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A gynecology um lecture. Um So this is quite an interactive talk. So feel free to answer in the chat and unmute yourselves to answer the questions. Um And at the end, there's also a QR code for the feedback. So if you want um a copy of the slides of the recording, then please fill that out and that will be um really helpful. Um So without further ado I'll hand over to Doctor Anamika. Thank you so much, Callen. Um Hi, everyone. I hope you can all hear me. OK. Uh Please say yes in the chat if you can and call will kindly let me know. Unfortunately, I can't see the chap myself. Yes. Yeah, we can hear you. Oh, good, perfect. Awesome. So my name is I'm a current academic foundation year too working. Um I graduated from Imperial College and um today I'm presenting on gynecology conditions. Um and I've done this uh presentation along with a senior colleague, uh doctor a who's ast one trainee in OBS G working at Leicester as well with me uh currently on my obs and rotation. And so I guess a little bit of background into be um as Callum knows a lot more than I do the British Indian Medical Association's National Organization aiming to essentially uh increase opportunities for education and um research and tutoring uh to all medical students as well as um healthcare professionals across the UK. And we have a lot of activities going on. Um And I'm sure uh I'm hoping that you guys have attended previous events as well and thank you also for joining today. OK. So today we're gonna be focusing predominantly on gynecology conditions. Um I've tried to use a mixture of conditions that are not only common but important to be aware of and touching on some of perhaps not necessarily less common but perhaps a less uh well covered subjects particularly in medical school. Uh which hopefully will give you some um I guess more insight and background and that we can use this knowledge uh when not only for exams but also for clinical practice. OK. And as Callum has said, it's gonna be quite an interactive session. So uh please do um help answer questions as we go along through the chat or if there's a facility 10 mute, that's also fine and uh we'll get cracking. OK. So, um like I said, we have a number of cases. Uh they're gonna be interactive and I'll do my best to get through as many as we can I think and have it. Is it now or today that we have Callum? Yeah. Yeah, we just got an hour so cool. So we as many as you can and hopefully, uh we'll get to learn something. Um So as I said, we're going to try and learn about the different gyne presentations and conditions, um know how to uh appropriately diagnose and investigate them and then apply them to clinical cases as well. OK. Uh Before we start, uh just in the chart, um roughly how confident are you guys in knowing about gynecology, topics or conditions? Um 10 being most confident. One being not confident at all. So you just dropped some numbers in the chart whereas mhm Call him if you can let me know what the responses are. Yeah, we've not got any responses yet, but personally, I'm at about a five or a six. So OK. That's OK. I'll give it another second in case people miss up any responses. No. OK. That's OK. All right. Well, I'm assuming the chat was working because we had a few yeses earlier. But that's OK. You can keep it to yourself if you want. That's not an issue. All right. Anyway, we'll get cracking and then hopefully by the end of it, we'll become more confident. OK. Case one. So like it's an interactive session. So let's work through this together. OK. So you have a 31 year old female who's come to A&E with really sudden onset severe right electro of pain. OK. And these are some of our observations at this stage, what are sort of the author processes and what differentials are we thinking? Um So someone to put an ectopic. Yeah, that's a very important differential to consider. Anything else P ID. Mhm. Anything else? That's OK. Not, yeah. So there are very two very important um presentations in or differentials rather in this type of presentation to be aware of. And um of course, with pid being an infected thing, you would hopefully expect the temperature to be a little bit higher but not always, which is quite right. So you still keep it in that differential because often people with any form of infection, the temperature does get up and down. So at the point of measuring the observations doesn't, if they're apraxic at that time, doesn't mean that they aren't uh infected picture. So that's good. OK. Now, of course, in these contexts, you always want to think if they're a female that coming in with abdo pain, you need a urine pregnancy test, especially if we think about topics in this case. However, she has a negative urine pregnancy test. OK. So at this point, how does that change your differentials here? So we have a bit more things you, yes, P ID is one of them ectopic perhaps less likely in this case than as she has a negative pregnancy test. OK. And other features that I can mention now is on examination, she's got a distended abdomen and you can feel a mass in the right elect fossa where the pain is? Ok. So now what are the differentials? Anything else you'd like to add in, in addition to your ectopic and P ID? Um, ovarian torsion and, or tumor? Very good. Ok. Anything else appendicitis? Yeah. And another appendicitis. Yeah. Always make sure you think about not just gyne specific but normal other things that can happen very good. Ok. So we're going to break down some further differential plan. So yes, in terms of you guys have said the main ones already. So ovarian torsion, ovarian cyst accidents, um tuber ovarian abscess in the context of pid that can also present in this way. Uh ectopics, as you guys rightly said, and of course, the gi thinks appendicitis, anyone with right iliac fossa pain, you wanna think about appendicitis as well, whether they're female or male, whether they're pregnant on pregnant, it still could be appendicitis. And um of course, other gi presentations perhaps less likely in the right iliac fossa context. But you want to think about