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Summary

Attention medical professionals! In our on-demand teaching session, we dive deep into Endometriosis, an often misdiagnosed condition that you regularly encounter in your ob-gyn placements. This session will empower you with the vital knowledge about this condition's symptoms, pathophysiology and potential complications such as chronic pelvic pain, dysmenorrhea, dysuria and subfertility. We'll also delve into the techniques for diagnosing this condition such as laparoscopy, its management strategies, including hormonal therapy, analgesics, and surgical removal of endometriosis through laparoscopy, and how these treatments can affect fertility outcomes. This is a must-attend session to better understand, diagnose and manage endometriosis in your practice. No questions are off the table. Make sure you read up and come prepared for an interactive, deep-dive into endometriosis.
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Description

St George’s Surgical Society is pleased to announce its Obstetrics and gynaecology-focused teaching series aimed at all medical students.

Session: MENSTRUAL DISORDERS

Having scored 100% in her Obstetrics and Gynaecology OSCE station, this is the perfect opportunity to also ask the speaker, a 5th-year medical student for some tips and tricks on how to ace the 4th year/ P year exams! To receive a certificate of attendance, one would need to attend 4/5 of the teaching sessions and fill in both the pre-feedback and post-feedback forms!

Learning objectives

1. Understand and describe the pathophysiology of endometriosis, detailing the roles of the endometrium and menstrual cycle dynamics in disease progression 2. Identify and characterize the symptoms of endometriosis, with a focus on chronic cyclical pelvic pain, dysmenorrhea, and subfertility. 3. Elaborate on the diagnostic pathway of endometriosis, highlighting the fundamental role of laparoscopy and its implications. 4. Analyze the management options for endometriosis, detailing the use and selection of nonsteroidal anti-inflammatory drugs (NSAIDs), hormonal therapies and laparoscopic treatment according to the patient's condition and desires. 5. Evaluate the relationship between endometriosis symptoms and the patient's quality of life, understanding that the size and location of endometrial tissue does not directly correlate with symptom severity.
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Computer generated transcript

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

You don't have to read a lot uh around it because questions are never asked uh about it, dysfunctional uterine bleeding, they sometimes do, but there's not a lot of uh information about it. So the best places to go to is like the Oxford handbook, etc. Um So yeah. Um so let's get started with endometriosis. So, endometriosis you see quite a lot um especially when you have your op and gyne placement and that's why it's really important for you to get your head around it. But pretty much everything that you need to know about endometriosis for your exams or even in clinical practice is pretty much on this slide. Um So what is endometriosis? Um Endometriosis is where you have your endometrium which lines your uterus. But sometimes this endometrial tissue can be found outside of your uterus in places that it shouldn't be. Um And that's what we call endometriosis. Now, the reason why um this is important is it's linked with the symptoms. Um And I'll explain a little bit about the pathophysiology because I think it makes it makes sense. Um And you can kind of like it makes you remember it easier Well, it makes me remember it easier. So hopefully it does for you. But essentially, I've been, I've mentioned before that blood is an irritant essentially. And when a woman has a woman go through menstrual cycles, um the endomet builds up and then over time it has to shed. Um And that's when you get your period. Um So the endometrial tissue thickens and then it sheds um during your menstrual cycle. But if your endometrial tissue is elsewhere, even though it's elsewhere, it's still doing the same function. It's um it's thickening up, preparing for um a baby to uh for fertilization and for um uh an egg to latch onto it. But of course, if there's no egg, then it will shed. The problem is that blood is an irritant. And if blood is in places where it shouldn't be, then it can cause pain, it can cause irritation, it can cause infection, et cetera. Blood is normally found in blood vessels. It's normally found, you know, in the uterus, et cetera. But just how we said about placental abruption in the previous um sort of teaching series. I was like placental abruption. If you get a collection of blood build up in your uterus, especially in your post fornix. Um That's when you can get the pain. That's why the placental abruption is so painful, it's tender um or that and it's because you have that collection, a large collection of blood in your posterior fornix. When a placental abruption occurs. And that's why you have the incredible pain. And it's pretty much the same case with endometriosis, you have this endometrial sort of tissue which shouldn't, which is in locations where it shouldn't be. And then not only that you have the endometrial tissue which thickens and behaves like normal endometrial tissue, it thickens and then after a month it sheds and then the blood, which shouldn't be in that specific location then builds up if it doesn't get out and it causes irritation and it causes pain. And that's why you have the symptoms that you get, which we're going to explain now. And one of the main symptoms which you um the Ys KT they always mention in the questions, but also in OS scenarios is this chronic cyclical pelvic slash ABDO pain. And exactly for this precise reason where you have the endometrial. Um and it's shedding, but it's not coming, the blood is not um co uh coming out as in like, let's say if it was in the uterus and you get your period and then, you know, you get your period because it just all comes out and then you have to use tampons, et cetera. It's not the same for um endometriosis because maybe the, it can't come out. And so it irritates and then, so that's why you have the pain and it's chronic again, during your periods, you have the shedding, you have the pain. So it comes on when you, uh when your endometrial tissue sheds. So that's number one. So that's the main symptom that happens next is