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Hi, everyone. Um I'm Simron. I'm one of the coun these committee members from N SMS. Uh Welcome to our uh episode. Uh three of our wrote to file series in collaboration with 6 p.m. series sponsored by the Medical Protection Society. I'm pretty sure the past few episodes were very useful to you guys. So we are back with another episode which is gynecology with Doctor Priyanka Ayer. So before we begin uh the lecture by Doctor Priyanka, I'd like to invite Sarah Fletcher from our sponsor Medical Protection Society um to give us uh to just give uh a short talk. So Sarah over to you. Hi. Uh Thank you very much. Can you hear me? Ok. Yeah. Yeah. Yeah. Um I'm just gonna share my screen. I've just got a couple of slides to take you through. Um when I did this the other day, unfortunately, when I put it in presentation mode, um it doesn't um it mutes uh sorry, it doesn't allow the slides to move forward. So I'm just gonna have to sort of leave it like this if that's ok with everybody. Yeah, I think that's ok. Yeah, in that way then we can uh we can see everything. Um So hi everybody. Thank you so much for having me on. Um I'm from Medical Protection Society. I'm one of the relationship managers. One of two, I look after the north of the country and my colleague s looks after the south. Um I'm just gonna run you through a really quick short presentation in terms of um your membership. If you currently have one, what you need to do moving forward into foundation years. Um and um how to join if you haven't already got that membership in place. So, and also a little bit about us as well because I know that um any anybody that's kind of 4th, 5th years currently probably didn't see us at fresh because we didn't actually have anybody in the post the year that you were in fresh. Um So whether you've gone on and joined off your own back through your elective placement or anything like that, that's um that's great, but in case you haven't, there's a couple of QR codes that will be on different slides and I will explain the difference between them. So for anybody that's final year, um or there is fourth year going into final year, year, going into final year, you need to complete a new application for your foundation year one and two. So it's, it's a different type of membership to your student membership that will continue until the day you graduate. But for foundation years, you need to fill out a new form. And the reason for that is it will ask for your bank details on it. The bank details of your F two years. You don't need to worry about that until then foundation year one is free with mps. We are the only medical defense organization that is free F one stage. And so you'll need to scan this QR code if you were either of those years, it does come up again through the presentation and anybody that's um not in end of fourth year or final year, you would need to join through the student um QR code, which is this one and it's a completely free student membership. It just rolls on each year until, until you graduate. Uh You do get entered to win 200 lbs a week. A student has to win that every single week. So um it's definitely worth doing. Um So a little bit about us then. Um we were founded in 1892. Um And we look after the professional interests of medical professionals, doctors, dentists, and other healthcare professionals across the globe. So we are a global organization. We cover 42 territories around the world. Please don't ask me to name them all. Um But um you can find that on the website, we also uh cover Australia and New Zealand, which a lot of people uh graduate from F two S are actually heading out to to Australia who can blame them. Um So we look after you from a medico legal perspective. Um and anything outside of your NHS contract with regards to clinical negligence, claims, disciplinary Coroner's court inquiries, the list goes on. So in terms of what is medical protection and why you need medical indemnity, I don't want to scare people, but the bottom line is doctors are legally required to have appropriate medical indemnity in place. So this is in the event that a patient will claim for compensation. Um GMC can remove your license to practice if they feel that you haven't protected yourself adequately and appropriately. So this sounds a little bit scary and you're probably all thinking, well, we have crown indemnity, so we don't need it. You're absolutely right. You do have crown indemnity as part of your NHS resolution, which is your um within your NHS contract. So this line is quite good because it explains that everything that your NHS indemnity does not cover you for. So, and there's quite a lot and I won't go through the whole list, feel free to, to say screen grabs at this. Um But GMC inquiries, disciplinary Coroner's Court inquiries, good Samaritan Act. That's a more common one should I say in a lower risk grade. Um So you are ethically and professionally obliged to stop a Good Samaritan Act. So let's say you're on your way home from work, somebody falls off a bike and gets injured and you stop to help them and something goes wrong in that situation, then you are in trouble. So you need, you need your professional indemnity ourselves to help you on that. We also have lots of other benefits to the membership. So CPD online learning webinars workshops and we also have a 24 7 counseling service as well that's available to you if you just want to chat to somebody. So there's lots of things outside of your NHS resolution. That is the reason why you need that professional indemnity in place and that won't cover you for a common one. actually for foundation doctors is speeding fines that they didn't know they had, um and it had gone to court and they've been obviously convicted of that speeding fine, of which they never knew they had because they had forgotten to change their address with the D VLA through medical school. It is your responsibility to let the D VL know obviously, if your address changes and therefore they ended up with criminal convictions for speeding that they actually never even knew that they had that they have to declare. So just things like that you need to just be aware of. Um but anything um medical legal, any help, any questions just ring us and we'll be able to help you with that. So in terms of your membership benefits, then you have 24 hour access to emergency support. So they are Medico Legal consultants, otherwise known as R MLC S. They are all doctors and they are all lawyers. They are all UK trained UK qualified and they have been in clinical medicine for a minimum of nine years before go on to become an MLC. So well in place to be able to support and help you. Should you need any help? Something that sets us a little bit different from the other organizations is that our MLC S are employed by MPS. We don't outsource the third parties. So they are there 24 7 for you. We also have our e-learning database or e-learning hub as it's now being called, which has your workshops, webinars CPD that you can get from that, you can download certificates, improving your C EV. There's absolutely tons and tons of stuff on there, loads of stuff for your exams, your vitals. Um So please, you know, access that it's all completely free as part of your membership. It's also completely free as part of your membership as a foundation doctor as well and beyond. And again, sets us a little bit different from the others um where they will charge extra for your CPD. We have that free counseling service which is really important um for, for your mental health and well being so definitely access that if you need that, the Good Samaritan Act that I've already answered. Obviously, we sponsor events hence this evening. So get in touch if there's any sponsorship that you need. And there's the Medical Protection Foundation, which is a research um funding service that we have. So we have grants available if you are embarking on any kind of research projects. So our relearning hub um has different videos webinars that you can access. So please make sure that as part of your membership go on and have a look at those, there's loads and loads of stuff in there that hopefully should be really useful to you or written by our MLC S. Let's just get that one through. Um So frequently asked questions that we get. Um Can I join more than one medical defense organization? Yes, you can. Um And um and a lot of you might already be members of more than one and that's absolutely fine. The GMC give you the opportunity to stay with um usually ourselves in M MDU. There is obviously MDU S as well. Um Until the end of your F two year, it's at that point that you need to decide which membership you're going to stay with into your two years. Um And at that point, it's a conflict of interest. So you do have to make that decision, which is why we openly encourage you to join whilst it is free as a student, join as many as you can because you can use the services of everybody. And then when you come to make that really important decision about who you're going to stay with when the cost jumps, then you can make a really informed decision as to which one is going to work best for me. So we openly encourage that you do that. Are we the same as the BMA? No, we're not there. You're trade union. We are a medical defense organization. So, although we work very closely with them, they are very different. Do you have to renew your membership each year if you are a student through your student years? No, it will roll on until the day you graduate for foundation program years. You do need to fill in that um new form. They'll ask you for your bank details. And like I said, that's the 20 lb payment for your F two year and they don't take that until you go into F two and they write to you beforehand as well. So you have the right to cancel if you wish. What happens if I'm involved in an incident where I don't have medical protection. Well, the bottom line is you'll have to defend yourself and you will incur the cost which can get incredibly high. So in terms of joining them, so that's the QR code, excuse me, for student membership, which is completely free. Takes about 60 seconds to fill in. You get automatically entered into the prize draw of 200 lbs. I was at a Liverpool event not last week, the week before and one of the lads in the audience turned around and said he had won the 200 lbs a couple of weeks earlier and he'd only been a member for about four weeks. So it definitely, it definitely works. Definitely