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do it as well. So I'm I'm happy to be doing this next year. Yeah, perfect. So I think, Yeah, our first slide is, um so we're just gonna go over the content, Um, so we're going to be going over the disorders of menstruation. So this is based on the curriculum that, uh, you guys have appear. Um, so this is the list of what we're going to be going over, and it's going to be in an SBA format, so hopefully, um, it's quite interactive. Okay, Perfect. Next side. Thank you. So, um, this is the first question. I don't know if we're able to get poles up, or you can write on the chat as well. Um, what you think your answer is, But the question is So a 17 year old girl presents to the g p, um, with concerns regarding menstruation, and she's not yet started her period. She's usually fit and well on examination. You know, there's no eggs, Ilary or pubic hair present, and she's relatively tall bilaterally. You can This, um, lower pelvic masses are palpable, and she's got a B m I. That's in the normal range. Um, on blood test it shows that she's got elevated testosterone levels. So what do you think is the most likely diagnosis out of these? Is there a way for us to get the poles up? I don't know if you can do it on here. If it's more soon because I'm sharing. I can't see anything other than my screen, but you might be able to do it in the chat. There'll be a let me see. Mhm. Oh, I'll just give you, like, a minute or two. Okay. So I can see, um, one answer in the chat. Um, so, uh, yeah. Okay. So, yeah, we'll go with that. So the most common answer in the chat is a, uh, which is correct. So, um, this is androgen insensitivity syndrome. Um, next side. So, um, here I've gone over the courses of primary amenorrhea. So with amenorrhea essentially just means lack of menses. Um, primary is when, um, menses or menarche has never occurred. Um, and secondary is when it has occurred previously, but it stopped for over six months with primary menarche. Um, it can either be diagnosed in two ways. The first way is if the patient is over 14 years old and they haven't had their men haven't had menses, and they also have no signs of any SEC secondary sexual characteristics. That's a diagnosis of amenorrhea or if they're older than the age of 16. But they do have secondary sexual characteristics. The most common cause is actually just late puberty, and you tend to find that this runs in families. So mother happened. I've also had similar problems and things like that, and usually those patients' just need reassurance and time. Um, if we go back to the question So, um, this is androgen insensitivity syndrome, which you can tell here because so you can tell it's primary amenorrhea because patient hasn't had, um, they haven't had their menses. They also don't have any sign of pubic hair and things like that. So that's a secondary sexual characteristic. Um, what androgen insensitivity syndrome is is when you have, um uh when you have testosterone receptors that are not as responsive or, um so the testosterone doesn't bind the testosterone receptors. So these patient's actually have XY chromosomes. Um, and, um so, as a result, um, they still have So these bilateral pelvic masses, or actually undescended testes um, so with androgen intense insensitivity syndrome so we can we can go on to the next slide again. Um, you can either get, um, a partial or complete with complete A I s, um You'll see, uh, the the case was there, um, where the patient has, um, externally female genitalia, but with a lack of body hair. But with partial A I s, um you can get ambiguous genitalia. So you might have, um, micro Penis or, um, uh, deferred scrotum and things like that, Um, and sometimes as well. With partial A I s You can notice even more changes when puberty comes along because, uh, just the surgeon test testosterone. So another cause is, um, an imperforate hymen. So in this case, what happens is when the hymen covers the vaginal in troyer's or exit. And essentially, these patient's get very severe pelvic pain. And then you can also see, um, kind of where the menses is meant to be. You can see that on the examination as well. And you just treat that by, um, cutting and removing the hymen, um, things like turner syndrome as well. Um, where they only have one X chromosome they can also cause amenorrhea. So those patient, even though they are being a typically female. But you also notice things like short stature streak ovaries on the trans vaginal ultrasound scan. And, um, they tend to have, like, a broader, broader chest and also, uh, webbing of the neck as well. Um, also, um, Children who have underwent chemotherapy and things like that because it can affect the HBO access. They can also suffer with things like amenorrhea. Yeah, So next question a 25 year old female student presents the GP because of her last menstrual period because of her last menstrual period was five years five months ago. Previously she was having regular periods. Um, since she was 13 years old. A urinary pregnancy test is negative. You order some blood tests which showed that she's got elevated LH and also elevated testosterone levels. Prolactin levels, thyroid function tests, epis age estra estradiol levels are all normal. In this case. What's the most likely diagnosis? So we've gone over primary amenorrhea already, and if this patient she's already known