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I it, it um I feel I feel enough. I'll just make a start now then. Um So this is the Gynecology lecture for peer share. Um And I'm Ciara mccaffery. Um One of the final years, that's my email. If anybody wants to email me about questions or anything in the lecture or anything, peer share related in terms of if you can't get in touch with your tutor or you've trouble like arranging teaching or anything, just drop me an email and I'll try and get it sorted. Um There's also an evaluation form to fill out at the end of the lecture. So, um it would be useful if you could do that for us in terms of we're trying to like improve peer share and like audit it at the minute. So, um the contents of the lecture then include uh period problems, menopause, H RT gyne cancer, urinary, incontinence, contraception, and early pregnancy. There is some other things that I've included that aren't on this list. So we'll begin by talking about period problems then. Um I've just a list of like definitions here. So no period is referred to as amenorrhea in gynecology, irregular infrequent periods are referred to as oligomenorrhea, heavy periods, menorrhagia, painful periods, dysmenorrhea, unceasing of menstruation is menopause. So the menstrual cycle, it's like, I think it's very useful to know the menstrual cycle and which hormones peak at which time of the month. And uh the zero to finals has uh like video on youtube for this and it's worth giving it a watch just because it makes everything makes sense in the long run. So the hormones involved in the menstrual cycle um are FSH LH, estrogen progesterone and a typical cycle lasts 28 days, but it can last 21 to 35 days. Um And the follicular phase is the beginning basically when the egg is inside the developing follicle and the luteal phase, which is always 14 days is when the corpus luteal is left inside the ovary and it usually produces progesterone. I think. So, fs H stimulates the development of the follicles in the ovary. And then the LH is what causes ovulation and it usually spikes before ovulation to cause one of the follicles to come out basically and release the egg every month. And then ovulation happens 14 days before the end of the cycle. Um So if a cycle was 28 days, it would be 14. But if the cycle was like 30 then it's 14 days. It's 30 minus 14 days. The luteal phase of the cycle is always 14 days. Just remember that. And um menstruation usually lasts for 1 to 8 days and the start of menstruation. The start of the period marks the first day of your menstrual cycle. Um and then estrogen is a steroid hormone that acts to promote female secondary sexual characteristics like breast tissue and the uterus. So it causes thickening of the endometrium. So the lining of the uterus and it causes thinning of the cervical mucus around ovulation. So the sperm can get into the uterus and get to the egg. Um progesterone then is also a steroid sex hormone that acts in tissues that have previously been acted on by estrogen. So it thickens and maintains the endometrial lining and thickens the cervical mucus to prevent things going in and out. Um It causes a slight rise in body temperature and can cause symptoms of like premenstrual syndrome uh before co before um having periods um cause it kind of goes up during the end of the luteal phase and kind of causes premenstrual syndrome. Um and some people and the placenta produces the progesterone from 5 to 10 weeks. But before this, it's the corpus luteal. So, amenorrhea then is the absence of periods. And if it's primary amenorrhea, this means that somebody has never had a period before and then if it's secondary, it means that they've had a period, but they've disappeared. So they've had no periods for three months, if they've had regular periods that diagnoses amenorrhea, and if they have had previous irregular periods. So they haven't got one every month. Um, it, they need to be amenorrheic for six months to have a diagnosis of a amenorrhea. So, primary amenorrhea then is when somebody's never had a period and it's diagnosed when you haven't started menstruation by the age of 13 with no other evidence of pubertal development. So you wouldn't have any like armpit tear or any like height growth or you wouldn't have breast bone. Um And then if you have other signs of puberty, then it's 15 years. Um puberty starts at around 8 to 14 in girls and 9 to 15 in boys and usually lasts for about four years. Um I remember the order of like female puberty by BPM. So breast buds first, pubic hair, second and then menstruation, which usually usually comes two years after the start of puberty, puberty itself. And then in their defin they mentioned about the tanner staging um of puberty, which is useful to look at causes of primary amenorrhoea. Then um basically, hypogonadism is a lack of estrogen and testosterone. So, there's two causes of two broad causes of primary amenorrhea. And it's this one here is hypogonadotrophic, hypogonadism is so it's to do with the hypothalamus and the pituitary not working properly. Um So when the hypothalamus isn't working properly, it doesn't produce enough GNRH, which, which is gonadotrophin releasing hormone and then the pituitary isn't stimulated to produce FS H and LSL H. In that scenario but if it's the pituitary that's not working properly, then it's just not gonna produce FS H and LH, um which usually stimulates the ovaries to produce estrogen. Then um, so problems that can cause it to do with the pituitary would be chronic conditions. So, like if somebody's got a chronic condition like CF like cystic fibrosis, celiac disease, something that's um chronic. And then if somebody is excessively exercising their diet and then they've got low body weight, then their body will just not produce a period, basically. Um And sometimes constitutional delay. So you can kind of measure it off their family history. So if their mum or their aunties have had um they were late starting periods and it could just be constitutional delay and then endocrine disorders like your hypothyroidism and Calman syndrome is something that causes um hypopituitarism, but it causes a lack of smell, I think as well. Um And if you've got the hypogonadotrophic hypogonadism, then you would have low LH and low FS H. So you can kind of work that out by like the purity will not produce it if it's not getting stimulated by GNR H or the purity is not just producing at all. Um And then hypogonadotrophic hypogonadism. Um and it's to do with the problem with the ovaries. So with the negative cycle, um that's in place in, with the pituitary and the hypothalamus to the ovaries basically, then the pituitary starts to overproduce LH and FS H because the, the negative cycle is disturbed and there's no estrogen to block the production of LH and FS H. So the pituitary produces a lot. Um And this is to do with, it can be caused by damage to the gonads such as like torsion um of the ovary. Um, cancer or infections like your pelvic inflammatory disease or something that causes damage to your ovaries, um can be caused by like radiotherapy and stuff like that to the ovaries as well or the pelvic area. And sometimes people can have a congenital absence of ovaries. I'm not sure of the um exact like genetic conditions that cause like absence of the ovaries. But sometimes I think Kinley Fer syndrome is one. and then Turner's and then other causes that you can read up about are your congenital adrenal hyperplasia. Um Androgen insensitivity syndrome, which are quite um complex conditions that they're in zero to finals to read about, but it takes a while to get your head around them. Um, structural pathology as well. So like somebody can have an imperforate hymen, um which means that like the opening to their vagina is closed and they may be having a period but it stays within the body and then female genital mutilation is something they always like consider. Um And it's something you should be investigating for when you do because the investigations include APV