dysmenorrhea. So, again, uh these are things that you just have to know, um, you can get pain during sex pain, uh during urinating, et cetera. Um And, um, and it's pretty much for the same reason and then you can also get subfertility. So, lots of the patients, actually, their first sort of uh line of presentation is they will come into um the doctors or the primary practice and you see it quite a lot um in your GP placement, especially for me. Um is they come in and they're having problems conceiving. Um And then after the males, male gets tested, the female gets tested, the female female normally um can get the laparoscopy done. Um And, and then from the laparoscopy, um you find out that the patient has endometriosis and that is the possible cause of um the subfertility. So that's something to bear in, bear in mind. Um that if someone comes in with subfertility, endometriosis is a possible um uh uh reason for having it. Um So that's that uh these are the main symptoms that you should know. There's quite a lot, there's a lot more. But um for your exams and your Ys Katie and Os chronic cyclical pelvic pain is the main one. And then ask additionally for um dysmenorrhea and dysuria and subfertility as well. Um And then for go diagnosis investigation, uh we do a laparoscopy. It's something that you have to visualize. So, endometriosis. Um If you ever go, I don't know if you guys have Singye in Saint George's, but it, there's this doctor called Suruc Pandi and she specializes in endometriosis. Um And if you go to one of her clinical theaters, um you, you can see a bunch of it and it's really interesting because endometriosis is so it, it's so varied. So a woman will come in and she will be in excruciating pain. She can't walk, she can't talk. Um she has to take days off from work every single time she has this chronic cyclical pelvic pain. And when you do the laparoscopy, you realize that it's not even it, it like it, the endometriosis can come in varying shapes and sizes, but the size and the location doesn't correlate with the clinical symptoms because a woman came in, she, she had to stop working because of how excruciating the pain was. And then when you, when we did the laparoscopy, it was um AAA minuscule sort of of like chocolate cyst on the ovary, which was cau which we think was causing the pain. And then she came back uh after um uh for a follow up and she said that she was much better. So just remember that just because endometriosis or endometrial tissue uh looks small, et cetera, it doesn't correlate with the clinical symptoms that patients present with. So, yeah, so laparoscopy is the goal diagnosis. You have to physically visualize it. And most of the time when you do a laparoscopy, uh the, the consultants will just take out the endometrial tissue uh right there. And then um because it's because you're, you're inside anyway, so you might as well and that's what majority of the consultants, if not all of them do in um in Saint George's. So, yeah, so that's all you have to know for that. And then in terms of management, management, remember this. Um but I've tried to keep it as simple as possible. So the first line of management is to uh try to help with the pain. So we like to start off with nsaids or paracetamol. Um And see if that helps, if that doesn't help, then we move on to hormonal management, hormonal management. We mostly like to, we uh mostly C OCP is recommended um sometimes progesterone only pill as well. Um And if, for example, this is where um you have to divide it into what the patient wants. If the patient had initially presented with subfertility, and that was the problem with her endometriosis and she didn't have um sort of the pelvic pain, et cetera, then you have to go down an alternative because medications won't help with her fertility. So instead you have to refer her to secondary care uh fertility clinic, et cetera. And then they would give her certain stuff like uh GNRH analogs. And this is um this is where um we uh uh this is where um you can give her sort of medication, but this doesn't help with the fertility. The fertility. The only way to actually improve fertility is doing laparoscopic treatment. So you would have to do a laparoscopy. You identify the endometriosis and you've removed the endometriosis. Um So that's the only thing that you can do for the f for fertility and helping to improve fertility, all the pain management and all the cop et et cetera that won't help with that. Um So, yeah, so if, for example, analgesia, hormonal therapy doesn't improve or fertility is priority, then you refer them to secondary care and then secondary care is GN A GNRH analogs et cetera. Um And so lots of the conditions that we're talking about um is due to um high estrogen levels. And so then one method of trying to succumb the symptoms um is to, to try and reduce the estrogen levels. And we do that via inducing pseudo pseudomenopause um via GNRH analogs. And so that's why sometimes we do that if pain management isn't working. But essentially all you have to know is that we, so first line is we like to uh control the pain. First line for that is nsaids and paracetamol. Um If that doesn't work, then we move on to hormonal treatment. If the woman initially presented with fertility problems. And her main goal is to improve her fertility and get pregnant. Then the only real treatment we have is laparoscopy. We go in, we identify where the endometriosis is and we remove the endometriosis. That's pretty much uh the what you need, what you guys need to know. And then for example, if let's say the pain management isn't working, we need to think about other alternatives, then you would, you can start them on the GNRH analogs which induces pseudomenopause. So you have a reduced estrogen level and that reduced estrogen level should help with the endometriosis and the symptoms associated with it. But if all doesn't work out, then you go on to laparoscopy. Um So yeah, that's endometriosis in an in um sort of a nutshell. Let me just check if there's any questions. Um And then we can uh yeah. So it sh I've already sent them out. Oh OK. Uh That's fine. Um I will send out the feedback form today anyway. So I'll just uh send out all of them. Um And then you can just fill them out and then I'll just resend it to the people who um have uh filled out the feedback form today instead of like the whole entire time. So, yeah, it's fine. I can just send out all of the feedback forms today again. Um So, yeah, if there's no questions