any acute abdomen causes as well. Ok. So this one is in the context of an ovarian cyst accident or ovarian torsion. So we'll go through some ovarian cysts which actually isn't covered um quite as much. So, there are different types of classifications for ovarian cysts and these are the sort of the overarching themes if you like, uh there are simple cysts versus complex cysts benign, and malignant and of course, you can divide them in terms of how the RCO G guidelines are divided into pre menopause and post menopause. So we'll break this down a little bit better. OK. So there are different types of cysts and we'll start with the more normalish or physiological cysts as we have. So, functional or physiological cysts are cysts that happen normally within a woman's menstrual cycle and they develop um from the follicles that grow and develop during the menstrual cycle. So, as you can see on the diagram on, on the side here, I'm not sure if you guys can see my mouse and I kind of is my mouth visible at all. Yeah. Yeah. OK. So on this diagram here, it kind of illustrates how the follicles develop during the menstrual cycle. Um essentially as we have the hormone changes, eventually, there's a selection process where eggs will mature and a follicle forms around them. And you have the dominant graphene follicle that forms um and then after which the egg gets released at the point of ovulation with the LH surge, and then the remaining follicle will eventually change to the corpus luteum. And that's important to produce more hormones, predominant progesterone where after the egg gets released and it travels down the tubes and into the womb eventually, if there's a chance of fertilization, and then the corpus litium will produce um hormones to keep the lining of the womb thick. So that if it does get fertilized the egg, then it can implant and then turn into the embryo fetus and baby. Um And of course, if that doesn't happen, then eventually the corpus luteum will uh break down in the loop and then the endometrial lining comes out with the menstrual cycle. Um So the natural follicles here are we looking at are the dominant follicles. So the graphene follicles or um as they develop the follicles here, and of course, the coleus luteum which also forms a cyst like uh picture as well. Typically, the physiological assist should be less than three centimeters. It can vary from person to person. But on average, the normal cyst would be less than three centimeters. A simple cyst is where these physiological cysts grow bigger than we expect them to be and potentially last longer than we expect them to be. And the simple cyst themselves can be divided into uh different categories based on size. Now, since when we try and diagnose these uh any person with a suspected cyst, the first line investigation is an ultrasound scan, particularly transvaginal and the key features I've highlighted in green here for your buzzwords in any uh exam or questions or just in, in general clinical practice. Um A simple cyst is a benign cyst. So it's a fluid filled cyst usually very, very thin wall, uh unilocular, meaning there's no sort of septa, it's just one blackish thing on, on the skin. If you like uh, anechoic meaning sort of, there's no heterogenous um, shadowing within it. It's just fluid filled and like we said, no nodules and no septa, no little line separating within it. It's a nice, simple cyst and they're divided into categories for management based on the size if it's less than five centimeters and the patients otherwise got, not got any symptoms with it. You can le usually leave it and, and it should resolve by itself. Um And some people on edge on the size of caution and then they might want to do a follow up scan. It depends on the clinical setting for the medium cysts. Uh between 5 to 7 centimeters. You do want to keep an eye on them. So you do a watch and wait approach and you do a follow up scan can be at a year, but if they are developing symptoms or any complications and bring it sooner and of course, large cysts greater than seven centimeters are higher risk of complications, but also being perhaps more complex cysts uh which need further looking into. And at that point, you would refer to gynecology, maybe consider other other scans like MRI scans that give us more information and may need surgical management. Ok. Now we're going into the pathological or complex systems and there are types of these cysts. So we have benign cysts, uh which are these examples and we've got the malignant ones in terms of the benign ones um have you guys heard of some of these types of conditions? So the dermoid cysts, endometriomas, et cetera. So if I say dermoid cysts to you, what sort of other key buzzwords if you like that, describe these sorts of cysts, what do they contain? Um So someone said an immature cyst like a hair material? Ok. So be very careful when we're saying mature versus immature teratomas. So, um dermoid says, yes, it does contain hair, teeth and any sort of differentiated tissues that can present in different aspects. Um And that's one of the key first words that we see. So when we have a cyst um on imaging or even when we search g and then they will be full of these mature tissues. An immature teratoma is where the tissue is developing but is not quite formed in the the differentiated states and it's higher risk of malignancy. That's why it falls in the malignant category. So there's a mature teratoma which is your dermoid cyst, the benign one and the malignant one, which is the immature teratoma. So just be careful on the wording there. But yes, you're quite right has, has it has teeth, there's all sorts of things in there and they're not only forming in the ovaries, they can form in other areas of the body. But in this case, we're looking here in the ovaries. Ok? And in terms of endometrioma, the chocolate cyst, anyone know any buzz words related to that in terms of ultrasound findings, that's ok. If not, I'll take the silence or not. No, that's fine. So, endometrium is a form in the context of endometriosis, which is the condition where we have ectopic um endometrial