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Summary

This on-demand teaching session will cover gynie oncology and will be relevant to medical professionals. It is based on the Georges curriculum and will include history taking, an overview of different types of gynie cancers, symptom review, history of presenting complaints, gynie history, social history, and risk factors for cervical cancer. The session will be interactive with polls and questions, and will help participants to better understand gynecologic oncology and to be able to assess their patient's risk factors.
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Description

This course will cover the basics of history taking in obstetrics and gynaecology. Suitable for all clinical, pre-clinical years and health care professionals. There are 7 lectures available to watch and follow along with the slides. These lectures are delivered by foundation-year doctors and final-year medical students.

Please note that this is not a part of the St George's University of London curriculum, we are a group of medical students in St George's Student Union Obs & Gynae society hoping to provide students with useful materials for revision.

The lectures are as follows:

  1. An overview of Obstetrics and Gynaecology history taking (Dr Madeline Witcomb)
  2. How to tackle an antenatal history and exam (Sukanya Thavanesan)
  3. Gynaecology oncology history taking (Dr Misban Sheikh)
  4. History taking on pregnancy complications (Dr Madeline Witcomb)
  5. How to approach infertility awareness and fertility treatments (Dr Oriek casanovasortega)
  6. Menstruation and Menstruation disorders (Dr Misbah Sheikh)
  7. Obstetrics and Gynaecology investigations and analysis (Dr Madeline Witcomb)

Please email us with any queries. We hope you will find this helpful.

sgulobsgynae@gmail.com

Learning objectives

Learning Objectives: 1. Understand the importance of taking a complete medical history of a patient with gynecological issues, including present complaint, menstrual history, sexual history, and past medical history. 2. Identify high-risk factors for gynecological cancers, including HPV infection, smoking, age of menstruation and menopause, high number of sexual partners, and low socioeconomic status. 3. Recognize potential signs and symptoms of gynecological cancers, including pelvic pain, vaginal bleeding, post-menopausal bleeding, and abnormal vaginal discharge. 4. Describe the relationship between HIV and gynecological cancer, including an increased risk of false positives and a need for annual screenings. 5. Differentiate between common gynecological cancers such as ovarian, endometrial, and cervical cancers, as well as the rare fallopian tube cancer.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

