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Well, I'm gonna be talking through some gynecology stuff today. I know that I think Laura was one of the previous people who spoke and I think she did a mix of OBS and Gynie. So hopefully, between us, we won't have too much overlap because I'm not doing as much acute stuff as she covered. So I'm fellow imperial uh ex student. I graduated nearly six years ago now, which feels crazy. I'm currently doing research at Queen Charlotte's and I've kind of always done OBS and Ghani stuff. So I integrated in OBS in Guinea and then did an AFP in women's house. And now I'm doing my specialty training in Northwest TEM. So, although life has changed a lot, I haven't moved geographically very far. Um And it's a great career and if anybody wants to get in touch with me about a career in of Cingrani, I'm always happy to support people who have gone through the same path that I have. So essentially this is a, this is a quite a heavy topic and I've tried to provide a lot of information that will be useful at a later date. So previous feedback I've had is that there's not been enough time to cover everything or that's intentional. So there is more in for information on these slides, then I can give you in 45 minutes. The committee will have access to the slides and understand and being recorded. So hopefully all of the information will be available to you at a later date. So please do not try and scribble down notes urgently. You will be given this information. So we're going to break into two sessions first doing any cancer and you're a guinea which quite surgical sides, Robson Gynie. And then we'll move more into the reproductive medicine and benign Gynie side of things. Um I can't see the group chat. So if somebody's got questions, uh please just interrupt me and I will try and have a look at the chat, but I don't know how to do that myself. If you, if you have your phone, you could potentially set up teams on your phone on the side um to see the chat. But if not, we can, we can then interrupt and speak out any questions that why don't you just periodically interrupt me because I've got two screens and I think a third might be too much for me. Sure. Ok. Um So just to say, I've written all these questions, if anything I say is not in line with what imperial have told you, go with what imperial have told you because they're the ones that sit that right, your exam. So without further a do, we're going to go through some S P A s. So I'll give you sort of, I'll read out the question, then give you about 10 seconds after I've read it, try and get the answers and then we'll go through the answers and a bit of an explanation about why. So hopefully these are relatively at the level of your exams. So question number one, 65 year old woman presents to her GP with episodes of heavy vaginal bleeding with clots. Over two weeks. She completed her menopause at the age of 52. What would be the most appropriate next step in her management? One commenced norethisterone to referral to rapid access clinic under two week, wait three urgent ct abdomen and pelvis. Four urgency, a 125 level or five urgent trans vaginal ultrasound. Okay. Yeah. And I move on. Someone says something I'm gonna move on. Um which HPV subtypes are screened for at cervical cancer screening. Is it 21 20 for 6, 11, 21 20 for 16 and 18, 6 and 11 or 6, 11, 16 and 18. Getting a lot of three in the chat. Oh, so uh that's good. I will go through the answer to you in a second but I like the interactive nature. I will tell you the answers. I'm trying to do a bit like an exam. Um which type of ovarian cancer is derived from primary embryonic germ layers. So, borderline epithelial granulosa cell fibroma or immature territo hma. Okay. Question number four. 22 year old girl presents a rapid access clinic with persistent bloating. 5 kg weight loss and lower abdominal pain. Abdominal examination demonstrates 10 societies V reveals a mobile antiverted uterus with a firm right sided adnexal mass. What would be the most appropriate next step in her management, staging ct chest abdomen, pelvis, admit for inpatient investigations, urgent ultrasound abdomen, pelvis, referred to medical oncology or admit for a same day th BSO. So that's total abdominal hysterectomy and bilateral salpingo oophorectomy. I'm going to log into teams on my phone while you're thinking of this. So I can see what people are typing but we will go through the answers together in a minute if I could work out how to get teams up uh join. It's okay. Next is question number five. Last question of this section. So an 84 year old woman presents with persistent Volvo itching and has noticed some spots of blood on wiping, which is the following features of her history would make you most concerned regarding valve, all cancer, a personal history of atrophic vaginitis, lichen sclerosis like um planus Volvo vagin itis or lichen simplex. Okay. It won't let me log in on my phone. So I'm just gonna see if there is a way but I can change my display settings. Oops. Okay. That's not what I wanted. To do. Okay, let me just try and fix this so I can see what's going on at the same time. It keeps going into presenter mode. I don't know why unless I do this. Okay. Don't worry about it. Right. So let's go through the answers. So, um answers. So, question number one, what did most people put in the chat? You seem to be the most popular answer? Great. Perfect. So um correct question number two. So the main thing is that this is a post menopausal woman. So, postmenopausal bleeding is endometrial cancer until proven otherwise. So when you want to think about causes of post menopausal bleeding, I tend to think about it in terms of the anatomy. So if you just imagine this diagram in your head, if you're in your paces, you can then just come up with all the causes if somebody says what your differentials for PNB. So you can think, okay. Is it coming from the vagina itself? So it could be a vaginal cancer or atrophic vaginitis, then you can move up. So the cervix, okay. Could it be a cervical cancer or a polyp and then moving up into the uterus itself? So, bleeding from the endometrium? So is it hyperplasia of the endometrium atypical hyperplasia or an endometrial cancer? And then you can think also about vulva cancers. So Volvo intraepithelial neoplasia, which is a bit like see a A C I N that you get with cervical cancer, but it's in the vulvar or it could be a Volvo cancer. You can get bleeding with ovarian cancers, but that tends to be with the hormone secreted tumours. So, sex cord stromal tumours and then much less common in post menopausal women, you tend to see them in young women, but it is possible. But your standard sort of serious ovarian cancer or Mucinex, ovarian cancer doesn't really cause you to have vaginal bleeding. So when you're thinking about diagnosing endometrial cancer, you'll refer someone to a two week wait clinic and they will have like a one stop service. So they'll all have ideally a trans vaginal ultrasound which allows you to accurately assess the endometrium. And in a postmenopausal woman, you expect the endometrium to be under four millimeters, anything over four millimeters, you think? Okay, we need to do some sort of investigations. So in a clinic setting, you can do a purple biopsy, which is basically do a speculum. You put a little tube through the cervix and you suck out themselves from the um you try and cavity and you could send that off for histology. But ideally what you'd want to do is organize a hysteroscopy. So you could actually properly visualize the cavity. 90% of endometrial cancers are adenocarcinomas and they can be estrogen dependent or non estrogen dependent. And the east independent ones are much more common. So the risk factors for Easter independent cancers are basically being exposed to too much estrogen. So whether that be having a history of obesity, sub fertility policy, polycystic ovaries, um tamoxifen use and they tend to be the endometrioid carcinomas. And you can then have the non issue independent cancers which have a poor prognosis. And those are the or serious and clear cell cancers, uterine sarcoma, zara bit different. They arise from this muscle of the uterus. So you can develop a leiomyosarcoma or some other rare types of sarcoma is and those have a much poorer prognosis. So anyone presenting with P M B or unscheduled bleeding on HRT or bleeding between her periods or really heavy long periods, you should examine her abdomen, perform a speculum and do a pelvic examinations. That's usually a by manual examination. Um Essentially trans, as I said, trans vaginal ultrasound is the investigation of choice. And anybody over four millimeters will need a biopsy ideally via hysteroscopy. For those of you who haven't done obscene gyne yet. This is what a hysteroscopy up looks like. So you can, well, actually this is more of a propel. So it's a little thing that goes through the cervix and you can suck out a sample of endometrium. And then a hysteroscope is a rigid thing that inflates the cavity with water and allows you to visualize the endometrial lining. So when you're thinking about the management of invented endometrial cancer, I know this is quite a busy slide, but for early stage disease. So stage one and stage two disease. So sort of confined to the uterus really, you can perform a history hysterectomy and bilateral salpingo oophorectomy to remove the uterus tubes, cervix and ovaries. Um You