exam. So you need to be looking, have they got an imperf for hymen or have they got female genital mutilation. Um You need to get bloods as well because they could have like a chronic anemia which is blocking, which basically act for a chronic condition then and would be causing the hypo this one here for the chronic condition. Um and a hormone profile would be useful because you can measure the FS H and LH and then that will work out which type it is. Um you could get imaging of the pituitary, um the pelvis and just do APV exam. Um management then would be treating the underlying cause. So like if it's constitutional delay, just reassure the person and tell them that like based on their family history, like it may still come. And if not, we'll just investigate further, then if they've got low body weight, then they need to be advised for weight gain or referred to psychology or psychiatry. Um if they've got like an eating disorder or something, um management of chronic health conditions, um and then replace hormones where needed. So you can give pulsatile um gonadotrophin releasing hormone. Um And there are two examples of it. Um So that would act if the hypothalamus isn't working properly. And then the combined oral contraceptive pill includes estrogen and progesterone. So if uh that works for all hypothalamus, pituitary and the ovary problems, um because it basically replaces estrogen and progesterone, um secondary amenorrhea, then the biggest thing that you need to rule out is pregnancy. Um, so if somebody's got a late period or they haven't had a period in a couple of months, like they could be pregnant, basically. Um, then the other causes would be, um, could be. So the ovarian ones are pregnancy, menopause premature ovarian failure, which is basically menopause before 40 years old. Um PCO S is your Polycystic Ovarian syndrome. They have irregular periods and then hormonal contraception, um, can sometimes cause amenorrhea, like especially progesterone ones. Um And then hypothalamic causes which are like hypothalamus problems are the same as your primary amenorrhea. Uterine causes. Then would be um, like possibly Asherman syndrome which causes like um adhesions to form within the uterus. Usually followed. It usually follows a procedure like your um, dilation and cartage or a miscarriage or ac section. Um And then your pituitary causes would be tumors, Shanan syndrome, which is a syndrome that usually comes after a postpartum hemorrhage. Um because it causes basically ischemia and necrosis of your pituitary. Um, and then trauma to the pituitary, radiotherapy surgery, hyperprolactinemia is a good one to rule out. Um And w with the blood test or if they've got like discharge from their breasts, um, and chronic conditions as well and exci excessive diet and or exercise. Um, the same thing kind of applies here in terms of your low FS H and LH for your hypothalamic and then ovarian is increased LDH neck SC H. So your investigations and management of secondary amenorrhea. Then the biggest thing you need to do is a pregnancy test. Um And I think it, I think all females of childbearing age get a pregnancy test when they present a anyway and then hormone profile bloods and imaging. Um your imaging would kind of be the same as your primary amen investigations and then treat the underlying cause and then some of the examples of management. So for your PCO S, you can give the combined oral contraceptive pill and the dye is a good one because it's anti anti androgen basically. So um we'll go over P CS in a while but they have high androgen levels which causes acne and the weight gain and stuff. But it's usually given for three months and then one week break because there's a risk of clot with it. I think like BTE with it. Um hypothalamic amenorrhea, then you would treat it with the pulsatile GNR H or you could just replace a progesterone with the combined pill and then pituitary causes, treat with the combined pill and Asherman syndrome. You would do um like adhesion lysis and um just for this, just to keep in mind if somebody is over 12 months amenorrheic, you need to start thinking about bone protection. So possible dexa scan, um bisphosphonates Vitamin D calcium supplements. Um just because low estrogen causes low bone density in some cases. And then oligomenorrhea is your irregular menstruation. And um it usually happens at the extremes of reproductive age. Um So when somebody's just after shaping their periods or coming to the end, like near menopause, um P CS is one of the biggest causes of it. Um And physio biological stress can cause someone to have late periods or like absent periods for a while. Um medications like your progesterone contraceptives cause irregular periods and antidepressants and antipsychotics, which I haven't really heard of before. Um hormonal imbalances like your thyroid Cushing syndrome, hyper lactone. So PCO s then uh sorry, this is heightening a wee bit but it is um it basically says Rotterdam criteria up there and the three things, the three criteria for it are your um oligomenorrhea. So your irregular periods and hyper androgynism. So you would look out for acne and like hair growth. So sometimes they might have hair on their face or elsewhere on their body. Um And then Polycystic ovaries on ultrasound. So the criteria for the Polycystic ovaries would be 12 cysts in one ovary or in ovarian volume, more than 10 c 10 centimeters um cubed. So they need two out of three of those criteria to get a diagnosis for Polycystic Ovarian Syndrome. So, they might necessarily not have any cysts on their ovaries, but they have hyperandrogenism and irregular periods um or absent. So then the signs and symptoms you need to be looking out for is your irregular periods. Um They might present, somebody might present with infertility and they might be having trouble like getting pregnant. And then you find out basically that they don't have regular periods and then you might notice that they have acne and then you just prompt you to investigate it more. Um, obesity is a big problem in P CS. Um Hirstia, which is your hair growth um uh like on your face or on your tummy or like in all the places, Acne is a big one as well and hair loss and a male pattern insulin resistance and type two diabetes, which kind of goes along with the obesity. Um, so your investigations, then this is how you, it, there is questions that come up and um, there's an increased LH to FSH ratio. So your LH is really increased, um, and it's, um, really increase in, in relation to the FS H and then there's increased testosterone as well. Um, increased insulin and then on transvaginal ultrasound, the like kind of common way to describe it as a string of perils appearance for the cysts, appearance of cysts on the ovaries. And then you would do um, an oral glucose tolerance test for type two diabetes and they may have increased estrogen as well, but it can be normal. Um, your management then of P CS, if they have infertility, you're gonna give them, well, you could try clophen, which basically causes the ovaries to ovulate, but it can cause ovarian over of the hyperstimulation syndrome thing. And ovarian drilling is a good way to increase fertility and then weight loss, which you can give them orlistat, which is basically a tablet that like doesn't allow you to absorb lipids in the intestine. But it's only usually with ABM I of over 30. And um to stay on that, there is strict criteria like you have to lose so much and whatever number of months and stuff. Um The biggest thing they need to do is probably exercise, stop smoking cessation and then just lifestyle advice. Um So your weight loss and all that as well. If they've got hypertension, you can give them antihypertensives. Um Statins if their risk is over 10 or they have got um cardiovascular disease, your Mirena coil can be used um your combined pill as well, especially the diane that one cyclic cyclical progesterones um to prevent endometrial hyperplasia, which can be a problem with PCO S. Um But of course, then things are