, appendix, um sometimes it can mimic appendicitis, sometimes it can be found on the lungs, sometimes very rarely though it can be on the nose. Um pleural cavity patch of D et et, et cetera. Um It's been named one of the top 50 most common chronic painful conditions uh as per the NHS. So that's cool. Um It's important to know what location, size and depth of infiltration, endometriosis goes to. But it's also important to know that some people may have very superficial but very painful endometriosis and others can have very deep, very asymptomatic endometriosis. So, um the location and depth do not really uh determine the pain severity. Um So the risk factors um again, estrogen dependent. So anything that increases your estrogen, um so early menarche, late menopause, all of the other things. Um The signs and symptoms mostly vary based on the, the location. So let's say they start as dysmenorrhea, it could be cyclical, but then it can become more and more progressive and become constant. And that's because endometriosis causes inflammation locally and therefore adhesions in scar tissues and that can cause chronic pain. Um You can also have dyspareunia, which is one of the most common, let's say clues when, um, when it comes to exams and, and the way exams are worded. Um So you'd have deep dysmenorrhea and deep dyspareunia. You can also have again cyclical or chronic pain and it does cause infertility, especially when it affects the ovaries. Um You can also have painful defecation. If it does affect the bowels. If it does affect the bladder, then you'd have hematuria, which would be very, um, let's say interesting because it, you, you'd only bleed um when you pee when you have a period, very, very niche, um, you don't have a lot of things that could cause that uh you could also have ibs like symptoms. Um, rarely, if you do have endometriosis on your lungs, it can cause uh something called catamenial pneumothorax, but that's, that's very rare. Um And sometimes as I said before, it can be complicated. Asymptomatic. What you do need to know is there is nothing more important than a laparoscopy uh and it's the only gold standard diagnosis for endometriosis. Um but not everybody does get a laparoscopy. Um A lot of people just get treated based on a suspicion of endometriosis. Um And sometimes you have to bear in mind that accessing the, let's say peritoneum or excising the lesions would cause more and more adhesions as well. So you'd have to think pros versus cons when it comes to that. Um Sometimes, especially when you have uh ovarian endometriosis, you can see that on a um ultrasound. So, transvaginal or um just a regular ultrasound but not seeing. It does not in uh exclude endometriosis. Uh So that's very important to know uh on examination most of the time it's gonna be normal but you can have some tenderness or maybe, maybe feel some nodules or some masses like an endomet like like a very large endometrioma. Again, very rare. Um ca 125 has been shown to be elevated in endometriosis but not having an elevated ca 125 doesn't exclude endometriosis either. So that's good to know. Um So when it comes to the management, uh a lot of people have previously mentioned to me that gynecological disorders are a little bit confusing when it comes to management because we don't know when Mirena is used first when um hormones are used first and it's a little bit confusing. So we're gonna try to break it down. Uh when it comes to endometriosis, it's important to know that the uterus itself is not the problem. So the Mirena is not the first line you'd use. Uh sometimes they do like to trick us in UK Mra questions and you know, the, the answer would be just paracetamol as a first line. Obviously, paracetamol is the first line. We, we do know that. But um, aside from paracetamol and NSAIDS, uh we can have other managements. So if you do suspect endometriosis, you can start by treating it. How do we treat that? We, we start with some medical uh management. So the goal of that would be uh suppressing the pain. It does not reduce the recurrence or the size. It only masks the symptoms and it works by just um inducing like a pseudo pregnancy or pseudomenopausal state. Uh because, well, they won't be receptive to estrogen as when you don't have a suppression of sorts if that makes sense. So we can start by uh CO PSP OS um gene antagonists uh et cetera. Uh So, about 80% of women do find uh this medical management um effective. Not always though. So we do have to resort to other stuff. Um Like for example, the Mirena, um Mirena has been shown to be useful when it comes to post laparoscopy. So, after diagnosis, after excision, uh a lot of people choose to have their Mi Mirena inserted because it helps prevent recurrence. Uh or so it's uh so, so the new research says, um, still very up in the air, still very, um, well, on the research topic, in my opinion, so if a woman does come and say I wanna conceive, then obviously the first two options are not gonna be um, on the table. So you'd have to resort to some more um, elaborate kind of management. And you'd need to refer to a