for endometriosis, then I will move on. Um But sorry, essentially. Yeah. Um That this is pretty much all you need to know, but go to B MJ Best Practice and please read through it. It's quite a lot and it goes through the nitty gritty. You don't really need to know like the management except for the management listed here. But get your head around the symptoms because symptoms really do vary. I've written down only the ones where I've seen a trend in terms of examinations from past med and from ques meed. Um They use certain phrases. Um So for example, they will specifically say chronic cyclical pelvic pain and then lots of them will have um, a patient presents with dysmenorrhea, dysuria and then they will be like, uh what investigation would you do if you suspect this? Um So that's why I've written these specific symptoms down because they're the ones that I've seen come up the most when um I used to go on ResMed and pasmed, et cetera. So, yeah, that's endometriosis. Next is adenomyosis and this is pretty similar and people get really confused and I'm surprised how many people get confused, but it's not that hard to get your head around. Um But when I said that when, when I said for the endometriosis that we have endometrial tissue outside of the uterus, adenomyosis is specifically where the endometrial tissue is located within the myometrium myometrium. And that's when we diagnose someone as having adenomyosis. Um And if you are in a tertiary center, you actually do see a lot of adenomyosis. Um, so, yeah, and this one again, it's pretty, these conditions, you know, it comes across and when you go on to placement you realize, um, the conditions they come across as, oh, it doesn't, like when you read it off a paper or a BMJ practice it doesn't seem like it's, um, you know, all that horrible. But when you go into clinical placement you see, like people in their early thirties coming in with adenomyosis, they've quit, they've quit their job, you know, they're at home just dealing with the pain. Um And in fact, there was one patient who I saw in the early thirties wanted to have a family, wanted um uh to, you know, get pregnant, et cetera, but the pain was so excruciating that she eventually ended up getting a hysterectomy. Um So it, it really uh this, these sort of topics like when you read it, it really doesn't sound all that bad, but you really should go into placement and see how it's like because then it allows, allows you to empathize with the patient and it really does help in your o scenarios. Um for, for when I uh for this, this can possibly come up because all of the conditions are pretty similar in the sense that they can present with menorrhagia. Um all these sort of problems. And then, so you would have to be able to distinguish between them and that's the whole point of an osk differential diagnosis, et cetera. Um And this is really good for testing your empathy skills as well. Um So, yeah, so, adenomyosis is when you have your endometrial tissue and it's specifically located within your myometrium. Um And again, as mentioned, lots of the conditions that I've mentioned today, they're very much hormone dependent and in fact, the they're more so estrogen dependent. Um so the higher your estrogen levels, the worse the symptoms. And then when you go get to menopause because you have low estrogen levels, the symptoms seem to go away and it helps. Um So yeah, and is similar for this as well and fibroids that we'll talk about. Um So with adenomyosis, most of the patients or the risk factors associated with it is that they're multi class females. So they have multiple Children and they're normally at the end of their reproductive years. Um So they're nearing their uh menopause. Uh And in fact, some of them, um I believe adenomyosis if I'm correct is very common in the Black African community. Um So that's something to bear, bear in mind as well. So, multiparous females and towards the end of their reproductive years and again, so with, with adenomyosis and fibroids and things like that, the symptoms are pretty similar. So the way you figure out what it is in terms of differential is via examination, uh you have to take the whole question, the question as a whole, don't look at the symptoms themselves and be like, ok, this sounds like this and this sounds like that. No, for endometriosis, if you have chronic cyclical pelvic pain, ok, then you can think about it's a high likely chance that it's endometriosis. But look at the clinical symptoms, look at what investigations are done. If they've done a laparoscopy, et cetera, then maybe you're thinking about endometriosis. But with adenomyosis with fibroids, it's really hard to just diagnose someone or just think that it's this based on the symptoms. So look at the examinations, look at the investigations done, look at the reading, uh, look at, um, what's been found, et cetera. Um So yeah, so again, see, um, it has dysmenorrhea, menorrhagia and dysuria paraneura. So it doesn't really help with, uh, figuring out what it is. However, with examination, when you do an examination on the patient, you have an enlarged and tender uterus. And that's the key thing with adenomyosis. Again, we've said that, um, blood where it shouldn't be, um, can cause irritation. It's the same thing here. That's why the woman has a tender uterus. And it's not if it, if it was le let's say something like which we'll talk about later on. Actually, I'll leave it for later on because I don't wanna confuse you guys. But then I'll mention this, uh, and why it's tender uterus. But again, blood where it shouldn't be such as in the myometrium. That's why it can cause a tender uterus. Um But it's enlarged again because you have endometrium, which is accumulation of um endometrium, which shouldn't be there. And so you have an enlarged feeling uterus. Um And then uh th this is a distinguishing thing but you won't be able to know uh you, you won't be able to know this, but you know, it's more soft uh of a uterus than a fibroid. Um But to be honest with you fibroid is a benign tumor, whereas adenomyosis is endometrial tissue and it's hard to determine that. Um unless you do lots and lots of examinations um in your obs and gyne placement and to be honest, not a lot of people come in with adenomyosis. Um it's more so endometrio uh endometriosis. So it's harder to be able to distinguish that. Um So in terms of investigation for an adenomyosis pretty much uh with ob zingy, they like to use a transvaginal ultrasound. And the