only used like if they need contraception, it doesn't like, it obviously doesn't work if they're having problems with fertility. Um your complications, then they have an increased risk of cardio cardiovascular disease and high BP type two diabetes and obesity, infertility, obstructive sleep, apnea, depression and anxiety. Endometrial hyperplasia is a big one. possibly because there's increased estrogen and because they're having irregular periods. Um and you can get endometrial cancer from endometrial hyperplasia. So, ovarian cysts then um a cyst is a fluid filled sac and sometimes it can be asymptomatic. Sometimes it can cause pelvic pain or fullness or bloating and sometimes people can actually feel them in their abdomen. Um, premenopausal cysts are most likely benign and your postmenopausal ones are most likely to be malignant. So your benign ones then can be split up into larger groups of your functional ovarian cysts. And these are due to fluctuating hormones of the menstrual cycle. Your follicular cyst is the most common, common type of one. And it's to do with incomplete rupture of follicle during ovulation. And I think most premenopausal women have these um just asymptomatic and then your corpus luteum cyst is during early pregnancy. Um and it's basically just where the corpus vs fail to like degenerate and just form a cyst. Uh your benign germ cell tumor is most likely your dermoid cyst. It's the most likely to like cause torsion of the ovary. And dermoid cysts are the ones that contain all of the um germ cell lines with the hair, the, the teeth and all that in it. And um they will have a raised A FP and DH CG um as like tumor markers and then your benign epithelial tumors, serous cyst adenoma um which is quite common like and can they quite similar to the serous carcinoma of the ovary. Um And it's usually bilateral than about 20%. And then your mu mucous cyst adenoma. Um They become, can become massive. I got that there question in past med one time they asked me like that, the mucous cyst Anoma had burst and basically what bacteria had caused it. And I don't even know how to pronounce that. Um So then your complex ones would be like multilobed and most likely in your postmenopausal women and they should be biopsied to exclude malignancy. Um And you wanna do like your cca 125 and stuff like that for your tumor markers for ovarian cancer. We'll go over that in a minute. Um And then your complications of ovarian cysts. This came up as a question for me as well. Um It's torsion, hemorrhage and rupture. So, an infection isn't a risk factor for ovarian cysts really? So your investigations and management of ovarian cysts, then here's the risk of malignancy index. Um, it includes your C A 125 tumor marker, um, ultrasound findings and menopausal status. Basically, this is a table of how I basically split them up into inve further investigations. So your premenopausal cysts that are below five centimeters. So you basically don't investigate them any further. If they're postmenopausal, their cyst is five centimeters, then they need to get a six monthly ultrasound scan and you need to complete a risk of malignancy index. Um, so you'd need to be doing your C A 125 premenopausal cysts that are 5 to 7 centimeters, then they get a year, yearly ultrasound scan. And then if they're premenopausal and the cyst is over seven centimeters, then you need to get um MRI and surgical expiration. If a woman is under 40 with complex ovarian mass, you basically complete all of these tumor markers um for your possible dermoid cyst um and postmenopausal cyst red flag referral. So all of them would be getting, this would be getting red flag feral if they, even if they're under five centimeters as well, cause they need biopsied. Um Your menorrhagia then is your happy periods. And the definition is really over 80 MS. But if somebody reports that their periods are heavy, then you basically listen to them and you, you are, you can't really decide if they're heavy or not. So you just listen to the person. Um and sometimes in histories and stuff you'll ask about how many tampons and pads they're using. Um And it just kind of gives you an idea of how heavy it is, but you never really know. So if they're reporting it as heavy, you basically class it as menorrhagia. Um a period that lasts over seven days if there's flooding or clots, um like large clots kind of the size of a 50 P coin would red like it would flag up Menorrhagia. Um Your causes of menorrhagia, then sometimes there can be no cause found your extremes of age again. So like if they're near menopause or just starting their periods, fibroids is um one of the most common causes of it and your P ID and copper coil. Um, endometriosis can also cause anticoagulation, bleeding disorders, endometrial hyperplasia or cancer. PCO S and endocrine disorders. Your investigations, then you need to do pregnancy test, the bimanual speculum exam. Uh just to find out like if they've got any fibroid or if they've got a fullness in the uterus that might be caused by fibroids or tumor like endometrial hyperplasia or a cancer in there. Your swabs for P ID and which will be covered in the sexual tra sexually transmitted infections lecture. Um You need to do an FBC to see if they're anemic. Um And if they've got low platelets or like a bleeding disorder, so do a co a screen do at TSH for your thyroid transvaal ultrasound scan. Um Basically, your endometrial lining should be below four millimeters if they're postmenopausal, sorry, I should have put that in there. Um I'm not sure what it is like, it obviously, it changes if you're premenopausal throughout the month. So if you're postmenopausal, it's um like a red flag if it's over four millimeters and they'll have to get a biopsy, um then management. So it's split into if the woman wants contraception or not. So we go with no first. So basically, if the woman says she, she's trying to get pregnant or doesn't want contraception, then um your options are transam acid. It's an antifibrinolytic, but it doesn't provide any pain relief. It just stops like helps the bleeding. Basically. Um You can give NSAIDS or mefenamic acid. So they basically say that mefenamic acid and nsaids work the same way. So they are antifibrinolytic as well and they pro then they give you pain relief. Um So then if the woman does want contraception, then your first option would be your I I've put an IUD there. It's going to be I US. So your Mi Mirena coil, um your combined pill or progesterone. So this is your eye, your Mirena coil would be first line, your combined pill would be second line and then your progesterone injection or pill or implant would be third line there. Um And then if those things don't work, then you need to start thinking about endometrial ablation. So it's balloon thermal ablation where they just basically burn the lining of the wound. And the last resort is a hysterectomy. Your fibroids then are benign tumors of the uterus. Um smooth muscle, more common in Africa Carribean women. Um like very common in them and they grow in response to estrogen. So they can, they usually grow during pregnancy more and then they get smaller after menopause. Um The submucosal is the most common type. Um I think when I was on gyne placement, they asked me basically all the different types of fibroids, um symptoms and your me menorrhagia, lower abdominal pain, bloating, urinary and bowel symptoms, subfertility and deep par. I can't pronounce that, but it's basically pain on sex. And then your diagnosis would be your transvaginal ultrasound scan and your management. So, if they're symptomatic, you manage to see him as the menorrhagia on the previous page. And um, you treat the treatment to shrink or remove the fibroids, then you can give the GNRH agonists um surgery myomectomy, which isn't performed in the UK. And you find some people go um to like turkey or elsewhere to get that done. Um And then your hysterectomy or uterine artery embolization, which is basically where they cut off the blood supply to the uterus. Red