gynecologist or specifically an endometriosis specialist, gynecologist, they could try something called danazole. Um, but for the purposes of UK ML, we'd go for surgery. So based on where the location is, we try to excise these lesions. Um, if they are on the ova ovaries, then you'd try to go for a cystectomy. So, just removing the cyst while trying to preserve as much as, uh, you can the ovarian tissues. Um, sometimes you may need to, um, ca do something called adhesiolysis, which is just breaking down the adhesions and in very severe cases, you might need to remove everything altogether. Um, now, do you think that endometriosis, um, uh, do you think that hysterectomy is a cure for endometriosis? What, what do we think? Uh, so someone asked if pain medication are an answer, would that be considered first choice? Yes, of course. If, if, uh, you have a person with some mild symptoms mostly around, um, their periods and they would tell you, uh, parcetol and NSAIDS are enough for me, then, yes, that, that would be, that would be first choice. Definitely. Um Most people do not feel that way though. And especially because it could be progressive. So most of the time we'd stop at medical management, I would say a lot of people just go on the pill to suppress the symptoms. Um That's not ideal, obviously, it, as I said before only masks the symptoms. Um But if it works, that's, that's the, that's the guidelines for now. Um Yes, a hysterectomy might not solve the issue. Um And that is because the tiss, the uterus itself is not the problem, as we mentioned before. Um You could have the scars anywhere, you could have the tissue, tissue lining anywhere in your body causing any sort of symptoms. Um Now, I if a woman does need hysterectomy, then it can be done laparoscopically as well as excising, then endometriosis if that makes sense. So if she has a, a need for an a hysterectomy for other purposes, let's say large fibroids or um cancers, anything of the sorts, then yes, we can, we can remove it. And a lot of people after menopause and hysterectomy because of the decrease of estrogen, it would help their symptoms. So the endometrial tissue um or the deposits would not react to estrogen anymore because you had that surgery. So, in some ways, it is helpful but it's not curative. Um Does that make sense? I hope, I hope it does any questions? Ok. So what you really, really need to focus on is how endometriosis presents uh in the questions, what kind of clues they're giving us, um, when it comes to symptoms and just try to see whether the woman's looking for conceiving or not and just go, uh, go by, you know, systematically basically. Uh, have you tried paracetamol and nsaids? Yes. And it doesn't work? Ok. Let's go for medical. If medical doesn't work, we'll try surgical then, um, yeah, and complications of endometriosis. Uh again, depends on the locations of the endometrial, the endometrial tissues. Um, a lot of time because of the adhesions, you can have a lot of problems. Um, you can, we can have it as bad as sometimes needing a stoma bag for their bowels because of how severe their endometrial tissue is on, on their bowels. Let's say, uh some people may need catheters because uh they have extensive endometriosis in their bladders. Um Sometimes you may have, again, as we said before pneumothorax. Um some people may have chronic appendicitis that would be excruciating in pain but would not be technically appendicitis. And therefore, it could go unnoticed for a very long time. And there's some new research saying that uh it could increase the risk of IBD. Now, bowel obstruction would make sense because of adhesions. Um But yeah, and if you do have some adhesions around the tubes, then that would also increase your risk of ectopic pregnancies. So, while endometriosis itself may not be fatal or severe um it does cause a lot of complications and that's something we should always keep in mind. Um So I hope that was a nice recap of endometriosis. Um I'll move on to adenomyosis, which is the little brother of endometriosis. Um It's endo but confined to the uterus, uh mostly in the myometrium. Again, I apologize for the graphic pictures. Um This is a very representative, um let's say, picture of what the adeno my adenomyosis feels like. Um It's well uh endometrial tissues inside of the myometrium causing inflammation. Again, it's not where it's supposed to be basically. So it causes contractions. It's cau it causes deep pain, it causes because of the inflammation, you'd have an enlarged and boggy uterus. And those two words are very, very uh common when, when, when it comes to stems, uh question stems on pam or on the UK ML. You'd always see enlarged and boggy uterus for adenomyosis. And that should be a clue. So it causes menorrhagia, obviously, because of the tissues, um very deep pain, uh chronic pelvic pain and pain after intercourse uh or during intercourse. So it's more common in multiparous women at the end of their productive years. So typically, you'd have a 40 ish year old woman with these kinds of pains. But uh the good thing is adenomyosis can be diagnosed uh