happens and it would be nice to win that money. If you need any further information or help, then feel free to reach out. That's my email at the bottom of that slide for foundation year one. So for those of you that are, that will need to join for your um F one F two year, that's the QR code there again. Super quick. We do have incentive gifts for joining um for your foundation year um which obviously we, we can't post out as an organization, we're going for net zero to help save the planet. Um and therefore postage and um everything like that is, is, is not something that we're going to do. So any events that we are physically at that you see us, please come over, show us on your phones that you have joined us through and explained. It was from one of the talks and we will happily give you one of the free gifts. So we have the um bags that go across bodies that you can put all your equipment and bits and Bobs in on the wards. We have ocean friendly water bottles made from preventive plastics and we also have torch pens as well. So please reach out um If you see it as an event to get the um the free incentive gifts. And thank you very much. Thank you for listening. All right. Thank you so much, Sarah, um and NPS for sponsoring today's talk. Now we will move on to the talk of the day by Doctor Priyanka. Um She is an OB and Gyne trainee in London. Uh Before we begin, I'd like you all to know that the recording of this talk and the slides will be available to you after. Um And if you guys have any questions or wanna ask Doctor Banca, anything, please put them in the chat box below. Um And I'll monitor them so Doctor Prica can read them and answer any questions. So over to you now, Doctor Prean. Um ok. So can I just check before I start um that you can hear me? Ok. And then you can see my slides as well? Yes, everything's fine. Great. Um Fine. So Simon, if, uh I've got a few MC Qs during the talk, would you be, are you happy to do the polls for the M CQ? Uh Yeah. Can you just let me know how many questions are there in total? So I can uh clear them up. Uh um Let me have a look if you just let me just stop sharing and then I can just, no worries do that quickly. So it should be 12. Yeah, so there's 20 in total. All right, I'll uh keep them up. So uh as and when you go through them, I'll put them on the pole. Perfect. Um sorry guys, sorry for the delay. Let me just bring that up again. Um ok, so um good evening everyone. I'm Priyanka. I'm one of the ST two ob trainees working in North central East London Den. So I'm in Newham at the moment. Um So I did the talk last week on obstetrics and I believe that that has been recorded. So if anyone wants to kind of go through obstetrics in an hour and a half, going through MC QS and stuff, so, uh, feel free to listen to that talk in today's talk. We'll be covering gynecology. So there's quite a few things to cover in gynecology as well. So I've tried to kind of pick the things that commonly come up in exams and the things that maybe aren't covered so well. And, um, um, you know, uh, in med school or like in um, um in like revision sessions and stuff. So hopefully you guys find this useful. Um I'll get started just so you don't, you guys don't have to stay on too late. Hopefully, we should try, I'll aim to finish by half seven and you guys will have access to the slides and stuff. I've got my phone on. So I should be, I should have access to the chat, but someone will also, someone will also keep an eye on the chat and just let me know if there's any questions or anything coming up. OK. So, uh the f we'll be covering a few topics today so you can just see that on the slide. So we'll start off with abnormal vaginal bleeding and we'll go through menorrhagia, fibroids and postmenopausal bleeding. And um as I mentioned, uh before I started, there are quite a few MCQ questions. So, um we really appreciate you guys engaging with that and then we can go through the answers and stuff as well. OK. So this is just a diagram just for you guys to have in mind whenever you're trying to answer a gynecology, pathology. So just think about the female reproductive tract. So you've got your uterus, you've obviously got all of the abnormalities in your uterus. You've got your ovaries, you've got all of the things that can go wrong in your ovaries. You've got your tubes, you've got the cervix, you've got the vagina and you've obviously got um lots of different pathologies and each of them kind of present in different ways. But these are kind of like your common differential diagnosis whenever you're seeing um a gyne gynecology patient. And obviously, you've got other things. You've got kind of physiological iatrogenic, systemic things as well like thyroid disease, coagulopathies and obesity that can then influence your gynecological presentations. OK. So, starting off with abnormal vaginal bleeding. Here's your first M CQ. You've got a 41 year old woman who comes to you with heavy menstrual bleeding. She, it's been worsening for the last 12 months. She's also got severe dysmenorrhea as well, which begins a few days before each of her periods. Her periods are regular and she has a 29 day cycle. She's not been sexually active over the past, over the past year. She doesn't take any regular medication. She's para two, so she's had two normal deliveries without any complications. You've done an abdominal examination which suggests a bulky tender uterus. Um And you've done a speculum examination as well, which shows a normal looking cervix. You requested a full blood count. What would you do next? In this case, guys, the pool is in the chat box. Ok. So we've got a couple of answers coming through. I might just wait for a few more responses and then um I'll go through the answer. Ok. So most of you have said e which is requesting a transvaginal ultrasound scan, which is the correct answer in this case. So, because obviously you're suspecting some kind of uterine pathology. So in this case, she's got dysmenorrhea, she's got heavy menstrual bleeding and she's got a bulky tender uterus on examination. Do you guys know what kind of pathology you might be suspecting? Um Which is why you are, you need to do an ultrasound scan before you do anything else. What kind of things are you guys thinking with regards to differentials? Um, feel free to put it on the um on the chat box, fibroids. Yeah, that's definitely one of the differentials. Anything else? OK. So the other thing that you guys would be thinking of is adenomyosis. So that's um, so endometriosis as well. And you've also got adenomyosis as well, which essentially gives you heavy periods. It gives you a bulky tender uterus and it's essentially presence of the endometrial tissue within the myometrium, um, as opposed to endometriosis, which is where you've got the endometrial lining, which is present outside of the uterine cavity. So that's your difference. And often actually, patients can have coexisting adenomyosis and endometriosis. Good. So, here's your second question. You've got a 27 year old woman coming in with heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. So, quite significant. Uh So it significantly affecting her quality of life. She's otherwise asymptomatic. She has no desire to have Children in the near future. You have a normal examination. What's the most appropriate management in this case? So what's your first line in someone who doesn't have any fertility desires and is having significant menorrhagia? Ok. So, uh most of you guys have said d which is the uh Mirena Coral and that's correct. That's the right answer. So, in some month that would like to get pregnant in the future, your first line management would just be conservative, things like tram acid to help with the severity of the bleeding and nsaids as well that can help with the pain. But it has also been shown to reduce the uh the menstrual blood flow as well. Um Obviously, things like, nor I USC op, those are all your hormonal methods for managing menorrhagia. And those would be th those wouldn't be appropriate if someone had um future fertility kind of needs. Ok. So going through heavy menstrual bleeding. So obviously, you've got lots of different things that can cause it ovulatory dysfunction. For example, PCO S patients can get quite infrequent. So they get irregular periods, but when they do get periods, they can be quite heavy as well. So it can be a sign of ovulatory dysfunction, especially if it's irregular bleeding disorders. So if they've got Von Willebrand disease, for example, that could cause heavy menstrual bleeding, uterine adenomyosis, which is what we've mentioned already. Pid as well can give you heavy menstrual bleeding, uterine fibroids, which is what someone mentioned already in the chat. Polyps can give you heavy bleeding, especially bleeding in between your periods would make you quite suspicious of uterine polyps. And also you need to think of more suspicious pathology as well. So things like s cancers, either of your cervix or of your uterus. So whenever you're taking history of the patient, it's really important to look at the nature of the bleeding, but also asking about related symptoms. Are they getting any bleeding in between their periods? Are they getting any bleeding after sex? Are they having any pelvic pain? How is that pain related to their periods? Right. Because endomet osteosis pain, often you get it right before the start of your periods and once your periods finish, that pain would usually resolve. In most cases, you can get pressure symptoms as well. So if you've got quite large fibroids and you can get increased urinary frequency. Because if you think about the fibroids pressing on the ureter or on the bladder, you can also get bowel symptoms as well with quite large fibroids and same with endometriosis. Again, you can get uh urinary problems and you can get bowel problems as well because everything is quite closely related together in the pelvis and impact on quality of life. And if you actually look at the nice guidelines, there's really good guidelines on uh management investigation of heavy menstrual bleeding. And actually, we're kind of going away from quantifying how much blood someone is losing to actually looking at how is that impacting their quality of life? And that's what our treatment should be focused on. How can we improve these patients' quality of life. And obviously also look for other comorbidities in any previous treatment as well. So if you've got heavy menstrual bleeding and you don't have any other symptoms as