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Phase 3a Euan & Pat

Gynaecology Revision. Phase 3a Euan & Pat. The Peer Teaching Society is not liable for false or misleading information. Aims. Brief overview of menstruation Menstrual disorders Gynae cancers Infertility ( amenorrhoea , PCOS, STIs, PID) Prolapse

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Phase 3a Euan & Pat

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  1. Gynaecology Revision Phase 3a Euan & Pat The Peer Teaching Society is not liable for false or misleading information.

  2. Aims • Brief overview of menstruation • Menstrual disorders • Gynae cancers • Infertility (amenorrhoea, PCOS, STIs, PID) • Prolapse • We won’t cover contraception or the menopause due to time constraints • No obstetrics The Peer Teaching Society is not liable for false or misleading information.

  3. Introduction • Gynae is one of the harder topics • Quite a lot of physiology • We have used Impey and Vander’s The Peer Teaching Society is not liable for false or misleading information.

  4. Physiology of Menstruation: Puberty • Menarche = onset of menstruation • Occurs usually ~13 • GnRH released after age 8 ---> FSH & LH • FSH & LH ---> Oestrogen ---> 2° characteristics The Peer Teaching Society is not liable for false or misleading information.

  5. Physiology of Menstruation • Initially menstruation is irregular • Becomes regular as oestrogen secretion increases • Hormones in menstrual cycle cause ovulation (release of egg from ovary) • Also prepare endometrium for implantation The Peer Teaching Society is not liable for false or misleading information.

  6. Menstruation: Day 1-4 • Endometrium is shed • High FSH & LH • Several antral follicles enlarge • Myometrial contraction can occur The Peer Teaching Society is not liable for false or misleading information.

  7. Menstruation: Days 5-13 • Is known as the proliferative phase • Single dominant follicle selected • GnRH pulses from hypothalamus --> LH & FSH ---> follicular growth • Oestradiol + inhibin have feedback effect • Ovulation occurs after LH surge • Oestradiol causes endometrial proliferation FSH LH Oestradiol + Inhibin The Peer Teaching Society is not liable for false or misleading information.

  8. Menstruation: Days 14-28 • Known as luteal or secretory phase • Follicle becomes corpus luteum after ovulation • Produces progesterone– secretory endometrium • Corpus luteum atrophies if egg not fertilised • Lower oestrogen & progesterone - cycle The Peer Teaching Society is not liable for false or misleading information.

  9. Questions: A few definitions… • MENORRHAGIA • IRREGULAR PERIODS • PRIMARY AMENORRHOEA Heavy menstrual bleeding – subjective, impossible to measure so no defined volume of blood loss Periods outside the range of 23-35 day cycles with a variability of more than 7 days between the shortest and longest cycle Never had a period The Peer Teaching Society is not liable for false or misleading information.

  10. A few more definitions… • SECONDARY AMENORRHOEA • OLIGOMENORRHOEA • POSTMENOPAUSAL BLEEDING • DYSMENORRHOEA • PREMENSTRUAL SYNDROME Previously had a period, but have stopped for 6 months or more Infrequent periods – between 35 days or 6 months apart bleeding more than 1 year post-menopause = painful periods physical and/or psychological symptoms worse in luteal phase (days 14-28) The Peer Teaching Society is not liable for false or misleading information.

  11. Menorrhagia: definition • Excessive bleeding in otherwise normal cycle. • Can occur alone or with other symptoms. • Affects QoL, physical, emotional social life. • Defined as >80ml loss in a cycle but impossible to measure. • Up to 1/3 women complain of heavy periods The Peer Teaching Society is not liable for false or misleading information.

  12. Menorrhagia: background • Unknown aetiology if primary • Uterine fibroids and polyps account for ~40% of menorrhagia • Other causes include PID, tumours, endometrial/cervical malignancy • Rare causes: coagulopathies The Peer Teaching Society is not liable for false or misleading information.

  13. Menorrhagia: the patient • Hx: may be flooding/passage of large clots • O/E: may be signs of anaemia (you know these better than me), however usually no pelvic signs. • May be: uterine mass (fibroids), • tenderness (adenomyosis) • ovarian mass The Peer Teaching Society is not liable for false or misleading information.

  14. Menorrhagia: Investigations • Bloods: FBC (Hb), Coagulation screen, TFTs • TVS: assesses endometrial thickness, fibroids, ovarian masses • Biopsy if: endometrial thickness >10mm/polyp suspected/age >40 and recent onset menorrhagia/not responding to Rx The Peer Teaching Society is not liable for false or misleading information.