via ultrasound. Uh Most of the time it can be seen on like endometriosis. And as I mentioned before, because adenomyosis is a uterus problem problem. Then Mirena here can be used as a first line uh option. So for, for your exams, you should always make sure to read whether the woman wants contraception or not and whether she wants Children or not because that would guide you. Um If they say actually we're trying to conceive, then Mirena would not be the proper choice and they always, always try to trick us like that. Um At least from, from all the UK MLA um previous have done. So pay attention on, on what the question says, pay attention on, you know, what, what they're asking basically what, what the woman wants out of the management. Um If they don't want any hormones, then you can go for tram acid, which is just i it's there for, you know, reducing the bleeds. So it does, it does help quite a lot with the, with the menorrhagia. Uh You can try uh nsaids like mefenamic acid instead. Um you can go for hormones, hormonals. So co PSP O PS again, but usually Mirena is the first line uh when it comes to hormonal treatments and if they've tried everything and everything else failed and they don't want to conceive any anymore, then obviously, we can go for a hysterectomy or an endometrial ablation because that would also mean no more preg pregnancies. Um Any questions about adenomyosis adeno itself is not lifethreatening. It's just affecting the quality of life. Mostly I would say. Um So you should always consider, consider that when it comes to DD AIS of gynecological disorders. Um And in this case, Hysterectomy would be curative unlike e endometriosis. Um ok, so, moving on to another very common um disorder, fibro uh fibroids and leiomyomas. Uh So these are benign tumors um per peripherally uh sorry, proliferations of smooth muscle cells and fibroblasts. Um It also um usually comes about ages of 30 to 50. Um And it's one of the most common benign uterine tumors in reproductive age. You'd see that very, very, very commonly um amongst women of this bracket of age, let's say. Um And typically, these are also hormonally receptive. So after menopause, they do tend to regress on their own, which is also important when it comes to management because if you do have a slightly biggish um fibroid, but the woman is almost near the stage of menopause, then you could watch and wait and just let it regress on its own without having to treat it. Um So you have three types of fibroids and that's very important to remember. Um because they could affect the signs and symptoms that the woman presents with. So you could have subserosal fibroids, which are usually near the outer surface of the uterus. Um they can extend to the peritoneal cavity and therefore cause pressure like symptoms. So they could uh put pressure on the bladder, put pressure on the bowels. Um That sort sort of thing and therefore cause symptoms. It could also be intramural, um mostly causing menorrhagia and dysmenorrhea. And it could also be submucosal. So in the inner lining of the cavity, which I guess would be bad when a woman would try, would be trying to conceive because, well, it reduces the size of the like the volume of the available uterus. Uh plus sometimes they can twist on each other and cause torsion. So those are the three main types of fibroids. Um Sometimes they can be asymptomatic if they're small. And other times uh just as we mentioned before, we can have uh infertility, menorrhagia, menorrhea, et cetera. And uh in comparison to adenomyosis, this is not a buggy uterus. This is rather an irregularly enlarged uterus because what you have the fibroids on different areas of the, the uterus itself. So it's not like a smooth enlargement. It's just a bumpy. Um This is a picture of um one of the fibroids. I um I saw myself. It's very cute. It's well cool, let's say. Um So we have a lot of treatments for fibroids. Um and fibroids are um diagnosed by ultrasound. Uh Most of the time, sometimes you can di diagnose it via hystero, uh hysteroscopies. Um abdominal and bimanual exams would be relatively helpful, not so much um in real life. So, the treatments, as I said before, if it's asymptomatic, just watch it. Safety net, don't, don't touch it basically. Um Because it's a uterus disorder, then you'd go for a Mirena first. As long as you don't have a distortion of the cavity, that's very, very important. You cannot use Mirena Coid if you have a distortion of any kind. So bear that in mind. Just don't forget it. Um Mefenamic and tranexamic acids are very important. Um Hormonal treatments can also be used. You can also have um some sort of benefit to gener h agonists because they've been shown to reduce the size of the fibroids within like three month. About 50% of the size would be shrunk. But once you stop the gener h agonist, then they just grow back. So, not very useful. Um And yeah, surgery, obviously, we can either have a myomectomy. So just the removal of the fibroid itself or um uterine artery embolization or just a hysterectomy altogether. And as I said before, depending on the compressions