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So I think we'll make a start because we have three cases to get through and some SBA S. Um So I'm Susanna, I'm one of the fourth year medical students at Leicester. Um And today is session two of our Sing Gyne uh revision series and today is gonna be on general gynecology. So just to um go through our session, so we'll have um three cases um menorrhagia, dysmenorrhea and oligomenorrhea and uh some SBA S at the end as well. So this is just um to say that our resources are made by medical students. So um they might not be representative of what comes up in your exams and there might be some errors. Um Obviously, this is a revision but it doesn't um cover everything um in the Il Os. So um use other resources for revision as well. Um And then there's gonna be a feedback form at the end if you could fill out. Um That would be great. Thank you. So, this is our first case. So, Mary, 40 year old woman comes to see the GP she complains of heavy menstrual bleeding and urinary frequency. So, what are some important questions to ask her. So, if you just put it in the chart, anything you can think of that would be good to ask if she's having heavy menstrual bleeding. Yeah. How often is she changing her period products? That's a really good question. Especially to see if it's increased from her usual use, duration and onset yet. So, history of presenting complaint, how long it's been going on for? Is it a change to her usual? And has it been increasing over time? Anything else? Is she passing any clots? Yeah. So if she's passing clots, that would suggest uh quite a heavy flow. Is she sexually active? Yes. Her sexual history is very important. Regularity of bleeds is very important to see whether um they've changed it all. Um Lovely. So let's go through a bit of um how a history should be taken for Gynae. So history of presenting complaint, menstrual history is very important. So going through her last menstrual period, duration of um her periods, uh regularity. So how often they come about the flow, um Any clots or flooding, um that would suggest more heavy flow and then ox. So when she started her periods, other symptoms which um are important to ask about in a gyne history, intermenstrual bleeding, postcoital bleeding, discharge pain during sex, any uh vulval changes, abdominal pain, uh pain, um when she's menstruating or any bowel or urinary uh changes as well. Um As she's having urinary frequency, I think it's important also to ask about any other symptoms of um that would suggest maybe a uti, so just dysuria, hematuria contraceptive history. So, is she using contraceptives? Are they barrier contraceptives? Is she planning pregnancy? Because if she's having heavy menstrual bleeding, we want to treat her. That may be something we think about uh gyne and obstetric history. So smears any gyne disorders and then any um malignancy symptoms. Um so she's having urinary frequency, maybe a compressive symptoms. So, uh to sort of maybe think about um ovarian cancer or endometrial cancer, um, bleeding issues. So, has she got some coagulopathy that's underlying and hypothyroidism, um which can also cause heavy menstrual bleeding. So, those are some things to cover. So this is what we've got from the rest of the history. So, her menstrual cycles are regular. Um, they've become longer so they last seven days now. Um and they're every 28 days. So they are regular. However, it's heavier and it's been going on for the past four months. She's been using more sanitary pads per day. She's passing clots. She started her periods at 10 years old. So quite early, she's got urinary frequency, uh which has been going on for two months. Um No other symptoms, no urinary symptoms, other than the urinary frequency doesn't use contraception and isn't planning any more pregnancies. She's up to date with smears, no gyne issues, no bleeding or um, malignancy issues anywhere else. Um And the patient is of African Caribbean background and she's got a BMI of 35. So she's got severe, um, obesity. So, what is the most likely diagnosis in this patient? So, taking into account all of the main things. Yeah. Yeah. So, fibroids, that's a, that's a great. Um, so if that's the diagnosis, what are the risk factors for fibroids if you know any respect is full fibroids occurring? Yeah. So, Afro Caribbean ethnicity. A men. Yeah, these are all great anymore. They may already be in the history or they may not obesity. Yeah. Lovely. Ok. So, so um yeah, so she's got fibroids. Um It's the most likely diagnosis in this patient. She's got heavy menstrual bleeding. She's got a Menno which is a risk factor. Um There's obesity, uh she's of Africa Caribbean ethnicity and um all of those link in with our diagnosis. Um So a bit about fibroids. They are benign smooth muscle tumors of the uterus. This is an example of where they can occur. So they can be intramural. Uh they can be some mucosal