reason why they like to do a transvaginal ultrasound is because it's um it's very accurate. Um it's minimally invasive. Um and it's, it uses ultrasound, so it's pretty safe. Um So, yeah, so transvaginal ultrasound is what we do. Um The gold diagnosis and now I know this, it sounds like, oh yeah, it's, isn't it obvious like uh you can only do a histological examination after a hysterectomy? But the questions have come up on this quite a lot. Um And so I have added it in. Um but just remember that for goal diagnosis, the only way you can actually fully diagnose someone as having adenomyosis is you would do a histological examination. And the only way you can do a histological examination is if you take the myometrium out, but because it's part of the uterus, you have to take the whole uterus out. So a hysterectomy has to be done. So that is a goal diagnosis, but we don't do that. So we do a first line um which is transvaginal ultrasound and then examinations can help get uh determine what the patient has. So, yeah, so just remember the first line and remember go diagnosis even though the gold diagnosis is like self-explanatory, but still keep it in mind. Um and then management. So the management pretty much for adenomyosis is symptom control. Um So if the patient is presenting with heavy periods, then you would start them on um the medications uh that you give them for that. So when the pa when a woman doesn't want contraceptions, you want to treat them um for symptomatic relief uh during their menstruation. And so you can give them trans uh transam acid um when they don't have any pain because transam acid stops the bleeding. Um And so that will help with the menorrhagia and it works as an antifibrinolytic. However, if the patient has adenomyosis and they're complaining of pain as well, um then you can give them the um mefenamic acid and that essentially is an NSAID which reduces bleeding and pain. And this is really, really important to remember. It's a question that comes up a lot in both p uh ques ques meed and pasted. Um And it, it comes up, I've like obs and uh questions. I think around 15% of them is just variation of questions asking for uh you determining. Do you give them transam acid or do you give them een acid? So please please, please just remember this. Like you don't need to go into much more detail than this. Just remember if a woman comes in and she's complaining of no pain and you give them transam acid, which is an antifibrinolytic. And in fact, you give that for surgeries as well. If someone's bleeding profusely, et cetera uh during surgical theaters, you can get you uh they do sometimes prescribe transam acid and then if they do have pain, then you give them an NSAID called methalonic acid, which helps with the bleeding and the pain. So, yeah, so the these two drugs just be aware of because they're asked quite a lot. Um But if a woman doesn't mind having contraception, um then first line, uh you can give them is a Mirena coil for adenomyosis. If they don't want that for whatever reason, then you can give them a contraceptive pill which is second line and third line is cyclical po um I recommend you remember all of the 1st, 2nd and 3rd line for adenomyosis. So, yeah, um that's pretty much adenomyosis. Um It is uh so endometriosis, adenomyosis and fibroids, which we'll come up to, later comes up a lot and you have to be able to distinguish it. So in a summary, don't just look at the clinical features and be like, OK, this is this and this is that look at the whole question and look and don't, and pick out see what the examinations are, see what the investigations are. Sometimes they give you the management and they're like, what do you think this patient has, um, et cetera. So, yeah. Uh and then remember the management, especially transam and mefenamic acid, remember the contraceptions that you would give them if they don't mind having contraception and remember first line on your old diagnosis. Um So yeah, that's all of adenomyosis. Uh Let me see if there's any questions and then I will move on. Yeah. So there's no question. So I'll just move on for time's sake. Oh, that's so weird. Ok. You know what, I'll send them all? Um That's so odd. Ok, that's fine. As long as you've emailed me before I will send all the feedback forms again. Um And I'll just send them all today and then I'll just send all the uh the slides and all the. Ok, that's fine. I'll send it all again and then whenever everyone replies. Ok. Ok, that's fine. Um, as long as you've emailed me, I will just email everyone again with all the feedback. Oh my gosh. Ok. Ok. Just make sure that you email me today everyone who's had the problem. That's so weird because I've sent it to majority of the people actually don't send it on my email. I'm gonna give you my number, just send me your name on whatsapp and I will just message it. I will just email it. Um not email it. I'll just like whatsapp it. Um So yeah, just send me a message and I'll get it out today. Um Yeah, I don't know why that happened. I've sent it to most of the people and they have received it because I've got thank yous, but I don't know. Um sorry about that, but if you send me the message, um I will make sure to get it to you or otherwise I will wait until the very end because we only have one more session left and then I'll just send everything all at once because the recordings I'm going to do all at once. Um But yeah, um that's sad anyway, um I will move on. Um But yeah, just message me on whatsapp and I will uh send it to you. Um And that will be much more quicker and you won't have that problem with the feedback form. OK? So next is fibroids. Um Again, very high yield, make sure that you go on zero to finals. If you don't like very like literature, heavy sort of things. B MJ. Best practice II would say do B MJ best practice. OK. Someone has emailed me now as well. So I will see what's going on and I will message everyone again. Um But yeah, fibroids um again, high yield question, go on 0 to 5, go on B MJ. Best practice. You don't have to memorize it, just read it just like get an, get an overview and then use this notes and slides for your exam because it's literally all you need. Um So yeah. So what is fibroids? Well, fibroids are benign tumors of smooth muscle of the uterus. So it's just tumors uh of smooth muscle located in your uterus. Um And that's pretty much about it. They're pretty much estrogen sensitive as we've been talking about before and they grow in response to