degeneration is a complication then and it's ischemia infarction, necrosis of the fibroid during the second or third trimester of pregnancy. The fibroid basically outgrows the blood supply and the vessels can become kinked. Um They get severe abdominal pain, they get fever tachy and sometimes vomiting. Um And there's nothing really you can do for them. Only supportive management like your fluids, analgesia. Um dysmenorrhea then is um painful periods and your primary one is basically where you can't find anything pathological. So there's no underlying pelvic pathology and sometimes it comes in the one or two years after they start their periods and it's caused by excessive endometrial pro prostaglandin production. Um The pain starts just before or within a few hours of the period, starting super pubic cramps and they can go to the back or down their legs and then the management would be just uh like nsaids or your, you could control the periods by taking your combined pill. Um secondary dysmenorrhea then is when there is pathology there and it like develops many years after menarche. Your most common one would probably be your endometriosis, your um adenomyosis pelvic inflammatory disease, um fibroids. And I think that there is meant to be copper coil. So that's meant to be IUD um your symptoms then would be, your pain usually starts three or four days before the onset of the period. So when it's primary, it usually starts with the period, but with the secondary one, it starts before and you just refer to gynecology because there's not much you can do in primary practice, you can still give them like your nsaids and stuff. Um in primary practice, although, but for endometriosis, um it's basically where there's ectopic endometrial tissue. So there's basically we tiny bits of endometrial tissue that are implanted elsewhere. They're not in the uterus. So they could be in the abdomen. Um in the cervix, it could be like in, I heard of someone having some in their lungs one time. Um And the symptoms include like cy cyclical pelvic pain or like cyclical pain anywhere. So, pain that comes on with their period because basically the hormones stimulate all of the endometrial tissue to break down. So it starts to bleed. Um So they might get blood in their urine or stools during menstruation if the, if it is within their pelvic area or like within their bowel or something and it causes subfertility. Um, and the pain then becomes noncyclical cause there's adhesions that form basically within where the ectopic endometrial tissue is endometriomas in the ovaries are chocolate cysts. That's a question that comes up. Um, quite often and then your investigations and diagnosis, pelvic ultrasound, laparoscopic surgery. There's a huge waiting list in Northern Ireland at the minute, um, for endometriosis. But your laparoscopic surgery is kind of like your goal line. Um, to find out cause it's quite hard to diagnose your management. Then would be your nsaids for pain. Your hormonal management can be um your combined pill, progesterone only pill that's meant to be Mirena coil. Um, your GNR H agonists, the GNR H agonists um induce like a pseudomenopause. Um, so they could like cause the negative feedback cycle to increase and then it just disrupts it all, I think and causes a pseudomenopause. Um And then surgery would be your laparoscopic surgery or like a hysterectomy with taking out your ovaries. Um, adenomyosis then is endometrial tissue within the myometrium. It causes painful periods, menorrhagia, and painful sex, subfertility. Uh Your diagnosis then would be transvaginal ultrasound scan and you treat the same as menorrhagia. And you can also give endometrial ablation, hysterectomy, uterine artery embolization and um GNRH agonists as well. So this is just a question if you just wanna um, put your answer into the chart. So a 24 year old patient presents to GP with 12 months of pelvic pain. The pain is at its worst before and during her period, during her last two periods, she reports blood in her urine and dysuria. She denies any heavy bleeding. A recent swab for chlamydia and gonorrhea was negative which of the following is most likely diagnosis. Yeah. So it's the, it's endometriosis. Um just cause of the like cyclical pelvic pain um and then negative swabs. So, menopause is the ceasing of menstruation. Um It's a retrospective diagnosis was made after basically, you've had no periods for 12 months if you're over 50 or 24 months, if you, if you're under 50 the ovaries basically stop producing eggs and therefore stop producing estrogen. So your LH and FS H go way up because of the negative feedback cycle disruption. And um the ratio of LH and FS H will go down, which basically means that your FS H is higher in terms of compared to your LH. So really high FS H um and then decreased estrogen, progesterone, premature ovarian insufficiency is when menopause is, you've basically got menopause before you're 40 then postmenopausal increased risk of cardiovascular disease, osteoporosis, prolapse and urinary incontinence. Um Your symptoms of menopause then would be your hot flushes, mood changes, irregular periods, joint pain, vaginal dryness and atrophy and reduced libido. Um Your management of menopause then can be broken up into non hormonal and hormonal we had counseling for H RT this year and final oy. Um and one of the things you had to do is basically discuss the alternatives to H RT as well. So it was basically all the hormonal like lifestyle advice, um, exercise, reduce caffeine balanced diet, reduce alcohol, stop smoking. CBT and SSRI s especially if they're having problems with mood. Then the fact seem, seems to be like the one that's most used for this kind of thing. And then cloNIDine is an alpha agonist. Um It helps with the hot flushes and vasomotor symptoms and then vaginal moisturizers help if they're having problems with vaginal dryness, your hormonal treatments, then um so you can get creams, um patches tablets, you can use coils. Um your vaginal estrogen cream can help with the vaginal dryness. So that is hormonal testosterone um gel or cream to help with libido hormonal replacement therapy and your tibolone, which is a synthetic hormone tablet. I don't think it's used that much, but just to mention it, then hormone replacement therapy is um basically estrogen and progesterone. Um given to a woman who's just stopped periods because it replaces the lack of estrogen and progesterone then and helps with their symptoms. So, your contraindications would be uh undiagnosed, abnormal vaginal bleeding, endo atrial or breast cancer, uncontrolled hypertension or VT E um liver disease, recent angina and stroke. Um Also if they've had a family history of breast cancer or VT E this is also contraindicated. Um So your mode of delivery can be your patches, tablets, creams or coils the benefits. Um So you get relief of symptoms, you've a reduced risk of osteoporosis and ischemic heart disease. But if you take HRT um compared to people who don't and then risks, so there's no risk if you had premature menopause um cause you're basically replacing what usually would already be there, but it can cause increased risk of breast cancer, your VT E and stroke. Um but if you use the patch, there's no increased risk of VT E or stroke. Um and ovarian cancer is increased, the risk of ovarian cancer is increased if HRT is used for over five years, endometrial cancer um is a risk. If you don't give progesterone to people with the uterus, um side effects then are estrogen, breast tenderness, leg cramps, nausea, bloating, progesterone PMS symptoms um and bleeding if you have cyclic and HRT. So this is basically what I use to learn how to give HRT. So if they've got local symptoms, so say they've got vaginal dryness and you basically just give them estrogen cream like they don't need systematic. So systemic treatment, then you basically need to ask them, have they got a uterus? And if they don't, then they just need estrogen H RT. They don't need progesterone cause the, basically the