per the guidelines, you can just go straight to pharmacological management without carrying out a physical examination. But obviously, if you've got heavy menstrual bleeding, pelvic pain, pressure symptoms, you must carry out a physical examination and you must organize an ultrasound scan as well. So, can you guys think of any patients where you would think about sending off a coagulation screen? What kind of things would make you consider? Could there be like an underlying coagulation disorder? So, um hyperlipidemia. Ok. Anything else that um so let's so the kind of things I was thinking of was if someone has always had heavy periods right from their menarche. So they've always had a history of heavy periods. That's the first thing or if they've also got things like um bleeding from their gums, if they bruise quite easily, those kind of things, or if they've got a family history of any coagulation disorders, those kind of things would make you more likely to send off a coagulation screen. Um And obviously, if you can palpate the uterus abdominally, if you've got a pelvic mass or it's, it's someone who's quite obese and you wouldn't really be able to be confident in your abdominal examination or if they're having significant painful periods and you have to offer an ultrasound scan and your gold standard is a transvaginal ultrasound scan. Obviously, some patients would prefer a transabdominal one and that's fine. You just need to make sure that you explain the limitations of a transabdominal scan. So when would you offer an outpatient hysteroscopy? Obviously, if your scan shows some kind of polyp, if it shows you a submucosal fiber, then you would organize a hysteroscopy. If someone is having persistent bleeding in between their periods and irregular bleeding, then you need to offer a hysteroscopy. If they've got PCOS, if they're obese those kind of things, increase your uh risks of endometrial hyperplasia and endometrial cancer. So you must offer these patients a hysteroscopy if you are taking tamoxifen for breast cancer, that also increases your risk of hyperplasia and cancer. And if they have had any previous unsuccessful treatment, you need to always think, could there be something else going on? So you must have a look at the inside of the cavity and obtain an endometrial biopsy. Um So those are just some of the pictures or some of the ways that we can manage um heavy menstrual bleeding. The thing at the top is called an endometrial ablation. And that's essentially offered for patients who don't want to have a hysterectomy. They want to preserve their uterus and they don't have any future fertility needs. So what it basically does, it's a very cool device. It's not very commonly done uh these days. Um I haven't seen very many of them done at all. So you uh you essentially just go in with this device and it applies radio frequency ablation and it essentially kind of ablates the lining of the endometrium. So it should make your periods much lighter, but obviously, you can't have any future Children or anything you can get pregnant. But the chances of a successful pregnancy are quite low post endometrial ablation. It increases your risk of having miscarriages and stuff. The second thing is a photo of a uterine artery embolization. The impact on fertility in the future is uncertain with uterine artery embolization. It's important to counsel patients about that. Essentially, the diagram shows you quite nicely. All you're doing is basically selectively embolize the uterine artery, which should then reduce the blood supply to the fibroids and the fibroids should therefore shrink and the patient's symptoms should in theory, get much better. The photo at the very bottom basically shows how you can do a operative hysteroscopy. So you go in with the hysteroscope, um which is just your camera basically, and you can introduce these instruments, which can help you remove any submucosal fibroids or any polyps, which should help with the bleeding symptoms. The most common causes of heavy menstrual bleeding are fibroids and polyps. So we've mentioned this already. If you're trying to conceive, then chronic acids and nsaids, if you're not trying to conceive, then Mirena coil would be the first line. And you've obviously got the surgical options as well, which I've mentioned to you already. And obviously the last line of someone who has completed their family, those kind of things would be a hysterectomy. Ok. So, um so I've just covered this already, but let's just move on to this M CQ as well, just to kind of drive the point home. So you've got a 40 year old lady, longstanding menorrhagia in the Gyne clinic. She's had three normal deliveries and no other comorbidities. She does have a raised BMI of 35. She's got a background of a large fibroid uterus which is causing significant impact on the quality of life. She's tried loads of conservative pharmacological management and she's confirmed that she's completed her family. So in this case, what do we think is the most appropriate management? Ok. So most of you guys, actually all of you guys have said discuss surgical management options for her including hysterectomy. So the clues and your option are um she's completed her family. She's tried the conservative and pharmacological management as well and that's not really helped her. So those things would make you consider hysterectomy. And in this lady, especially with the raised BMI of 35 obviously, preoperative counseling is very important. So you would counsel her on weight loss before her surgery. Uh because that will make your operation much easier as well. The other thing that will make your operation much easier that we see in clinical practice is these patients often receive hormonal injections called prostat, which is basically a GNRH analog. And we'll come on to that in a couple of slides. And what that does is basically preoperatively, it shrinks your fibroids, which should then make your operation much easier. And we do see that as well. These patients that have fibroids shrink massively actually, which definitely helps uh with the with the operation itself and any and any subsequent complications. So, moving on to fibroids, uh fibroids are basically just benign tumors, essentially of your uh of the muscle of the uterus. Risk factors of fibroids are increasing reproductive age. Um Asian and black women obese if you've had early menarche. And also if you've got a first degree relative with fibroids as well, and depending on where the fibroids are, helps you to explain the symptoms that patients would have. So, for example, if you've got a PED, if you've got a submucosal fibroid, then you are more likely to get symptoms like intermenstrual bleeding, heavy menstrual bleeding. If you've got an intramural or subserosal fibroid, you're more likely to get the pressure symptoms essentially. And growth is estrogen and progesterone dependent, which is why often actually after menopause fibroids should shrink and patients symptoms should improve. Um And I've mentioned this already, if you've got submucosal fibroids as well, that can impact your fertility. So, complications of fibroids, obviously, if they are large pedunculated fibroids and they can twist, you can have degeneration, which is basically where um which is called red degeneration in pregnancy. And what happens is these fibroids basically outgrow their supply and they can therefore uh cause pain. You can also get uh calcification as well and you can also get malignant changes. Uh the chances of uh malignant fibroids are like sarcomatous, changes in a fibroid is not 0.1%. So, they're not very common at all. Uh Features of malignancy are if you're having pain and rapid growth, uh growth in someone who's post menopausal because you would expect these fibroids to shrink. And if they are having poor response to these GNRH agonists or Prist acetate, and we'll go on to what those medications are. So, management of fibroids, you obviously you can divide them up into um medical and surgical. So you can always give the coil as well. But if someone has got large fibroids that are distorting that cavity, then uh then you know, the Mirena coil might not be as effective at reducing their symptoms. The other thing that you can give them is GNRH agonists, which you can only use in kind of over a short period of time because they can cause uh what they essentially do is they put patients into a state of menopause and that can then give you all of your symptoms of menopause. But it can also give you other things like bone density loss and increases your risk of osteoporosis as well. And the problem with GNRH agonists is that fibroids can then return to your normal size once the treatment is stopped. The other thing that um can be given to selected patients, um especially those that have large fibroids and they are premenopausal is ulipristal acetate. Does anyone know how this medication works. No worries if you don't, it's quite like a niche pharmacological question. So essentially, it's an SPR M or a selective progesterone receptor modulator. So it basically reduces your progesterone levels in the uterus. So, which means it thins your endometrial lining and on the ovaries, it basically reduces your ovulation and that's basically how it works and how it kind of shrinks your, it basically just reduces your, uh your hormone levels, which then shrinks your fibroids. Essentially. Um The thing that we do need to make sure people uh we monitor with rystal acetate is your liver function tests. And as soon as there's any derangement in liver function tests, you need to stop this medication straight away. So it's only so you there, there's a lot of caution associated with prosol acetate, essentially surgical management. Obviously, if it's a submucosal fibroid, which is inside the cavity, which you can see, which I showed you in the pic in the slide before you can do a hysteroscopy and basically transcervical. So through the cervix, you remove the fibroid, you can do a myomectomy which you can do open or you can do laparoscopic, you can do a uterine artery embolization which should essentially reduce the blood supply to the fibroid and shrink the fibroids or you can do a hysterectomy as well. So just a quick slide on sort of what's new in the management of fibroids. Um over the last couple of years, I think there was a statement issued in October 2022 with regards to this medication that's now finally been nice approved. And it's basically a combination of relux, which is a GNRH agonist, um plus estradiol