don't necessarily have to remove the lymph nodes. At that point. For more advanced disease, you may have to do a more advanced debulking. So removing um other tissues and mostly the lymph nodes. Um but it doesn't necessarily prolong your survival. And then this is a summary of the staging. So the question that everybody kind of asks is, well, when do I refer a patient for two week? Wait. So for endometrium, it's really straightforward if they're postmenopausal. Um and they're bleeding, you will refer them for two week. Wait for Volvo cancer. Again, it's quite vague and unexplained Volvo lump, ulceration or bleeding for vaginal. Again, a palpable mass inside the vagina or at the entrance of the vagina and cervical cancer, we'll obviously women will want to go screening will come on to talk about cervical cancer in a moment. But if you look at someone's cervix and you think it looks like cancer, you can refer them to colposcopy under a two week. Wait. Does anybody have any questions about anything I've said so far? I'm going to take that as a no. Then. So moving on to question too, I seem to recall lots of people put three in the answer to this. So that's great. Um So yes, the correct answer is that HPV, screening, uh, cervical screening looks at HPV subtypes 16 and 18. Now, the reason for that is because those are the ones that are high risk HPV strains and lead to cervical cancer. So, over 90% of cervical cancers. Oh, hello. Oh, maybe not the majority of squamous cell cancers and they are highly associated with HPV. So since the introduction of the HPV, vaccination rates of, um, cervical cancer are declining. And that's really good news. However, people do need to continue to come for the smears because not all cases are associated with high risk HPV. So the new protocol, it's not like new any anymore really. But um what used to happen was that you would take a smear test and send the cells off for cytology and then people would look at the cells under the microscope and work out whether there were any atypical cells, any dis carry ah tick cells. However, now what we do is we screen all the samples for HPV in the first instance. And if they have high risk HPV, then we look at the cells if you haven't done obscene gone yet or if you're doing it at the moment, make sure that you go to a Colposcopy clinic because then it will just make sense about what we mean when we say we apply acetic acid. So you basically put acetic acid and iodine on the cervix and areas of uh of uh C I N will show up. So you'll be able to see the areas that require biopsies. If you're worried about cancer. If you diagnose malignancy, then you need to do some cross sectional imaging. So usually a CT or MRI scan uh in order to stage them. So, microinvasive disease. So that stage one A is you just do a, let's procedure or cone biopsy, they're the same thing, but essentially, it's like pouring out an apple. So you just remove the inside of the cervix. And that allows you to remove the cancer on block. Anything more advanced than that will require surgery plus or minus chemo radiotherapy. So for stage 1 to 2 A cancers, they usually require radical hysterectomy, um or radical trachelectomy. So if they cervical cancer patient's tend to be young, unfortunately. And so if they want to preserve their fertility, you remove the cervix and then all of the tissue to either side of the cervix in order to preserve the uterine body. But otherwise you'll just remove the whole uterus if they have had Children or if they don't wish to have Children. And if there's any evidence that they had positive lymph nodes on that dissection, then you would give them chemo radiotherapy. And unfortunately, if they're above stage to be, then they usually just treated with chemo radiotherapy. In the first instance, any questions about any of that, we had a question for the earlier section on Endometrial cancer uh it goes are the ovaries not preserved in endometrial cancer, early stages because it is estrogen sensitive. So essentially the reason that you don't leave the ovaries in is because they're normally they're postmenopausal women. So, um the ovaries are doing nothing and they provide a risk of risk for you developing um endometrium, uh ovarian cancer in the future. So for a post menopausal women, you would definitely remove her ovaries. Now, the other thing, if I go back to the slide, there is a risk of the cancer spreading to the ovary as well. So if you're performing surgery, the safest thing to do is to remove the ovaries at the same time because that allows you to then look for any microscopic spread of cancer which would upstage you from a 22 or three. Does that make sense? Yes, perfect. And obviously, if you're under um uh if you're premenopausal with endometrial cancer, then there will be a discussion about fertility preservation prior to your surgery. So whether you would want to have some eggs harvested before, so that you could then have a pregnancy via surrogacy in the future. Okay. Question number three. Do people get this one? Right. Yes, I think so. I think this is when people stopped replying in the chat, but I think thank you. Excellent. Okay. Right. I'll just start talking then. Brilliant. So, immature teratoma. So, um oh yes, I'm going to go through both of these together So, and then question number four, the 22 year old girl with weight loss and a poppel abdominal mass. Um And you think she's got uh probably an ovarian malignancy. She would require out of these options and urgent ultrasound abdomen and pelvis. So we'll come onto all of that now. So this is my very simple diagram of an ovary. So essentially you've got the skin of the ovary. So the epithelium and then you have the stroma, which is the kind of connective tissue holding everything together. And then you have your follicles and in each follicle, you'll have an egg, which is a type of germ cell. So if you think about where ovarian cancers come from, you can basically pin them to one of the three layers, the epithelium, the streamer or the germ cell. So, epithelial ovarian cancers are the most common type of ovarian cancer in women over the age of 20. And they tend to be um uh most common one is a serious adenocarcinomas or mutinous adenocarcinomas. You can also get borderline tumors which are kind of like pre cancerous cysts, which have some suspicious features to make you think that they could become malignant and they have about a 20% chance of recurring once you've removed them, uh you have rare types of epithelial cancers such as endometrioid cancers or clear selk um carcinomas within your stroma. So you get your sex cord stromal tumor is, these tend to be your hormone secreted tumor's. So these are your granulosus sale tumor's and then your fibromas are benign. And then from your germ cells, you can get basically teratoma czar benign and then you can get dysgerminoma is which are malignant and then rarer types of cancers. So your embryo nulle cancers um and things like that uh you choriocarcinoma as. So that's essentially where they come from. So the nice guidance in terms of a primary care perspective, because in your paces, you may find yourself being a GP meeting a woman with an ovarian mass rather than being a doctor in a, in a gynecology clinic. So the way you manage these things will be slightly different. Um So if you're in G P land, um if you examine a patient with ascites or a pelvic or abdominal mass, then you refer them under two week, wait to have um uh to have cross sectional imaging um and an assessment by a gynecologist. If you have a woman with less specific symptoms, then you start investigating them in primary care. So women with vague symptoms, especially those over the age of 50 with persistent bloating, feeling full hell vic pain, changing urinary habit, then you might consider carrying out specific tests. So the here you ask, what are those tests? Well, the first one is A C A 125. So if the C R M C A 125, which is a tumor marker for ovarian cancer is over 35. Then you'll organize an ultrasound of the abdomen and pelvis. And then if the ultrasound suggests ovarian cancer, then you refer her on under two week. Wait. So, um that's essentially what I've just said. Um, if you see the patient in secondary care, you'll meet the patient, examine their abdomen. Do the bloods, look at their tumor markers, alpha feta protein HCG for your germ cell tumor is in women under 40. And you'll organize an ultrasound, the abdomen pelvis. And if you see a mass that looks like cancer, then you'll organize a CT chest abdomen and pelvis. And if, despite that imaging, you're not sure what it is, you can also do an MRI. So how do you manage ovarian cancer? Well, there's conservative medical and surgical approaches and that depends on the stage the fitness of the patient. Um, and they're sort of treatment preferences. So if it's a particularly um frail patient with a poor baseline, you might just perform conservative management. So best supportive care, especially if they have advanced disease. However, if they have um good reserve, then you'll refer them for surgery. So this is normally quite radical surgery in the case of ovarian cancer. And you can debulking people who are stage three C ovarian cancers. So you perform what's called either primary or interval debulking. So, primary debulking is when you go and you operate on somebody with disseminated ovarian cancer before they've had any chemotherapy. So you remove all of the microscopic