role of progesterone in H RT is to stop endometrial hyperproliferation. So then if they have a uterus, you need to give them estro, you need to give them progesterone as well as estrogen. Um And so if they've got a uterus and then if they've got a period in the last 12 months, then you need, if they have, then they need cyclical combined HRT. And if they haven't, then they need um continuous combined HRT. And um you need to remember the H RT doesn't offer contraception. So you still need contraception for two years. If you're under 51 year, if you're over 50 there's something about I'll annotate the lecture um before I send it to you. But um there's, you need cyclical for two years. If you're under 51 year, if you're over 50 you still got periods. But I'll add that in. Um And then important point is just to avoid depo injection in over 45 year olds because of the risk of osteoporosis and then avoid the combined pill in over 50 years to do with endo endometrial, endometrial and ovarian cancer. That's meant to be I us as well. It's meant to be a Mirena. This is just another question. You just wanna put your answers into the chat again. So basically, this is a 53 year old woman who has irregular periods. It started a year ago, but she has had, hasn't had a period in six months. So if she's over 50 you need to have contraception for one year. So she would need it for another six months because then she would be amen. She would um be aiming for one year by the time six months up. So urinary incontinence are, this is like a very content heavy slide. Your stress incontinence, the weakness of the pelvic floor muscles and le and then urge incontinence would be your overactive. It's caused by your overactive detrusor muscle. Um and it causes symptoms of like suddenly the urge to go. Um and they tend to avoid places and activities where they can't go to the toilet. Um They usually lose control of their bladder before they reach the toilet. Um Mix is just a mix of um urge and stress and you usually do urodynamic studies. Your overflow incontinence then is um basically where they have chronic urinary retention and they just get overflow and they don't get an urge to pass urine and it can be caused by um your anticholinergic meds, fibroids, pelvic tumors and your symptoms are passing about the urge. Basically. So you do history and examination, abdominal examination by annual bladder diary for over three days is an important one. You need to do urine analysis and post void residue, bladder volume. Basically, see if they've got urinary retention. Urodynamic testing. Then um and then for stress incontinence, you would encourage weight loss if they're overweight, pelvic floor muscles is first line and you try them for over three months. I think it's usually like 88 times like three times a day or something. Um For your pelvic floor muscle exercises, then you try surgery which with your tension free vaginal tape. Um But if somebody's not suitable for surgery or refuses, then DULoxetine is a good um, second line and for urge incontinence, you need a, the bladder diary is quite important for it because sometimes people can, can be drinking a lot of caffeine, a lot of fluid alcohol which like irritates the bladder. Um You need to do bladder retraining for six weeks. You basically get them to hold their urine for longer. Um And see if that works. Um anticholinergic medications. These I get asked like the name of anticholinergic medications. So just learn a few um and just be careful because they can cause like blurred vision, dry mouth confusion, um constipation like quite a bad side effect um side effects with them. So, and then your third line is your Mirabegron beta three agonists. And then your invasive procedures with the mixed incontinence, you need to address the one that has the most significant impact. And then overflow incontinence is more, it's actually more common in men with your prostate problems. So just urodynamic um test and then just refer probably this is another question. It's quite difficult if you just wanna give it a go. So basically, Missus Rosie is a 53 year old woman in a frequency urgency, no turning and urinary incontinence. She is a yoga teacher embarrassed by leaking certain yoga postures. She is referred to her GP um who treated with bladder bladder training to provide pelvic floor exercises with little benefit. And this is her Urodynamic study. Um I'll just show you the answer cause I know it's quite difficult. Um Basically there's a cough and like then there's this shows you where the leak is but um it, I don't think it showed leak. Like I can't, I say it's leak visualized. There you go. Um Lake visualized like vis visualized. Um And it was visualized with the cough and then there was deer overactivity as well. Um It's quite difficult. So it basically is mixed incontinence, pelvic organ prolapse then is when the scent of the pelvic organs into the vagina, the type. So your rectoceles when your rectum comes through the vagina cystocele when the bladder comes through uterine, uh prolapse when the uterus comes through and then the vault is usually the remainder of what's left after a hysterectomy can come down as well. Symptoms of feeling of something coming down, heavy sensation can get urinary bladder symptoms, sexual dysfunction. Um, it's caused by weakness and emptiness. The ligaments and muscles around the uterus rectum and bladder. Um, the biggest risk factors are obesity and childbirth. Basically, sims, speculum is like au shaped speculum that doesn't cover like half of the side. So it allows you to see which part of like what type of prolapse. It is, and then your management can be conservative. So your weight loss physiotherapy for pelvic floor exercises, vagina, estrogen cream, reduced caling. You can use vaginal pessaries but they must be changed every four months. Um And then surgery, mesh repairs, recurrence of prolapse is quite common though. And those are your grades um of prolapse. I've never been asked them, but I suppose it's useful to know like they're not, they're not hard to learn because it's just like one centimeter above and open to the vagina um within one centimeter and then grade four is full descent of the organ mentioned cirrhosis then is a chronic inflammatory autoimmune condition um of the skin. It basically looks like this here. Um On the vulval area, it predisposes them to people to um squamous cell carcinoma. Um And the way you treat it is basically with topical potent topical steroids, emollients and you need to do a biopsy to rule out that it isn't already squamous cell carcinoma. Um It's associated with other autoimmune conditions. So your vi vitiligo type one, diabetes can cause itch pain, skin tightness, you will see like shiny portion and white patches is what they usually say. Um And then cervical ectropium basically looks like that's what it looks like on a speculum. Um So it's when the columb alium of the endocervix is extended out to the ecto ectocervix, which is usually stratified squamous epithelium and it happens at the transformation zone. Um So that basically the change between the colors is quite noticeable like um and it can cause like bleeding after intercourse, pain on intercourse, increased vaginal discharge. And then you see the visible transformation zone and speculum, it's associated with higher estrogen levels. So, like younger women um during pregnancy and if they're using the combined pill, um just gonna talk about gyne cancer now. So you're like vulval, cervical endometrial ovarian vulval cancer is usually squamous cell carcinoma. Risk factors are age HPV. Um Vulval, intraepithelial neoplasia, immunosuppression, lynch and cirrhosis. Um, and then your symptoms are like lymphopathy in the groin itch, irritation and ulcer on the labia and then investigations and management. You need to do a red flag two week, two week, wait, referral and you need a wide local excision for um, biopsy, sentinel load biopsy may, might do, um, CT abdel chemotherapy radiotherapy. Um Vulva epithelial