to have her periods, but it's just she just hasn't had periods in about five months. I appreciate I haven't given, um, all of the descriptive factors in this, I just I've only given Yeah, the bloods, I guess. Okay, maybe you haven't actually given, um, enough, because I know that there's a There's a very big mix of, um, answers here. Um, so the answer is actually D um, I know I haven't given all the descriptive factors of polycystic ovarian syndrome, but the main things really are if you've got elevated LH and testosterone, those are typically seen with polycystic ovarian syndrome. With premature ovarian failure, you tend to find elevated t elevated FSH levels as well. And these ones are completely normal. So, um, it's if they've got majorly raised FSH and LH levels. Um, yeah, that's that. You see that with premature ovarian failure with hypothalamic economic amenorrhea again, you're going to see in these ones, you're gonna see low levels of the LH and FSH hypothyroidism you're gonna see, um, low levels of thyroid of t four and t three and hyperprolactinemia you're gonna see raise lactate levels. So this is really diagnosis of exclusion. Really? And that's why it's d. Because it just can't be the rest of them. Yeah, uh, so next night. Perfect. So, um, these are the causes of secondary amenorrhea here. Um, the other things I haven't listed are things obviously like pregnancy, menopause, contraception use. And, um, you can also get, like, lactation or amenorrhea as well. But the main thing to stress about in this case are so you have, uh, HBO access, um, causes. And you also have ovarian and uterine causes. HBO access causes are way more common than the ovarian uterine ones, and they're also probably easy to treat in that way as well. So, um uh, hypothalamic pituitary ovarian axis causes things are going to disrupt that are going to be things like stress. Um, increased exercise and weight loss. Um, so in those cases, um, you can usually treat actually with things like therapy, um, and getting to the root cause of what's happening with these patient's and just encouraging them to, um, gain weight if they are underweight. Um, with things like hyperthyroidism. Oh, sorry. You can actually treat that with Corbyn as all it's not fully written there. And with things like hypoprolactinemia, you can treat that with bromocriptine or um cap ago. Lean as well, just to correct those disorders there, Um, in terms of ovarian and new train courses, most common one is PCOS or polycystic ovarian syndrome. We're going to go into that in a little bit more detail afterwards. Things like premature ovarian failure. Um, they can be caused by things like chemo, autoimmune problems or radiotherapy that's been used previously. Um, similarly resistant ovarian syndrome, um, can present quite similarly to the premature ovarian failure. Um, it's just where, um, the ovaries aren't responding as, um, they should be. Asherman syndrome is where you have inter uterine adhesions, and that can happen after miscarriages and things like that as well. Um, in terms of investigating for both primary and secondary amenorrhea. So with the first thing with secondary amenorrhea is you definitely need to do a pregnancy test just to make sure that patient is not pregnant. Um, very quick and easy to do as well. Um, you want to check the FSH and LH levels? As I said before, If they're both low, then you're thinking of hypothalamic cause if they're high, um, then you're thinking of either premature ovarian failure or the resistant ovarian syndrome. Check their thyroid tests, check their product in. And you can also do pelvic ultrasound scan to check for things like Asherman syndrome. Also, to check the PCOS and, um, in terms of management, Um uh, it's so, um, some of them are already listed up there, but you can give hormone replacement therapy. Um, for those with premature ovarian failure, um, that can help with symptoms. Yeah, perfect. So the next question 20 year old female presented the GP because of irregular periods over the past year. Um, she's currently five days is Currently she has five days of heavy menstrual bleeding every 72 days. Her periods were regular previously, and they were every 28 days. She's what? Background History of acne. On examination you've noticed she's got raised VMI. She's got facial hair noted, and trans vaginal ultrasound scan shows 14 following calls. I don't really What is the most likely diagnosis? So lots of answers, which is good. I think it's a spot diagnosis for any. Okay, so I think we've got enough answers anyway, Um, so as you can see the chat, most of the answers here are B, which is, um, completely right. So, um, if we go into the next side. Yeah, so, um uh, the answer there was, um, Polycystic Ovarian syndrome. And as you can see here, um, the reason why it is is because of this criteria. Sorry. Um, so this patient score oligomenorrhea she's got, um, signs of hirsutism as well. And she's also got, uh, polycystic ovaries confirmed on the ultrasound scan as well. So, um, that's enough To fulfill the criteria, you only need two of the three. But in terms of the, uh, in terms of the epidemiology and things like that, it's very common, actually effects between 5 to 20% of women. And you have all those symptoms that we have already been talking about. Um uh, so you get you can also see that, uh, high percentage of women with PCOS are