disease from the abdomen all the way from the pelvis to the diaphragm. And then you offer them chemotherapy afterwards. And then if you, some centers don't do it that way around, some centers will give people three cycles of chemotherapy, then they'll d bulk them such your interval debulking and then you'll have the other three cycles of chemotherapy. After that, different centers seem to have different preferences on this. At Queen Charlotte's, we tend to do primary debulking. However, if you open someone and you find that they've got disseminated tiny disease like miliary disease, then you might close them to give them chemotherapy and then come back and do an interval debug the medical management. So chemotherapy, you tend to use a tax allow and then a platinum based. So um usually paclitaxel and then CISplatin or carbon platin. And then um new monoclonal antibody a vast in um is now routinely used in the NHS as well for advanced ovarian cancers. Does anybody have any questions about ovarian cancer? I have a good question about whether you do whether the ultrasound is trans vaginal or whether it's like a donor. So generally speaking, if you have a patient with a palpable mass, you would start doing a trans vaginal ultrasound. Um because you can actually assess a lot more than you think on TV, ultrasounds. So you can have a look at the bladder, you can look at the ureters, you can look at the rectal vaginal space. Um You can see if there's free fluid in the pelvis. If it's a small mass, which might not necessarily be palpable per abdomen, then you would definitely want to assess it on TV. View because you get a much better picture. However, if you have a large abdominal mass, you'll actually probably get better views on a ta assessment. But usually all of them will have a TV plus um abdominal ultrasound and we routinely will do that in clinic. We'll scan them internally and also over the abdomen. Thank you. Thank you. Hi. Sorry, I just had another question. Um I just got a bit confused. Um, actually in the G P setting, if the patient comes to you with suspected ovarian cancer, so you always do the cerium, um see a 125 1st and then the two week wait depending on the, on the results or essentially if they have a palpable abdominal mass. So you think they have ovarian cancer, you're 100% sure. Based on your examination, then you just go straight for two week. Wait. However, if they don't have a palpable abdominal mass and they have all of those kind of non specific ovarian cancer signs that we hear a lot about, then you will send off to do S C A 125. If that's the A 125 comes back raised, then you'll organize an outpatient ultrasound urgent. And then if that shows something suspicious, then you refer them under two week wait, once they arrive in primary care. So let's say I examine the patient in G P and she had a powerful mass and then I referred her in and the doctor receiving her as secondary care would then do a C A 125 for her in the clinic. If I was a very good G P, I might have done it before I even sent her. Um And then I as the, as the gynecologist would organize an ultrasound of her abdomen and pelvis and then if that confirmed ovarian cancer, then I would do a staging ct. Does that make sense? Yeah. Yeah. Thanks. Right. Any other? Yeah. Sorry. I just had a question. Um My question was more regarding the staging and if you could just go through more specifically through the subtypes. So for example, the differences between one A one and B one C. Yeah. Yeah. Absolutely. So stage one, ovarian cancer has quite a good five year survival. So up to 90%. So stage one, you can break it down. So one A is that it's in just one ovary. One B is that it's in both ovaries and see is that it looks like it's just in both ovaries. But when you do cytology, you realize that actually it's breached the capsule of the ovary or in your, in your washings, you find tumor cells. So that suggests that it's um, breach the capsule of the ovary. Then if you move to stage two, but that means that your, that the cells have spread from not just the ovaries but into other parts of the pelvis, but it hasn't left the pelvis yet. So it may be on the tube if it's a one, a two a or it might be sitting on the bladder if it's a to be, or you upstate it to a, to see if it's um if it's got again, positive personal washings, um then if you move to stage three, that means it's anywhere between the rectum and the diaphragm. So, cancer cells disseminated throughout the abdomen but they haven't spread outside of the abdomen. And then stage four is when it spread above the diaphragm. So usually to the lungs and then stage three is basically if the metastases and microscopic or microscopic. So you can see them but they're less than two centimeters in size or if they're microscopic, but over two centimeters in size or they spread to the lymph nodes. So some of the things you might see are spread to the para-aortic lymph node, you might see spread to the spleen, you might see deposits on the diaphragm. Um And so when we do bulk patient's, we do splenectomy, XYZ we may do a nephrectomy, we will do an omentectomy as standard. We might do a bowel resection, well, strip the diaphragm will strip the peritoneum. We try to remove all of the microscopic disease that we can see. And then the idea is that you get 100% microscopic clearance and then you give them chemotherapy afterwards to mop up any microscopic deposits which are left. Okay. Yeah, thank you. Right. Any other questions guys? No. Okay. So I'm gonna move on uh to the last question uh of this gynaecology bit. So valve, all cancer. So the only thing here that predisposes you to developing valve or cancer is like in sclerosis. So V I N is Volvo intraepithelial neoplasia and it is a bit like C I N. So it's associated with high risk HPV, but also smoking and immuno suppression. Um and that's the most common type that you see um in people who are HPV positive for those who have likened sclerosis, they get a differentiated type and they get squamous cell carcinomas of the Volver. Um and essentially most of this, most of the types, sorry, most valve or cancers of usual and differentiated type are squamous cell. The rest of them are other skin cancers. Essentially some melanomas, basal cell CASS cinemas or adenocarcinomas. Now, if you think about the drainage of the vulvar, it doesn't drain sort of into the abdomen, it drains into the limp, the inguinal lymph nodes. So the way that you manage them is slightly different how you would manage, say an ovarian cancer and endometrial cancer. And I'll go over how we manage that in just a second. But the main thing is if you're in the GP setting and you find an unexplained Volvo lump or an ulcer or a woman's complaining of Volvo bleeding and you can't see a cause then refer her for two week. Wait. So again, kind of reiterating my 0.95% are squamous cell cancers and they metastasize to your inguinal lymph nodes. So here and here and you can basically perform for early stage disease, a wide local excision which is basically chopping out the area that looks so typical. However, anything more advanced will require um sort of groin know dissection or they might need a radical vulvectomy. So you essentially remove the entire volver. Um you, this is a picture of liken sclerosis. So it tends to involve the kind of non hairy parts of the vulvar and it can be localized to one area or it can involve the whole perineum or the clitoral hood. And what you get is um sort of loss of architecture of the vulva. So the labia minora here tend to become sort of absorbed almost into the tissues and the clitoris can become buried and sometimes this can become really sore. You can get bruising and blisters from it and then that predisposes you to developing Volvo cancer. And this is an example of a Volvo mass. So other things that unfortunately, patient's with Volvo cancer can experience um is sort of invasion of their urethra. So they may need reception of the urethra as well and it can be really disfiguring having treatment for Volvo cancer. So some women will literally have just a small orifice to pass urine from and some won't even have that. They'll need a long term catheter. Um So it's like a super pubic catheter. So I don't think you need to know masses about Volvo cancer. I think this is enough for you to know an undergraduate level. Um And again, vaginal cancer is even rarer. Um Again, I don't think you need to know very much about it. Um But just know it tends to be an S B A thing that it's associated with exposure to D I fill till best role, which is no longer given to pregnant women. But it used to be. So there is this cohort of people that were exposed to this in utero and developed vaginal cancers as teenagers and then older women, you can get a primary vaginal carcinoma and that's also usually a squamous cell carcinoma, but they're very, very rare. And again, the staging is similar, so localized disease in stage one, stage two is it's breached the vaginal wall and invading the neighbouring tissues. Stage three, it's invading the pelvis and stage four, it's invading beyond the pelvis to other parts of the abdomen. Okay. Any questions about Volvo Council vaginal counsel or any other cancers before we move on. Okay. Great. Um So the next session is Uro GYNs. Now, there is um in this part of the talk, there are loads of tables with patient information about what each of the procedures involved because I used to find your Ogonis so