neoplasia. Basically your ones, um, that cause low grade squamous are like six and 11 HPV, six and 11. Um, and they're not neoplastic, but then high grade ones are, and it's 1618 and 33 strains of HPV. Um, risk factor for vulva cancer is smoking. Um, yeah, cervical cancer then is quite common and comes up the guidelines for cervical cancer actually changed northern Ireland this year. So I have them in the next slide. Um, but 80% of your squamous cell carcinoma, your HPV type 1618 and 33 are the most common to cause cervical cancer. And then you usually get a HPV vaccine between 12 and 13. It can be a counseling station in terms of like now boys get it as well just to give like um herd immunity kind of thing. And your risk factors are smoking HIV, your combined pill for over five years. Um If you've had multiple um ch childbirths, uh your symptoms would be abnormal PV, bleeding or discharge pelvic pain, pain and intercourse detected on smear or basically as asymptomatic um smear tests are offered to all women in Northern Ireland between the ages of 25 and 64. So when you're 25 to 50 I would say 5025 to 53 yearly and then 50 to 64 as your five yearly. Um But it can't be offered to over 64. I'm not really sure why that is um even if they request it. So your special situations then are cervical screening in pregnancy, which is usually delayed. So you don't, you don't do a smear on somebody who's just had a baby until three months after and then HIV positive people get um uh smear yearly just because there's such high risk with it. And then if, if you basically do go to do a smear and you insert the speculum, you see an abnormality, you see a growth or like um some abnormality, you basically don't take the smear, you just send them straight for a colposcopy. Um These are the guidelines. I find this here. I have basically wrote out like explaining how to interpret this graph kind of thing. So it changed this year from the fact that they do PCR for HPV before the test to see if there's abnormal cells because they've basically figured out that if there's no HPV, then there's no abnormal cells and it makes it a lot quicker um in terms of testing. So if they find out that there is no HPV, they'll just refer to like routine screening again. They don't even see if there's any abnormal cells because most likely not. But if there is, they need to go to cytology, um which is basically a camera test for the cervix. And then if there's uh they take a biopsy of it usually, and then if there's no abnormal cells, then they're invited back to cervical screening within eight, like in one year. Um And then after three negative results, but if they're still HPV positive, then they need to be referred for Colposcopy again, basically. Um And then this is cytology, sorry, this is testing for abnormal cells. So if there is abnormal cells, they go to Colposcopy, but then if they're HPV positive with no abnormal cells, they need to go screen one year and then basically three with no abnormal cells, but HPV positive, they send colposcopy anyway, I've wrote it all out here just to make sense of it. Um So you could read that in your own time. Uh Endometrial cancer, then basically 80% are adenocarcinoma, estrogen independent. And because estrogen causes hyper proliferation of the endometrio. And then your protective factors are your combined pill Mirena coil if they've had multiple pregnancies, because they've basically not been exposed to estrogen. Estrogen for as long smoking is a protective factor for endometrial cancer. Your symptoms are postmenopausal bleeding is a big one or if they've got bleeding in the intramenstrual bleeding. Um post cortical bleeding, which is after sex and then heavy menstrual bleeding, abnormal discharge or hematuria, which with blood in the urine, um risk factors, increased age, increased ovulations. So they've had an early menopause. Um that's meant to be late menopause, I think in early men uh no parity exposed to unopposed estrogen. So your obesity, PCO S tamoxifen uh type two diabetes. And then this is um hereditary non poly but something it's Lynch Syndrome uh can cause bowel cancer as well. Um Referral criteria. So, if somebody has postmenopausal bleeding, they basically go to a postmenopausal bleeding clinic and it's a red flag one. And if they have unexplained vaginal discharge over the age of 55 they need to go for a transvaginal ultrasound scan. And um this is quite rare kind of criteria, visible hematuria, raised platelets, anemia, elevated glucose, over 55 transvaginal ultrasound scan. I don't think you would be like need to know that. But um then basically, when they go for the postmenopausal bleeding clinic or they've got a transital ultrasound scan, they can do a papilla biopsy and this is where um the endometrial lining is over four millimeters. They need to get a biopsy. Um And then they're sent for outpatient hystero hysteroscopy as well, which is camera test into the room. And management would be your radical hysterectomy and bilateral sling ectomy is basically, they take out their ovaries as well. Radiotherapy chemotherapy or progesterone, which would be your palliative. So it just prevents it from going further aromatase is an enzyme that's found in fat tissue that converts androgen to estrogen. Um So after menopause, the action of aromatase in fat tissue is the primary source of estrogen. Um And yeah, ovarian cancer then um is a really like usually when people are diagnosed with ovarian cancer, they are nearly always palliative because it's such a late diagnosis and late presentation. Um and 90% are epithelial. Um The distal end of the fallopian tube is the most common place for it to happen. And they usually metastasize to paraaortic lymph nodes. Queens love asking that question. So it's part that basically like it's like what lymph nodes does? Ovarian cancer spread to its paraortic and then serous cyst adenoma is the most common subtype. Um uroprotective factors combined, pill breastfeeding pregnancy, fewer ovulations. Basically, um risk factors, greater ovulations, cloNIDine remember is the one in PCO S or in like it's a type of treatment for IBF as well that causes like ovulation. Um Usually people are diagnosed around the age of 60. They might have BRCA genes. Um, smoking is a risk factor for ovarian, but a protective factor for endometrial. So just don't get mixed up on those. Um, and then your symptoms. So people early, like, basically they have loss of appetite, bloating, pelvic pain, urine frequency. Um, they always put in the blo one in a question. So just look out for it. Um Surgery, chemotherapy palliative. Basically, most of them when they're um diagnosed and then the risk of malignancy index is here is the ovarian cysts. Basically, there's another question. So basically, a 60 year old woman presents to a general practitioner with four month history of vaginal bleeding. She says this occurs weekly and it's been getting heavier over the last few weeks. She reports some lower abdominal discomfort started her periods nine enriched menopause 47. She has four healthy Children. Her weight is stable and her BMI is 19.5. She smokes 15 a day. A diagnosis of endometrial cancer is suspected. Which of the following is a risk factor for endometrial cancer. It's MD so early men. So she started her periods at age nine. So, um uh she's been exposed to basically more estrogen, which is a risk factor for your endometrial cancer. Then a 31 year old woman attends the GP with post cortical bleeding uh for three months. She also reports some pink discharge. Her last mere test was six months ago. She has been needle phobic since childhood and that swab is negative for chlamydia and gonorrhea. On cervical examination. The cervix is inflamed and bleeding, which of the following is the most appropriate next investigation. So it's a day cause basically when you see something on the cervix, you don't, you don't do a smear or anything, you just refer straight for colonoscopy, contraception, then um your combined oral contraceptive pills. So