obese as well. Um, so it's difficult to tell whether um, obesity increases the risk of PCOS or whether PCOS actually increases the risk of obesity. Um, but yeah, you also tend to find that they have high insulin levels. They're more likely to get things like type two diabetes, but also gestational diabetes. And, um, they can they can develop things like acanthosis nigricans as well because of the insulin resistance. And that's something that you can find on the examination and yet also symptoms of metabolic syndrome. So obesity, high BP and things like that in terms of the blood in terms of the investigations, you want to check the FSH and LH levels, they're going to have a high LH FSH ray CEO check their thyroid function tests as well. Um, just to exclude any, um uh, hypothyroidism, um, you check their pros acting and their testosterone levels. Testosterone levels are normally on the higher side. And just check for any sign of glucose intolerance, too. Next slide. And, um, in terms of complications. As I said, high number of patient's with PCOS are obese. Um, but they're also more likely to get things like sub fertility miscarriages. And they're more like to get things like endometrial cancer as well, because, um, because they're not bleeding as frequently. That's the reason why they're more likely to get endometrial cancer because it gives more time for the endometrial lining to thicken up. And um uh, for, um, I guess dyskaryosis and things like that to occur, um, in order to reduce the risk of things in order to help with the symptoms as well. Um, you can try all these patient's on the combined pill or, um, the progesterone only pill or the marina coil. And, um, you also want to, um, reduce their cardiovascular risk as well. Um, but generally we want to take a holistic approach with these patient's, um, because, um, lots of the complications as well can affect things like their mental health. So if, um uh, so you want to ensure that these patient's are being looked after in, like an M D T approach? Really? Um, the main things really are conservative. Management is always really good, asking them to lose weight if they're overweight, increasing exercise and stopping smoking. Always good in terms of the hirsutism. You can treat that cosmetically, um, things like laser hair removal and things like that. But you can also have anti androgen creams. If they've got male pattern hair loss, that's a bit more difficult to treat. Um, yeah, Essentially, um, you can start these patient's on the combined pill. Like I said as well. Um, for, um, the oligo amenorrhea. And in terms of fertility counseling, losing weight, you can use things like Clomiphene and, um oh, very clomiphene first line, um, to stimulate ovulation. But also things like ovarian drilling can also be used. And, um, if nothing seems to help, you can, um, council these patents and try IVF. Perfect. I feel like we're living through uh, so yeah, the next question is, um, 30 year old female. She presents with chronic pelvic pain that starts days before her menses on examination, you know that there's reduced, um, organ motility, um, um of the uterus. Um, she's all she's got a known diagnosis of endometriosis. So what is the gold standard diagnostic test for endometriosis? Okay, so we've got a couple of answers through I'll just give, like, a minute or so. Okay. Yeah. So, um, in the chat, you can see as well. The main answer here is a, um, a laparoscopic approach. And that's the right answer. So, um, I remember when I learned this this really surprised me because I didn't expect the first line to be as invasive. Really? Well, the gold standard to be as invasive, but the main thing really is you need to visualize the endometrial tissue. Um, outside of the um, outside of the uterine cavity. And so that's why they Yeah. Um, next slide, please. Perfect. So this brings us onto the topic of dysmenorrhea, which is painful periods. So this is a bit up into primary and secondary. Essentially, primary means that there's no underlying secondary pathology that's noted, and dysmenorrhea actually affects about half of women, Um, and usually starts 1 to 2 years into menarche. Um, it can sometimes be quite debilitating for some patient's. And the first line is pain management NSAIDs, um, our first line. And you can try things like meth anomic acid. Second line is the combined pill, Um, in terms of secondary, so we'll go over. So the main causes of secondary things are things like IUD s they can cause quite significant dysmenorrhea pelvic inflammatory disease, endometriosis as well, which we're going to go into a night a bit of detail adenomyosis as well and fibroids. So we're going to go over all of them, and sometimes as well you notice that the pain start before the period actually comes on. So, um, in terms of endometriosis, which is what the patient in this case had, um, you find that the endometrial tissue is outside of the uterine cavity. And this affects, um oh, doesn't affect 10% of women, but affects. Um I'm not actually sure where that's written there. That's not It doesn't affect 10% of women. Um, but in terms of, I'll remove that afterwards in terms of, um, features of it. So it's chronic pelvic pain. You get deep pelvic pain as well. And, um, yeah, pain during during the period. Um, it starts days before the bleeding comes on. Um, you also notice that patient's have sub fertility