sub cirrhosal. Um The examination you do is mostly an abdominal exam and a bimanual exam. So you're checking for any solid masses. If they're quite large, you may be able to feel a mass or you may feel an enlarged um non tender uterus. Um investigations. First line is transvaginal or pelvic ultrasound. Um And yeah, so next question, um what management will you offer Mary. So I've highlighted some important bits. So if she doesn't use contraception at the moment, but she isn't planning any more Children, what would you suggest? Face line? Yeah. Lovely. The I US. And if um Mary did want to have more Children and she was planning on conceiving, what could you offer her instead? So, something non hormonal. Yeah. Tranexamic acid. Yeah. Lovely. And yeah. And then there's some secondary measures as well such as Myomectomy. So um if she requires contraception, um some options are the Mirena ius um which is first line for heavy menstrual bleeding, but also the cop or the poop can decrease your bleeding. Um the cop can be taken continuously without breaks. So, preventing a withdrawal bleed or every three months, you can stop and have a withdrawal bleed. Um If there's heavy menstrual bleeding, um if she does not require contra uh contraception or she does want to conceive, um then you can give transam acid or mefenamic acid. So, TriC Trex acid is an anti fibrinolytic. Mefenamic acid is um an NSAID. So both can decrease bleeding. Um And because she's got compressive symptoms with the urinary frequency, you might um think about referring her to secondary care. So what would secondary care do? So there's some other options that they can consider. Um if on trans vaginal ultrasound, the fibroid is quite large, they can um do a surgical approach. So a myomectomy is removal of a uh of a fibroid, there's also uterine artery embolization, hysteroscopic endometrial ablation, um for um heavy menstrual bleeding. Um, and sometimes they use a gonadotrope in releasing hormone analogs or agonists which can, um, shrink the fibroid down before surgery if it's quite large or causing lots of problems. But, um, gonadotrophin release and hormone analogs shouldn't be used for over three months because they can cause menopausal symptoms and um things like osteoporosis over a long period of time. Ok. Lovely. So, that was our first case. Second case is Sandra. So she's a 30 year old. 11 female, um, presents with a six month um history of severely painful periods and they were not pain, uh previously painful. So, pain usually comes on three days before her period. Nothing makes it better. Um Her periods are regular and light. She experiences di uh deep dyspareunia and hasn't been able to get pregnant even though she and her partner have tried for two years. Um, she gets painful and more frequent bowel movements around her period as well. So, taking into account, um the fact her main problem is secondary dyspareunia and um subfertility and deep um sorry, dyspareunia and um, dysmenorrhea. What do you think her most likely diagnosis is from these options? That's been go on for six months? Yeah, lovely. So, number two. So, endometriosis. So now, um what is endometriosis? What is the uh best answer out of these? The only correct. So, one is um endometrial tissue located in the pouch of Douglas, um adhesions. After surgery around the pelvic region, endometrial tissue within the myometrium or overgrowth of endometrial tissue in the uterus. So, endometriosis is when there's ectopic endometrial tissue somewhere outside the uterine cavity. So it's not number four because overgrowth of endometrial tissue within the uterus would be um endometrial hyperplasia. Um three is um adenomyosis um which is endometrial tissue which grows in the myometrium. So that can cause so sort of a boggy, enlarged uterus. And um number two, what cause chronic pelvic pain? So, adhesions can cause chronic pelvic pain. However, that's not a diagnosis. Um That's not a definition for endometriosis. So, number one is the best answer and the ectopic endometrial tissue doesn't just have to be in the pouch of Douglas uh which is behind the uterus. It can be over the ovaries. Um It can even be in the lung, the bladder, um over the uterus, uh sacral ligament um or over the pelvic peritoneum. So what findings might there be on a bimanual examination if the patient does have endometriosis, what are you sort of looking for when you're palpating the uterus? I'm the next one. Ok. Yeah. So, tender nodularity in the posterior fornix. That's definitely one. So if the endometrial tissue is a topic in the um posterior fornix, you may may be able to have some uh findings there. Adnexal massive endometrioma. Yeah, that's correct. So, some of the ones I've put down are a fixed retroverted uterus. So, this would occur if they've had a longstanding en endometriosis and they've um had some adhesions occur due to the endometrial um tissue maybe in the pelvic peritoneum, um