I know these slides are a bit um content heavy, but like it includes everything in it. So you can learn your counseling off this as well. Um Your contraindications, your biggest ones to remember are if they're smoking over 15 cigarettes a day and they're over 35. Um your migraine with aura and if they have a history of VT E or a family history of VT E and if they have a history of breast cancer or family history of breast cancer, those are the ones to remember. So your smoking um age smoking, VT and breast cancer, um your mode of action, then it stops ovulation, thickens Cervi cervical mucus, thins, endometrium um advantages. It's a tablet. You don't need an invasive procedure, perhaps heavy, heavy periods, reduces premenstrual syndrome symptoms and can control the timing of periods. It's 99% effective if taken correctly and reduces the risk of colon cancer and ovarian and uterine. But the disadvantage is then it can cause mood changes, increased VT E risk M I stroke and nausea, breast tenderness, no protection from S TI S user dependence. So if they miss a pill and there's a risk of like the effectiveness of it goes down. Um starting the pill, then if you start between day 1 to 5, you're protected immediately. But after this, you need to use condoms for seven days after starting. Um, and then how do you take at the same time every day? It's, there's pills for 21 days and then there might be a break for seven days or there might be dummy pills for seven days, um, during which you have a bleed. Um, but you can run the packs back to back if you wanna like control the time of your periods. If they miss one pill, you take the missed pills straight away, continue taking the pack as normal and emergency contraception is not required. It's if they miss two pills or more. So if they miss two or more, you take the most recent pill, you miss straight away and then you get emergency contraception if they've had unprotective sex in day 1 to 7 of the cycle, um, or you miss the pill free period. If day 15 to 24 of the cycle, you basically miss the pill free period and just run the packs back to back. Um, in between day seven and 15, there's no emergency contraception needed if they have had the full first week um off the course, the progesterone only pill, then your contraindications or your family, his or I don't think family history, maybe just personal history of breast cancer, your liver disease, undiagnosed bleeding and your peripheral arterial disease mode of action. Then thickener, it's basically the same as your combined your advantages, then it's noninvasive as well safe during breastfeeding. Whereas ERN is not for six weeks after you've given birth. Um and the problems with periods usually improve because most people don't get a period. Um on progesterone, start on the pill and you can start any day between day one and five and you're protected immediately. But after this, um you need to use condoms for two days and you take at the same time every day, no pill, free days and no blood basically. But some people can get um irregular periods. Some people can get heavier periods and some people can get lighter ones. So it just depends on people. Um you can get mood changes, especially with progesterone and it doesn't offer s ti protection and it user dependent risk of breast cancer, ovarian cysts is higher and progesterone. So missed pills. Then you take the most recent pills straight away even with the next dose. If over three hours late for just for a traditional progesterone only pill or if over 12 hours late for desogestrel, use condoms for two days and consider emergency contraception if had unprotected sex in the 2 to 3 days before the missed pill, um or since the missed pill. So the progesterone only one is very um depends like on time and, and like even if you miss one pill, you basically like need to consider have an emergency contraception. A ba based on these writers progesterone implant, an injection, your progesterone implant is your me meropleon, I think. And it does all the same things as the pills. It's effective for three years. Contraindications, breast cancer, liver problems advantages, long term um safe in breastfeeding, less heavy and less painful periods, reversed, easily disadvantages. Um You need to get a procedure to basically put it in. Um and you can damage local structures, breast cancer, increased risk. No S ti pro protection, progesterone side effects like your mood changes and all that as well. Um Progesterone injection then works the same way as well. Contraindications, breast cancer, liver disease, osteoporosis. Um You need to remember from the injection. It's long-acting can be used in breastfeeding, but it's the only um contraception to be proven to cause weight gain and it can cause osteoporosis and fertility problems. So, fertility only really um returns after a year of stopping and it's contraindicated in women over 45. I think your colitis then. Um Yeah. So I've got the ones mixed up and started the electro I um edit them. So your I US intrauterine system is your Mirena um we replace it every five years. Your contraindications are pelvic cancer, P ID, pelvic inflammatory disease or distortion. So, abnormal like anatomy, uh you can get lighter periods, easily reversible, safe in breastfeeding. No evidence of increased cancer can cause irregular region. Although um you can get an infection from when it goes in. So you need smears before they put it in. Basically, it can cause damage to the womb expulsion, ectopic pregnancy if fall pregnant IUD is your intrauterine device and it's your copper coil, it basically prevents sperms from surviving. It's like and then changes the cervical mucus consistency. You replace it every 5 to 10 years. Um Your only really contraindication is your Wilson's disease and then your P ID as well. Um Immediate contraception, easily reversed, safe in breastfeeding. It's the only one that contains no hormones and it can cause heavier, heavier bleeding, more painful periods. It doesn't provide s ei protection um damage to the room. Yeah. Then co I've included this slide just for tips on contraception, older women. Um I think I've explained all of that before just in terms of like you're not allowed to use injection over 45. Um The combined pill not to be used over 50 you can, so you can have a read over that in your own time. Emergency contraception then is another one that can come up on oscopies as well. Your first line is always your copper coil, but you need to ask them if they're open to invasive procedure. Um It can be started within five days of unprotected sex or within five days of the estimated day of ovulation. So your estimated day of ovulation is always um the shortest cycle that they've have. Basically. Um So if their periods usually like 35 that they've had a period that was like 28 you need to go based on 28. Um And it's the most effective second line is your L1 then and it can be given for up to five days of unprotected sexual intercourse, unlikely to be affected after ovulation has occurred. So you need to um take a menstrual history when you're asking them about me emergency contraception to basically work out their ovulation date. Um And you wait five days before starting the pill after it breastfeeding, avoid it for one week after and avoiding patients with severe asthma. And if they're under 18 levonogestrel, then it can be used for three within three days, one after sex. And it's unlikely to be effective after ovulation as well. It can be started. The pills can be started immediately after taking this one. So you need to ask what their long term plans for taking contraception and it's, the dosage is based on weight and BMI I um it, it can be used during breastfeeding, but just avoid it for eight hours after taking. This is another question. Then a 37 year old woman presents her GP, she would like to start taking the combined oral contraceptive pill. Past medical history of controlled hypertension, previous gallstones, migraines and anxiety. BM I of 39 smokes 30 a day