quality. Um, but, yes, I'm an f two. I'm currently in A and e in, like, the East Midland. And I'm a Georgia's graduate, actually. So I was, um it's nice to be able to, like, give lectures to you guys basically, So I'm going to be doing a session on gynie oncology. Um, and this is kind of based on the Georges curriculum. So let's see. So, yes, Um, just a little bit about what? We're going to be going over. So we're gonna start with some history taking, so this is gonna be your guinea history. But then I'll point out the specific oncology questions that you do need to ask, Um, as you go along, and then we're gonna be going over the different types of gynie cancers as well. So that includes full vial cancer, which is quite rare, but you need to show a little bit about it. Endometrial cancer, ovarian cancer, cervical cancer and HPV screening as well. We'll just move on to the history then. This is only an hour session. So, um, yeah, we'll try to I've tried to make it interactive with some polls and things. Um, so, yeah, we'll have some questions as we go through. So, yes, with the history you start off as you would any history. Really? So that's introducing yourself to the patient, gathering what the presenting complaint is and doing the history of presenting complaint. Um, so the history of presenting complaint is going to be either Socrates, if it's pain or you're adapt to Socrates if it's something else. Um, so say, um with the common presenting complaint with in terms of a gynie point of view, I've listed some of them below here, but they might be things like pain bleeding, abnormal per vaginal bleeding changes in, um, they're vaginal discharge. Um, discomfort, rashes, Um, those kind of things. Um, yes. So your presenting complaint will be one of those things. Um, and then you go through your history of presenting complaint. So, uh, um, the one thing I just want to point out with this he with gynie histories. Um uh, in terms of the time, um, you want to also ask whether it's cyclical. So whether it's related to their menses, um, that can be at any point of their cycle or any. But if they've noticed that there's any correlation there. Um, and whether yeah, the symptoms are intermittent or if their continuous, um And in terms of your systems review and slash red flags that you want to rule out, obviously fevers, night sweats, weight loss they're always some key questions to ask if you want to exclude any malignancy. Um, but there are also some gynie cancers. So especially ovarian cancer that can present quite a typically and a bit, um, with just very general symptoms of, uh, bloating, abdominal distension. Um, maybe some abdo pain, maybe diarrhea as well, So it doesn't necessarily present with those typical gynie symptoms. But yeah, the main things I've just written here are the fevers, night sweats, weight loss, any increased fatigue, any of the altered bowel habit. Um, so anybody I think over the age of 60 with altered bowel habit, you need to be suspicious of ovarian cancer. There any changes to their per vaginal bleeding or any new PB bleeding? And whether that's inter menstrual, whether that's postcoital or or uh uh, postmenopausal as well Any vaginal discomfort or rashes? Um, any changes to their discharge, Um, and whether any abdo pain or pelvic pain as well and just any urinary symptoms. And you can always summarize back to the patient once you've said those once you've asked those questions too, and then the actual gynie part of the history. Um, so I don't know what you guys were taught, but, um, I was taught this and it's just always stuck in my head. It's Oh, my gosh. Sex. And it basically covers everything that's in the gynie obs and gynie history, actually, um, so in terms of, if you are focusing more on the gynie side, um, in terms of obstetrics, you just want to know their gravity, and they're parity. So, um so, yeah, how many times have they been pregnant? How many times have they given birth? Any miscarriages or ectopic pregnancies in the past? And just an overview of each of those pregnancies as well. Any complications before, during after kind of thing. Um, and then you want to move on to your menstrual history. So, um, with menstrual history, you want to, so you will go through this as as we go through the lecture. Well, you'll see this, but sometimes some types of cancer are, uh, more likely in, like early menarche. and late menopause. Things like that. So you want to know the age that they started their period? Um, and you also want to know when they have their last period. How regular are they? How many days do they bleed during a cycle? Um, how's their flow? Um, do they consider it heavy or light? Any changes there? Pain again? Any changes and how, like, do they cope? Do they feel like the pain's too much or not? Too bad and yet eight. Or they hit menopause and ask whether they've had any bleeding post menopausal. They, um uh, whether they have any inter menstrual bleeding so bleeding in between the periods or any postcoital bleeding. So that's bleeding after sex. So then you want to move on to the gynie history And, um, you want to ask about any previous gynecological diseases, um, that they already suffer with and also any cervical smears and whether, like they know the results of them as well and whether they needed any further investigation afterwards. Um, in terms of