  15. Menorrhagia: Rx Exclude other pathology Consider contraceptive needs FIRST LINE: IUS (Mirena) SECOND LINE: antifibrinolytics (tranexamic acid) NSAIDs (mefanamic acid) THIRD LINE: Progestogens (oral/IM) GnRH agonists LAST RESORT: Surgery e.g. endometrial ablation/hysterectomy The Peer Teaching Society is not liable for false or misleading information.

  16. Dysmenorrhoea • Painful menstruation • Primary: no organic cause, pain at start of menstruation. • Very common. • Rx = NSAIDs, COCP • Secondary: due to pelvic pathology. Pain relieved by onset of menstruation. • Causes: fibroids, adenomyosis, endometriosis, PID, ovarian tumours. Rx accordingly. The Peer Teaching Society is not liable for false or misleading information.

  17. Irregular bleeding/Intermenstrual bleeding • Causes: • anovulatory cycles e.g. puberty/near menopause • Non-malignant • Malignant – think ENDOMETRIAL • Investigations same as for menorrhagia • Rx: 1st line = IUS or COCP • 2nd line = surgery as with menorrhagia The Peer Teaching Society is not liable for false or misleading information.

  18. Endometriosis: background • Presence & growth of endometrial tissue outside uterus • 1-2% women • Associated with subfertility • Endometrial tissue is estrogen-dependent • Common sites: uterosacral ligaments, on ovaries, vagina, rectum, bladder • Postulated to be due to retrograde menstruation The Peer Teaching Society is not liable for false or misleading information.

  19. Endometriosis: the patient • Hx: BIG cause of cyclical chronic pelvic pain. Also pain (dysmenorrhoea) before menstruation, deep dyspareunia, subfertility. • Ruptured chocolate cyst may cause acute pain. • O/E: Often normal, but may be tender/thickened adnexa • Investigations: laparoscopy and biopsy. TVS if ovarian endometrioma suspected. The Peer Teaching Society is not liable for false or misleading information.

  20. Endometriosis: Rx • Rx ONLY if symptomatic • NSAIDs, analgesia • Hormonal therapies: COCP, IUS, GnRH analogues, androgens (rare) • Surgery: see & treat in diagnostic laparoscopy • ++ radical if needed The Peer Teaching Society is not liable for false or misleading information.

  21. Fibroids • A.k.aleiomyomata are benign tumours of the myometrium • Occur in ~25% of women, but more common near menopause, in afro-Caribbean women and if +ve FH. • Less common if on COCP and in parous women The Peer Teaching Society is not liable for false or misleading information.

  22. Fibroids • Fibroids are intramural, subserosal or submucosal: The Peer Teaching Society is not liable for false or misleading information.

  23. Fibroids: background • They are estrogen-dependent, therefore….. • Regress after menopause, HRT use can cause continued growth • During pregnancy, rule of 1/3’s – can complicate pregnancy • Can also enlarge, degenerate or transform (0.1% become malignant) at any time The Peer Teaching Society is not liable for false or misleading information.

  24. Fibroids: the patient • Hx: • 50% asymptomatic • 30% have menorrhagia • Dysmenorrhoea can also occur • Other rarer symptoms due to location • O/E: May be a palpable mass • Investigations: USS/MRI/Laparoscopy The Peer Teaching Society is not liable for false or misleading information.

  25. Fibroids: Rx • IF asymptomatic and slow growing, no Rx • Medical: tranexamic acid, NSAIDs, COCP can be trialled • GnRH agonists but only for 6 months at a time • Surgery: • Transcervical resection of fibroid • Myomectomy • Uterine artery embolization The Peer Teaching Society is not liable for false or misleading information.

  26. Endometrial Carcinoma: background • > common genital tract cancer • Prevalence highest aged 60 • Only 1% occurs in women < 30 • Presents early • 90% are adenocarcinomas The Peer Teaching Society is not liable for false or misleading information.

  27. Endometrial Carcinoma: aetiology • Cause = high ratio of oestrogen:progesterone • Therefore, RF’s: • Obesity • PCOS • Nulliparity • Late menopause • Tamoxifen therapy • COCP and pregnancy are protective The Peer Teaching Society is not liable for false or misleading information.

  28. Endometrial Carcinoma: the patient • Hx: *******postmenopausal bleeding******** • If premenopausal, then irregular or intermenstrual bleeding • O/E: often normal • Investigations: USS, biopsy, hysteroscopy. • Staged with FIGO 2009 • Rx: hysterectomy & bilatsalpingoophorectomy • Radiotherapy can be used, chemo has little value The Peer Teaching Society is not liable for false or misleading information.