plus norethisterone acetate. Um and essentially helps to reduce menorrhagia in women who have moderate to severe symptoms of uterine fibroids. And one of the benefits of this compared to your other GNRH injections and surgery is that it's taken orally. It's a non surgical management. It's uterus preserving, it's quite well tolerated. And essentially you can take VCO for an unlimited period of time. It's not like with GNRH analogs where you have to think about uh putting them into menopause and the bone loss side effects and stuff. So it's quite a new way of, you know, treating fibroids and patients tolerate it quite well actually. So just quickly going through GNRH agonists and GNRH antagonists. So GNRH, actually, if you remember from your kind of um endo endocrinology lectures and stuff, you basically need that pulsatile release of GNRH for your anterior pitu to lea to release the LH and FSH. What GNRH agonists do is that they just give you a constant uh wave of GNRH. And what that basically does then suppresses the LH and FSH production because you lose that pulsatility and that's how that works. The way that GNRH antagonists work is that and, and essentially with GNRH agonists, it takes a little bit of time for it to work. Whereas GNRH antagonists, they just immediately block the receptors and they, it causes immediate suppression in LH and FSH. That's basically just the difference between the two. So essentially the end result is the same, but it just takes slightly longer with the GNRH agonist and with the GNRH agonist, you can, you can have an initial kind of spike in the LH and FSH and over time it then reduces. Ok. So um next question on abnormal vaginal bleeding. This is to do with postmenopausal bleeding and how you would investigate it. She's got a 67 year old lady, three episodes of postmenopausal bleeding. She went through the menopause 10 years ago and this is kind of her first time that she's having postmenopausal bleeding and all of that time. Um she did take HRT for five years previously. Um We performed an abdominal examination which is unremarkable vaginal examination is normal apart from some vaginal dryness, what should we do in this case? And just a bonus question, does anyone know at which endometrial thickness you would offer this patient? A hysteroscopy and biopsy? Ok. So, um most of you guys have said b which is the correct answer. I just wanna go through some of the other answers. So some people have said hysteroscopy. So the reason why you wouldn't jump straight to hysteroscopy is because actually if your ultrasound scan shows that your endometrial thickness is less than four, then you don't actually need to do a history. You don't, you don't need to do a hysteroscopy. You don't have to put a patient through a hysteroscopy. That's why you must do an ultrasound scan first and it would be a two week weight ultrasound scan just for purposes of your uh exam and stuff. If they were to differentiate between like a routine one or a two week weight one, this is postmenopausal bleeding. So you are suspecting endometrial cancer. You must do a two week weight referral. So that's why it's not a hysteroptosia. It's colposcopy is basically looking at the cervix. Um So in this case, actually, we think that it's postmenopausal bleeding and you've done a vaginal examination. I'm II should have mentioned the cervix would have looked normal on the vaginal examination. Obviously, if there was an abnormal cervix, then you would have gone for a colposcopy. I hope that kind of clarifies why B is the correct answer over DNE? OK. So postmenopausal bleeding differentials. So the things that you wanna think about are endometrial cancer, cervical cancer, ovarian cancer. Um and some of the other things like HRT as well. So you can get some, some bleeding on HRT. Um you can get bleeding on tamoxifen, which is um used to treat breast cancer. And I've mentioned vulval and vaginal cancer as well. So the guidelines. So anyone over the age of 55 with postmenopausal bleeding gets an ultrasound scan within two weeks and a normal endometrial thickness in someone who's postmenopausal is less than four millimeters. So to diagnose endometrial cancer, you must have a look and take a targeted tissue biopsy. And obviously anyone with hr two who presents with postmenopausal bleeding, you need to investigate them essentially uh management of other causes of. So once you have kind of ruled out uh cancer, some of the other causes of postmenopausal bleeding are vaginal atrophy. So you treat that with topical estrogens, with lubricants, you can give them HRT as well. If a patient is already on HRT, what you often have to do is just kind of tweak some of their current HRT regimens to try and get them on a bleed free regime. Basically, uh with regards to endometrial hyperplasia, the guidelines can split them up in two with atypia. So atypia is abnormal. If someone has hyperplasia with atypia, basically, there's a risk of progression to cancer. So you offer them a hysterectomy if they don't have if they have hyperplasia. But without atypia, there's a less than 5% risk of developing cancer. So essentially, you just manage them with progesterone which should thin their lining and you just, you basically just do surveillance biopsies on them every year or every six months. So that's kind of like your postmenopausal bleeding um in one slide. So it's two week weight referral, normal endometrial thickness is less than four. That's basically all you guys need to know for postmenopausal bleeding, so quickly, looking at endometrial cancer, uh some of the risk factors for endometrial cancer because they do like to ask about this in exams. So, obviously, age obesity, PCO s, early menarche and late menopause null parity and uh using estrogen only. HRT. That's why anyone with a uterus needs to have estrogen and progesterone because unopposed estrogen can result in uh endometrial hyperplasia, which can then cause cancer. Protective things are cop and smoking. Uh treatment options. Um Obviously, if it's localized disease, then you can do just removal of the th is total abdominal hysterectomy. So just do at and BSO is basically removal of both the tubes and the ovaries. If you've got extra uterine disease, if it's inoperable, um or if you've got recurrence or if it's a palliative patient, then you can do radiotherapy. If someone's quite frail and elderly, then you might just think about giving them progesterone progestogens basically just to manage their symptoms. And that's a useful diagram, basically looking at all the different stages in case you guys need that for exams and stuff. And I find that the diagrams are really useful for staging of like endometrial uterine ovarian cancer and stuff. Yes, that's just um like an aid for you guys for a vision. OK. So that's everything to do with um abnormal bleeding. If you guys have any questions to do with that, please do pop it in the chat and I'll try and answer that. Um I'm gonna move on to pelvic pain now and if any questions come up, I'll just take it as we go along. Ok. So, um looking at pelvic inflammatory disease and its management. So what do we think the answer is for this question? You've got a 22 year old woman in A&E no abdominal pain, some vaginal discharge she's had previous PID which was treated temperature. 36.9 pulse is 90 normal BP, no signs of peritonism on examining her abdomen and vaginal examination. She does have adnexal tenderness and some offensive discharge. Pregnancy test is negative CRP is mildly raised. White cells are 12.2. So your working diagnosis is P ID. What do we want to do with this patient? How do we treat him? So I'll wait for a couple more people to answer. This is a, this is a trick question I have to say because obviously there's loads of different correct answers and you essentially need to decide whether you need to admit this patient or you think they can be treated in an alternative way. Ok. So the correct answer actually was C which is oral metroNIDAZOLE and Levofloxacin, which is most commonly used as your oral um your outpatient P ID protocol actually. So in this case, the reason why you would treat her in an outpatient setting is because she's not pyrexial, her obs are stable. She's not, she's got no signs of peritonism. When you're examining her. So you don't think that she's got any kind of tube ovarian abscess or anything very mildly raised CRP when white cells are not that raised as well. So actually, she would be suitable for your 14 days of oral outpatient antibiotics in this case. And obviously, if she becomes any worse, and you would ask her to come back in and you do imaging and repeat bloods and stuff so quickly going through pelvic inflammatory disease. Essentially, it's ascending infection from the cervix which basically then spreads to your female pelvic organs. Risk factors are prior STIs s any recent new sexual partner. So anyone who are, who are suspecting P ID, you have to do a very thorough sexual health history, having multiple partners unprotected sexual intercourse. Um just to kind of uh j just on a side note, actually, um P I can happen in people that are not sexually active as well. Uh Most common organisms are chlamydia and gonorrhea, which actually only comprise 40% of pis and most infections are actually polymicrobial, which is why you're treated with broad spectrum antibiotics. And this inflammation in the long term can give you all the things in that picture. So it can give you scarring, it can give you adhesions, obstruction of your fallopian tube, which can obviously have long term impacts on someone's fertility as well and you often get what we call a frozen pelvis. So, management of P ID analgesics, antibiotics duration is 14 days. If it's mild P ID, which is what that question was testing, you just give them oral antibiotics if it's severe. So obviously, pelvic peritonitis, tubo ovarian abscess, if they're pyrexic, then you give them IV uh, cefTRIAXone and doxy and Metro. Um And if there's no significant improvement after 24 hours, the guidelines need to consider laparoscopy if you do find a pelvic abscess and you can either laparoscopy or ultrasound guided drainage. And it's important to treat the sex treat, treat their sexual partner as well. Careful counseling in the future with regards to barrier contraception partner tracing, advise them to attend their sexual health clinic. So with regards to, does anyone know what the picture at the top shows the ultrasound scan at the top? Um and what are those adhesions at the bottom