tissue. So, the endometrial lining that's normally within the womb starts forming outside of the womb in different places and can technically be in anywhere for any other parts of the body, predominantly, usually within the pelvic regions. Um like the ovaries, like the tubes around the pelvis and also can happen in the lungs and other places. Um And the chocolate cyst is uh the characteristic picture of what an endometrioma, which is the cyst that forms when nobody is affected by endometriosis looks like because the um secretions and, and sort of blood of you like that's made by the endometrial cells within the ovary forms. It looks a bit like chocolate. That's why it's called like that. And on the scan, it will be described as a glass ground, sorry glass ground appearance. Um because of the nature of the shadowing. Ok. That's just touching on some of these. And of course, uh there's a lot more details that can, we can go into, but um these are just to be aware of and in the context of malignancy as well. In addition to your primary malignancies, um you also can think about metastases and a key name for the metastatic tumors that form in the ovaries are called Crippen beg tumors. So they arise typically either from if the patient has breast cancer or gi tract or even lung cancer and then they have an ovarian tumor, then you want to think about that as well. OK. And this slide um uh interestingly, I just found these uh very useful tables online um that go through the sort of key findings that you've seen the different types of cysts. I won't go through this now, but all these slides will be made available to you after. So you please do have a look and it goes nicely through the descriptions of what you'd see. OK. And um another important thing about ultrasound is it is one of the first line investigations that we use for um investigating any form of ovarian cyst or mass. And we divide scan bindings by the iota criteria to help us with the diagnosis and management. There are the benign criteria, the B criterias which are the basically features within the ultrasound scan that help us determine whether it's a benign cyst. And the M criteria is the features at the bottom in red, which help us to determine if there are any malignant features. And um they can be scored according to these findings. OK. In terms of how they present what we've seen in this case, it was quite an acute presentation, but there are different ways that they can do uh particularly with your simple cysts and the um physiological cysts, they're often asymptomatic. Um, even some of the complex cysts as well and can just be instantly found on a scan that they've had for another reason. For example, um, other indications or presentations, of course, abdominal swelling and bloating, especially the cyst is growing larger and larger. Um, you'll have often a lower abdominal pain, sometimes a pelvic pain or radiating uh sort of more posteriorly. Um It also, um depending on how it's affecting uh the hormone levels and fs it can also affect periods. Uh, there may be pain during sex known as dys and of course pressure symptoms. So any large thing within the abdomen, within the pelvis can put pressure on other organs there. So you wanna think about things near it. So, if it's pressing on the bladder, urinary frequency, potentially is some erg um pain on bowel movements or difficulty in passing bowels. If it's pressing particularly on the rectum or lower bowels, you're not going to be able to open the bowels properly. And if it presses more upper on uh on the bowels and potentially the stomach, if it's big enough, it can lead to um, feeding problems. So you, you won't be able to eat as well. And um, of course, they may also be affecting pregnancy if it's uh large enough to affect the function of the ovary. But also, um in the context of endometriosis, which can affect other aspects of the cycles. And also Polycystic Ovarian Syndrome, uh it can indeed affect fertility. OK. A torsion. Um as some of you rightly mentioned at the start is a very important condition to recognize uh and is needing uh immediate surgical or very urgent surgical uh attention. Um A bit like testicular torsion in the context that um when the ovary twists on itself, it may disrupt its own blood supply at which point. Um it can uh essentially cause ism necrosis. And therefore, we need to have the urgent surgery to untwist it and save it uh in time. And the presentations are definitely acute so severely, a fossil pain, often sudden onset. Um and sometimes in some cases, it can be intermittent in the sense, I have very sudden onset severe pain and then maybe a few days later, it untwists itself naturally and then the pain goes away, but then it may come back again depending on um whether it's stable or unstable. There's of course a tenderness and guarding, especially as it becomes more and more ischemic as it's cutting off its blood supply. Uh it can present with nausea and vomiting very much like appendicitis, they look unwell. Um And sometimes there may be some bleeding as well. Um depending on how the, the cyst and how the ovary is behaving. Uh This is just a slightly illustrating some of the key features again, on imaging, how we can identify torsion, a key sign for anything that twists on itself um is a well pool sign so often picked up in torsion as well as ovarian torsion and sometimes in bowel um Bulus as well where it twists on itself. The whirlpool sign is quite a common feature. Ok. Then cyst rupture is another type of ovarian accident that again presents in quite similar way, very acutely unwell. But because the cyst itself pops and releases the material within, into the peritoneum uh peritoneal cavity, it can cause peritonitis in addition to the other features. Um And so that's another important feature to be aware of and referred pain to the shoulder tip. Why does that happen in terms of any pelvic or intraabdominal issue? Why, why would you get referred pain to the shoulder one? No. Ok. Well, the diaphragm is innervated by which nes oh, so someone was just put into the to rupture, the fluid caused irritation in