confusing and I found reading the patient information leaflets the best way of understanding the procedures. Um I'm not going to read the tables out to you. So please feel free to read through the slides at a later date. I'm just going to go through the overarching principles of why certain types of procedures are performed. Okay. But anyway, we've got five questions to go through. So same sort of drillers last time. So let's kick off. So question number one. Um So which of the following statements is true. Detrusor overactivity leads to stress and continence, overactive bladder is treated with the ring pessary stress. Incontinence may be provoked by chronic cough, interstitial cystitis should be treated with the daily dose of prophylactic antibiotics. Physiotherapy is the first line management for visa co vaginal fistula. Okay. You are the doctor in gynecology, outpatients. An eight year old woman presents with a 15 year history of leaking urine and coughing and sneezing. She was referred for physiotherapy by her GP but has not had a significant improvement in her symptoms on examination. There is a small Cystocele which would be the most appropriate next step in her management. One insertion of ring pessary to start DULoxetine three anterior repair for vaginal mesh repair or five attention free vaginal tape. Okay. Which of the following lifestyle measures is not recommended by nice for the management of pelvic organ prolapse. One weight loss to increase physical activity. Three, prevent constipation. Four stock caffeine five, minimize heavy lifting. Okay. Question number 4, 45 year old complaints have increased Germany frequency and episodes of incontinence. She reports she cannot make it to the toilet on time. She's keen to try medication for her symptoms, which is the following has offered first line for an overactive bladder, one imipramine to flavoxATE. Three oxybutynin four desmopressin five Merabet gram. Question number five, a woman presents with a feeling of rectal fullness and having to press inside the vagina to a defecation. A diagnosis of rectocele are suspected which of the following surgical procedures would be most appropriate. One posterior repair to anterior repair. Three sacred Colpopexy for Manchester repair or five vaginal hysterectomy. Okay. Are people happy for me to move on to the answers? I'm gonna take that as yes. Okay. So question number one. Uh so of the statements, the one that is true is that stress and continence maybe provoked by a chronic cough. Question number two for the patient who has been leaking urine on coughing and sneezing and has failed physiotherapy. The next best step will be in session of a ring pessary. The only thing that's not recommended for pelvic organ prolapse is stocking caffeine and first line treatment for overactive bladder in a 45 year old would be oxybutynin. So the main things in your a Gynie urinary incontinence and pelvic organ prolapse. So, urinary incontinence can be due to stress incontinence. And that's because you've got a weakened pelvic floor and surgery can help that urge incontinence is associated with an overactive detrusor muscle. Surgery is less helpful with that. You can have a degree of mixed stress emerging continent. So surgery might be helpful for you and stress and continence can be associated with a week pelvic floor and can lead to pelvic organ prolapse as in having weak pelvic floor can lead to a prolapse. Now, the types of pelvic organ prolapse is a cystocele, a rectocele, a prolapse of the uterus or a prolapse of the vaginal vault and we will go through those in just a second. So the main thing when you're taking a history is to establish if it's stress and continence or urgent continence or mixed and if it's mixed, nice says treat the predominant symptom. So, stress and continence, you get leakage of small amounts of urine when you have a rise in your intra abdominal pressure. So that's mainly coughing, laughing, straining, jumping on a trampoline urge incontinence is when you get suddenly this feeling like you have to pee and then you'll leak urine. Sometimes women can completely lose bladder control or they can just lose a little bit and then overactive bladder is when you're needing to pass urine all the time, but you're not necessarily incontinent and then mixed again, as I've said is what it says on the tin. A bit of virgin, a bit of stress. So when you want to investigate a patient, you examine them and you do a vaginal examination and rectal examination, you look for signs of pelvic organ prolapse and you'll dip the urine that you want to exclude a uti and you ask a patient to keep a bladder diary. So when they're peeing any symptoms, leaking urge, et cetera, what you also can do is ask them to go for a wee and then do a post void residual volume. So that's normally with a bladder scan. Er, and it allows you to understand whether somebody is effectively emptying their bladder when they go for a wee. So if you have chronic urinary retention, what can happen is you can just void small amounts of urine, but actually, you still have a large amount of urine still sitting in the bladder. And if the, if you think the patient might need surgery or if it's particularly complex case, you might refer them for uro dynamics. So that's when you send them for tests to look at um sort of raises an intra abdominal pressure and whether they leak urine and speed in which they void. So when you're thinking about urinary incontinence, the non surgical management. So lifestyle interventions, reducing caffeine is recommended for urinary incontinent, but it's not going to treat prolapse. So, prolapses when your organs are kind of falling out, no matter of reducing your caffeine is going to put them back in. You can modify your fluid intake. So obviously, if you have a problem with peeing overnight, you say, okay, we'll try to stop drinking two hours before you go to bed. And if they've got raised BM, I, then weight loss can help you refer them for supervised pelvic floor physio therapy to try and strengthen the pelvic floor, which can help support the pelvic organs and you can do bladder training for urgent continence. So that's getting them to void before they feel the urge to go to the loo. So going to the toilet at specific times. If there are non surgical interventions don't work, then you can try medical things. And that's generally just for overactive bladder or urge incontinence. And you can use um anticholinergics such as um tolterodine or oxybutynin. You avoid oxybutynin in over eighties and then second line anti cholinergics are Mirabegron, then you have invasive options if the incontinence is caused by detrusor activity. So, over activities, this is your urgent continence. So you can give a Botox injection which will stop the detrusor muscle from being as active. Obviously, one of the risk factors for that is that if you give them too much Botox, then they can end up going into retention and then there are other things, I don't know if anybody watched that hospital program on the BBC, but they gave one of the women a sacral nerve stimulator. And then another thing is sort of reconstruction of the bladder or ultimately, you can give them a urinary diversion. So usually super P per capita. But again, I've never, I've never really seen that. So these are the kind of things that I've, I've found online, I think they're really useful. Um So these are the kind of patient information things. So they've been offered lifestyle changes. They've had some pelvic floor training, but they've got stressing continents and they're having surgery. So this is your second line management for stress and continence after conservative measures fail and you can basically offer them to procedures. So if you think about it, the issue with um stress incontinence is that they've got a degree of pelvic floor weakness. And so we'll probably have a degree of pelvic floor, uh, pelvic organ prolapse. And so you want to kind of um, lift up the organs if they don't have prolapse of their bladder or prolapse of their rectum, then the problem is probably that they've got a kink in the ure urethra. And then, so you want to support their urethra. So that's where these procedures come in. Um So you basically have a culpa suspension which lifts up the neck of the bladder and basically straightens the urethra and the same with the breakfast facial sling and again, that's just to wake up the urethra, then you have other options. Oh, I think I've got pictures for you actually. So this is the Corpus suspension. So you put sutures and you basically lift up the urethra so that you get a nice straight line. And the same with the fascial sling. The difference is that the sling, the fascial sling is made from um fascia. So it's from your abdomen. So it's not a foreign body and then a mesh sling again, tapes are kind of not really on vogue anymore because of all the tape. Um the mesh controversy. So I don't really see people using mesh anymore, but it is still in the nice um leaflet. So that's to get your urethra to straighten essentially. So pulling up the bladder neck. So these are the links I'd recommend reading through those guidelines. So essentially, just to summarize what I've said. If you have stress incontinence, you can try um you can try pelvic floor physio therapy. If that doesn't work and conservative measures don't work, then you might need a culp a suspension or erectus facial sling. If you have urge incontinence, you can do