estrogen. So whenever you have an estrogen, high state and that is commonly in pregnancy, et cetera, then you have a growth of these tumors and we'll talk about why that may, that may become a problem later on. But just remember that whilst pregnancy is a high estrogen sort of state, menopause actually is a low estrogen state. So lots of the patients who have adenomyosis who have fibroids, they have the problems during their pregnant, uh the during their reproductive years. And then whenever they hit menopause, their low estrogen levels means their t nooses goes away, their fibroids go away, all these symptoms go away and that's why some people, they actually take GNRH analogs to induce the sort of like pseudomenopause phase. Um if it's, if it's like pretty bad. But um there are other alternatives as well. So, yeah, so that's something to bear in mind. Uh Risk factors again. Um It's most commonly seen in uh black females, um and mostly in later reproductive years. Um and you should be able to know the different types of fibroids. So you have pedunculated fibroids. And this basically means like a fib, a stalk, pedunculated means a stalk. So if you have a fibroid which is attached to a stalk, then that's what we call a pedunculated fibroid. Then you have something called a submucosal fibroid. And it's not really hard to learn this as long as you understand, a bit of l not even Latin, like just un like submucosal underneath the mucus underneath the mucus layer. And so it's just underneath your, the, the lining, the uterus itself and then intramural is in between. Um and then sub cirrhosa is just underneath the outer um layer. So, um yeah, remember these types, this que this picture I think was taken from zero to finals and it, it demonstrates it very well. Um You should be able to identify each of them on an image and be able to tell if it's sub cirrhosa or submucosal intramural. Um So, yeah, and I think you have, you should be able to do that on an ultrasound. So if you have your on placement and a patient comes in with fibroids and you're in the clinic and you get to see it like in your head, I like figure out is this an intramural fibroid? Is this a submucosa, sub cirrhosis, et cetera? And it will really help consolidate your learning. Um And then we have um clinical features. So again, patients can come with prolonged menstruation, um et cetera, they can come in with menorrhagia even, even. Um So you have the classical uh symptoms. Um again, not very uh specific enough. And that's why uh you know, examinations is really important, et cetera um and taking a very good thorough history. So such as a family history, et cetera. Um So examination wise wise when you do an examination, now, this is where I bring in the thing I was talking about with adenomyosis. Um and that is it, when you do the examination, it's palpable. So it feels like an enlarged uterus, however, it's firm, it's much more firm because again, it's muscle and it's nontender. And this is what is important like these subtle things they were mentioned in the question, but not a lot of people understand why there is such a distinction. And if you understand the path of physiology, not for all conditions, but especially for obs and it really will help you out with getting the top grades for obs. And so, as we mentioned before, with adenomyosis, with endometriosis, you're working with blood, you're working with endometrial tissue which sheds blood and blood is an irritant. Fibroid is completely different fibroid. We're not working with blood, we're working with benign tumor and we're working with benign muscle and that doesn't produce blood that doesn't shed blood. Um And so where does the irritation come from? There is no irritation, there's no pain. Um It's just non tender uterus, it's just a hard palpable, firm mass that you can feel. And that's what you distinguish when an exam, when you read the question and it says on examination, this patient had this and then you see it tender or you can completely, well, you don't completely, but you can rule out that. It's, it's, well, it's not gonna be a fibroid. It's probably either an endometriosis or it's going to be um adenomyosis and then you read along. Whereas if the patient says that they have tender uterus and it's enlarged, then you can be like, well, it's not going to be fibroids because fibroids doesn't cause a tender uter just because you're not dealing with irritation like blood, et cetera. However, if the fibroid is big enough that it like presses on stuff, et cetera and causes pain that way, then that's a whole different matter. But with your exams, they're not gonna ask these kind of questions. But in clinical placement, um it it can be quite different. It's a different scenario. So, yeah, so just remember this is just for, this is just for your exams sake for you to get like the top grades. Um But just remember that every person is different, everyone presents differently and at different stages. So um just bear bear that in mind. Um So one other thing which is really important for you to know is that um fibroids can actually be associated with secondary polycythemia. Um And the reason why this is the case is because fibroids can induce a sort of like increased production of a EP O which we know produces uh which role is to produce red blood cells. And that's what causes the polycythemia. Um It's quite rare. Um And you don't come across it a lot. Um But the reason why I mentioned this is because there's a couple of questions in past med um et cetera which do talk a which give you a case like this. Um And it's just um something that again I've mentioned because it's, it comes um up often in exams, exam questions. Um So yeah, that's clinical features. So just remember with fibroids, the most important thing is your examination, your examination is the key thing in the question that you look out for in order for you to uh increase your, you know, to make sure that you're happy that it fibroid. Um in terms of investigations, investigations vary depending on the type of fibroid and depending on the size of the fibroid, uh if it's a submucosal, so just underneath the mucous layer, um we can do a hysteroscopy. Um and it's uh yeah, it's the best way to find out uh to identify a submucosal fibroid. Um However, if it's a larger um sort of fibroid, then a pelvic ultrasound is the best way to go. But these are all like they're all pretty optional. Again, it's a case by case basis. So that's why for your exams, essentially, all