the peritoneum. Yeah. So peritoneum. Yes. But in particular, we're thinking when, when it goes up to the shoulder. So peritoneum will cause a peritonitis. You yes or you get a lot of tense tenderness around here. Um But to get to the shoulder tip pain, it's actually if it irritates the diaphragm because the nerves are the phrenic nerves um have this sort of visual path. I feel like that if it becomes irritated from intraabdominal pathologies, um particularly if there's um any rupture of fluid irritating the stomach. Um sorry, in irritating inside the abdomen and up to the diaphragm or any pressure on the diaphragm, you can get shoulder chip pain. So that's an important one to be aware of. Ok, key investigations kind of mentioned some of them already. But I we always take a bedside blood and imaging and then invasive approach for anything um to keep your system. So at the bedside, you want to do a history and examination. Um of course, urine, pregnancy test and urine dip to rule out any other um infected features there, basic abs as we have bloods a full routine. So you might consider a septic screen if they're looking particularly clinically unwell. Um If you're thinking about potentially surgical menses always get a group and safe. Uh because you may need that if they need a blood transfusion or not. And also, um in particular, when we're considering about the complex type of cysts, tumor markers might need to be considered either based on history or if you already have some imaging findings that suggest a bit of an abnormal cyst, you want to see what's going on. And this table quite nicely illustrates the common team markers that we look for in G and what type of conditions that they would be related to imaging wise, as we said before, transvaginal ultrasound is usually the first line. Um And if there's any further contraindication or to transvaginal, for example, they are a young child um or they've not yet been sexually active, then abdominal ultrasound is fine. MRI scan gives a lot more details. So if there's some abnormalities or difficult ultrasound scan, MRI scan is your next step. And um if we're thinking about complexes or potentially cancers, do um think about your staging scans. So, Ct Chest Abdel vs um or pet CT if if indicated, but that would usually be guided by your gyne oncology team and management wise. Yes. So depending on the cysts, as we said, some cysts don't always need attention. Some do. Um Gyn referral is fine to make sure we're figuring out what we're doing. Um and gyne oncology. If we're thinking about cancers, some cysts um are stable and may just have a watch and wait approach with follow up scans. Some cysts may, it's basically the acute presentations may need urgent surgical uh intervention. Um or sometimes uh surgery can be done under elective point a little bit later on. And then of course, if they're malignant, uh cancer treatments can be in place either chemo radiotherapy and hormonal therapies in addition to any surgery if appropriate. Ok. And these are just some of the guidelines that cover these issues. Um Any questions on that before I move to the next case, no questions in the chart just yet. Cool. Perfect. All right. Let's go to case two. Then I'll try and get a bit more speeding. Now, that was a bit more of the dense one. Let's go to some more, slightly more straightforward ones. Ok. So here's a case. So we have a 31 year old who's coming to a GP with quite a long history of having a lot of heavy periods. Um, and, uh, the periods are pretty long lasting 7 to 10 days. Lots and lots of clots passing and really, you know, heavy having to change the pads every hour. She's also had a lot of pain with her periods and also describes having some lower abdominal bloating and distension. And she's also got increased urinary frequency and constipation with it. Ok. And then you've got some information about past medical history and again, the pregnancy test is negative. What are the differentials here? Um Endometriosis could be, yes. Any of this. So, endometriosis is a good differential. Any other differentials, fibroids, fibroids? Yeah. Ok. I'll take those due for that then, yes, they're really good differentials. So I will go through some of what this condition is overall. So, overarching name of heavy periods is menorrhagia. Um And cycle lengths can vary from person to person. Um But typically with the conventional cycle should be between 21 and 35 days. The average expected days of bleeding uh should be up to sort of seven days, but typically we see around five days. Um and the typical blood loss shouldn't be very much about 30 to 40 MS, but men are age is where we have excessive blood loss within menstruation. Um Traditionally, it was described as 80 mils and above, but no one can really quantify that. Um No one really measures. So uh now the clinical definition has changed and nice guidelines express it as excessive blood loss that affects a person's uh physical, social and emotional wellbeing essentially so their daily life and, and how it affects them. Um And you can gauge how much they're bleeding by asking the right questions in terms of how often they might have to change their. Um if it's sanitary pads they use or tampons, um physically sort of how many clots there are. These, these are all important questions to ask about the amount of bleeding. Ok. Causes as you what you said. So the differentials you guys gave were great. Um So we had uh in we had fibroids, we had endometriosis, but always remember the actual most common cause of menorrhagia. So heavy periods is actually dysfunctional uterine bleeding, which essentially means uh there's abnormally heavy bleeding. Uh But we don't actually know what the underlying cause is as other tests and imaging or investigations usually don't sort of result in anything. Um And this is quite common. It, it just perhaps is just a variant um from women to women that some people would have these heavy periods, uh fibroids, as you quite rightly mentioned, um adenomyosis. So that's where we have um the endometrial lining within the muscle aspect of the uterus itself, but not