bladder retraining and all the other conservative measures. And if that doesn't work, then you might need things like a Botox injection or a sacral nerve stimulator. However, lots of people who have stress and continence will also have a degree of pelvic floor prolapse. So sometimes a different procedure might be better for them. So if you think that somebody stress incontinence is caused by pelvic organ prolapse, then you fix the pelvic organ prolapse. So this patient would require a posterior repair for a rectocele. And I'm going to go through what a rectocele is, what cystocele is and how you treat it. So, when you meet a patient with, sorry, I should ask, has anyone any questions about the first half of that before I go through all the pelvic organ prolapse stuff? Okay, fine. I'll carry on. So when you're looking at prolapse, you, basically, there's a scoring system you can use, I don't know the scores off the top of my head, but it's called the pop Q score. You assess the pelvic floor muscles. You look at the vulva and vagina, look for any atrophy. You might want to give them some Vagifem to give some local estrogen. You can give Vagifem with HRT uh with uh you can give Vagifem even if there are contra indications to systemic HRT. So it's not really absorbed into the bloodstream, it just has local effect. So lots of women worry about the risk of breast cancer or Easter independent cancers, but Vagifem is fine. So for pelvic organ prolapse, you try the lifestyle management. Again, you give a vaginal estrogen. If there's an atrophic vagina, you can give four months of physiotherapy and then you can offer them a ring pessary. So that's a nonsurgical option. Um Oh, I've put the pop skews, pop Q score there for you just to look at in your own time. But there's four stages. So this is a ring pessary. Um And essentially you put it into the vagina and it goes sort of above the pelvic floor and just literally holds the pelvic organs up. So it provides support to the uterus. You have to make sure that the size is correct because if you imagine you put a big ring pessary and you can accidentally block there urethra and then put them into urinary retention. So you pop it in, in clinic, get them to walk around, make sure it doesn't fall out and make sure that they can we before they go home and then that can stay in usually for six months, sometimes a bit longer. Um And lots of women find that that really helps. The only thing is some women don't like having it in, especially if they want to be sexually active, they don't like having the ring there. So they would rather have something else. But for older women where that's less of a priority, it's a really good option and it works really, really well. So if that, if those measures don't work, then you have the surgical management for pelvic organ prolapse. So you can either remove the hysterectomy, uh remove the uterus and perform a hysterectomy. You can hike the uterus up, so attach it to something. Um And or you can repair defects in the anterior vaginal wall of the posterior vagina wall. So we'll just go through that now. So, again, this is the nice uh information leaflet. But essentially, um so you can do a vaginal hysterectomy. Um And you can then suture the vault of the vagina to the uterus Accra ligament to hold it up. So that's a sacred spine as history pexy, essentially stitching the vagina vault to the um uterosacral ligament and that holds it up. Um Again, you can do that with a uterus in situ. So you basically tighten the uterus sacral ligament. So you pull the uterus sacral ligament up, then essentially with the Manchester repair, you remove the cervix and then you pull the vagina up to the bottom of the uterus. So that basically helps the, helps to hold the uterus up by removing some of the length of the, of the cervix. Um And then the final thing is a fixation. So, sacro history pexy. So attaching the uterus to the sacrum using mesh and essentially it holds the uterus up. I have to say most of the time I see sacrospinous fixation. I don't, I've never seen it with mesh. Then if we think about sister seals and rectoceles. So a cystocele is basically when you have weakness in the anterior vaginal wall and you get bulging of the bladder into the, into the vagina. And so what you do is you can basically reinforce the fascial layer of the vagina with using sutures. And then that basically helps to reconfigure this architecture here. It's the same thing on the back. So again, you can get weakness of the posterior vagina wall, which leads to the rectum bulging into the vagina posteriorly. And again, you can then just reinforce the fascial layer with sutures. And then that helps to push basically the rectum back out and hold it up. That's essentially all you need to know for your Oh Gynie. So in summary, if you have urgent continence, it's basically medical management. And then some invasive procedures like Botox or sacral nerve stimulation. If you have urge incontinent, you can treat that with physiotherapy, try and strengthen the pelvic floor and conservative measures. If that fails. And there's no pelvic organ prolapse, then you can do a culture suspension. So support the bladder and that can be with a sling or with sutures. And then if you've got pelvic organ prolapse, then you can either support the uterus by attaching it to the uterus sacral ligament or to the sacred itself. Or you can do a Manchester repair, which is less often done. And if there's just a cystocele, so the bladder bulging in, then you reinforce the anterior vaginal wall uh with an anterior repair. And if it's just that you've got a defect in the posterior vaginal wall, so a rectocele, then you just reinforce the posterior vagina wall with sutures and do a posterior repair. Does anybody have any questions about anything from those first two sections? No questions in the chat either? Okay, great. So there is another half to this lecture. Um So, uh why don't I give people like a five minute break? You can go for a, we have a drink. Um And then we'll come back and then the second half is a bit shorter. Um And it's benign Gynie and then reproductive medicine and sub fertility. So I'm hoping we'll be done by quarter past eight. So I'll give everybody five minutes. I'm gonna have a drink as well and then I'll see you back here at 7 32. Sounds great. Yeah. Yeah. Okay. It's 7 32. So let's carry on. Um So same drill again. Um We're going to go through some past questions, not passed questions, the questions I wrote. Um and then uh hopefully we'll be done in about 45 minutes. But again, please feel free to interrupt me if you've got any questions because I can't see the chat. So, um fashion three or four, Burdon Gynie. So here we go. So 16 year old presents her G P with absence of periods, she reports cyclical lower abdominal pain, however, no bleeding. She has normal secondary sexual characteristics and normal growth. What is the most likely diagnosis? One imperforate hymen to Asherman syndrome. Three Turner syndrome, four, bicornuate uterus or five Kallmann syndrome. A 33 year old woman is referred to gynecology. Outpatients with heavy menstrual periods. A by manual examination reveals a mobile uterus at 20 weeks size. A diagnosis of fibroids are suspected. She is keen to fall pregnant would like to avoid treatment for now, which is the following statements is false regarding fibroids and pregnancy. One women who have had a breach of the cavity at myomectomy will require a cesarean section. Two large fibroids in the upper uterine segment may cause obstructive labor. Three women with sub mucosal fibroids are at higher risk of major obstetric hemorrhage. Four fibroid degeneration may occur during pregnancy. Five, most of them with fibroids will have an uncomplicated pregnancy. Okay. Next question. A 25 year old girl is referred from her GP to gynecology. Outpatients with severe dysmenorrhea, she has tried meth anomic acid by manual reveals a fixed in mobile, 10 week sized uterus. A pelvic off sun demonstrates a globular uterus. What is the most likely diagnosis? One endometriosis, too complex atypical hyperplasia. Three endometriosis with adenomyosis, four endometrial cancer or five adenomyosis. Okay. Question number four, 38 year old woman presents a mood disturbance during the week prior to her period. She reports increased tearfulness and irritability. Which of the following is not a treatment for premenstrual syndrome. One evening, primrose oil to the combined pill. Three SSRI forCBT or five hysterectomy and bilateral salpingo oophorectomy. So, SSRI selective serotonin reuptake inhibitor and for CBT is cognitive behavioral therapy Okay. Oh, sorry, I didn't realize there were only four questions in this section. Okay. Well, I guess we're going through the answers. So, uh 16 year old girl, so when you're looking at this question, uh the key things are she's got cyclical, lower abdominal pain. So that suggests that something is happening on a cyclical basis. Uh And she's got normal secondary sexual characteristics and normal growth. So that suggests her hypothalamus, pituitary, gonadal access is intact. So then you think, ok, this must be a structural issue. So, Asherman syndrome, for those of you who don't know if you perform curettage of the uterus. So, essentially suctioning inside the uterus or scraping inside the uterus, you can get adhesions inside the uterus. And so essentially you get scar tissue and that prevents implantation um and can cause you