um of the adjacent structures, then you'd have different symptoms. Um Sometimes you can have sub fertility and infertility. And if you do have some fibroids and you do get pregnant, then you'd have some uh a higher increased risk of miscarriage, um fibroid vascular infarction, which is what uh what I said before about the twisting of the fibroids causing acute pain. Um sometimes some bleeding, um fetal mild presentations. So they could, they could be breach because they don't have enough space to, to turn preterm labor, et cetera. So usually we do not interfere when a woman is pregnant and does have some fibroids because it's just more risk than just leaving it alone and observing. Um I think that's it for fibroids. It's pretty easy. Um Those three come very, very often and you can emulate gyne topics. Are we good so far? I'll take that as a yes. Um So a normal uterine bleeding. Um This is a broad term. It used to be called dysfunctional uterine bleeding. Um It's well, uh an abnormal bleeding in absence of pregnancy or genital tract pathologies or basically any cause that we know we, we would call that abnormal uterine bleeding. Um and that would be heavy menstrual bleeding is the most common symptom. Uh A lot of people with heavy menstrual bleeding do not have a definitive diagnosis of what the underlying cause is and they would fall into that category. So you have to have to rule out any other diagnosis first. So, most importantly, pregnancy, uh and then other bleeding problems, the one Willebrand or any um sort of disorder that could cause you to bleed more. Um hypothyroid, hyperthyroid fibroids, P ID, PCOS endo and Adeno as we discussed before. So you'd look for everything before saying it's an AU and the treatment is uh more or less the same. So we'd start with non hormonal, we'd start with pain relief and then we go to Tranexamic Acid for uh trying to reduce the menorrhagia, mefenamic for the pain if that doesn't help, we'd go for hormonal. Um Usually because it's a uterus problem, you can go for Mirena first and hormonal is provided that the woman is OK with her having a um contraceptive on. So provided she's n not willing to conceive any time soon. And the surgical, which is the hysterectomy, which is obviously curative. Um I do have some, yeah, this is a nice picture um of all the causes, let's say of uh abnormal uterine bleeding based on the fecal classification. So it, it it could be read as palm coin. I don't know if you guys have heard of this before. Um P stands for polyps, A for adenomyosis, L for leiomyoma or fibroids. M is for malignancies. So any kind of cancer, uterine cancer, mostly um C is for coagulopathy. So any bleeding disorders or is for ovarian dysfunction, e endometrium, iatrogenic. So for example, inserting a Mirena coil and and is otherwise unclassified. Um Yeah, usually endometrial ablation is what people go for um surgical as a surgical intervention uh because they do have a lot of improvement without having to undergo a massive surgery like a hysterectomy. Um So that could also be an option. Um But for the sake of the UK MLA, you should just focus on the first um too. So nonhormonal and hormonal au does not come that often, but it's good to have it as a kind of DDX. And after you rule out everything you should, you should think about AU and that's, that's it for that. Um So why is Mirena so important um before the discovery of Mirena, um what people resorted a lot to surgeries. But because of that miracles, invention, let's say, um a lot of people don't need surgery anymore. Uh It's very effective. It has been proven to help a lot with menorrhagia. So it's usually recommended as a first line option when it comes to uterine bleedings in general. So, adenomyosis and fibroids and A B and that's why it's always so um prescribed, let's say, or it's always a buzzword, let's say when, when it comes to gynecological disorders. And I would say the only, the only time it's not a first line is when it's not a uterus problem. So, again, endometriosis, um otherwise you do use Mirena quite a lot. So, on this slide, you can see a reduction of um over a 12 month period for all of these methods. Um Although, yeah, it's, it's not very accurate, but I tried my best. So, yeah, so Mirena is the most, let's say ef ef efficacious, which is why it's always just first line. Um moving on. So I'm gonna talk a little bit about a amenorrhea before I move on to PCOS just because it's important to know that there are other causes. Um You can have a primary cause of amenorrhea and a secondary cause primaries before kind of age. Uh So w when you don't have any periods by the end, by the age of 15 or 13, but with no sexual characters, secondary sexual characteristics. So, like uh um hair growth and breast augmentation, stuff like that. And that would mostly be either genetic like turners, congenital adrenal hyperplasia. You should always think of inferred hymen. Um for some reason it's common and it's, well, not that big of a deal. It's very easily fixable, Um congenital malformations and, and functional hypothalamic amenorrhea. So very thin, very