outside of the uterus. So endometriosis is where we have endometrial tissue outside of the uterus. And adenomyosis is where it just goes into the muscle there. And that can cause quite a lot of pain and potentially some heavy periods as well. Other things that cause a lot of bleeding are polyps both within the womb, endometrial polyps or in the cervix. Um but cervical issues. So, polyps or ectropions, um don't always are, are not just restricted to when you're having periods, but can have bleeding outside of that. So it could be between periods, instrument bleeding and also could be uh uh particularly after sex known as post corticoid or bleeding. Ok. So, those are quite common, right? Um And of course, iatrogenic causes. So things that we can do as doctors do in accidentally induce extra bleeding. Um So actually the copper coil is, is a, is a well known side effect that that can actually induce a lot more heavy periods. Um So in anyone with a history of heavy period, you tend not to use this as a form of contraception, of course, antico medication or anything that thins the blood will increase the risk of bleeding. And in line with that, you wanna think about bleeding disorders that can also increase the risk of bleeding and these are just a few to name them. Ok. So in this case, it was indeed fibroids and why do we say that if I just go back to the case? So, here, we're looking at heavy periods with lots of clots. But the main thing that differentiates from other differentials is this idea of the this mass type effect. You've got bloating sensation, uh swelling of the lower abdomen and increased urinary frequency and constipation. Remember how we talked about cysts. So if it's quite big, it presses on the adjacent organs. Same thing here. If the wound gets big and bulky with lots of fibroids, it can press and cause these symptoms. So, yes, we're gonna talk about fibroids now. So uterine fibroids, what are they? They're essentially blind tumors or growths. Tumor just means growth um within the womb uh that is made of the smooth muscle and connective tissue and it can grow in different places and hence, are divided into different categories. Intramural means it grows within the wall of the womb. Submucosal means it grows sort of into the cavity of the womb and then you have subserosal where it's growing on the outer aspects of W OK. And pedunculated is just a term which means I don't know if you can see my arrow here, but just a little stalk is there separating it from where it's starting to grow and the actual tumor itself. So, if it's pedunculated, any mass that's pedunculated, just means it's got a little stalk attaching to something. Ok. So risk factors. Um So fibroids grow based on estrogen and progesterone exposure, um particularly with estrogen and anything that increases this will increase the risk of fibroids. So, estrogen wise, um the things that will increase it are early menarche. So starting periods early and also finishing the late menopause. Um and also no parity, family history is of course very important obesity interestingly increases risk um in a lot of uh Eastern independent conditions because it it there's an association between the higher fat levels. Uh that kind of store and distribute estrogen in more um uh in more aspects in the sense, there's more estrogen in the body with the higher fat levels and adiposity and um fibroids results are more common in those of Afro Caribbean origin. Interestingly, studies found that the protective factors or things that reduce risk of fibroids are multiparty and possibly smoking, but there's no causal relationship. So that does not mean everyone should go around smoking to prevent it. It's just an association that was found in some studies. Ok. And what's it present like so that with anything it can be asymptomatic and just incidentally picked up on a scan and but most often it's presenting with heavy me bleeding, like we said, uh or sometimes uh abnormal bleeding. So, like we said, the different options of the intermenstrual and postcoital et cetera, uh often it's quite painful. Um and there can be pressure symptoms like we've said, and it may affect fertility particularly if it's uh within the womb because it affects the ability for the eggs to implant. But also affects the ability for them to develop and grow properly uh during development and may lead to miscarriages or um early pregnancy losses. Um But some of the signs and symptoms you look for again, of course, um when you palpate in the abdomen, particularly being bulky, very multifiber because you can actually feel them that is quite irregular and lumpy. Um And uh you'd also also check for any signs of anemia. So anyone with heavy bleeding of any form, you wanna rule out the signs of anemia, such as shortness of breath, dizziness, headaches, um sometimes fainting funny turn, you always wanna check for that. Now, red degeneration of the fibroid is essentially where a fibroid is growing very rapidly and it outgrows its own blood supply, which means it starts to become ischemic and necrotic. And remember, ischemia often is associated with pain but lots of things. So at that point, it becomes very painful as the fibroid starts to break down and become necrotic because it's not got enough blood supply. And that can be very, very painful and very unwell. And quite commonly when women with fibroids who become pregnant because of the increased um hormone exposures, a lot of degeneration, fibroids occurs within pregnancy. So, acute cause of abdo pain in pregnancy. If they had fibroids, you want to think about this as well. Ok. Investigations, as we said, bedside bloods and imaging, um, always make sure you on bleeding. We have the full blood count to check for anemia and again, group and safe if you're thinking about any blood transfusions or surgery, imaging is ultrasound. First line and MRI for more details and management wise, again, conservative medical, this time intervention also adoption and surgery. Conservative wise, we've got lifestyle diet and exercise often helps quite well and again, um reinforcing a healthy balance side with um