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Ok. Hi everyone. Welcome to your um OG lecture today. Um We have Olivia with us today and she will speak to you about irregular menstrual bleeding. I'll hand over to Olivia. Thank you. Um I'm just gonna share my screen. Um So let me know if it doesn't work for any reason. Oops. Ok, cool. So we'll be going through um abnormal menstrual bleeding today. Um I've got the ment code over there. If you guys wanna join the mentee, I'll just double check. Um We'll be asking questions throughout. So if you just um join and then you can put your answers on the mentee and kind of test yourself a little bit. Um Yeah, we'll see if that works. Um Just a little bit me. So I'm finally it currently doing my PFA at Hillingdon um hoping to do an elective in New Zealand in Obstetrics. Um So yeah, and then this is kind of what we're gonna be going through today. So I'll be covering part of this. Um the bit on contraception. I've got the slides for, but it's a bit kind of low yield on a lot of content. So I think that's probably better just looking at yourself. Uh There's also the QR code for the mentee if you'd like to join that. So I'll just get started into our first um like warm up question. So a 62 year old lady presents to the GP with menstrual bleeding despite having gone through the menopause five years prior, she does not experience any postcoital bleeding and nothing is seen on speculum examination, which of the following is a risk factor for her likely diagnosis. And if you, you guys are on the mentee, I'll just quickly go back to the code. Um you can start filling out the questions, the answers. OK? I'll just give you another five seconds. Um and I'll just put the Q RK back up for a moment. OK? Cool. Let's see like OK, so um risk factor for her diagnosis. So what do we think her diagnosis is? Um So you guys were all correct? Um We think this is probably endometrial cancer for any woman who is postmenopausal bleeding until proven otherwise, endometrial cancer. Um Other things are quite likely like vaginal atrophy, but that's the main one you want to rule out. Um So well done. And then, so this is um I'm just gonna quickly go through this bit instrumental bleeding because I think your other lectures should cover it. But when we're thinking about bleeding in between periods, we want to think cervical endometrial cancer. We wanna think of S TI S and we also wanna consider pregnancy of unknown location. So that could be a normal pregnancy. It could be a miscarriage or it could be an ectopic pregnancy. So just quickly cervical cancer, we want to think about risk factors. We want to think about treatment and we also want to think about the main risk factor HPV. Have they been vaccinated for that? Again, I'm just gonna quickly go through these L CO they should be covered endometrial cancer. So that's what this um lady in the question, we were kind of leaning towards um quite um early diagnosis um pops up because um of postmenopausal or instrumental bleeding is quite an early sign. Um So it's quite good in that regard. S TI S obviously most prevalent chlamydia, we always wanna be thinking about um how they're presenting with the yellow green discharge. Um But a lot of it comes down to um the pathology that we find also wanna always remember pelvic inflammatory disease and that's when the um infection ascends higher into um the um uterus and that can cause much greater problems and more lasting problems. And then finally, pregnancy of unknown, unknown location. So what we want to be thinking about there is we want to be thinking about um are they, what is a um beta HCG doing if it's increasing at a normal rate, then probably a normal intrauterine pregnancy if it's increasing less so, but still increasing, maybe an ectopic. And if it's decreasing. It might be a failed pregnancy. So, a miscarriage and that could be a threatened, inevitable or missed miscarriage. Um, but hopefully that will have gone through previously on your obstetric f sections. Ok. And then next question, uh, let me change the slides of the mentee. A 13 year old girl has recently started her periods. She's complaining of painful periods since this has started and would like some treatment as hot water bottles are not helping. She is not currently sexually active. What treatment do we want to be offering? First line? Let me just quickly. Apple you. Oh, sorry. Ok, cool. So I'll just see what you guys said. Cool. Yeah. So we always wanna start um conservative but not only that we want to think about our individual patients. So this is a young girl who um is not sexually active. So we do, we need to start her on contraception. No. Um Transam acid is a good first line treatment that, but that's for um heavy periods. That's for menorrhagia and would not really target the pain. Um uh in regards to Ibuprofen versus paracetamol. Ibuprofen is an NSAID and that can be better for period pain, but you can combine the two. Ok. And then when we're thinking about um painful periods and painful sex, we want to think about three main differentials, endometriosis infections, and vaginal atrophy. So, endometriosis. Oh, sorry. Firstly, with some definitions. So, diasia excessive pain, um associated with periods, dyspareunia, painful intercourse, and then menorrhagia is excessive bleeding. And that is according to what the woman considers to be excessive, there's not a certain amount. And then when we're thinking about amenorrhea, so lack of periods, we want to think about, is it primary or is it secondary primary meaning um, that they never started their period? And that's before the age of 15, if they're developing normal secondary characteristics or by 13, if they're not developing um at all, and then secondary amenorrhea is when someone's had periods before, but then they've stopped for a few months. Um and that can have different causes to a primary which we'll discuss a bit later. Um So back to painful periods, we always want to think has this pain been primary or secondary that is, has it been present since they started periods or has it developed later? If they've always had pain such as this girl when she was 13, started getting pain, it's less likely to have a pelvic pathology because um pelvic pathology such as endometriosis and adenomyosis take um years to develop. Um and that can be treated more conservatively. However, if you've had a woman who has gone about her life having periods and then starts experiencing pain, you want to be referring her to gynecology for further assessment. Um And that's like a big one in cases if a woman um hasn't had is getting period pain, you want to really ask her is this has this always been the case and if not, shall we refer you to gynecology? Um and then heavy periods. So sometimes this can have no underlying pathology. Um Sometimes this can be due to fibroids and then more systemic problems such as bleeding disorders or it can also be due to um kind of thyroid function. Um So, yeah, this is again, according to what the woman considers to be excessive and a lot of the time this doesn't have an underlying cause. Um But sometimes it does such as hypothyroidism, it can be part of um an infection such as P ID or um part as a result of uh contraception. Specifically the copper coil. A lot of people have problems with bleeding, quite heavy on that.