called? You cannot say either one of those or both. Yes, amazing. So it's called Fitz Hugh Curtis syndrome. And those are basically a perihepatic adhesions. So those are the adhesions between the liver and the anterior abdominal wall. You don't see it very frequently. But now and then we do see it actually in our patients, especially we're doing a diagnostic laparoscopy and then we're doing our 360 degree look at the liver and then you just see the adhesions. So it is a sign of previous P I. Um anyone know what the ultrasound scan at the top shows it basically shows you a tubo ovarian abscess, that's what the abscess would look like. So, uh when look, when looking at the complications of P ID, there's a useful pneumonic called eye face P ID. So it can give you infertility fits you. Curtis, abscess, chronic pelvic pain, ectopic pregnancy, peritonitis, intestinal obstruction. That's and the last two are less commonly seen because, you know, we're quite good at picking up and treating for PID with quite broad spectrum antibiotics. But it can give you intestinal obstruction and disseminated infection, like endocarditis, sepsis, and meningitis. Ok. Good. Um Next question, looking at pelvic pain and how to investigate it. She's got a 32 year old woman with a history of painful regular periods. Um She stopped the combined oral conceptive pill eight months ago and her periods are now more painful and heavy. Um She's upset because she'd like to conceive, but the pain is limiting sexual intercourse. She would like to know the cause of her symptoms. So you're examining, her abdomen is soft with no masses and you've done a bimanual examination which is limited because of pain. So, what's the gold standard diagnostic test? And the clue in the question is gold standard, even if it might not be the thing that you would do next. What's the Yeah, what's the gold standard? Yeah. So most of you guys have said B which is laparoscopy. I think someone has said e um the reason. So ca 125 can be raised in endometriosis because of endometriomas and stuff. But actually, ca 125 is not the gold standard diagnostic test. The only time you would send off a ca 125 in the community if you are suspecting ovarian cancer. And I think in answer to your question, you guys will get um access to the slides in the recording. Um So don't worry if I've kind of, if I'm skimming through a few of the things that's because you guys will have access to everything. So you can go back and look at it. So, moving on now to the differentials for dysmenorrhea. So you've got primary and secondary dysmenorrhea. Primary dysmenorrhea often coincides with the start of menstruation and it responds quite nicely to nsaids and cop secondary dysmenorrhea is basically where pain starts before and then it's relieved by the onset of menstruation. And it's often associated with deep dyspareunia, which is uh when you're having sex, you get pain kind of deeper in um deeper in the pelvis. Um As opposed to superficial dyspareunia, you can get heavy bleeding and irregular bleeding is also quite common. So, differentials for secondary dysmenorrhea are postmenstrual, uh sorry, premenstrual syndrome. Um endometriosis, adenomyosis, which we have spoken about already fibroids and pelvic inflammatory disease and sometimes ovarian tumors as well, but less commonly. So, going to endometriosis. So, it's basically presence of the endometrial tissue outside of the uterine cavity. And this extra uterine endometrial tissue responds to the hormonal fluctuation of the menstrual cycle. So, just think of pain when you think of endometriosis and you've got the four ds, dysmenorrhea, painful periods, dyspareunia, painful sex, dyschesia, pain on opening your bowels and dysuria pain on passing urine. So, it's basically all of the different cavities inside your, uh, pelvis are affected by the inflammation. Um, and all the adhesions on examination, often you see a fixed uterus, you see pelvic tendons and enlarged ovaries as well because of the endometriomas. Um So investigations, you do an ultrasound scan, but laparoscopy as we did on the M CQ is the gold standard for diagnosing endometriosis. So, management and complications of endometriosis. So, management essentially is hormonal suppression. So which can be any form. It can be oral tablets, it can be the coil, it can be injections, pain relief and surgery as well. So you can either resect the endometriosis, you can remove these endometriomas. If you know, if it's very severe, it's not um kind of responding to any of the other treatments. You've, you, you don't have any future fertility needs, then you can do a hysterectomy and uh uh removal of the tubes and ovaries as well. In refractory cases, complications are obviously, if you're removing the ovary in someone who's uh premenopausal ovarian failure, post treatment, formation of adhesions, infertility as well as another one of the complications of endometriosis. Sadly. Ok. Good. So, moving on to, I think this is our last pelvic pain question. This is more of um kind of like an acute uh pelvic pain as opposed to chronic pelvic pain. So, you've got a 33 year old woman who's presenting with worsening, left-sided abdominal pain. She reports the pain started suddenly five hours ago, a sudden onset, steadily getting worse and it started following intercourse. She's unsure of the date of her last menstrual period because she currently has a coil fitted. Um So abdomen is tender, no guarding or rigidity. Pelvic examination is unremarkable. The Mirena coil threads are clearly visualized and our a scan shows free fluid in the pelvic cavity. Um and importantly, urine pregnancy test is negative. What do we think the answer is in this case? Ok. So most of you guys have said the right answer which is c which is ruptured ovarian cyst. Good. Sorry, one more question on pelvic pain. So you've got a 19 year old woman who's referred to A&E with a fluctuant lower this time, the abdominal pain is on the right associated with vomiting. There's some rebound tenderness. Um serum beta HCG is negative. You've got free fluid in the peritoneal cavity but no other pathology to account for the pain, white cells are 14 and CRP is 100 and 84. So this is a slightly tricky one. What do we think is the answer in this case? So the most likely diagnosis. Ok. Yeah. So as I can uh maybe I'll wait for a few more responses. I think you guys are obviously picking the right kind of answers. I th this, this is a tricky one actually. Do you need a little bit more information? So it looks like people have picked ABC and D most people have picked B So the answer actually from the text from the book that I took the question from is acute appendicitis. The reason why they've said it's not an ear ectopic pregnancy is because the beta HCG is negative. So it's very, very unlikely for it to actually be an ear ectopic pregnancy. That's the first one. The reason why it's not a tubo ovarian a. So the reason why it's appendicitis is because you've got quite significantly raised CRP and white cells and it's pain associated with vomiting as well with some rebound tenderness. The only thing is that she's afebrile, that kind of is is it is the only thing that doesn't fit with the acute appendicitis, but that's still the most likely diagnosis. The reason. So the reason why it's also not an early ectopic pregnancy is because you're not really going to get raised inflammatory markers as an ectopic pregnancy. We barely, we, we never see that basically, the only thing you would see on the blood would be obviously um uh raised beta HCG. The reason why it's not um P I in this case is because there's no, you know that that doesn't tell you anything about discharge or like sexual partner? Nothing like that. So, actually, appendicitis is more likely than pito vri abscess is actually an ultrasound diagnosis and ovarian torsion. Again, you would see something on an ultrasound scan, you'd see a mass, you'd see, uh, lack of blood supply to the ovary. And that's why it's not d so it is a tricky one. yeah, the textbook that I took the question from says that the answer is for this question. So when we're looking at ovarian cyst accidents, you've got two types of accidents that you can get, that we've kind of covered in the M CQ questions already. So you've got ovarian cyst rupture and you've got an ovarian torsion and a cyst. So both can present in quite similar ways, both present with acute abdominal pain. Uh, cyst rupture can give you PV bleeding as well. And in both cases, you must rule out topic. So you must organize an ultrasound scan. You must do a beta HCG in an ovarian torsion. You basically see a large ovary with impaired blood flow. Does anybody know what that picture at the top shows you? It's actually an ultrasound scan finding that you can see, um, in an ovarian to, it's a sign that, uh, it's a sign basically. And obviously with the torsion, you must take them to theater because you need to de to that ovary and you need to see if that ovary re regain is blood supply. Once you basically untwist it, ovarian cyst rupture. If they are stable, then you could just manage them with just analgesia. But obviously, if they're unstable, there's lots of blood in the pelvis and you must take them to theater. Yeah. So that picture actually shows you a whirlpool sign, which is a sign that you can see an ultrasound scan in someone who's had an ova, who's we are suspecting an ovarian tumor. Um And I've mentioned that already. Ok, good. So I thought we'll just take a little bit of a break from Gynae and just go through some sexual health stuff. So we'll cover contraception, ST is and uh vaginal discharge. Ok. Ok. So we've got an M CQ on emergency contraception because that's often something that people are a bit less familiar with. So we'll go through it, but I just thought we'll uh do an N CT first. So you've got a 16 year old girl history of um unprotected sexual intercourse 70 hours ago. Uh Last menstrual period was eight days ago. Uh Her only past medical history of note is epilepsy which is well controlled by carBAMazepine. She's worried about becoming pregnant, does not want her mother to find out and she's in a hurry to get home before suspicions are raised. So which of the following options are available to her? Sorry guys, I realize a lot of these questions are quite tricky. I think that I'm just useful to do the slightly trickier questions and actually work through the reasoning. Um So I will give you guys a bit more time. So this question tests both. Um You need to know first of