athletic, young uh teenagers would, would fall into that category as well. Um You also have secondary, so you'd have periods and then you stop having them for, for some reason uh for about 3 to 6 months, um or just 6 to 12 months of previous oligo with previous uh let's say on and off periods. And PCOS would fall into that uh as well as premature ovarian failure, thyroid problems. Um Sheehan problem. Do you know what she had? Is, does anyone know what she is? I think it's a hot topic on past med, but it doesn't really come, let's say in the exams. Um After birth, you'd have a pituitary infarct and that would cause something called Sheehan syndrome. Uh You'd also have Asherman Syndrome under that category, which is just uterine adhesions and always, always, always exclude pregnancy before seeing the patient's aic. Um So a good rule of thumb is usually gonadotropins. If they're low, then it's hypothalamic cause if they're high, then it's usually a primary ovarian failure or like an ovarian cause. Um And for investigations, you can always try covering all your bases and go for thyroid prolactin, ultrasounds, FSH and LH estradiol testosterones and then the treatment of amenorrhea is based on whatever the cause is if that makes sense. So I've put a nice table here, um, took it from somewhere and I think it just encompasses a lot of important diagnosis of secondary amenorrheas. Um What we're gonna focus on today is PCOS mostly, but you can have a look what, what other causes of Amenia would look like. Um I'll go to PCOS then. No, not yet. Uh We'll talk about anovulation first, which is just before the PCOS, let's say. Um So what, what is anovulation? It's when you have menstrual cycles, but without any release of eggs. So you could still have bleeding or menstruation per se, but you don't have any progesterone progestin secretion from the corpus cum after the ovulation because you don't have it ovulation. And therefore you'd have a persistent endometrium. Sometimes it does shed and cause like me. Uh well, menorrhagia kind of or oligomenorrhea periods on and off. Um unstable. So, but it's, it's really unstable and you're prone to heavy or irregular bleedings. Um And fertility is a very common symptom, obviously, and we have classifications of ova uh anovulatory cycles. So you could be in group one, group two or group 31 would be a hypothalamic cause. So, um you'd have a problem with the pituitary. So it's the higher, let's say, kind of the chain. Um Group two would be the hypothalamic pituitary ovarian dysfunction. And that's where um PCI S would fall. And that's the most common cause of um um anovulation. And then you'd have the group three, which is the lowest of the chain, ovarian stuff. So, like ovarian failure, primary ovarian failure, um we're gonna focus on group two today. So PCO S because it's around 80% of the most common stuff um or causes of anovulatory cycles. Uh Ovarian failure does come sometimes quite well, not very often, but it does come. So bear in mind that ovarian failure is a an important DDX when you have a woman with menopausal symptoms, less than 40 year old with no clear reason. Um or sometimes post chemo for, for any other cancers. Um they would have a very raised FSH and low estradiol. So you treat it just as you treat menopause, which we'll discuss in a bit and let's move on to. Yeah. So the primary ovarian failure causes, you'd have premature ovarian failure, turners, autoimmune disorders or sometimes even uh medication. So, antiepileptics and psychotics chemo and then you'd have the secondary hormonal disturbances. So, anything like contraceptives, pregnancy, hyperprolactinoma, PCOS. Um So I think we should focus on PCOS today because that's the most common topic, let's say in um anovulation. Uh I'm sorry for the very bulky uh slide. I tried to cover as much of the pathophysiology. Uh but it's a very common endocrine disorder in women and therefore very um important. So, um 80% of all anovulatory fertility, as we mentioned before, the, the root of all the, let's say problems in PCOS is not really clear um because everything interferes with each other, but the most common, let's say clue that we have is hyperinsulinemia. So, um because of the high insulin that we have, you'd have a reduced sex hormone binding globulin or SS Hbg um produced by the liver, which itself increases the unbound active testosterone. And the free testosterone itself is one of the key factors of the symptom, let's say presentations. Uh it's a very vicious cycle because as I said before, the insulin resistance itself causes weight gain and excess body fat, which in turn would cause increased insulin secretion and therefore worsening the PCOS. Um and the insulin itself um modulates the GNRH which would cause an increase in LH. The increase of LH to FSH ratio ratio is very, very important um in here because um the increased LH pulse um and frequency from the pituitary well is not working properly. And therefore, uh the ovaries prefer synthesizing androgen rather than estrogen when you have such, let's say hostile environments. Um And obviously, the