and they can get things like this cheesy A so pain on passing stool and also dysuria so pain on urination. Um, because of essentially, you've got, um, you've essentially got endometrial tissue all throughout the abdominal cavity, so that can just cause chronic pains across the abdomen. And because of these, they're essentially they're similar to adhesions. So that's why if they're all over the uterus, that's the reason why you get reduced motility. Because essentially, they're just anchoring the uterus on two different parts of the abdomen. Um, so, yes, that's where you get the reduced mobility motility they have. Um, they have, um pain notice on examination as well. And, um, sometimes you might be able to visualize the endometriosis, But the main way to visualize it is to do, um, is to do in that process Coptic procedure, too, just so that you can actually see. And sometimes as well you can biopsy, um, these, uh, this endometrial tissue just to make sure that there's nothing else going on in terms of management. Main first thing is N says meth anomic acid. You can use the pill, um, the combined or the progesterone only IUD s and order it ideas. But I U s s can be helpful, but sometimes they can actually just worsen the pain. So, um, yeah, um, you can use gnrh analog as well. They reduce the estrogen levels and so they can inhibit the endometrial growth both inside and outside of the uterus. Um, and also you can use you can do laproscopic eXistenZ as well when you're visualizing Um, yeah, essentially, every time that you're gonna be doing, um, if you're going to be doing any abdominal surgery on anyone, you can increase the risk of adhesions as well, and these things will grow back. Um in terms of complications. Um, you can end up with a ruptured endometrium are that's going to cause severe pain. And it's also going to, um, build, um, increase the amount of fluid within the purpose as well. And also patient's with endometriosis are more likely to get ectopic pregnancies as well. Yeah, okay. And add endomyosis, um, similar, I guess, to endometriosis. But it's when you have endometrial tissue within the myometrium. So that's the muscle layer of the uterus. Um, this is more common in patient's who have had multiple Children, and it's usually more common at the end, Uh, at the end of the reproductive years. So, um, just think I was just thinking about Mom's as a classic patient who, um, in terms of the features, they get painful, heavy periods, and they have a large boggy uterus as well. Um, you can use ultrasound scan to diagnose these patient's. Essentially, you're looking for when I say ecogenicity. What I mean is, you're looking to see the different types of tissue within the myometrium so you can see that on the uterus you might be able to see, um uh, that the uterus that the my mutual lining has got different types of tissue there. It's not all the same. Um uh, same thickness and things like that. MRI is a much better study in order to look at this, but it's not as relatively available again. Same things, Um, in terms of analgesia, you want to use things like NSAIDs, meth, anomic acid, things like the combined pill progesterone, only Marina. They can all help. Same as with endometriosis. And the only definitive management really is to do a hysterectomy. Um, but that's obviously for patient's who have already completed their families, and they don't wish to have any more Children. Perfect. Um, just one thing I want to note with endometriosis as well. Um, they have they usually have sub fertility, and that's something that these patient's need to be cancel counseled on as well. Um, and it's a very debilitating disease. So, um, they usually suffer with chronic pains. So, um, counseling and just managing these patient's in holistic approach is really important. Yeah, this is the next question. So a six year old female presents with heavy PV bleeding. Um, menopause. Menopause occurred, not started. Occurred at age 52. Um, she now has actually Sorry, I think, um, Samiha. Sorry. So I just, um I don't I don't know if, um if you re if you refresh the page, I think there's actually a different question there. Just move the questions around a little bit. I don't know if it don't if it will work. Yeah, that's perfect. Okay, no worries. Let me put it back in. Thank you so much. So this is actually the fifth question. 20 year old female friends with heavy menstrual bleeding to the GP. Usually fit and well, what is the most common cause of disordered menstrual bleeding, so I'll just give, like, a minute or so for people to answer. So the reason why I actually put in this question quite last minute was because when I learned this answer, it actually made me laugh. So the answer is actually a So, um, the most common cause of, um, heavy menstrual bleeding menorrhagia or disorder? Menstrual bleeding is actually just dysfunction, not dysfunctional. You try and bleeding when there's no underlying pathology. That's noted. So, um, the answer is a essentially, but we'll be We'll be going over the different things as well. So next slide, please. So, yeah, As I said, um, uh, the most common cause of menor Asia is just dysfunctional uterine bleeding. When there's no underlying pathology, a patient has got diagnosed menorrhagia if the patient thinks that they have menorrhagia so essentially they used to be guidelines where, like if the patient's