uterus, sacral ligament nodules. Um if the endometrial tissue is there and general tenderness. Um but yeah, but they also might be endometrioma, adnexal mass and there might be tendon nodularity in the posterior fornix. Is that correct as well? Ok. So what is our um Gold Standard investigation for endometriosis? Yeah. So it's three. Um So the findings are um you may be able to see some peritoneal uh deposits of this endometrial tissue. You may be able to see adhesions form and in areas that have previously had endometrial tissue, chocolate cysts may be seen. So here on this picture, you see chocolate cysts um which are areas of endometrial tissue uh which have become a cyst due to bleeding. Ok. So, uh a bit on management of endometriosis. So, if it's asymptomatic, you may not need to have um treatment um medical management. So there's analgesia. So it's obviously causing chronic pain in the patient cyclical chronic pain. So you could use paracetamol or nsaids, there's also treatment to suppress ovulation. So, this works by um preventing that um sort of bleeding of those endometrial ectopic endometrial tissue uh lesions. Um and over time it can cause atrophy. What is a peritoneal deposit. So that's when A mm. So a peritoneal deposit is when uh the endometrial tissue, er, deposits onto the pelvic peritoneum and it may just look like a, a bleeding lesion or it may look like that chocolate cyst. Um I showed you in the previous one but I personally haven't seen one myself. Um, so to suppress ovulation, you can use cop norethisterone. Um, the Mirena um coil, the intrauterine system contraceptive injection and then there's also gonadotrophin releasing hormone um agonists which can induce that pseudomenopause. However, those shouldn't be used for over three months um surgery. So, if it's affecting their quality of life and they have severe sym symptoms, they do that gold standard laparoscopy. And during that laparoscopy, if there is lesions, you may use excision um to take away that ectopic endometrial tissue laser ablation um or athe lysis. So, if what's causing that chronic um pain is actually adhesions formed from the endometrial um endometriosis, um you can um break those up but surgery is not a definitive treatment. So they will most probably relapse because endometriosis lesions would form in different areas. Um And it's only treating that small um focal area of the tissue. Ok. So case three, we have lola uh 23 year old female comes to see her GP um due to irregular menstrual cycles. Um and she's been having difficulty losing weight. Um Her menstrual cycles have been irregular for the past few years and they are ranging from 35 to 45 days. So they are quite long cycles. Um and she has struggled with acne, she has some unwanted facial hair growth on her upper lip and chin. Um her self esteem has been affecting uh affected. Um and the GP is suspecting a diagnosis of uh P CS. So, Polycystic Ovarian Syndrome. So, what are the most common symptoms of P CS? Ok. Yeah. So, hi, tourism, hirsutism. Sorry. Um So yeah, that would cause the uh facial hair growth. Um obesity, irregular periods. Ane Yeah. So, yeah, so this is all great. So yeah, so the main signs and symptoms you see are so they would come in, they would have maybe oligomenorrhea or amenorrhea. So either irregular periods um or no periods at all. Um and this would usually be a secondary amenorrhea. So they would have had periods in the past um and then become amenorrheic infertility of subfertility. So, uh not being able to get pregnant as they are not ovulating. Um uh hirsutism which is the excess facial hair growth or uh just excess um hair growth on the body, obesity and acanthosis. Er Nigricans is a good sign um which comes, it's darkened skin that is um caused by um insulin resistance. So, uh what are your differential diagnoses if it's not PCO S, what else would you consider or what would you want to rule out? Maybe in this patient? Yeah. Hypothyroidism. Yeah. Cah um the C A congenital adrenal hyperplasia. I don't know uh thyroid problems, um hyperprolactinemia, fibroids because of irregular periods. So, fibroids usually don't cause irregular periods. Um They cause more um heavy periods. Cushing's. Yeah. Ok. Um So these are the ones I was thinking of. So hyperthyroidism. So you would want to do their TSH levels um to rule out hypothyroidism. So they would be um have elevated TSH, hyper prolactine uh prolactinemia. So, serum prolactin and Cushing's disease. So, PCO S, so what is PCO S? So it's a endocrine disorder and it is caused by hyperandrogenism. So, increased uh testosterone and androgens in the body. Um it comes with insulin resistance. So in increased insulin levels um and um resistance to those levels. So they get um higher risk of cardiovascular disease and uh diabetes, um hormonal imbalances. So they have a high LH uh causing the high LH to FSH ratio and then it shows through um either