increase in androgen would stop the follicular developments and therefore cause anovulations. So you'd still have some uh increased as uh some increased estrogen. And that's because um well, the follicular development stops before the maturation of the oval uh over later cycle and there will be no ovulation but estrogen progest uh pro production may continue. So it's very tricky. And what you basically need to know is the three things that are hyperinsulinemia, raised LH to FSH ratio and increased in androgen production. And those are the three pillars, let's say of P CS. Um I know it's not a gynecological disorder per se, but it does affect um the way. Well, it it causes oligomenorrhea, amenorrhea, sometimes may be increased vaginal breathing menorrhagia, which is why it has to be in our di axis today. And um it's very important to know Rotterdam criterias for the investigations and diagnosis that does come quite often and you need at least two of the following criteria on the left. So either irregular or absent ovulations um or you'd have clinical or biochemical you don't have, you don't have to have both. You can have either or of a uh hyperandrogenism. So, anything that's leads to uh you thinking, ok, maybe this woman has high androgen. So could be clinical like acne hirsutism or it could be just an increase in total to uh testosterone or a low sex hormone binding globulin. And the third criteria would be polycystic ovaries on ultrasound. So, more than 12 follicles or an ovary volume of more than 10. Now, it's very important to know that PCOS itself can be diagnosed without having Polycystic ovaries. But the fact that you have a Polycystic Ovary does not mean you have a diagnosis of PCOS. Um, sometimes for some reason, you can just have an ultrasound and find some follicles and say, oh, you have a lot of follicles, but that doesn't mean you do have the PCOS this like syndrome. Uh You can have PC, which is different. Um So it's important to have two or more of the criteria. Asperin I guidelines and the management. Uh you'd, you'd start with uh conservative management, you'd start with something like lifestyle advice, weight loss. Um If that doesn't work, we can consider co ps. So syndiol is used a lot. Um you can have it as cyclical P OS, for example, or a Mirena coil that does help manage the symptoms. Um Metformin is used especially to aid the woman lose weight, but it's used as an off label use rather than an actual treatment itself. And then again, when it comes to gynecological disorders, you have to have to ask the woman, do you, are you thinking about conceiving or are you thinking about contraception because that would also guide our management. So if in the stem it says they don't mind waiting, then you can go for all of these we've discussed before. If they are trying to conceive, that would cover something else we'd go for. Obviously, you'd refer to um someone more senior like gynecological specialist specialists, they need endocrine um input as well. But clomiPHENE is used, uh Letrozole is used generator is used sometimes in very severe cases or very extreme cases. When you've exhausted everything else, you can use ovarian drilling and if everything else fails, then you'd go for IVF or assisted reproduction techniques, any kind of technique. Um So PCS is very, very complex endocrinological disorder, but it's relevant and I think this is what you need to know mostly um any questions about PCOS. No. OK. Um So I'll move on to pelvic inflammatory disease. So P I is also not really a gynecological issue, but it's more of a sexual and uh infectious kind of um cause. But it again presents as um same things we've discussed before, which is why it's an important DDX to think of. Um So pelvic inflammatory disease almost always comes from um an sti very rarely. It could be because of a descending appendicitis. Very, very rarely. Uh So it causes endometritis, salpingitis, oophoritis, basically inflammation of the entire gynecological tract. Um It's more common in young people with early first and sexual intercourse or with multiple sexual partners. People who have a history of STIs s et cetera. So the most, most common cause of PID is chlamydia by far. Um Nigeria is also one of the other common causes, but chlamydia is by far more common than Neisseria and the symptoms would be something like fever, dysuria, a pelvic or lower abdominal pain, deep dyspareunia as well, which again would um make you think of other stuff. So like endometriosis and adenomyosis also cause dyspareunia. So, be careful. Um In here, you'd have more of an infective and inflammatory um picture uh fevers, especially abnormal vaginal discharges. Um Fitzy Curtis is um always, let's say taut. It's not really that common. Um Don't think it comes that much in questions either, but it's something you have to be to, let's say, remember, um it does come with the pelvic inflammatory disease and it's a a complication of P I let's say so it's a right upper quadrant pain and it's due to uh the adhesions of the anterior abdominal wall with the diaphragm and the liver capsule. So they uh