sexual history, you want to ask about any previous S t. I s any HIV as well. If they've had that too um, and use of any contraception or h r t. Um, yeah, basically. And in terms of including in the S T. I s you can always include, um uh, the cervical Smith's can go a little bit in that. We'll see if they had previous HPV infection, Okay. And, um, just the last part of the history. So that's you finished? Um, kind of the gynie. Section there. Um, you want to ask about their past medical history? So specifically, um, if you are thinking about cancers, ask about any specific types of cancer that they might have had in the past. Any surgeries in the past Do they suffer with any conditions? Um, then you want to ask about their medications and allergies and obviously always with allergies as well. Just highlight what happens. What kind of reaction do they get with the medication that they are allergic to? Because sometimes it's an intolerance more than an allergy itself and then family history. So you want to ask about the any gynecological diseases that have been in the family and also when they happened. So how old were the family members? When when they had those diseases? When they started and also any cancers. So that includes, um I didn't specifically only list gynie cancers here because, um, there are conditions such as lint syndrome and things like that where colorectal cancer is linked with endometrial cancer and also, uh, ovarian cancer and things like that that can be linked with the braca kind of cancer. So, um, so just ask about any previous cancers in the family. And, um, there are some associations that will go through as well. Um, in terms of social history, um, smoking, alcohol, recreational drugs. Um, smoking is linked to quite a few different types of cancer. Um, and we'll go through them as well, which ones that they are the case for. So you always mentioned always ask those things just so that you can assess someone's risk factors for different types of cancer, occupation and just carers and whether they need any carers and what their home situation is like just in that social history. And, yeah, so that's the That's a just a brief overview of gynie history is, um, and, uh, with a specific oncology slander as well. So yes, I'll start the questions now. Um, I don't know if we've got the pole, if we are able to get the poles up, but I'll just read this out. Um, so a 40 year old female presents to the G p with postcoital bleeding and pain during sexual intercourse. The patient noted that these changes started a few months ago, but she thought she thought that they would settle. She has noted that she's had multiple sexual partners, and she's a current smoker on the system. You notice that she's had an abnormal smear test three years ago, but she didn't attend the follow up colposcopy and biopsy. What kind of cancer is most likely? So I can see some response is actually. That's good. Yeah. So I think we've got 12. 13 responses now. How many people are here? Okay. Should we go? We've got 14 response to them. They're all the same. So none of you fell for my trap. So, um, yes. The answer is the The answer is D cervical cancer. Um, I put c i n um, uh which is actually not a type of cancer just to try and trick you guys. Yes. So, um, just an overview of cervical cancer, then apologies if this is a bit worthy, but so cervical cancer is so essentially a cancer of young people. Uh, 50% of the cases happen in under 45 year olds, uh, majority of them being in their twenties. 80% of the cases are squamous cell carcinoma, Um, and 20% or I don't know, carcinoma. It's just important to note here as well with cervical screening. It's, um it's very sensitive at picking up squamous cell carcinomas. Um uh, but not so it detects for HPV. But it's not as sensitive when it comes to the adenocarcinomas. Just the whole screening process. Um, in terms of risk factors for cervical cancer, um, HPV. So the human papilloma virus, especially strained 18 and 16. They're high risk for cervical cancer. Smokers are more likely to develop this as well and those of low socioeconomic status if they have an increased number of sexual partners and also those who are HIV positive. Um, I just wanted to make a note here that those who are HIV positive so usually you want to get screening every three years, Um, 33 years until you hit the age of 50 and then it's every five years. But for HIV positive patient's, you want them to have annual smear tests, and you also want to make sure that you do the HPV test at the time of the HIV diagnosis. Um, with these women, even if they have low grade C i n, which is cervical intraepithelial neoplasia. Essentially, all that means is that there's some changes there that we've noticed that the cervix, but it doesn't technically, cap. It doesn't. Is it technically a cancer? Um, but with those women who even have low grade C i n um, and the HIV positive, it tends to progress to higher grade of C i N or even cervical cancer. So that's why it's important for them to be followed, followed closely. So even women who have, um, good antiretroviral, um, good control of the HIV and they're on antiretrovirals. They're still at increased risk of false negatives and things like that. Um, in terms of cervical cancer, um, it is mainly picked up on the smear test, But some other symptoms that you can get