passing, um, like X amount of units or um or x amount of, uh, if she's going through this many pads, those kind of things. But they've changed it now she's a bit more broad. If the patient believes that they're bleeding, it's excessive. Then you will treat it as that essentially. And, um so the main thing is, so yeah, so dysfunctional. You try. Bleeding is the most common cause, But other things like fibroids, hypothyroidism, IUD s can also cause that as well. Um, so the copper coil, um, and public inflammatory disease and also some bleeding disorders as well. So with the bleeding disorders, you might notice that there's a familial history there and also save the patient has had, um, bleeding from other sites as well. So say if they get recurrent nosebleeds or recurrent bruising or bleeding from other areas of their body then that's going to make that bit more likely, Um, in terms of, um, the investigations, the main things you want to check for our full blood count, you want to make sure the patient's not anemic. Um, you also want to check things like their ferritin levels and iron levels. Um, and just assess if they've got any, any symptoms of anemia, too, Um, in terms of coagulation screen. As I said, if they if they've had heavy menorrhagia since their periods have started or there's any family histories or that's going to make it more likely, um, check for their thyroid function tests Um, uh, if they've got other signs of hypothyroidism and, um, you want to do the trans vaginal ultrasound scan as well, um, if they have any symptoms that suggest that, um, they might have, uh, public inflammatory disease or any kind of fibroids or things like that, that might be happening. Um, in terms of management, if the patient doesn't want contraception or doesn't need contraception, um, then you want to give meth anomic acid or tranexamic acid. Essentially, um, if the patient does want contraception, then you want to try things like the i us to the marina coil first line. But you can also try things like the combined pill or the progesterone only pill. Um, surgically, you can do an endometrial ablation with, essentially where you just burn away the endometrial lining. But that's only for people who have you want complete, I guess. Contraception and have completed their families. Yeah. So we're going to move on to fibroids now. So, um, these are small muscle tumor's. They're benign. Um, they affect half of black women in their late years and 1/5 of Caucasian women. Um, they have a high association with estrogen, so you actually tend to see that, um after menopause, the fibroids tend to regress, or they don't tend to be as common after menopause. And, um, they're very rare before puberty as well, because of the fact that they respond to estrogen. And that's what causes them to increase in size. Um, you can get different symptoms. So as you can see, there's those are different sites that the fibroids can occur on. But this sub mucosal layer here essentially because that increases the surface area of the endometrial lining. That's what's going to be you if you have menorrhagia, that's where your fibroids are going to be. Um, but depending on where the fibroids are, depending on how big they are, you're going to get different symptoms so you can get mass effects as well. So you can get, um, increased urinary frequency hydronephrosis as well. If there's a backlog of the urine constipation, um, and dysuria as well as mass effects. Uh, it can also cause pain as well, Especially if the fibroids have, um, twisted. And essentially, that's gonna cause decreased blood supply there as well. And so that's what's going to cause, um, severe pain. Um, and it can also cause some self fertility, depending on which type of fibroids they are. But but also because they change the shape of the uterus. Um, in terms of, um, complications. So fibroids can increase in size during pregnancy. And so, um, if they grow and they outgrow their blood supply, essentially, that's going to cause the fibroid to breakdown. Become necrotic and, um and, uh, yeah, it's going to cause extreme pain there because of the necrotic tissue. And um, yeah, um, those things they can regress, um, and go back into the body, but it's going to cause extreme pain. So next side, um, in terms of diagnosis is with ultrasound scan so that you can visualize the fibroids. Um, management takes different forms. Um, again, it depends on whether or not the patient, um, has completed their family or not. And, um, if once you've canceled them about fertility, um, in terms of symptom control, R us is always good, um, again, it can decrease the size of the endometrial lining as well. So it's going to help with things like menorrhagia tranexamic acid and said combined pill. Just don't only pill, um, all help with that as well. Um, you can do surgery to just physically remove the fibroids before the surgery. You can give g n I h agonists and essentially they reduce the side of the size of the fibroid so it can make them more manageable. I mean that essentially, there's less scarring of the uterus Afterwards. Um, you can do, um So, as I said, you can do a myomectomy. Remove the fibroid itself. Um, you can do endometrial ablation, remove the lining of the endometrium, or you can do a complete hysterectomy as well. and but those are the people who essentially won't complete. Um uh who? Yeah, who, um, Who have no