to have no bleeding or less bleeding, more often less bleeding. Um Turner syndrome is eggs, a karyotype sofina typically, um these patient's are female, however, they'll have streak gonad, so they won't have functioning ovaries. Um A bicornuate uterus. So that's essentially just a uterine anatomical difference where you basically have two horns of the uterus rather than one body. Um And then Kallmann syndrome will come on to talking about that in a second, but essentially causes hypothalamic amenorrhea. So, went to suspect primary amenorrhea. So girls who have not had a period by the age of 13 with no secondary sexual characteristics and no breast development know, um pubic hair development or girls who have not established menstruation by 15 years who have normal secondary sexual characteristics. So, what are the causes? So, I'm sure you guys are very familiar with these um with this diagram. So you have your um your hypothalamus which secretes GNRH gonadotropin releasing hormone, which then tells the pituitary to secrete F FSH and LH those stimulate the follicles within the ovary and the eggs, the follicles secrete estrogen and then there's a negative feedback loop. Um And essentially, if you have failure, one of these three points, you may end up with hypogonadism. So that those your differentials for amenorrhea as a problem at the hypothalamic level at the pituitary level or the ovarian level, you also have your um sort of higher centers which can suppress your hypothalamus. So that's times of high stress, low B M I, uh excessive exercise. Um You can also have um structural causes. So, tumor's that suppress the hypothalamus or Kallmann syndrome where the neurons don't migrate normally to the hypothalamus. Um sorry, that neurons don't migrate normally from the hypothalamus and pituitary, which reduces your FSH secretion. And then you can have other things that affect the access. Um You then can have pituitary issues. So, uh pituitary tumor is which press um uh on the pituitary gland um or arise from within the pituitary gland or she hand syndrome. So that's infarction of the pituitary gland normally after major of sexual hemorrhage and with the most common type of pituitary tumor, uh prolactinomas and they're treated with care, Berglund and bromocriptine against, you'll have low FSH and LH because the pituitary is not secreted any of those. And therefore, the ovary will not be producing estrogen. And then you can have ovarian causes so premature ovarian insufficiency. So that's essentially like an early menopause. Um or you can have the menopause Turner syndrome. We've spoken about it. There are other causes of gynecologist, Genesis, um So into sex conditions and also other things like androgen insensitivity which prevent you from producing estrogen. And you'll have uh sorry, raised FSH and LH and the low estrogen because the problem is occurring here, then you have to think of structural causes which are separate to the H P G access. That's like the stem of this question. So, um outflow obstruction. So an imperforate hymen I E the blood can't drain out of the vagina Rocket Stansky syndrome. So M R K H, you basically have congenital absence of the uterus and the upper two thirds of the vagina. So they'll have um little sort of uterine remnants called anlage. They'll have a rudimentary vagina, but they'll have normally functioning ovary. So they go through puberty and then present with primary amenorrhea. Um and then cervical stenosis. So, the cervix essentially won't allow menstrual blood to pass out and that's normally secondary to some sort of surgical procedure. Any questions about that? No okay, great. So, question number two, which of these is not true. So this is not true. It's in the lower segment. A fibroid might cause obstructive labor. You have fibroids in the upper segment, it's fine. The main thing is that if you have a lower segment, fibroid prevents the head from coming down into the pelvis. And so closer to the time of birth, you have performing arts sound and basically check of the head is below the fibroid. Um You can also get other complications like the head will come, but then the shoulder will get stuck behind the fibroids. And that's obviously an emergency. So what are fibroids were there kind of benign tumor of the, of the uterus of the, of the muscle of the uterus that myometrium um and they can occur in different places. And this is something you do need to know for your exams. So you can get subserosal fibroids which are under the cirrhosis. So the outer layer of the uterus, you can get intramural fibroids which are within the wall of the uterus or you can get sub mucosal fibroids which are under the mucosa layer or the endometrium layer of the uterus. And then you get podunk elated ones as well. The but in pregnancy, obviously, if you have distortion of your cavity, you can go into preterm labor uh because it might affect the, the sort of shape of the uterus, you can have mild presentation because the baby cannot engage in a normal way. Might see a trans ESL I um and there is a risk of postpartum hemorrhage as well because the uterus cannot effectively can track down again if you have sub mucosal fibroids. Um If there right near the endometrial lining, they have a very strong blood supply and that can lead to you having menor Asia. Um and they can pay your fertility if they distort the shape of the cavity because they can prevent implantation or they can obstruct the osteo, which is this bit where the tube comes into the endometrial cavity. So, how do we manage them? Well, most of the time we just leave them alone to you. Scan a lot of women that have fibroids and they won't even know that they had them. However, there are medical and surgical options. So for medical, you want to treat heavy bleeding's, that's the tranexamic acid for pain. You can give ibuprofen other NSAID aids. Um If they're bleeding very heavily, you can give them progestin Jen's normally give them some norethisterone for five days and that will normally stop them from bleeding. You can also give GNRH that essentially induces a surgical menopause because it um essentially it up regulates your FSH and LH and then it actually performs a negative feedback loop. Um So it suppresses everything and you can use that to shrink your um fiber's price surgery, but you can't use it for a long time because as I said, it's kind of like putting someone into a temporary menopause and it will reduce their bone mineral density um surgically. So, um if it's a sub mucosal fibroids, then you can access it through the cavity. So you can perform a hysteroscopy and then do a transcervical reception of fibroid or A T C R F or you might need to do something where you approach abdominally. So you can do it open or a laparoscopic myomectomy, um normally do that if the patient's wish to preserve fertility. However, if they're not that bothered, you may just do a hysterectomy. Now, what's relevant here is if you breach the cavity, that's a bit like having a cesarean. So you cut through the entire muscular layer of the uterus. And therefore, if you know that you breach the cavity during a myomectomy, then the woman will require a cesarean section during uh during pregnancy because they're at higher risk of uterine rupture. So the uterus tearing Oprah open at those weakened points. The other thing is um uterine artery embolization. So you essentially reduce the blood supply to the fibroids to help them shrink down. There's no good data about whether this is something that will impact pregnancy, but there is a theoretical risk that you can reduce placental blood supply or rupture. However, there's so much supply to the uterus during pregnancy that actually people think it probably won't make that much of a difference does anyone have any questions about fibroids or anything else? Okay, great. So, question number three. Um So a young woman with a globular uterus, that's immobile. So the immobility is telling you and, and severe pain. Um that's making you think OK, is an endometriosis. But then the, the globular uterus is like a pathognomonic pathognomonic sign of adenomyosis. So it's endometriosis with adenomyosis. So, what is endometriosis? Well, its presence of endometrial tissue outside of the uterus. So, during normal menstruation, everybody has retrograde menstruation. So everybody who's menstruating will have a degree of menstrual blood that goes into their pelvis and most people's bodies will mop that up without any issue. However, there are a small number of people where the body doesn't. It's actually not that small. It's actually quite a large number of people where the body doesn't do that effectively. And what happens is those little cells will implant on wherever they land. So they can implant on the bowel and the bladder and the pelvic sidewall on the ovaries on other parts of the uterus. Um And they will respond to hormonal changes in the menstrual cycle the same way that the endometrium does. So they will thicken up in, in the follicular phase and they will bleed during your period. So that's really painful because you're essentially bleeding into your pelvis. Um and it can really affect people's quality of life. So to investigate endometriosis, you can do a trans vaginal ultrasound And if you think that they've got deep infiltrating endometriosis, you can do an MRI you may do a diagnostic laparoscopy and staging. So these are the stages of endometriosis. So, stage one is just a few