are those abnormal bleeding. So post menopause or inter, inter, menstrual or postcoital or and also um if they've noticed any changes in their vaginal discharge or any pain during sexual intercourse as well. But lots of patient's who are HPV positive, um, are a symptomatic as well. So they might have these changes and not necessarily have any of the symptoms of cervical cancer. Um, in terms of screening, we obviously have the, uh, cervical, uh, the HPV screening test. Um, and if they are any signs of cervical cancer, you want to send them for an urgent assessment. So that's going to be a colposcopy, or we have a closer look at the cervix and also a biopsy in terms of management. So I just want to clarify this as well. See, I a. And essentially, as I said, it means cervical intraepithelial neoplasia. But essentially, it just means that there's some changes to the cells around the cervix. So there's some degree of dyskaryosis iss, and we essentially we just grade as we see. Really. So, um, if there's C i n one, um, you want to check for any signs of HPB? If the patient is negative, then they can go back to normal screening. Um, so every three years or five years Um, and if it's positive, then you want to send that patient for a colposcopy and a biopsy C i n two or three. Which just means that there's more dyskaryosis there. Um, we want to send the patient for a less procedure, which is essentially a, um, local excision of the trans, uh, of the transformation zone. Sorry. Yeah. So I had a bit of a I think it's a local loop excision of the transformation zone, which is just that area around the cervix that's more at risk of, um, of the cancer developing. So those women you want to do that? Let's procedure for which essentially is where you do your colposcopy and you have a look at the cervix, and then you take a biopsy. So a loop biopsy around the whole area and, um, with those women, So then you have a look there and see if there's any sign of cervical cancer. If there are any signs of cervical cancer, you're going to need to do further imaging and staging, um, and also surgery. Um, so the main surgery that is done is a hysterectomy with lymph node clearance, and then that obviously will get rid of the cancer entirely. Um, that obviously, um, uh, it will impact a woman's fertility as well. So the other options that you can get, um, in terms of surgery. But you should only consider these if the cancer has doesn't have any, um, local or metastatic spread, and it's very, very confined. So in women with Type I A one cervical cancer, which essentially means that it hasn't spread very far around that transformation zone, you can do a cone biopsy, which is similar to a let's procedure. But it's just a larger biopsy so that you can get so you can get some margins there, Um, and then that can help preserve a woman's fertility. And if there, even if it is a little bit more spread, you can do a removal of the cervix itself. So radical cervix, cervix self check to me where you remove the cervix, the a public vagina and supporting tissues. But that can also be helpful in women who want to preserve their fertility. Yes question, too. Um, we we've got a 25 year old female who calls the GP practice after getting a notification that she's do a smear test. The patient notes that she's in a long term. She has a long term female partner. She's never had any sexual intercourse with the mail. And she has no previous S t. I s the patient's not sure whether she requires a cervical smear on these grounds. Just to note, this patient should have I should have written this in here. She is sexually active, but just not with males. So does this patient require a cervical smith? So all the responses are correct at the moment. Okay, so we've got 13 responses. Um, and I think you guys know your stuff because everybody got it right. And so yeah, the answer is yes, she does. Um, so this is something that has been encountered. Um, so HPV the human papilloma virus, it can be transmitted through anal vaginal oral sex. It can even be transmitted through share ing of sex toys. So, um, with this patient here, she does require a cervical smear because she's still at risk of getting this, um, this infection. So, in terms of screening, it starts at age 25. When you're 25 to 49 it's every three years and then after 50. It's every five years for patient's are over 65 you don't routinely screen, but you would. You would give them a screening every five years or so if they've had any previous abnormal cytology or if they haven't had any screening in a really long time. Um, in terms of, um uh, people who have never had any sexual intercourse. Um, because HPV is a sexually transmitted infection, Um, they are low risk, so if they choose, they can choose to opt out and things like that. Um, transgender men who still have a cervix do need to be screened unless again they choose to opt out. And, um, pregnant women if they've had previous smear tests, Uh, and they've been, uh, normal. Or if this is their first smear test, that there do we normally want to wait about three months post partum to have the smear test. If they've had any abnormal smears in the past, it's best to consult with the specialist at that point. But, um, you'd normally be able to do the smear test unless there's any contraindications there. Um, and in terms of the vaccine, So it