you need to know is that your goal diagnosis is transvaginal ultrasound, just like lots of them. Um The reason why is a larger fibroid will be able to be picked up on a, on a, um on a pelvic ultrasound. So then you don't have to go through the whole process of doing a transvaginal ultrasound, which can be quite painful. Um, especially i it can be quite painful because lots of the transvaginal ultrasound, I've seen, um, the females are in quite a lot of distress and it's very, and, and it is quite uncomfortable actually. Um So, yeah, if you can, if you can do a pelvic ultrasound and identify the fibroid that way, which is the case for larger fibroids, then of course, do the pelvic ultrasound. But the goal diagnosis because again, um it's an ultrasound, it's much more safer. It's much more accurate. You get closer to, you know, identifying the, to the lesion, not, not the lesion, but the problem itself. And so I can give you a better idea about what it is and what may be going on. Um So, yeah, transvaginal ultrasound is your goal diagnosis as in majority of the uh and gyne cases. Um And then you have your management. So the management, if it's asymptomatic, you don't have to do much about it, you can just monitor it. However, if it's uh symptomatic, um then depending on the size, you would have to uh figure out what to do. So for a fibroid, which is less than three centimeter. Um And you want to do a medical sort of treatment then, um, just, uh the, the management for heavy periods is what you would, um do for this uh for a fibroid and for surgical options, surgical options really do vary. You can do endometrial ablation, you can do resection of the fibroid and you can even do a hysterectomy if it's too painful, et cetera. Um And again, like in, uh because Saint George's is a tertiary center, uh you do see quite a lot of hysterectomies, unfortunately. Um Yeah, so there's quite interesting cases that come in, uh if you have your obs and placement at Saint George's. Um So yeah, so you have quite a varied option. So again, in terms of examinations, then probably not gonna ask you a question on that just because of how varied, uh how many different sort of surgical treatments, uh that can be done. Um And then if a fibroid is more than three centimeter, um then again, medical treatment same as heavy periods, you go through the whole thing. However, for surgical, if it's bigger, you can do a uterine artery embolization. And this works really well. Actually, if you uh cut off the supply to the tumor to the fibroid itself, um then you'll, you can practically solve the problem that way. But sometimes myomectomy works and then hysterectomy. But what you need to know is that um if you're doing a surgery, lots of the time with patients with fibroids, you like to give them GNRH analogs. And the reason why we like to give this is um again, we know that fibroids uh is controlled or works with estrogen. So it's estrogen sensitive. So, estrogen when there's an increase in estrogen, you may see an increase in the size of your fibroid. But we know that GNRH induces menopause. That's how, that's how it works. And so when you induce menopause, you have less estrogen levels. And so you may sh you can actually shrink the fibroid. So if in scenarios where the fibroid is so big that it was compressing on things and you may have had, you may have complications associated with um how big the fibroid was. If you were to shrink him, you have less of that problem with. Uh oh I could just ii could accidentally cut off the ureter or whatever because of his close proximity. Um, you won't have that problem and it makes the surgery, um, a little bit more, uh, less likely to get complications essentially. So that's why with fibroids, if it's big or if they believe that by shrinking it, it can help. Um Then that's why we do. Um, that's why they give, they administer GNRH before surgeries. So that's something to bearing in mind. And also if I if fibroid, uh if the uh person presented with fertility problems and then you diagnose them with fibroids, then in order for your management for your fertility, myomectomy is the only way um that can help with that. So that's something important to bear in mind. So, if a patient presented um with fertility problems, then your management option would only be myomectomy. Um So yeah, and then complications. The one complication you should know is the red degeneration of the fibroid. So, as I mentioned, um a fibroid is an estrogen sensitive state. Pregnancy is a high estrogen sensitive state. When you have a pregnancy, you have high estrogen, the high estrogen increases the size of the fibroid. But because of how high estrogen state pregnancy is, it can actually rapidly increase the size of the fibroid to the point that the blood supply is not enough for the fibroid. And so it eventually strangles itself. If you say that in that, in those sort of terms, it strangles itself and it goes through, uh it can go through ischemia, infarction is literally like a heart attack in a way. Um because you have reduced blood supply, going to this fibroid. And so you're getting infarction and then eventually necrosis of the fibroid. Um Now, the interesting thing is the management is actually supportive. Um You just rest, you give them fluids, you give them analgesia and that's what you do. Um So, yeah, and the key thing is that the patient will come in pregnant and they, the question will mention that they have a fa uh they have past history of fibroids. Um So that's what will um make you realize that this is a fibroid and it's very interesting when you come across ResMed and password and you read through the, the red degeneration of the fibroid question, you'll never forget it because it's very odd that um a woman comes in and it seems like she's in excruciating pain. And the only thing that the question says is that she has a past history of fibroids. And then if you didn't know about this, you'll be like, well, what has fibroids got to do with her pain, et cetera? Um So it's quite an interesting question when you come across it and you'll probably never forget it after. Um So yeah, that's pretty much all of fibroids. Uh Let me have a look if there's any more questions. Uh Yes, it was sent email. So, if you've already sent it to me. Um, ok, that's fine. That's fine. I've sent my number and I sent my email. I will do it once more now and I will do it once more, um, at the end. So once I've done all five of the teaching sessions, um, I will