adhere with each other and causes sort of hepatitis picture. Um You can also have adrenal tenderness because adnexal, sorry, adnexal tenderness because of the inflammation around that area and infertility as well as increased risk of ectopic pregnancy because of the salpingitis. So you, you'd have more adhesions around that area making it more likely for you to have um ectopic pregnancies. So for pid, always, always, always exclude the pregnancy before um looking for anything before treating anything. Again, this is very important. Uh we go for vagina swabs and regular blood test and then you'd screen for all the kind of infections especially HIV and syphilis because if you do find an sti, then you're likely to find other STIs. Um, you'd go for an ultrasound, that's the most, um, accurate way to diagnose pid. Um, you'd also be able to see any hydrous salpinx or abscesses. So that's very important. But the gold standard obviously is laparoscopy. Um, it's not really routinely done, um, in reality, um, since the treatment is more or less antibiotics, there's not really, not much of a need for a surgical intervention. So they wouldn't go for that unless it's um it's called for, let's say, um the treatment would be obviously pain relief if they do have any iuds ius s, they have to be removed um because they would harbor more of the infections and the bacteria. So those have to be removed. Uh If they're septic, obviously, they, they need admission and then you'd start uh treatment until you find the results of the swabs. So usually according to the guidelines, we start with this kind of um empirical treatment. And the rationale behind the first line is that cefTRIAXone uh covers for gonorrhea, doxycycline covers for uh chlamydia and metroNIDAZOLE covers for bacterial vaginosis. So, those are the three main antibiotics we'd give. Um So the cefTRIAXone is just one single dose and then the rest is for 14 days doxy and metroNIDAZOLE. Um Obviously, we have some other variations. Um So a floxacin can also be used with metroNIDAZOLE or if they do have mycoplasma, then you'd use moxifloxacin, but those would be usually much more niche. Um So always, always use first line um as a first, let's say, go to. Um Yeah. Uh so always also give advice. So safety net, uh make sure they're uh safe for later, make sure they um uh use contraception. Meanwhile, as, as you know, they're highly unsuitable for a pregnancy at this stage. Um because of all the infections and inflammation and the adhesions, blah, blah, blah. Uh If they do have HIV, then you'd need to refer them to a clinic HIV clinic. If they do have an abscess that may need draining and you may need to contact trace depending on, on what notifiable versus not notifiable diseases. They have. Um not all of them do need a test of cure, but some may need the test of yours. Um We're not gonna go into that. Uh It's not that let's say relevant um for you. Um, well, is that so far fine? Any questions? Nope. Ok. Um I'll move on to discuss menopause. Um I'm not gonna go too much into menopause. It's fairly um straightforward. So loss of menstruation after about 12 months of amenorrhea. If they're less than 50 then that would be two years of amenorrhea. Um The mean age of menopause is 51 and you'd have these hot flashes, unpredictable periods. Um They'd go and come back, uh dry skin, night sweats, vaginitis, all of these things. They could, it could affect your sexual function, it could affect cognition, joint pain, osteoporosis. Um So it's a multitude of symptoms all across the body. It could be very debilitating when it comes to quality of life. Um And so we do try to help as much as possible. Um And while you do have a high FSH, this is not routinely done, at least not in the UK. Um it's more of a retrograde um diagnosis, let's say. So you just wait for a year and then you say, well, um this is the diagnosis. It's, it's, it's done. Um The management, you'd go for lifestyle changes first try to help as much as possible. And I've listed them all here. We all know them and it's important to know that because you don't have that production of estrogen. You do have to consider the risk of cardiovascular diseases. So, um you have to assess for that and manage as necessary. Osteoporosis is also common. So we do need to prevent and that is usually done by giving them some calcium, you know, safety net, all of these things. Um You'd also have to screen for cancers and um you do need contraception uh even though they have menopause for at least two years after the last menstrual period, if they're less than 50 or for at least a year if they're more than 50 that's until 55. And when, I mean, contraception, I don't mean HRT HRT is not contraception, HRT is hormone replacement and that's very, very different. So, if the woman is still sexually active at the age of, let's say 50 then she would need HRT and progesterone pills. Don't forget that um, non HRT treatment would be also dependent on what kind of symptoms they have. So, if it's mostly psychological, they can go for CBT SSR R, SSRI S, SNRI S. Um if it's mostly vaginal dryness, they