deposits, what we call minimal, mild. Again, you may have some involvement of the uterus sacral ligaments a little bit on the blau model. Moderate again, more extensive disease. And stage four is really severe and this can cause you to literally have a frozen pelvis. Um Some women with endometriosis will suffer infertility as a result of the extensive scarring, causing the fallopian tubes to become clubbed blocked. They can get sort of toxic fluid accumulating in their tubes and leaking into their uterus which affects the implantation. So, um it can really impact peoples' quality of life and their subsequent fertility. Adenomyosis is a bit is basically like endometriosis, but you get endometriotic. So, endometrial cells within the muscle layer of the uterus. And so you get this kind of globular shape of the uterus. And you can see um and they will bleed into that which will cause them to have very heavy and painful periods. So, the treatment of endometriosis, well, you basically want to stop them from having their periods. So the reason that they're endometriosis causes them pain is because those little deposits are bleeding. So you want to suppress their bleeding. So you can use hormonal therapy in order to do that. However, um there are a number of women who will be trying to conceive. And so what are the options for them? Well, the options for them are to do operations. So you can do keyhole surgery, laparoscopy, and excise, the endometrial deposits. You can remove any endometriomas which assists made up of endometriotic cells and you can cut any adhesions, try and free up their pelvis. If it's really severe, women may want to have a hysterectomy in order to manage their, their symptoms and remove the root cause. But it can be a really difficult operation because obviously they might have a significant scarring. So essentially, this is the nice guidance on how to manage endometriosis. So it depends on whether fertility is a priority or not currently a priority. And again, you may do excision or ablation, remove any cysts and you don't offer them hormonal treatment. And then um if fertility is not currently a priority, then again, you can still do surgical management, but you might offer them hormonal treatment as well. Any questions about endometriosis? Okay. Okay. I'm sorry, I just, I don't have a question, but it was about the specific patient in the question because it's because they had endometriosis with adenomyosis. How would you manage that patient? So, it's exactly the same. So um you essentially managed them depending on their fertility wishes. But I don't know, aosis and endometriosis are treated in a very similar way. If somebody had adenomyosis on its own, you can, they don't necessarily need surgical management because there'll be nothing to exercise really because all of the endometrium deposits are within the uterine wall. So you can't really remove them, but you would still want to suppress their cycles to reduce their bleeding. Okay. Thank you. Thank you. Um Sorry, I also had a question. Um So uh my understanding was that with adenomyosis, you can also get dysmenorrhea. So with that particular question stem, I was wondering why we, for example, where you couldn't just advance legitimizes essentially, I don't know if I've missed something. Yeah. So the main thing was the uh fixed and the mobile uterus. So the fact that it's fixed in the mobile makes you think that there's a degree of endometriosis as well because she sounds like she's got adhesions in her pelvis. All right. OK. Thank you. Yeah. Any other questions guys? Okay. Now, this was a bit of a mean question because evening primrose oil theoretically does help PMS. However, it is not in the nice guidance as a evidence based treatment for PMS. Therefore, that is the one thing that is technically not a treatment. So what is PMS? Uh it's mood disturbance associated with the luteal phase of the menstrual cycle. So just as a reminder to everybody, you have your follicular phase, uh it's in the name, the follicles are secretive thing, estrogen. Um Then you have your ovulatory phase where you get your LH surge and your egg is released and then the corpus luteum is formed from the old follicle and that secretes progesterone and then your luteal phases where you have high progesterone level. And that's when you get sort of civilization of the lining. So you get uh invasion of your arteries and nice glandulous cells and it's like a little, little bed for an egg to implant into. So the main hormone that causes PMS is progesterone and the symptoms are mood swings, tiredness, it can be debilitating. So, uh people get changes in the appetite and their sex drive, it can really affect their relationships. Um and it can be serious to the point where people would want to have um uh hysterectomy and bilateral salpingo oophorectomy rather than go through their menstrual cycle. So this is the, the R C O G guidance for the management of PMS. So your first line treatment exercise CBT uh vitamin B six, you can give them a pill to try and reduce that sort of fluctuation in their hormones or you can give them SSR rise just during the luteal phase. Um and that's citalopram. Usually again, second line, you can give them other forms of hormonal therapy or higher doses of SSRI S or give them the marina. And then third line, the GNRH analog, which basically put you into a menopause and then you give add back HRT. So the doses of H R T are much lower than those in the pill. So you can give them, um, you can give them just a little bit of HRT to minimize their sort of hot flash symptoms and the, uh, reduction and bone mineral density. And then if that doesn't work, then you give, then you can offer surgery. So, um, that would be a TH BSO usually. So, um, I think that's all you probably need to know for PMS. But at least when I was an Imperial, they liked combining station. So they liked having like a G P come obs and guinea station. This would be quite a nice obs and guinea with psych station. Any questions about PMS? Lovely? OK. Last section. So we should be done within the next 20 to 25 minutes. So hang in there. You're all doing very well. Um I hope you're all asleep but not sleep awake even. Uh So last section, reproductive medicine, some fertility in the menopause. So let's do it. Question number one, 17 year old girl since its acne irregular periods and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? Polycystic ovaries, physiological puberty, polycystic ovarian syndrome. Very realizing tumour, pituitary adenoma. A 32 year old woman has been trying to conceive 14 months blood and imaging are normal. She has a history of chlamydia which was treated at the age of 24. What is the most likely cause of her sub fertility? Premature ovarian insufficiency, tubal scarring, a congenital uterine structural anomaly, Polycystic Ovarian syndrome or Idiopathic A 52 year old room presents to the one year history of amenorrhea, hot flashes and mood swings. What is the most likely pattern? Pretty on her bloods. Low FSH, high straddle, high FSH, low estradiol, low FSH, low estradiol I FSH, high straddle normal FSH, normal estrodiol. A 40 year old woman presents with a two year history of amenorrhea. She complains of dyspareunia and hot flushes. What is the most likely diagnosis, menopause, premature ovarian insufficiency, turner syndrome, hypothalamic hypogonadism or pituitary hypogonadism. Okay. Right. Question number one again. So let's go through the answers. So the answer to question number one is Polycystic Ovarian syndrome. Now, you could argue this if you've read your Nice guidance and I'll tell you why in a second. So to be diagnosed with Polycystic Ovaries, you have to meet the Rotterdam criteria which is oligo or an ovulation. So, um basically irregular periods, clinical features of hyperandrogenism is that your acne or hair statism and then polycystic ovaries on ultrasound. So why do you get these sort of hyperandrogenism? Well, the estrogens are converted to androgens. Um So that's why and there is an association with uh insulin resistance. Now, the new nice guidance for this is actually that you should avoid diagnosing teenagers with Polycystic Ovarian Syndrome, purely based on ultrasound because actually physiologically, most teenagers will have appearances on ultrasound, which look like polycystic ovaries and it's just normal physiology. However, you can make the diagnosis if they have significant signs of Polycystic Ovarian syndrome. So, in this case, you can make a diagnosis of Pecos because she has the hyperandrogenism and the irregular periods. However, if you had, I don't know menorrhagia, you would not call her over, you would not call her Polycystic Ovarian syndrome because she probably just has physiological changes in her ovaries. So how do you manage P costs? So, conservative weight loss. So um there is good evidence that about 5% weight loss of their total body weight can actually restore normal period medical options. So the dina or a contraceptive pill contains a proton acetate which has anti androgenic effects. So it's quite good for people with pcos and acne. Um again, Metformin um can also help. There's some evidence to show that taking Metformin can improve your fertility as well. You can refer them for management of symptoms on the NHS. So they can get laser on the NHS for excessive hair if they're trying to conceive and the pill is not an option for them, you can give, again, advise them to lose