used to be only for girls aged 12 to 13. But now it's four girls and boys age 12 13 and a colposcopy, which is where you visualize the cervix. You can do that. Um, if the patient's got cervical stenosis or if there's difficulty visualising it and things like that, I just got this from Pass Med. Um, good old pass med. And it basically I just wanted to put it here so that we can say so. It's what we were talking about with the C i N. Um, essentially, it's just a way of I guess, uh, grading it. Really. Um, based on how much change you can see in those cells that surround the subjects Uh, next question, um, a 65 year old female presents to the G p with post menopausal bleeding. This patient notes that this started two months previously, and she bleeds every day. The patient has type two diabetes and Cinelli Paris. Her last bleed prior to this was age 55. What kind of cancer is most likely? Just give another minute or so for, um, people to make their responses. Okay, so we've got 15 responses, and I think that's okay. So um there's been a little bit of a mix here, which is interesting. Um, but, um, I let I want you to know that the answer here is See, So it's endometrial cancer, and, um, we'll go over endometrial cancer and why that is now. So, um, with this patient, the main reason is any patient with post menopausal bleeding is endometrial cancer until proven otherwise. Um, and she is 65 years old, her last menstrual bleed or her last. So essentially, what I meant by this question what I meant by this line here was she reached menopause at quite a late age, which is again, another risk factor. Vendor, mutual cancer. But essentially, she hasn't had a bleed in 10 years. So this is definitely post menopausal bleeding. So, yes, it'll be endometrial cancer in this case. Yes. So she does have some risk factors. So, as I said, she hit menopause at quite late age. She's got type two diabetes, and she's newly Paris. So the reason why, um uh, late menopause and Nelly parity. Our risk factors are because they during those times when you're pregnant and things like that, um, you're obviously your estrogen levels and things like that change. So if she's never had any Children, then yeah makes them more at risk. And if she's late menopause as well, she's had She's had longer periods, Um, essentially with this unopposed estrogen. And so so again, she's more at risk than, um so yes, most cases are seen in post menopausal women, and about 25% are seen in premenopausal women. Some of those risk factors are having unopposed estrogen increased levels of unopposed estrogen. So that's starting a period at an early date. Um, late menopause, Nolly parity, obesity, PCOS and, um, tamoxifen as well. Um, which is used in breast cancer type to die diabetes, um, and then linked syndrome as well. So there's a link there between colorectal cancer and endometrial cancer risk factors. So we have seen there is, um, a lower correlation, I guess, in people who smoke. But there's, um I guess there's some debate there, but yes, so, yeah, protective factors are the pill and smoking, and the main feature really is post post menopausal bleeding. And if a patient is premenopausal, they might have intermenstrual bleeding there in terms of your investigations. Um, if they're over 55 years old and they've got post menopausal bleeding. You want to put them on the two week cancer pathway and a trans vaginal ultrasound scan to have a look at how thick the endometrial lining is is your first line, um, investigation. And at that point, you can do a biopsy as well. Um, or you can do a hysteroscopy and an endometrial biopsy as well. Yes. And, um, in terms of diagnosis. So you diagnosed based on the biopsy results and, um, in terms of management, so it depends on how much and how much spread has happened. So if someone has quite local local disease, um, then then, um, they can have a total hysterectomy and bilateral salpingo oophorectomy which essentially where you remove the uterus, remove the ovaries and you remove the fallopian tubes as well. If there's, um, stage to be cancer, then you also want to remove the lymph nodes as well. High risk patients'. They may require some POSTOP radiotherapy as well, and patient's who are not suitable for surgery. So in this case, I mean your frail, elderly ladies who've got endometrial cancer, you can start them on progesterone therapy instead. And then that helps know the growth. So endometrial cancer actually has a good prognosis because of early detection. I know I didn't put the statistic down here, actually, but, uh, it's it's got a better prognosis than other forms of cancer. Other forms of gynie cancer. So, um, yes, we'll move on to the next question, then. So now you've got a 60 year old early Paris female. Um, she presented to the G p with six month history of abdominal distension, early satiety, generalized abdo pains and diarrhea. So very vague symptoms. Six months ago, she presented with the same symptoms and the g p diagnosed her with I b. S. Um, the patient states that the symptoms are still not resolving, and she's quite worried because her sister and her mother both had Bracha positive breast cancer. In this case, what type of cancer is most likely I'll just wait another minute or so. Okay, so we'll go about the results here, So, yes. Um, this answer is ovarian cancer. And, um, the main reasons