iron supplementation if you need to um if they have low iron medical management. So, first line, in terms of pain control, plus bleeding control is nsaids. So that's the Ibuprofen metam acid because it affects the prostaglandin. Um release Ibuprofen metha metal acid, which is involved in how um I guess the pain and bleeding works within the womb and it can actually reduce the amount of bleeding in a lot of cases. Uh You'd also wanna think about if it's very, very acute, heavy bleeding. Um uh in anemic patients, you wanna think about stopping that bleeding more acutely with a short course of tranexamic acid or even short courses of uh norethisterone. Uh a type of progesterone which can help stop bleeding. Other hormone options are there as well. C ACP and of course the coil uh remember if the there's too many bulky fibroids within the actual cavity of the womb, then a coil may not be appropriate if it doesn't fit properly. So it just depends where these fibroids are uh generate analogs can use because it helps to essentially use a lot of um stimulate, overstimulate the gene Rh receptors and then essentially stops the whole axis. Uh The endocrine axis that controls secretion of hormones from the ovaries um and then prevents further growth. Um And then you've got other options. Uh uh hormo hormonal and nonhormonal options as well. And always remember the management of anemia and to monitor for anemia of any patient with heavy bleeding. Interventional approaches for fibroids include uterine artery embolization. And also there's new developing techniques using ultrasound and MRI as well. But uh uterine artery embolization have been able to assist on quite a few times. Um Actually, it's quite an interesting procedure where it's just essentially using um tubes and wires. Um as most individual procedures do going in through the femoral artery and then inserting a wire to get to the point using a special X ray machine known as a fluoroscope to see exactly where you were. And then you pass over these little tubes and wires which are the devices. And then within that you find out where the uterine artery is and you just block it off with different equipment such as be be no PVC particles or um other substances to essentially block up the artery so that it reduces the supply to the fibroids and then they eventually break down and go away because it doesn't have any more blood supply. Um So that's an option. And of course, surgery is uh an option, especially if they have a very big bulky uterus with multiple fibroids if they have a lot of symptoms with it. Um, and of course, if the other options aren't controlling it, and the options include removing the actual fibroids themselves, the myomectomy or if there are too many fibroids and they're very symptomatic and they're not planning for any further pregnancy, hysterectomy to remove the wound itself. Ok. And these are some guidelines on the management for it, right? Just in the interest of time, we'll skip on to the next case and hopefully we can finish all cases today. So this one, we have a 59 year old female who's come into the GP this time with two weeks of abnormal PV bleeding and she's already postmenopausal and she's only on the SSRI um for her postmenopausal symptoms. She's got a history of breast cancer on tamoxifen, hypertension and hypercholesterolemia in the background. And when you examine her, she's got some PV bleeding and you can see some blood is there around the cervix already. Um But there's no obvious other abnormalities you can physically see from the outside. OK. So what are your differential? Say? So in the chat, we've got C in mhm Any other differentials, cervical ectropion? OK. Is there anything above the Cervix you'd wanna think about in the postmenopausal woman or bleeding? That's OK. I probably caught you all off by saying blood at the cervix. Um That just essentially means you're seeing active bleeding, uh, blood at the cervix doesn't necessarily mean blood is coming from the cervix. It could be, but it doesn't necessarily mean. So, um, and we've also mentioned there's no obvious cervical or vulvovaginal abnormality. So, yes, you're quite right in saying c in, you can't always physically see it unless you do the necessary tests. But anything else that causes PV, bleeding that is very, very important to be aware of in the postmenopausal age group. I'll just go into the differentials to save time. Always want to worry about endometrial cancer. Ok. So in a postmenopausal women with bleeding, the main thing we worry about is endometrial cancer. Interestingly, cervical cancer um which is caused by the HPV viruses typically um HPV virus 16 or 18. Um they happen more in the younger age groups, not, not restricted to, to them, of course, but more. So in the younger age group, particularly those who are sexually active because it's HPV tends to be acquired in that manner. Endometrial cancer is the main one we worry about in the postmenopausal age group. The most common cause of actual bleeding in the post menopause age group is in fact vaginal atrophy, which is essentially because um the estrogen production from the ovaries goes down after the menopause as we stop having the menstrual cycles. And um when you have lower estrogen that leads to dryness and thinning, um an atrophy, which is the term of not only the vagina but the walls of the womb, um and even the vulva region. So the outer part, so it becomes a lot more dryer, more viable, very thin and more easily to bleed. Um So that's actually the most common cause of bleeding in the postmenopausal age group. But uh endometrial cancers are sort of red flag thing to keep in the back of our mind. Also, if the patient is on any H RT the hormone replacement therapy, um uh that can also cause some bleeding depending on how uh the linings are reacting to them. Ok. So let's go into endometrial cancer as this case is trying to highlight that as the main uh sort of thing to think about. So, endometrial hyperplasia is sort of like a precancerous state if you like where you have an increased number of the cells and it can be divided into with and without