send everything all at once again. Um, on Thursday or Friday. Um, ideally it would be Thursday because I won't be in the country on Friday. So yeah, um I'll send everything now so far. Um But on Friday or Thursday, I will send out everything from, from session one, all the way to session five, which will include all the slides and all the recording. So it will be a big chunky email. Um And because I've given my number if you don't receive that email by Friday message me and I will just um send it all to you on whatsapp. So that should help clarify that. Um But remember I'm not, I won't send it unless you fill out the feedback because I use the, I use emails which have been added on the feedback form to send the emails out. So just make sure that you fill out the feedback form, especially both of them. So, yeah, the pre and the post. Um So if there's no questions on, if there's no questions of fibroids, I'm going to now move on um to cause we only have like 23 minutes, no, 13 minutes Um and I would really like to get through. Ok. Yeah. Uh I might need to continue this next week and I'm because this is very high yield and I don't think this should be missed at all, but I will quickly get th, actually, let me do PCOS next week and let me do premenstrual strum now because this can be done in like 12 minutes. P CS is high yield. Um It's very, very high yield because it comes up all the time and it's related to endocrinology and it's related to OBS and Gynae and endocrinology and OBS and Gynae are both two specialties that Saint George's loves to ask questions on and I don't know why. Um So yeah, if you've had Doctor Seal, I mean, you should be fine, but if you haven't, then I'll teach you that next week because that is very high yield. Um But this one is also uh it doesn't come under comprehensive, but it's a, it's, they like asking about this and I don't know why, but it's very interesting. Um So premenstrual syndrome. Now, this is essentially where um women go through menstrual cycles. Um And we have, there's a lot of hormones that work. Um And essentially some females they go through and during the luteal phase prior to like a couple of days prior or even um a week prior to their menstruation during the luteal phase, some females go through this sort of emotional and physical and psychological symptoms and when you, when it's not diagnosed, people are like, oh, she's going through her mood swings, et cetera. And it can be quite distressing for the, for the patient because she doesn't understand what's going on and she's depressed and she's, she's going through all this and she doesn't understand what's happening and then she gets a diagnosis and, and you, you realize that, oh, there was something, um, and this is what happened to a very close friend of mine. So I've seen her go through the symptoms and like us not understanding what's going on and then she gets the diagnosis, she gets, she gets the medication and then she's all of a sudden she's fine. So it's a, it's a natural thing. Um, at first II was like, I didn't, like, when you read these kind of things, you're like, I mean, I didn't even know these kind of things existed. Do they actually exist? And then when it happens to one of your close friends, you're like, oh, my gosh, like you don't forget it. So, yeah, it's pretty much a real thing. Um, so it's where before your menstruation a week or even a couple of days before they will go, they will change. So they will have they, some of them start crying. My friend just started crying. She's, she never gets angry. She gets really, really angry during that period. Sometimes people go through physical symptoms, et cetera. They're just not themselves. And it's specifically during the luteal phase. And that's the key thing that I want to highlight because the question may ask like this patient was diagnosed with premenstrual syndrome. And then they'll ask you just a random pathophysiology question and it's like which phase of the cycle does this most likely occur in? Um And you would have to know it's the luteal phase. So, yeah, but what's key to remember is that they go through these mood swings, whatever. And then as soon as their period starts, the menstruation starts all the symptoms go away and they come back to normal and that's the key thing. So the diagnosis for this is no test, no, nothing. They keep a diary. And when you see their diary, you realize that they have these mood swings or whatever. Um I wouldn't say they're mood swings at all. I would say that the psychological and emotional symptoms, when you realize a pattern, you realize that they have the um psychological and emotional symptoms just before their periods and then afterwards it comes better. And the key is that you have to monitor them or that you have to see their progression by them keeping a diary over a span of two months. Um So 22 menstrual cycles see, does it happen during the first one? Does it happen during the second one? And when you get that diary and you, and you analyze it and you see it, you realize that the patient has PMS. Um And yeah, so, so again, the symptoms again vary so much, it varies depending on the patient. Some people, again, as I mentioned, some people have mood swings, some people get really fatigued, some people get really angry, some people get a lot of anxiety and some people even get physical symptoms such as bloating and breast pain. And so the diagnosis is a diary across two menstrual cycles. That's important to menstrual cycles. Um And yeah, so that's how you would do it. Now, the definitive diagnosis, which um not a lot of people do. Just because if so the definitive diagnosis is essentially you give them GNI h because it induces menopause. And again, because this case, this condition is very estrogen sensitive when you induce a menopause, the, the the symptoms go away. So, um if they were going through their PMS, um they were in that phase or in their middle phase and you give them the G NH, then it will completely stop the, the, the PMS symptoms. And that's when you know, you've got an official diagnosis of um uh PMS. But like that doesn't happen, obviously, because you're giving someone a medication um just for diagnosis and to hold the menopause uh menstrual cycle, et cetera and you induce temporary menopause in them. Um So, yeah, uh for PMS, the important thing is the symptoms. So you have to know mild, moderate and severe. Um, and all of them are important. So, with mild symptoms, if it's not, if it's like, it's