all, what can you give us emergency contraception? And second of all, if you've had oopsy 70 hours ago, which forms of contraception can you actually use? Ok. So we'll actually come back to this question. We'll cover the emergency contraception bit first and then we'll come back and we'll go to the answer to this question. So, um I just thought I'd do a quick whiz through contraception. I'm sure you guys are quite familiar with it already. So you've obviously got hormonal methods and nonhormonal methods as this table shows you um a question that's commonly tested is the UK MEC four criteria which is basically when um cases where combined oral conceptive pill is contraindicated essentially. And these are some of the uh some of the instances. So obviously, if you're breastfeeding up to six weeks, age of over 35 and smoking over 15 cigarettes a day, if you've got uncontrolled hypertension, history of stroke or ischemic heart disease, history of vte breast cancer, severe liver cirrhosis. So, these are all of the UK ME four criteria because you were supposed to have that list in your head. So going through special cases of contraception. So, postpartum and emergency, think of those two as your special cases. So uh postpartum, you in theory, you've got this lactation amenorrhea method. So it's not needed for 21 days. But often actually on our postnatal ward, we discharge women home with contraception. They want to start the progesterone only pill. We actually start it as soon as they leave because that improves their compliance and same with the Depo Provera as well. We can give them the injection before they go home. Um, the cop is contraindicated if they're breastfeeding less than six weeks, the coil needs to either be inserted at the time of cesarean section or they, they've had a normal delivery. It can be inserted within 48 hours or if you know, if you've lost that window, then it needs to be inserted after four weeks. Basically to allow the uterus to kind of come back down or to start to in and come back down to its regular size. So, moving on to emergency contraception, um you can essentially use the Leno gastro up to 72 hours after you can use oli presil acetate, uh which is a progesterone receptor modulator up to five days after. But you need to be cautious in severe asthma. Um copper IUD, you can insert up to five days after or five days after the estimated date of ovulation. So we'll quickly go through uh some of these contraception methods. So which contraception would be uh contraindicated in a patient who has migraine with auras and you guys can just put the answers in the chat. Yeah. Correct. So the answer is C OCP. Perfect. Which one do you have to take regularly without any breaks? The P RP? Perfect. Uh which one results in a delay in fertility? So there's only one which is, so it's actually the depo Provera that can result in a delay in fertility. So just something to remember what is the most effective form of emergency contraception of your three options that you have copper coil? Perfect. Uh And which one is useful for Menorrhagia? Which is your first line for Menorrhagia? I think that's your last question. We've gone through this already in the Menorrhagia slides. Perfect. Yeah. So it's your Mirena coil. So just going back to that question in case you guys were wondering um what the answer was for this one. So um I think it was kind of split. So most of you guys said C um and some of you guys have said B so the reason why you wouldn't give C So I think they, they mean Leno Gastro 1.5 mg. I think they actually mean the Mirena coil. So you wouldn't actually give that. You can't give that but the ela one the there any. So the reason why you can't give LLA one in this case, which is the, let me go back. Sorry. So L1 0 no, that, that is Leno GSR sorry. The reason why you can't give Leno Grl in this case is because she's got epilepsy, which is being treated with carBAMazepine and carBAMazepine can actually affect the way that L1 or Levonogestrel works. So that's why you can't actually give her that. So the next thing that you can give her is a copper IUD. And the reason why you can give the copper IUD in this case because is because you can give the copper IUD up to five days. So it's 100 and 20 hours and you can give it up until. So she'd actually be within the time frame of the copper IUD. So this is a slightly tricky question with loads of little bits in it. So if they said, what, what would be the most effective one, then it's very easy. It would be the IUD because that's the most effective form of emergency contraception. In this case, you can give the, if she didn't have the epilepsy, you could give the L1 or you could give the LEV, no gastrol. But the reason why you can't give her L1 is because of the epilepsy. So I hope that kind of clarifies that question. OK. So we've gone through this. So uh next question, looking at bacterial vaginosis. So you've got a 22 year old woman presenting to the gum clinic with an offensive smelling discharge. Um And you've kind of taken swabs, she's diagnosed with BV, which of the following organisms is not likely to be the cause. So BV can be caused by loads of different things. Um which one does not cause BB and actually causes a different kind of um S ti a different kind of kind of um in different kind of infection. Sorry, pelvic infection because B is not an ST so most of you guys have got this answer correct. So it is trichomonas because trichomonas actually causes a different kind of infection and we'll go through that now. So just I'm just gonna quickly um kind of whiz through this. So this is useful for when you guys have your aus stations. So really important to ask about abnormal vaginal discharge. This peria, any bulbous skin changes and itching, we always forget to ask about lumps and bumps, ask about last sexual partner was a consensual regular partner type of sex, any form of contraception and need to ask about any other partners in the last three months and always do a HIV risk assessment as well. And all of the especially in your sexual history. Vignettes. Ok. So going through uh kind of vaginal discharge, the common causes of vaginal discharge are physiological. Candida. Candida gives you cottagey discharge. You would be quite itchy vulvitis, trichomonas gives you offensive yellow green frothy discharge. You often see a strawberry cervix on examination is what they tell you in exams. Uh BV, again, you see offensive but it's thin white gray discharge with a fish oda, worse with intercourse and trichomonas is the only one. The one reason why I put a star there is because that's the one that's sexually transmitted basically in can and BVI are not sexually transmitted infections. Less common causes of vaginal discharge are gonorrhea, chlamydia, ectropion and foreign body as well and cervical cancer. So we shouldn't forget. So, um, quickly going through your non sexually transmitted infections. So we've got BV and you've got Candida. So BB is because of loss of lacto bas an increase in your anaerobic and BV associated bacteria. Uh You guys would remember your AMLS criteria. So those are kind of the four things that you typically see in BB, your management basically is oral metroNIDAZOLE for 5 to 7 days in pregnancy. Uh Sorry. Uh That's how you treat it. Risks in pregnancy. Are it can give you preterm labor essentially. Um That's your risk, candidiasis, risk factors of pregnancy. And we actually see it quite frequently in pregnancy. And if you've got Candida in pregnancy, you can't give fluconazole, you would give them the pessary instead. Um And that's just a picture of your two cells which are basically just your vagina cells with the bacteria stuck to them, which is what you see under the microscope. Then moving on to chlamydia and gonorrhea. Um Essentially the things that you need to know is treatment of chlamydia is you can either give azithromycin as a single dose or doxycycline for seven days for gonorrhea, you give them I am cefTRIAXone as a single dose. Um Both of them actually can be silent, which is why there's a lot of kind of chlamydia and gonorrhea that patients don't even know about because usually they're asymptomatic, but they can present with vaginal discharge into menstrual bleeding, postcoital, bleeding and stuff as well. And um, if you guys remember, sorry, this, the slide hasn't really projected very well. You've got the triad of, you've got reactive arthritis. So I remember from past me, it was can't c can't pee, can't climb a tree. You've got arthritis, urethritis and conjunctivitis. That's your triad for reactive arthritis, which you can see with this uh with kind of untreated chlamydia infection. Um So going through three other sexually transmitted infections. So remember the strawberry cervix for trichomoniasis uh for genital herpes, it's just painful ulcers. If there's primary herpes in pregnancy, then you have to do elective cesarean section because of risk of uh transfer to baby if you have a normal delivery. Um syphilis, you have primary secondary tertiary and you treated with iron penicillin. So I am going through these slides quite quickly just cause I'm conscious of time. But you guys will have access to this, as I've mentioned already. This is from past medicine just looking at the overlap between BB and trichomonas. Just remember they both get treated with metroNIDAZOLE. But obviously BB, you've got a S criteria. Trka is a yellow green discharge, the strawberry strawberry cervix um And that's a slide for you guys to go away and look at in your own time. I just made this table for re revision and I thought it might be useful for you guys as well. So just looks at the clinical features treatment and of all the different um infections that you can get. Cool. So we'll quickly go through um some of these questions and you guys can just put the answers on the chat. You've got an 18 year old girl who presents to her GP with discharge. Um, she's got thick cottage cheese like discharge um with no other symptoms. What's the most likely diagnosis? And how would you treat it? Yeah, exactly. So it's vaginal thrush. Perfect. So the next patient has offensive fishy thin gray vaginal discharge testing. The discharge shows a Ph to be over 4.5. What do we think the answer is for this one? And how would you treat it? So, with the first one, obviously, you just give them either clotrimazole pessary or you can give them oral fluconazole. You can't give fluconazole in pregnancy. So, how would you manage the second patient? What would you give