weight. Um clomiPHENE is a selective Eastern receptor modulator and it can help to induce ovulation in people with Polycystic Ovarian Syndrome. Uh and surgical option is um ovarian drilling and no one's quite sure why that works, but it does help to induce ovulation in Polycystic patient's. So the reason that patient's with peco's get irregular periods because they don't have a dominant follicle. So if we go back to this diaphragm diagram, all of the follicles in your ovary will be producing estrogen. And the problem with P cost is that they don't really get a dominant follicle. They just get loads of follicles secrete ing Estrin, Estrin estrogen and so they don't get ovulation. Now, your luteal phase is fixed, it's 14 days. So you get that sort of irregular period given the fact that they, they're not having regular ovulatory cycles. Um So if you have a woman with a 35 day cycle, she would have ovulated on day 21 because that 14 days is fixed. If you have a patient who has her period on Delhi 28 that means she ovulated on day 14. So you can calculate someone's ovulation date by subtracting 14 from the length of their cycle. And again, patient's with polycystic ovaries may go months without having a period because they haven't ovulated. And therefore, um they don't have that sort of luteal phase to set a clock for when they're then undergo and shedding of the endometrium during their period. Anyway, sorry, did we go back? Um Does anybody have any questions about Pecos? So I have a question. Um So I read some of that. Um Let result is being used above clomiPHENE. I'm just wondering what you think about that. That's probably right. I haven't even included Letrozole on here, but yes, I would read them up. They just, there's recently been an update to the nice guidance. Um and I hadn't changed my slide and I probably would have changed my stem to being older than 17 as well. Sorry. So you would, so let's all be like first line and then call my friend. I think so. I would just double check because I think the guidance literally came out this year. Okay. But that sounds probably right. Thank you. Thank you. Anybody else. Got any questions? Okay. Thank you. Um A 32 year old woman. Oh yeah. Right. So she's had chlamydia and she can't conceive. So the most likely cause is chewable scarring. Um So when you're investigating sub fertility, you want to look at a few things. So you want, first of all, check that their hormones are right? So you want to look at their FSH and LH sort of day 2 to 3 of the cycle and the estradiol and then the A M matrices, the anti malaria in hormone will give you an idea of their ovarian reserve. You want to check for S T I S because obviously you want to treat those before you try and put someone through fertility treatment. Um You would also do an internal scan and count how many follicles they have. Um You can also assist their tubes. So the way you do that is either by um it's a ultrasound based thing and you squirt con well, saline through the cervix into the cavity and then it spills out the tubes and you can watch it come out of the tubes on scan. And that gives you a good idea if the tubes of patent or you can do a laparoscopy and inject dye through the tubes and check that it spills into the pelvis. And then obviously male factor, you want to check um steam in for sperm quality and count. So, treating some fertility ultimately depends on the cause. So, um if they've got an ovulation, you give ovulation induction or laproscopic affair, drilling or lecture. As long as you said, uh male factor, you can do intrauterine insemination. If it's mild or you may need a donor. Um If there's a tubal factor or failed IUI or ovulation induction, then you can offer IVF or icsi. So intracytoplasmic sperm injection. So you literally inject the sperm into the egg. Uh lack of not lack off, lack of you sights. Um So if they have premature ovarian insufficiency or Turner's, you can get egg donation and then have IVF or if there's an anatomical cause. If you can correct it surgically, then you do that. But some anatomical anomalies are not correctable with surgery. Any questions about that? Okay, great. So quickly onto the menopause and then we're done. So um with the menopause, your ovaries have essentially run out of eggs. So there's no follicle secrete ing estrogen. So you're pituitary is shouting at your eggs, at your ovaries, too mature eggs, but they're not doing anything. So you get a high FSH and low estradiol. This patient um is a 40 year old. So anyone under the age of 42 with histories such as this, so, amenorrhea and then signs of the menopause is probably a diagnosis of premature ovarian insufficiency and then you would investigate the causes of that. So, um essentially with the menopause, you, I've can already explained this, but your ovary essentially is no longer producing estrogen. So you get up regulation of FSH and LH. So the menopause is a retrospective diagnosis. So it's the absence of periods for 12 months and the premature ovarian insufficiency is that before 42 years of age and it can be idiopathic or it can be because of something we've done such as given someone chemo or remove their ovaries, all women with primary uh variants for since the premature ovarian insufficiency required eastern replacement. So you put them on HRT. Um and you do that until the average age of menopause in the UK. That's about 50. You can't give estrogen without progesterone if a woman has a uterus. So if you give unopposed estrogen, they will develop endometrial hyperplasia, which will eventually turn into endometrial cancer. So, if they still have a uterus in situ, you always give progesterone progesterone can be given as a marina coil or as a pill. So like you to suggest an or something like that in terms of Eastern HRT, that can be given orally or transdermally. So that can be a patch of pill or gel and atrophic vaginitis, which is um sort of dryness of the vagina. Due to lack of estrogen, you can give topical estrogen. So that's Vagifem. So you give it to them every day for two weeks and then twice a week thereafter. Um you can give cyclical or continuous HRT, but you tend to give continuous HRT to women who are definitely post menopausal because they can um it can cause erratic bleeding. If they're perimenopausal, then you can give them cyclical HRT. But I have to say most of the women that um I see are on continuous combined. HRT. Does anybody have any questions about menopause? Okay. So that's the end. Well done. We finished a little bit earlier than planned, which I think is a marker of success. Does anybody have any questions? I think I saw one question in the chat from earlier. Um It was about pre mental syndrome. Um How is evening primrose oil useful? So that that's a very good question. So evening primrose, well, there is no evidence base for it being useful, which is why it's not in the nice guidance. However, there is a a number of people who feel that it does have a useful effect in reducing your PMS PMS symptoms. But there is no scientific basis for that. Yeah. So just to quickly say I've just put the feedback link in the QR code for everybody who's left. Uh Sorry, I please go ahead. Uh Sorry. Um This is a while back but for management of five words, um Could you mention that uh North this room could be used in pregnancy or I don't know if I know. So norethisterone is used when they're having heavy bleeding. So if you have a woman who comes into a and e with a heavy bleed and you know, she's got fibroids, you'll give her five days of norethisterone and that normally settles her down. You can give it to patients who don't have fibroids as well. So some women that just come in with menorrhagia, you give them norethisterone and essentially stops them bleeding. Okay. Great. Thank you. Any other questions? Yeah, sorry. Um Just for question for I just missed it. What was the answer again? Let me share my screen. He, oh I okay. Thank you. Yeah. No, that's fine. Just wanted to confirm any other questions about anything, even if it's something I haven't spoken about. Very happy to answer any questions or anything else to do with jobs and go any. Yeah, I think uh this is just going back to when you were talking about um a station kind of being mixed between psych and also Gynie just looking at the PMS things just wondering in terms of management how you would kind of balance that. Um And would you kind of go for more of a psycho social approach again or uh something different? Yeah. So what I would say is, um you know, at the beginning of that guidance, it's like conservative measures and then you go onto the intervention, I would talk about the biopsychosocial stuff in that conservative section. So the main thing with psych is that as far as my limited understanding of psychiatry is, is that you rule out any organic causes first and you treat organic causes. So if you can find a treatable course for someone's mood disturbance, then you try and treat that medical issue. However, you as part of that, it's really important to explore all of the other things with a biopsychosocial approach. So I would include that within your first line conservative thing and then go down and then obviously you would want to risk assess someone. So you, so I've seen patient's who are suicidal from their PMS in real life. So you do need to also risk assess people as well. Okay. Right. Yeah. So I guess incorporating that and part as part of the history as well then. Okay. Thank you.