atypia atypia, meaning having atypical cells which are precancerous or potentially cancerous. So, without atypia, there's no abnormal cells and with atypia, there are the abnormal cells which is a high risk of developing into a malignancy. But hyperplasia itself is not the cancer. It's just for that pre malignant stage. Endometrial cancer itself is usually a type of carcinoma, which means it's an epithelial cell tumor. And then the cancer, you've got all sorts of different types of sarcomas, carcinomas, adenomas, all that. So, carcinoma is a malignancy of epithelial cells and within uh endometrial cancer. There are two overall main types. Type one and type two. Type one are typically classed as endometrioid mucinous or secretory adenocarcinomas. Um which means sort of the glandular epithelium, adenocarcinoma, glandular epithelium. It typically presents in younger age groups and it's usually estrogen dependent and it can come um usually from the hyperplasia with atypia as it develops on. But because they are picked up quite um more commonly and more easily, they can be diagnosed often at the lower grades, uh or lower stages of cancer. The type two cancers, however, are your serious and clear cell types and typically found in older patients and a bit more tricky to diagnose um and often seen at higher grades a bit more aggressive. So how we assess them or how we see them, um Clinical presentation can be uh different. So again, sometimes can be asymptomatic and just picked up on a scan. Um but typically will present with this abnormal bleeding. So it could be postmenopausal bleeding could be bleeding after sex, postcoital bleeding, intermenstrual bleeding. So, between periods and uh menorrhagia having heavy periods. Ok. And often uh any cancer you want to think about floor symptoms. So in your histories and assessments, floor stands for fevers, lethargy, appetite changes, weight loss and night sweats. Always ask that in the context of giving you about cancers and you also wanna think about metastasis. So you wanna do a system, a review of the patient going head to toe to see. Is there any other symptoms that they're having? That could suggest they've got metastatic cancer? Ok. Investigation wise. Again, bedside bloods and imaging your bedside will cover your history, examination and s bloods wise. Um yes, do a full set of bloods and also hormone profiles. But also it comes markers may be helpful imaging, as we always say. Um ultrasound is usually first line and a cut off for endometrial thinking about endometrial cancer or hyperplasia. In the postmenopausal age group is four millimeters. So when the endometrial thickness, the lining of the womb is more than four millimeters, then we're worried about potential cancers and of course invasive options. Uh you wanna refer them if you're having these concerns to a two week wait hysteroscopy clinic or um to be able to see exactly using a tub camera with a light to see inside the womb if there's any abnormal cells or patches or areas and also allow to take a biopsy from the area. So we can test it how we manage it. Um as we cancer pathways, it's different depending on the stages and type. Um some that are responsive to estrogens can be man uh oh sorry estrogens and the hormone management will be managed accordingly and that some that are not may need further radiotherapy or chemotherapy treatment if it's endometrial hyperplasia without ATP so there's no obvious cancer cells or abnormal cells. Um or if the patient wants a fertility, try the more conservative approaches first. But then obviously have, you know, the active surveillance to monitor them in case they do develop a need further intervention. And here's again, some guidelines for further reading. OK, I've got the last case now. Um Do you have any questions for that? Uh Previous one before I move to this one? Uh No questions in the chart so far? Cool. All right. I hope you're all still with me. Uh Last one, I promise. So we have a 26 year old female who's coming to a GP this time, worried about facial hair. She's noticed increasing weight over the last seven months and she's also got some irregular periods, but she stopped taking the pill about a year ago and she really wants to get pregnant but she's not been successful yet. What's her top differential in the chart? We've got PCOS. Yeah, exactly. It's quite, pretty much on the tin, isn't it? I don't have to give you that anymore. Yes. Absolutely. Right. So Polycystic Ovarian Syndrome, um it's kind of defined in slightly different ways by different uh diagnostic criteria, but essentially you'll have the three elements. Um Well, not all three, but at least two of the three, you'll have hyperandrogenism where you have excess amounts of the androgen hormones like testosterone, W which results in this male pattern. Um type of hair, presentation of extra body hair. You have natural irregularities. So, irregular periods or perhaps um very long gaps in periods which can in turn translate to infertility and on the ultrasound imaging uh or imaging of any sort. You'd also see the multiple ovarian cysts. Ok. Um So Polycystic Ova Syndrome, why does it happen? No one really knows. Um We haven't quite gotten to the bottom of the pathology as to exactly what stimulates it in the first place. But in general, it's an endocrinopathy. So it involves problems with the endocrine system. Um and we have increased androgens made by the theca cells in the ovaries. And also PCOS is associated with high levels of LH, which is a luteinizing hormone made by the um pituitary. And you've also got higher insulin levels and it just means PCOS has a degree of insulin resistance, which is pretty common and that can translate to having weight gain um as well as uh developing sort of the uh glucose intolerance and diabetes type pictures. But also it seems to affect our androgen production and also the ability for the liver to make the sex hormone binding globulin, which is essentially a protein that binds and um sort of holds a lot of the different sex hormones, particularly testosterone, it holds it. So if you have less of that, you can have