subjective, if you think the patient has mild symptoms, uh, you do conservative measurements. But what's interesting is that you give them regular, frequent meals and they have to be rich in complex carbohydrates. Whereas if it's moderate symptoms and that's when you would add on a medication. Um, however, I've seen that majority of them, like they like for your exams, obviously, like you would do mild and then moderate and severe, but most of the times when you go into actual practice, um they would, they would give the medication and then they would also tell you to have the complex carbohydrates. So, yeah, so your moderate symptoms are new generations of C OCP. They like to use Yasmin cause it's a new one and it works pretty well. Um And it's well tolerated. Um And then if it's very severe, then you would like to give them an SSRI. So, yeah, those are the three things that you should know, mild symptoms, you give them conservative management and the conservative management is frequent meals high in complex carbohydrates. I did try to look up why they wanted something rich in complex carbohydrates, but I haven't come across um sort of like good data or good explanation. So, um yeah, unfortunately, I don't have any more information around why that is, even though it's a very interesting sort of advice to give. Um, but with moderate symptoms again, you give them cop and then severe symptoms you wanna give them SSRI S. Um, so, yeah, that's pretty much it for premenstrual syndrome. Uh, you don't need to know much about it otherwise. Um, no many questions. Ok. Yeah. So there's no questions. Um, yeah, and then the other ones is an ovulatory cycle. Uh, there's nothing, this is, this is a completely separate topic but uh in under the menstruation, there's not a lot that you need to cover for it actually. Um Yeah, at all, like management is these ones, but I'm going to give you these slides which will include all of this anyway. Um So you don't need to worry about that. Um PCOS I will go through next week because this is probably one of the highest yield alongside endometriosis and you need to get your head around this. It's not hard, but it's a lot of information when you read off like a zero to finals in BMJ. And if someone doesn't explain it properly, it can be quite overwhelming, but it's pretty simple to be honest with you if you understand it. Um Yeah, uh, dysfunctional uterine bleeding. I realize that there's not a good of a lot of good sources and the pretty much the only one which I think is worthwhile and which is a good source is the Oxford handbook. Um So this is the, the, that's where I've got all this information from. Um So yeah, yeah, that's pretty much it for menstruation. Um I see no one has any questions. Um So yeah, regarding the slides and everything again, um I won't be back today until like around 12:01 a.m. So I will aim to send the email out again for the first two sessions and slides. Um If you just make sure you fill out the feedback form and I should be able to send because it has gone through majority of the people. But as long as you whatsapp me, then I will send you the first two slides, uh the first two sessions, slides and everything, not the recording. Um But after the last session, which will be on Thursday, um that's when I can send out, uh just make sure that you fill out um all the feedback form on the Thursday and then on the Friday, everyone who's done it, I will send it and if not, then just message me on the whatsapp and just give me your name or the email address. And then if I see you on the feedback form, I'll just send you all the slides and all the recordings via whatsapp because I don't know why it's not sending. If not, I'm just gonna give you my send George's email. Maybe it's my email and it's not going through. So if you're an Imperial, uh if you're a Saint George's student, send it to me on this, maybe it'll work like that. Um So yeah, so, uh if it doesn't come through, just email it, it's better you whatsapp me because I see my whatsapp with emails. I have like four emails. NHS, email and Imperial and Saint George's. So it may be because of that or maybe it's because of you sending it to a different organization. Ok. If you send it to me on whatsapp, then it's fine. Um, Oh, you've also got a Saint George's. Yeah, that's fine. Just send it, just email me on the Saint George's one. But I will s the thing is I would rather just sit down and send it all, all at once. So I'll send everything today or tomorrow for the first two sessions, but for um all of the sessions, I will send a whole chunky email out on Thursday and then I will send out according to everyone who's filled out the prefeedback and postfeedback. That's when I will send out all the slides and all the recordings um for the last and then the attendance for each one of you guys. Um So yeah. Um and then the attendant's name is based on um what you guys write in your uh write on the feedback form, et cetera. So, yeah. Uh Any other questions at all? I have to leave in a minute. Ok. That's fine. Whatsapp number. Yes. If you have any questions, just let me know. Oh, I'll send out the feedback form, but I will send it out at like 12 a.m. or 1 a.m. That's my number. Just message me and I will send it. Ok. Yeah. Um so I've given you all my emails and my number so just message me or email me, I will send it all. Yeah, I think there's a problem. Let me see if I I've had this problem before because yeah, med isn't great. I think I'm gonna up, I'm gonna mention this to the president. Um Hopefully I'm gonna do the next ones on MS teams. Um Not the next one but any future sessions that I do, I'm, I'm sticking with MS teams. Um So yeah, I will make sure to send it out tomorrow ideally cause I can't like one am I'm gonna be sending emails out. Um And then Thursday, I will send out all the feedback forms. Um And then for Friday, I will send out all the slides and all the recording depending on who's filled out the feedback form. And if you haven't received it by Friday, then you whatsapp Me. Um And then I will send it all to you, but everything will be done by the end of Friday. I'm not sending anything else after that. So make sure that if I don't send anything on Friday, you message me on Friday and ask for the slides and everything if you filled out the feedback form. Um So, yeah, OK. I'll see you guys um soon um uh for the last teaching series session. Um So, yeah, thank you very much and hopefully I'll see you on Thursday. Ok, bye.