them or if you can't remember, just tell me what the um, what the presentation is. Yes, perfect. So, it's BV and oral metroNIDAZOLE. Thank you. Uh Next lady has an offensive musty frothy green vaginal discharge. You see an erythematous cervix with pinpoint areas of exudation. What's the differential here and how would you treat it? Trichomonas? Perfect. And again, that would also be treated with oral metroNIDAZOLE. Next patient uh presents with thin purulent, mildly odorous vaginal discharge. She's also complaining of dysuria, intermenstrual bleeding and dyspareunia. You've taken a swab which shows a gram negative diplococcus. So, slightly more tricky, does anyone know what the uh differential diagnosis is in this case and how you would treat it? So the gram negative diplococcus kind of gives it away gonorrhea. Perfect, good. And do you know how you would treat it? Um So I was gonna say Kef but maybe you can give doxy as well. I've already actually remembered one of them. Um So gonorrhea is actually cefTRIAXone doxy is for chlamydia. Yeah. So it's cefTRIAXone for gonorrhea. It's just a single dose. Um Good, well done. So we've gone through that already. That's just for you guys to have a look at. So I'm just gonna quickly whi through this fertility um history because you guys kinda know that already. How long have you been trying? How frequently do you have intercourse and need to basically consider each of the partners separately approach to fertility. So just think about there are five things that you want to examine. So firstly, are they releasing an egg every month? Secondly, are there any uterine things like fibroids? Polyps? Thirdly, do they have patent tubes? Do they have P I? Do they have blocked tubes and four male factor, infertility and five peritoneal factors. Think about endometriosis in the peritoneal. So, investigations obviously in men, you would do a semen analysis in female. You do a mid luteal progesterone, you'd do FSH and LH to have a look at your ovulary function. And you'd also do tests to check the patency of the tubes. That can be a hysterosalpingogram or it can be a laparoscopy and dye test as well. Good. So, um, let me, oh, I forgot to put, I might actually skip this question just because I forgot to give you guys a normal value. So it's actually difficult to answer without the normal values. So I'm gonna skip this one and I'm gonna go to the next one. You can keep the same pull up because it's the same kind of uh it's just a to e. So, um let's move on to this question. You've got a 27 year old woman struggling to conceive. She's got a raised LH FSH ratio, mildly raised testosterone, ultrasound scan is showing you loads of peripheral ovarian follicles. So we know this is PCOS, what single set of symptoms is she most likely to have? OK, good. So you guys have said c which is the correct answer. So the answer is oligomenorrhea and facial hair so quickly going through Polycystic Ovarian syndrome. So that picture is very good because it basically tells you your rod criteria, which is basically a combination of the three. So features of Polycystic Ovarian syndrome are subfertility or infertility, menstrual disturbances. You can have amenorrhea, you can have oligomenorrhea as well. Hospitalism and acne because of the raised testosterone levels, obesity, um acanthosis Ricans is basically darkening of the armpits. And that's again, with regards to the raised um uh estrogen that's being secreted. Um You've got the RO down diagnostic criteria for PCOS and it basically requires two out of the three. So you need to have clinical or biochemical hyperandrogenism. Clinical is basically, for example, where you can see hirsutism, acne or biochemical, which is basically just elevated the testosterone levels, oligomenorrhea, which is defined as less than 6 to 9 menses per year or Polycystic ovaries on ultrasound scan, which is basically over 12 follicles in one ovary or an ovarian volume of over 10. Um So, yeah, so you guys just need to remember what the features are and what the, what the diagnostic criteria is. So it's anovulation or anovulation, hyperandrogenism and polycystic ovaries. So, with regards to treatment, um when it comes to the treatment of oligomenorrhea, you basically give them the cop, it helps to treat Herut and also helps to regulate their menstrual cycle as well because obviously, the problem with PCOS is you've got this unopposed estrogen. These patients are not having regular cycles which means that their endometrial lining is quite thick. So to try and thin the lining, you basically give them the coil, you give them the combined conceptive but those are some of the things that you can give them life cell interventions are actually really important because these patients are at increased risk of cardiovascular disease, increased risk of type two diabetes, increased risk of endometrial cancer. So, healthy balanced diet, regular exercise, you want their BMI to be between 90 to 25. And that basically improves your acne and hair growth, regulates your periods and also improves your fertility as well. And we've mentioned the long term implications and stuff of um of PCO S good. So, uh this is another infertility question. It's looking at the comp one of the complications of IVF. So you've got a 34 year old woman, she's just feeling generally unwell. Her abdomen has become quite distended. She's suffering from loose stools, she feels quite breathless as well on exertion. Uh She's got generalized abdominal tenderness, she's undergoing fertility treatment and she was injected with a um hormonal injection basically as part of her IVF last week, given the above history, which of the following is the most likely diagnosis. So as I said, this is looking at one of the complications of um of IBF specifically. So I'll wait for a few more responses and then we'll go through the answer. OK, good. So the correct answer is actually ovarian hyperstimulation syndrome and we'll go through what it is and how it presents. So, ovarian hyperstimulation syndrome is basically one of the potential side effects of ovulation induction. Um and it's basically a spectrum and severe hyperstimulation syndrome is seen in less than 1%. So it's quite rare, but you can kind of be in the mild to moderate end of the syndrome as well. So, part of physiology, essentially what happens is because of these injections, you have ovarian enlargement, which increases the permeability of the capillaries. And basically, you get these fluid shifts. And because of that you have abdominal distension, you can have a lot of fluid in the lungs as well. Which mean with the breathlessness, you can get life threatening complications like hypovolemic shock, acute renal failure. And there are also um risk of VTE as well because of the thrombotic processes involved. And essentially the principles of management is just fluid and electrolyte replacement anticoagulation therapy. And if obviously, they've got massive amounts of fluid in the abdomen, then you can remove the fluid as well. So anyone coming in with severe abdominal pain, deranged electrolytes, um If you know, if you can see that they've got distention and they have a history of undergoing ovulation induction as part of IVF, you must think, could this be ovarian hyperstimulation syndrome? Good. So this um this is just quickly going through um suspected ovarian pathologies. Um So you've got a 63 year old lady nulla paris. She's got quite vague symptoms of abdominal bloating, diarrhea, family history of ibs abdomen, soft, non tender, but you have a palpable pelvic mass which of the following is the most suitable next step. So you need to think of it from the GGP point of view. So what do the guidelines say? So actually, I would say there are two correct answers in this. It will actually be a combination of two answers. Um So most of you guys have said d so you guys are on the right track. So obviously you need to, you basically do a two week, wait, you do a few things for her side by side, you'd request an urgent trans, trans vaginal scan. You'd organize a ca 125 for her and you'd refer her urgently to guys oncology. So you'd kind of do all three things uh simultaneously. But on, in the textbook, I think the correct answer was b but I would accept D as well because I think you would obviously organize that as well. And what is your differential diagnosis? What do you have to rule out in this case? What are we kind of concerned about? So, the reason why we're doing the ca 125 and the scan and stuff is because we're suspecting ovarian cancer. So anyone that's presenting with these vague bowel like irritable bowel syndrome type symptoms in someone who's kind of over the age of 50 you need to think about ovarian cancer. Good. So, uh risk factors of ovarian cancer, obviously, early menarche, late menopause BRCA one and two mutations, parity protective factors are your pill pregnancy and lactation. So we mentioned already the clinical features ca 125 and TB us are um your investigations. But just remember that ca 125 can be raised in endometriosis. You've mentioned already, menstruation and benign ovarian cysts as well. And essentially ovarian cancer. First, it spreads within the pelvis and the abdomen and later it spreads via the lymph and the blood um as well. And malignant features of a cyst on imaging are if they've got what we call a complex cyst, so they have lots of little bits to it. So if it's bilateral, if it's solid, if it's multiloculated, if it's got increased vascularity, those are some of the things that would make you suspicious of a uh cancerous cyst basically, as opposed to a simple cyst. Ok. Um Just gonna quickly just take that out just to see kind of where we are. Um Just cause it's 725. I think what I will do is I'm gonna skip through the cervical screening bit just cause you guys can have a read through that. Um Essentially, it just tells you what you would do in each of these cases and you guys can read through that. Um Let's go through two of these amenorrhea questions and we'll go through your gyne and finish off. Um If anyone needs to jut off because um you know, we are, we are reaching the end of the session, please feel free to um to go and you can fill out the feedback forms and stuff later on and you can obviously catch up on the lecture in your own time. Um So amenorrhea, um M CQ one, you've got a 15 year old girl attending pediatric gynecology with primary amenorrhea. So she's never had a period, but she does have features of secondary breast development. She's got