a lot more free testosterone in the bloodstream, which means it's free to bind to different receptors and lead to its androgenic effect. And also there's a lot of an ovulatory cycles within PCOS, which basically means in the context of ovulation, the egg doesn't get released and the cysts can remain. And at the same time, that will lead to the irregular periods, it will lead to infertility. But also because of the anovulation, you don't get the normal cycles and the shedding of the endometrium within the menstrual cycle that can increase the risk of endometrial hyperplasia and cancer. So, uh we kind of went through some of the criteria at the start. But essentially, uh we want to look at at least two of the three of these different criterias in the older textbooks. Uh it was called Rotterdam criteria. But I think recently there's been a move to try and change it. So you don't need all three of them, but you need to have at least two of them to make a diagnosis. Um which is your polycystic ovaries, the oligo anovulation. So having the irregular periods and, and the hyperandrogenism, um there's also some degree of insulin resistance that's not part of the diagnostic criteria, but it's just to be aware of in terms of how they present um which can present with obesity. So your weight gain and also um acanthosis mis uh which is essentially uh typically on the, the underarms or uh under the body folds, you can get those velvety sort of dark black brown um patches, uh which is quite a common feature in insulin resistant states. Ok. Investigation wise, um you need to do your bloods, uh bedside bloods and imaging, save bloods. In this case. Importantly, are the hormone profile because like we said, it's an endocrine type issue. We want to check your total testosterone amount of testosterone in the whole body, including that's B bound to the sex hormone binding globulin. But also the free testosterone, the total testosterone may be within normal limits, but the free testosterone is the important one and that should be raised in PCOS. The sex hormone binding glob globulin will be lower than normal or at least on the lower end of normal. Um and then your LH and FSH, you wanna see and usually the LH is a lot higher than the FS H at least in the LH FSH ratio. It should be great than t estrogen progesterone should also be measured. And of course, you want to think about the other types of differentials that can present like this. The things that cause uh increasing weight gain with irregular periods and changes in mood. Think about Cushing's syndrome with cortisol things that cause irregular periods and again, weight gain, hypothyroidism. Uh prolac high prolactin levels can also affect fertility and 17 HYDROXYprogesterone um is a hormone that we used to measure for other adrenal related problems that can affect androgen at least particularly congenital adrenal hyperplasia or things along those lines and imaging wise, like you said, ultrasound scan first and then further imaging if needed. Um how we manage it. So lifestyle is always first for everything. Uh always weight loss is actually one of the biggest things that improves uh the symptoms as well as fertility within PCOS. So always encourage healthy diet and exercise to improve weight loss. Also went to optimize cardiovascular risk factor control because actually with this uh increased um sort of in insulin resistant state, but also general metabolic changes increases the risk of a lot of cardiovascular disease, as well as diabetes. You really want to get on top of that as well. If they're not planning pregnancy, your medical management options include uh using hormone treatments to control periods and try to regulate them better. Also the Mirena coil and progesterone mainly because we want to encourage the shedding in preventing the buildup with these anovulatory phase. And Metformin can be used. But typically we don't use it if we're not planning for pregnancy unless there are other indications like diabetes uh or something like that. And there's a quite a key important information on the nice guidelines about the use of Metformin here. If they are thinking about pregnancy again, weight loss, diet, lifestyle exercise. And clomiPHENE is a medicine that we use to help induce ovulation to help um release the eggs and, and get the uh fertility improved. Metformin also helps to improve fertility by improving insulin sensitization. So, response to insulin um and also invasive approaches include laparoscopic ovarian drilling where they essentially drill tiny weenie holes into the ovaries to help improve ovulation. Uh Of course, uh if they've been trying for so long, particularly one year's trying and there's no success you refer to fertility services to see for further support. And then this is just to summarize some of the key differentials about infertility. Um In any case for women, you wanna think about three parts of the reductive system, your um uterus, the ovaries and the tubes. But of course, always think about the male partner as well and any infertility investigations are done in pads, both with the female and male. Ok. So, and there are some further guidelines on the case. I know that that was a whistle stop to for quite a few things, but I hope it was useful. Uh Are there any questions at all before we finish? Uh, there's no questions in the chat just yet, but we'll just, uh, give it a couple more minutes, just sure, no problem. I hope it was useful. And, um, yes, I would be grateful for any feedback. There's a QR code here as well and I'm happy to answer any questions. Yeah, that's great. Thank you very much for that talk and thank you very much for everyone that participated. Um, I put a link to the feedback form in the chat. So, um, either scan the QR code or follow that link and that will lead to the feedback form that will allow you to get access to the slides and the event recording as well. Um And we'll just give it another minute or so if you've got any questions in the chat, um also feel free to unmute yourself. Um Yeah, thanks. Uh So the slides will be available online through the middle page.