really are. So, um, this patient she's presented with quite vague i b s type symptoms. So the abdominal distension, early satiety and just generalized Abdo pains. And also the family history as well makes her increased risk there as well. So, um, a little bit of an overview on ovarian cancer. So it is the fifth most common type of cancer in females, and you mainly get about 60 years old, which this patient is as well. Um, most of the cancers are epithelial and orange in, and just to know as well, that some ovarian cancers are actually not found in the ovary itself. At the distal part of this, fallopian tubes are nearly over breed in terms of risk factors again, early menarche, late menopause and early parity. Um, they're all risk factors for ovarian cancer. Um, protective factors are the pill and multi parity. And as I said, the symptoms are quite vague. And so that's why that's why essentially, the prognosis is so poor because patient's present with very vague symptoms and, um, so ovarian cancer isn't isn't always even thought about, rather than maybe some, uh, Bs or IBD that could be causing this in terms of the investigation. So you want to do a C A 125? Um, so see a 125 can be raised in multiple other things as well. So it says endometriosis or benign cysts and things like that. But essentially, if you've done your C a 125 and it's over, um, this threshold here, then you want an urgent ultrasound scan. And yes, just to to help have a better look at the ovaries themselves. Um, and after that, So I've written a diagnosis. If I think what I meant to write there is, If the diagnosis is difficult and you are highly suspicious of cancer, then you the patient might require diagnostic laparotomy. Obviously, that isn't too common, Really. Um, if the patient does have a suspicion of those ovarian cancer and they also got a pelvic mass, then you just need to, um, they need to be essentially referred to gynecology as soon as possible so they can have the surgery, Um, in terms of, um, staging the cancer. We, um uh, say stage one is when they're combined to. The ovaries, too, is when there's any local spread. Their three is when it's in the pelvis and into the abdomen, and obviously you can spread it. It can spread into the blood. It can spread into the lymph nodes, and it can also spread. Um, yeah, yes, we can. You can spread to the blood and then influence as well in terms of management, um, surgery to essentially remove the ovaries. So again you would have a hysterectomy with a bilateral sub into, uh, for ectomy, which would be the best type of treatment that you can get unless there's even a more extensive spread their into the pelvis. Um, prognosis is, um, so five year survival of ovarian cancer is that's a 50%. And that's because most women do present at a very advanced stage. Um, and again, that's why I said it's because of the symptoms are so vague. And so it's not always, um, on the It's not always on the differential diagnosis list when a patient presents with these symptoms. But if you have a patient that's over the age of 50 and they've got new onset IBD symptoms, definitely ask your questions to try and see if they have any of the risk factors for these different types of cancer. Yeah, I just thought I'd put this in as well, so this is from Pass Med. It's just some of the different tumor markers. So obviously with the varying said with See a 125 and this is actually the last question. So we're a bit early on time. But so a 75 year old female she presents to the GP with increased itching and redness at her labia majora. She's been suffering with lichen sclerosis for about 10 years now, and she uses topical and steroids and topical steroids and Imodiums. And that seems to help. The patient noted, however, that she's got a new lump, her labia majora that started six months ago. In addition to that increase itching and redness, what type of cancer is most likely in this case here? Okay, so we've got 12 responses so far. Yeah, I think that's okay, because all of you've got them, right? So, um, but yeah, you might have noticed as well that we've already covered the other types of cancer, but yeah, So this one is a it's warble cancer. So I've only written a little bit about this because you you don't It is quite rare. Um, but you just need to know a little bit about the risk factors, I guess here. So 80% of these are squamous cell carcinomas. Um, and they mainly occur in older women. Risk factors include being older in age previous HPV infection, immuno suppression. That can happen with age. Um, but also, if they've got anything like HIV, lichen, sclerosis, which is essentially, um, an inflammatory condition. Um, at the labia majora, it can cause increased itching, increased redness, um, and yeah, you usually treat it with emergence and steroids topically. Um, and if they also had, um, Volvo Intraepithelial neoplasia, which is essentially just where you've noticed changes to the cells at the vaudeville area. And yes, so usually patient's will present with a new lump or a new ulcer at that at the Labia majora and or maybe increase it train and irritation as well. So yes, uh, that's the end of the presentation. Sorry was a little bit short. I think it's about 45 minutes or so, but I guess that leaves us some time for questions. If anybody's got any

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