issues essentially with their fertility and completed their families. Main complication is adhesions and adhesions can lead to pain, and they can lead to things like small bowel obstruction as well. And also in the surgery you can also get You can also get damage to the uterus. Um, to get you can also get damage to the uterus to the bladder and the ureters, but they're a lot less common. Perfect. So this is the last question, um, a six year old female presents due to heavy PV bleeding. Um, menopause occurred for her age 52. Um, she's had PV bleeding persistently over the past six weeks, and she's presenting just because of the ongoing discomfort associated with the bleeding was the most likely diagnosis in this case. So I see a couple answers, which are good. Okay, so I think I'm looking at the answers, and I think you guys already know here, but yeah, the answer here is d um, any lady with post menopausal bleeding is endometrial cancer. Until proven otherwise. So, yes, it's good that all of you guys have to Dundee. Um, So, um, next slide, please. So, um, we're going to go on to post menopausal bleeding here. Um and, um yeah, As I said, any, um so essentially, menopause is classified where you haven't had your period in 12 months. Um and, um, women with. So even if the patient's on HRT and things like that, you still need to, uh, but they've got, um postmenopausal bleeding. Um, still, you need to invest save endometrial cancer. That's just the main thing. Any patient that you come across with post menopausal bleeding, you need to exclude endometrial cancer. Um, but, yeah, other courses of, um, postmenopausal bleeding can be things like vaginal atrophy. So you could just actually be getting some quite superficial bleeding there because of the fact that, um uh, with with reduced estrogen levels, you can get drying up at the vagina, and so that can just cause them to bleed. Um, uh, you can also get endometrial hyperplasia. That's not the exact same as cancer, but it's a precursor there. And, um, risk factors, um, to endometrial cancer. Are things like, um yeah, obesity, PCOS, type two diabetes and being on tamoxifen as well. Um, essentially rarer things as well are things like bleeding disorders. Um, you want to investigate these patient's under the two week wait rule, And you just want to be doing, um, an ultrasound scan to check for the endometrial lining. Um, you can also do biopsy as well. Um, in terms of the immediate testing that you can do in the G P, you can do things like blood tests, and you can just do a urine dip as well, just to see if there's any other sources of bleeding. Yeah, As I said, um, trans vaginal ultrasound scan and biopsy of the main things, um, CT and MRI are usually, um, they're usually to assess for spread normally. Um, once after you've done your, um, your initial investigations. Yeah. Next slide, please. Perfect. And, um, treatment if there is, um, uh, post mental. If there is endometrial cancer, um, you're going to refer that patient on for secondary support there, and Yeah, relevant. Um, I think we went. I went over this on my last lecture, so more information will be there. Really? Um, if there is vaginal atrophy, just secondary to low estrogen levels. You can give those things topically. Um, you can also use HRT if the patient's experiencing other symptoms of menopause. Um, before you start HRT, make sure you cancel the patient about the risks and things like that First, um, And, um with endometrial hyperplasia, uh, diagnosed patient and curettage there. The main things we need just to remove that excess tissue, Um, in terms of, um, other types of bleeding so you can get, um, inter menstrual bleeding. And you can also get postcoital bleeding. Um, with both of them, Um, uh, So the most common causes get actually gonna be cervical ectropion in. That's more common on ladies on the pill. But you also want to exclude things like cancers, polyps, trauma and infection as well. Yeah, and this is the last slide. I didn't really have a question for this one, but, uh, I just thought I'd mention it, um, PMS premenstrual syndrome. Um, it can be different. Um, so you can get different. Severity is that's what I mean, uh, based, um uh, from patient to patient. Um, some patient's, um, will experience depression, anxiety, um, extreme irritability and mood swings prior to their period's starting. They may also get, um, uh, pain. So, uh, so nostalgia breast pain and also associated bloating and other physical symptoms as well. Um, in terms of management again, as with some of these other conditions I mentioned, it's good to take a holistic approach with these patient's. And, um, you always want to start conservatively, really, to just encourage good sleep hygiene, good diet, good exercise and things to help reduce their stress, including things like therapy. The combined pill can help with symptoms. Um, and it will regulate their periods as well. And you can also start things like SSRI is if the patient's experiencing more. Um, I guess psychological, um, issues associated with their PMS. So yes, uh, also a very quick whistlestop tour of mental disorders. Um, if anybody has any questions, you can put them on the chat things like that or feel free to a mute. Um, I'll look to any questions, have my recollect. You want sex on you? Oh, no worries, guys. I'm sorry. I felt like the sides were a bit wordy. I might add some