oligomenorrhea, amenorrhea, subfertility. Um and those hyperandrogenic um hy hypo hyperandrogenism uh symptoms which would be acne and hirsutism. So, if um you were, you were going to diagnose PCOS, what three criteria make up the Rotterdam criteria if you know any of them, what would you consider? Yeah, over 12 cysts. So that would be an ultrasound ultrasound, er finding hypoandrogenism, oligomenorrhea. Yeah. Lovely. So re has more lovely. Yeah. Yeah. So fewer than nine periods a year or cycle over 35 days, which would be oligomenorrhea. Ok. So this is the criteria. So, hypoandrogenism. So, this can be either uh clinical. So through their symptoms or biochemical um through blood test, um menstrual irregularity. So either the uh less than nine cycles a year or over 35 days between cycles showing um oligomenorrhea or amenorrhea. And then uh polycystic ovaries on the ultrasound. So that would be either over 12 cysts uh being present or over 12 an follicles. Um or you can also have an ovarian volume over 10 centimeters cubed. So you would do a transvaginal ultrasound for that and for the um biochemical hyperandrogenism, um you would test testosterone and sex binding globulin. Why is hormonal treatment with C OCP or um other um measures such as C OCP um pop or I US important in patients with um PCO S. What is the best answer? Ok. Yeah. So that's great. So it is number one. Um So, yeah, so it reduces risk of endometrial cancer. And this is because patients with PCOS have un ovulatory cycles, meaning they don't ovulate every month. If they don't ovulate, they don't form the corpus luteum which will release progesterone. So that means that they get unopposed progesterone or higher levels than pro of estrogen, sorry. Um and lower levels of progesterone. So that puts them at risk of endometrial hyperplasia which may result in malignancy over time. So things like the I US um can um sort of thin the endometrium um or the cop um can induce a withdrawal bleed. Um thinning the endometrium as well. So we've got two SBA S left. Is there any questions fully go to the SBA? Ok. That's fine. So um Lily, a 50 year old female comes in with symptoms of hot flushes, night sweats, mood changes, loss of libido. Uh She thinks she is perimenopausal, she is still having some periods but they are less regular. She wants to start HRT. Why would you prescribe combined HRT? So, estrogen and progesterone to this patient are not unopposed estrogen. Why would you add that progesterone component? Yeah, lovely. So yeah. So it's number three to reduce the risk of endometrial cancer. So, when someone has unopposed estrogen, it proliferates the endometrium and can cause endometrial hyperplasia. Um and over time, um this can get atypical changes and become endometrial cancer. Any questions? OK. So this is gonna be our last question. Um So it's the same uh patient. Uh She wonders if she needs to stay on contraception while she takes HRT. Uh she has been having the depo Provera contraceptive injections for the past three years. What would you advise Lily? So what would you advise this patient? Does she no longer require any contraception while she's on H IH RT. Um Should she stay on the depo Provera injections or should she be switched to another contraceptive method such as the I US or the pop? Lovely. So, yeah, it is number three. So um patients who are over 50 should be switched from the depo Provera injection. So, um it is UK ME C three for over 45 year olds. Uh but the advice is to switch them to a progesterone um contraceptive such as the progesterone only pill or the levonogestrel I US system. Um patients who are taking HRT still require contraceptives um as she is still having those periods but less regularly. Um So yeah, and if we just go back, I just wanted to say that this patient um requires that um progesterone component because she is still, she still has a uterus. So any patient still ha who still has a uterus is at risk of endometrial hyperplasia and endometrial cancer. Um On H RT Lovely. Is there any questions at all? If there isn't, uh there is a feedback sheet. Um could you explain the last answer? So, so the patient should be switched to another contraceptive. Um And so she's currently on the depo Provera contraceptive injections. Uh Patients shouldn't be on this over 50 years old. Uh The advice is to swap them onto um a progesterone only method. Um As um as the depo Provera, I think becomes UK ME C 3/50. Um Meaning that the benefits don't outweigh um the risks. Yeah, side effect is reduction of bone. Yeah. So as they become menopausal, they already have a risk of osteoporosis. And the depo Provera contraceptive injection does have um a side effect of reducing bone mineral dens density? Ok. Thank you for coming. Um The feedback form is just in the chart above the questions. Um So if you could fill that in and that's everything we have another session um in a week's time at the same um at the same time 7 p.m.