and drinks one bottle of wine a week. Which part of her history is an absolute contraindication combined or contraceptive. It's a, there, she smokes 30 a day and she's over the age of 35. So it's, the contraindication is over 15 cigarettes a day and over 35 22 year old lady attends sexual health clinic requests an emergency contraception after unprotected sexual intercourse. Four days ago, first day of her last menstrual period was 14 days ago. She has a regular 28 day cycle. She has a past medical history of seasonal rhinitis. Her medications include cetirizine as needed. She has no other unprotected sexual intercourse on day two. She has had one other episode of unprotected sex on day two of this cy cycle. She is not keen on invasive procedure, which is the volume is the most appropriate option. It's your L1 because it's the one that can be used for five days um after the sexual intercourse and usually it's a car recoil but she's not open on an invasive procedure. So then you go second line early pregnancy and this is kind of the last part of the lecture. Sorry, it's quite, it's run over. Um So I'm gonna discuss epic ectopic miscarriage hyperemesis gravidarum and molar pregnancy, ectopic pregnancy. Um, it's typically presents around 6 to 8 weeks, gestation. They have had a missed period, basically positive pregnancy. That lower abdominal pain, usually in either iliac fossa, they'll have vagina, bleeding, cervical motion, tenderness, um, during bimanual space to remove the cervix side to side, um, during the bimanual, um, your investigations, then you need to do a DH CG blood test and the way they determine. So if they do an ultrasound scan and they can't actually see it in the uterus and they start looking for it elsewhere. But if they can't see it in the fallopian tubes, then, then they need to basically perform this here where they watch or rise in the BD HCG of over 60% 63% in 48 hours. It confirms an intrauterine pregnancy that might just be like small, too small to see an ultrasound or something. And if the rise is less than 63% in 48 hours, it's an ectopic. Um, and if there's a fall of more than 50% it's a miscarriage. I think your transvaginal ultrasound scan can sometimes show like blob bagel tubal ring sign, um, and an empty uterus. I can't really get this to go away. Um, basically you just need a pregnancy test, three weeks, post procedure. And I think you need to give anti D if you're doing, um, surgical procedure or if they've had per vaginal bleeding and their um risk is negative. So expecting management then would be if it's under 35 millimeters and the HH CG is under 1500. Um, you just basically wait for them to pass it. Um But if that, then medical is with me, one dose of methotrexate and a follow up must be available. It must be unruptured below 35 millimeters and H CG below um 5000 must have no heartbeat, no pain. Um Then your surgical is basically indicated when they have pain. It's over 35 centimeters or a heartbeat. It's over H UD is over 5000. Basically just learn them because they, it's quite a common question as well. Um, the most common site is your ampla of the fallopian tube and surgery, laparoscopic sap sac sapling toy is your first line where they just basically remove the fallopian tube with the, um, ectopic within it. And then second line is a sapling oy. If so, they basically take the ectopic out and repair the tube again. If there's increased risk of infertility, your miscarriage, then, um, your types of miscarriage miss threatened, inevitable, complete and incomplete and an embryonic. Uh, your early miscarriage is below 12 weeks, late, is 12 to 24. And if they have PV bleeding and they're over 24 weeks and this is classed as an anti partum hemorrhage and death of the fetus is classed as stillbirth over 24 weeks. Um, your crown rump length, sh seven millimeters, a heartbeat should be seen. A gestational sac down under 25 millimeters feet and pole should be seen. I don't think you really need to know them. I think it's more midwifery things. Those, um, management then is expectant for if they're, if they're under six weeks and usually it's first line if they're over six weeks. But if they've pee and then they need to go to early pregnancy assessment unit. Um Mesoprosopic Prost analog which basically softens the cervix um and allows passage of the um f material, manual vacuuming, uh aspiration. You get them local anesthetic and they must be below 10 weeks for this. And then electric vacuum aspiration is under general anesthesia. It's usually if they're over 10 weeks or they got pain and stuff, um incomplete miscarriage, then medical management measle cross all again and CBCC soften cervix cause contractions. Surgical management, um anti prophylaxis for is negative and pregnancy a at three weeks, postprocedure as go, I'm not sure what that is an nonembryonic gestational sac but no embryo hyperemesis. Gravidarum is basically severe nausea and vomiting in pregnancy with 5% weight loss, dehydration and electrolyte imbalance. I think you have to have those things to get a diagnosis. Hyperemesis gravidarum. Otherwise, it's just nausea and vomiting, nausea and vomiting in the first trimester is worse at 8 to 12 weeks and it's the BD HED that causes the nausea and the risk factors are like first fat molar multiple. Um then your you need for investigation, you need to do bloods observations, hydration assessment, weigh the patient urinalysis and pu QE score is how you basically assess it. Um management of mild can be with oral antiemetics at home admission. Considered when they have the 5% weight loss ketones in the urine. Two plus other medical conditions need treatment and they're unable to tolerate the oral antiemetics so they can't keep anything down. So then if it's moderate to severe, they need admission with I VI M Antiemetics IV, fluids, trop, prophylaxis and thiamine supplementation. Your molar pregnancy then is um a type of tumor that looks like a pregnancy inside the uterus. But um it kind of has it, they call it a snowstorm, snowstorm appearance. Um and it's basically where two sparing, fertilize one egg that contains no genetic genetic material. Um It, that's complete mole. But then if it's a partial m mole, two sperms fertilize a normal egg and then uh basically has like three sets of chromosomes. Um it can cause your severe nausea and vomiting because there's a high H CG increased size of the uterus for dates. PV, bleeding, thyro coccic sosis because HED can mimic TSH basically um snowstorms here appearance on ultrasound suction, evacuation of uterus and stent for histology. 24 year old woman attends A&E with some nons severe lower abdominal pain that radiates to her shoulder tip. She says that this began two hours ago and has been associated with some brown watery vaginal discharge. The transvaginal ultrasound scan identifies an ectopic pregnancy in the left fallopian tube but no heartbeat seen in the embryo B HCG is 7500. She has no significant past medical history has never had an ectopic pregnancy before. What is the most appropriate management? I'll just, um, quickly go through these. It's B so that's the first line management. Just remember if you're getting somebody um methotrexate, you're not allowed to get pregnant on it for six months after cause it's TriC these are just some key facts that I think are really important for gynae um exams. Um I'll go through them all cause you should be getting this lecture anyway, sent to you hopefully soon and then if you wouldn't mind, like just find filling out this evaluation form, um That'll be really great. You can scan the QR code or I have put the link in the chat but I'll put in. Um and then I just have some off the advice on here. Uh Just your four PS for G history and your examinations, your speculum by manual smears and swabs and I just went through them while there. So like just for revision purposes and then possible counseling stations. That's it. If you have any questions or anything, you can send me an email or drop it into the chart if you want