could go for creams, vagina, estrogen creams. So basically, whatever the the issue is you try to address that. Um And what I really wanted to discuss here is um H RTI feel like H RT is a very important topic um sounds difficult but actually isn't. So why would we use HRT? Um First HRT can be used transdermally orally, topically, we do have a lot of options for HRT. Um And uh as a general rule, if a woman does have a uterus, then you need to add a progesterone. If they don't have a uterus, then you can just give them estrogen. Um And the rationale behind it is, can anyone, can anyone say why? So usually the main concern in HRT. Yes, exactly. Um The main concern in HRT is progesterone. So you do want to use it as least as possible, but you also do need it when they do have a uterus because it again prevents endometrial hyperplasia. So, um you have to aim to prescribe the lowest dose of HRT for the shortest possible duration. Um because after all, everything has side effects, um you start for, you start with, let's say preparations, oral or transdermal. If it's mostly vasomotor or mood symptoms, if they do have urogenital symptoms, then you go for um vaginal estrogen. And yeah, you consider uh consider the transdermal rather than the oral because they have a better um or less increased risk of VTES. Um And then you, you should always aim to review the woman to see how they've been doing on their HRT, make sure they don't have any new symptoms, any new bleedings because obviously, postmenopausal bleeding would make you think of more sinister causes. Um Sometimes you can use uh progesterone as a local instead of oral. So the woman doesn't really have to take a oral progesterone. A Mirena would suffice. Um That's the most safe, let's say way of giving HRT. Um because that's what we're worried about mostly, right? Like the, the reason we're using a progesterone is because they have a uterus, we wanna prevent hyperplasia, Mirena can solve that problem. So you can really get creative with Rh RT and um you have to consider the side effects. So, nausea, breast tenderness, et cetera, et cetera. The benefits of HRT they do decrease vasomotor and neuro genital symptoms. They decrease the risk of osteoporosis because you're constantly giving the estrogen that they've lost, it prevents fragility fractures. And some research has found that it also uh decreases colorectal cancers. Um So the risks of HRT is increased in breast and ovarian cancer, especially endometrial if it's estrogen alone, um it increases the risk of strokes, vtes coronary heart diseases. And it's contraindicated in women with uh breast cancer, either current or past um any sensitive, any estrogen, sensitive cancers. Um and especially contraindicated and undiagnosed vaginal bleed because you wanna make sure it's not cancer or hyperplasia again. So for the duration of HRT you can usually use it either cyclically or perimenopause uh for perimenopausal women. Um So for women who do still have their periods, you can use it cyclically with a uh let's say bleed period just so that you can regulate their periods better. Um That does help a lot with the symptoms and if they're postmenopausal, then obviously, they don't want any bleeds, they can't have any bleeds. So you'd use it continuously and they can be continued up to five years, stopping them gradually is the best. And as we said before, you should monitor for any sudden symptoms, any new symptoms, any bleedings that are abnormal and always reassess um their benefits, their risks, their needs, that should always be a continuous kind of discussion. Um So this is a, a nice uh diagram I stole from somewhere and it's a comparator, let's say um of how much HRT increases versus decreases the risks. Um And you can see here that it doesn't really, really make much of a difference. So this is the what what this shows is a difference in breast cancer incidence per 1000 women aged between 50 to 59 and approximately the number of people that are diagnosed with um breast cancer. In addition, uh due to having HRT and that's very low plus four. So in comparison, an additional 24 women um get diagnosed with breast cancer for having, for being overweight or obese. So a BMI more than 30 um So while it does increase the risk, um I wouldn't say it's that significant. Um But yeah, so this is another one just um yeah, saying that the risk after 10 years would be um one in 50 people have estrogen uh who take estrogen and progesterone daily. Got cancer diagnosis. One in 70 for people with estro estrogen and intermittent progesterone and one in 200 with estrogen only. So, estrogen is very, very safe and ana can be used instead. So there's that um and that's it for tonight. I hope I didn't bore you guys too much and thank you. Uh I would appreciate the feedback. I'll Yeah, I'll leave the, a few minutes for any questions that you guys may have. OK. Um This is the link for anyone who wants to have a feedback done. No worries. Thank you. Uh You'll get certificates for attending. So thank you for attending and keep uh look out for the next sessions. Thank you, everybody.