intermittent abdominal bloating speculum examination shows a bulging red disc. What's the most likely diagnosis in this case? Yeah. So uh the correct answer is imperfect hymen. The reason why it isn't Turner syndrome, congenital adrenal hyperplasia is because she's got secondary breast development. The reason why it's not anorexia, nervosa is because um she anorexia, nervosa would give you secondary amenorrhea, not primary amenorrhea. And the bulging disc basically tells you that she basically has hematocolpos, which is all of the blood which is then pooling in the cervix or sorry in the vagina because uh because of the imperfect hymen, basically, there's nowhere for the blood to flow out. Um Good. We will again, I haven't put the uh the normal values in this. So you guys, so when I send, when I send across the slides, I'll put the normal values and the correct answer for this. So we can go through this. You guys can go through this question in your own time. Um I'm gonna, then this is a very useful way of approaching amenorrhea, which you guys can also have a look at, I'm gonna just quickly whizz through urogynecology and then we'll be done with the session. Um So there's a few questions on incontinence and on pelvic organ prolapse as well. So, starting off with incontinence, you've got a 46 year old lady, uh presents to your clinic with a six-year history of incontinence. She's had four normal deliveries. BMI of 35. She's got a small cystocele. Um, urine culture is negative. Urodynamic studies show a weakened urethral sphincter. What's the most appropriate first line management? So you need to first figure out is this stress incontinence or is this urgent continence? And how would you treat it? What's your first line management? We've got one answer so far. Might just wait for a few more. So the correct answer is B which is weight loss and pelvic physiotherapy because the weakened joint with sphincter points you towards a stress urinary incontinence. Perfect. So next question, we got a 42 year old woman who presents to the Uro Gyne clinic with a three-year history of urgent continence. So this is urgent continence, which is because of an overactive bladder. Uh She's desperate to start treatment. She opts for medical treatment. What's the most appropriate first line management? All of these can be used to treat it. But what would you give? First line? Yeah. So the correct answer is actually oxybutynin, which is your first line management. You can give diphenacin PPP Sotero or solifenacin, but the B is the correct answer. Good. So looking at history taking again, you guys can read through this in your own time. You need to ask about frequency, how many times at night they are passing urine? About urgency symptoms. So stress is basically, do you leak when you're coughing or lifting things? And uh which is basically where they're not able to control their urine and they're basically leaking before they reach the toilet or they get a spontaneous urge to pass urine though, that's how you differentiate between the two. And often annoyingly, when you do Uro Gyne clinic, most people actually have mixed urinary incontinence. You need to ask them which of the two is having a greater impact on their quality of life. Um So investigations, you, you do urodynamic studies which are very, very difficult and confusing to interpret. You do a urine dipstick, ask to keep a urine diary. And um, the reason why you do a dipstick is basically, you need, you check for infection, also check for diabetes and hematuria and stuff as well. Um So this is just looking at stress incontinence versus overactive bladder. This is quite a useful slide. It's a little bit busy so you guys can read through it in your own time when you're revising and it basically just tells you what's your conservative management? What's your medical and what's your surgical management for stress? They basically try conservative if conservative doesn't work, they actually move to surgical. Whereas for overactive bladder, they do conservative first, then they do medical things like um your oxybutynin and stuff. They like to ask you about the side effects of anticholinergic medication. So always remember it's dry mouth urinary retention. Um And you can give Mirabegron as well if someone cannot tolerate your anticholinergic medications, and then you can also move on to surgical, which are things like Botox injections. You can do like cool and fancy things like sacral nerve stimulation and stuff as well. So I think you guys will be pleased to know this is actually your last M CQ for this session. So what do we think the answer is for this one? You've got an 89 year old woman long history of a dragging sensation in the vagina. She's got severe aortic stenosis but no other medical history. She leaks fluid when she sneezes or coughs. So she's also got an element of stress, urinary incontinence as well. On examination, you put in a sim speculum which is just a type of speculum. It's a lateral wall retractor basically uh in the left lateral position and you see a grade one uterine prolapse um with an additional cystocele as well, which is basically prolapse of the anterior compartment prolapse of the bladder. Uh What's the most appropriate management in this case? Ok, perfect. So you guys um know the answer. So the answer is e which is insertion of a pessary and the reason why you wouldn't do, why would we not operate on this patient? Why do we not want to operate on this patient? So why is a not the right answer? Age is one and also the severe aortic stenosis? I don't think any of the ads are gonna be happy to actually put this patient on the general anesthetic. So you and you have to think about it. She's 89 you know, you need to think about the risks and benefits of the surgery. So actually, this would, this would be someone who would be quite good for, you know, just an insertion of K good. So pelvic organ prolapse, some of the symptoms that you can get is dragging sensation in the vagina sensation of a lump that's worse at the end of the day or when standing up. If it's quite severe, then it can give you urinary and bowel symptoms as well. Um And essentially the management, obviously, you've got conservative things like weight reduction, physio, smoking cessation, you can put best reason as well. And we've got surgical options and that's just two examples of pessaries. And we've seen already some of the indications for pessaries if, if someone is unfit for surgery and they said just act as an artificial pelvic floor, uh, they usually change every 6 to 9 months, um, types of prolapse. So you can have the uterus prolapsing, you can have the vault prolapsing So, if you've done a vaginal hysterectomy, you remove the uterus, you've obviously got the vault, which is what the tissue that basically is left behind, right? That can also prolapse. You can get an anterior prolapse, which is basically a bladder prolapsing down into the vagina or you can get the bowel, the rectum prolapsing as well. Um And these are just some of the surgical procedures that you can do. So that's basically a sacrospinous fixation, which is basically where the vault is fixated. So you basically bring the vault up and you stitch it to the sacrospinous ligament for additional support. And the picture on the right is just a picture of vaginal hysterectomy essentially. OK? Um And that's a picture of a posterior repair and basically all you're doing with the posterior repair is you open it up and you put a few additional stitches because the problem with prolapse is because it's because of weakening of the muscle, weakened ligaments, weakened support of the pelvic floor, which is why everything is kind of just prolapsing down. And what you do is just put a few additional stitches just to kind of support and reinforce the area. That's all you're doing with all of these procedures. Um Good. So you guys would be happy to know that's kind of most of what you guys need to know for gynecology. Sorry, I had to skip through some of the bits like the amenorrhea and the cervical screening but I'm sure you guys can go back. Um And um kind of refresh yourself on those. These are just some of the really useful resources. So teach me OBGYN osmosis. Nice has some good guidelines. Past medicine, osk stop is really good for fertility and for contraception as well. They've got a nice table. Contraception is a really good one for to test you. I remember for our finals, we had a station in our, on like discussing contraception and stuff. So that's always a good thing for you guys to know what are the different forms of contraception, the side effects? How long do they last for those kind of things? Um And that was a textbook that I used when I was at Kings for and OK. Amazing. That is everything. Thank you so much to everyone for staying um and for um answering all the polls and um answering all the questions and stuff as well. All right. Thank you so much, Doctor. Yeah. If you guys have any questions, just put them on in the Q and E or in the chat box. Um Thank you so much, Doctor Piana. This was a fantastic revision. Lots of exam style questions there. You could see me attending uh to answer the questions as well. I'm only in my third year, but it was for quite a few years that's gonna come from my exams as well. So it's good revision for me. Um Thank you. So much for taking your time out of your busy schedule to prepare these in-depth slides. Um And everyone, thank you so much for attending, apologies for going over time, but I'm pretty sure this is very useful for you all. Can you all please fill in the feedback form that I've just sent? Uh you know, this really helps the speaker and helps us also to put out such amazing events. Um The slides in the recording will be available to you guys on the event page. They should hopefully be up by tomorrow um And do keep an eye out on our socials for the link to our next event where we will be covering respiratory conditions. Uh So, yeah, that's it. Perfect. And if you guys have any questions, just put them down there. Um Yeah, and if um on the feedback, if there are any topics that you guys felt wasn't covered that you guys kind of struggle with, please do put it on there any kind of feedback on teaching side, those kind of things. Um Yeah, I'm always open to kind of changing things around because I did, I did these slides last year as well. So I just kind of tweaked a few things here and there. So I would love to hear what you guys think. So. Yeah. Thank you. Thank you for staying till the end.