  29. CIN: background • Presence of atypical cells in squamous epithelium • Cells are dyskaryotic • Graded CIN I, CIN II or CIN III depending on frequency of abnormal cells • Diagnosis is made histologically The Peer Teaching Society is not liable for false or misleading information.

  30. CIN: staging • CIN I: mild dysplasia, atypical cells in lower 1/3 of epithelium, commonly regresses spontaneously • CIN II: moderate dysplasia, cells found in lower 2/3 • CIN III: severe dysplasia, cells found in full thickness of epithelium. AKA carcinoma in situ (no invasion of basement membrane) • Rx = large loop excision of transformation zone under local The Peer Teaching Society is not liable for false or misleading information.

  31. CIN in the UK • 90% in <45 • HPV main cause, therefore major RF is high number of sexual contacts • Other RF’s: smoking, COCP (very mild increased risk) • National vaccine programme for HPV 16 &18 The Peer Teaching Society is not liable for false or misleading information.

  32. CIN Screening • Good example of a screening programme for any public health questions • CIN is asymptomatic and not visible on examination • Screening programme in UK: smears from age 25 every 3 years until age 49, every 5 years between 50 and 64. The Peer Teaching Society is not liable for false or misleading information.

  33. Ovarian carcinoma: background • Presents late • 5 year survival < 35% • 80% cases in women over 50, highest rates between ages 80-84 • > common histological type = serous cystadenocarcinoma (50%) also endometrioid carcinoma (20%), also several others The Peer Teaching Society is not liable for false or misleading information.

  34. Ovarian carcinoma: risk factors • Risk factors relate to number of ovulations e.g. • Early menarche • Late menopause • Nulliparity • Pregnancy, lactation & COCP = protective • Can be familial via BRCA1, BRCA2 The Peer Teaching Society is not liable for false or misleading information.

  35. Ovarian carcinoma: the patient • Hx: initially vague symptoms (presents late!!!) • Symptoms may be absent, but if present: • Abdominal distension • Mass palpated by patient • Urinary urgency/frequency • PV bleeding • O/E: cachexia, palpable mass, ascites The Peer Teaching Society is not liable for false or misleading information.

  36. Ovarian carcinoma: how to investigate & treat • CA 125 in primary care in women >50 w/ IBS-like abdo symptoms also loss of appetite, weight loss etc • If CA125 high, USS abdo & pelvis • In secondary care, AFP and hCG measured • (could be germ-cell tumour) • Rx = hysterectomy, bilateral salpingoophorectomy and partial omentectomy, biopsy taken. • Chemo used if higher grade The Peer Teaching Society is not liable for false or misleading information.

  37. Not covering vulval malignancy due to time constraints and fact that it is very rare, worth having a quick look though

  38. AMENORRHOEA Primary • By the age of 16. • By the age of 14 and have no secondary sexual characteristics. Secondary • Absence of menstruation for 6 consecutive months in a woman who has previously had regular established menses. *Oligomenorrhoea- every 35 days to 6 months The Peer Teaching Society is not liable for false or misleading information.

  39. Hypothalamus GnRH Anterior pituitary LH FSH Inhibin Granulosa cells Theca cells Androgens Oestrogen Progesterone

  40. Physiological causes Primary Secondary Pregnancy Most common Lactation Menopause Drugs Progesterones GnRH analogue Anti-psychotics • Constitutional delay • Drugs

  41. Pathological causes Primary Secondary Hypothalamic Anorexia nervosa/malnutrition Exercise Pituitary Hyperprolactinaemia Sheehan’s syndrome Thyroid or adrenal +/- thy Tumours Ovary PCOS (common) Premature menopause Outflow Asherman’s syndrome Cervical stenosis • Hypothalamic • Anorexia nervosa/malnutrition • Exercise • Kallman’s syndrome • Pituitary • Hyperprolactinaemia • Thyroid or Adrenal • +/- thy • Adrenal tumours and hyperplasia rare • Ovary • PCOS • Turner’s syndrome • Outflow • Congenital

  42. Polycystic ovary syndrome • TWO of the following criteria are met: • Polycystic ovaries on US • Oligomenorrhoea • Hirsuitism • Clinically • Acne • Excess body hair • Biochemically • Raised serum testosterone

  43. PCOS cont. • Disorder of LH production and peripheral insulin resistance • Increased intraovarian androgens disrupt folliculogenesis • ++ small ovarian follicles & oligo/amenorrhoea • Raised peripheral androgens cause hirsuitism • 20% women have PCO, 5-10% PCOS • Family hx of DMII

  44. Investigations Bloods • Anovulation • FSH→PCOS, ↓hypothalamic disorder, ↑ovarian failure • Prolactin & TSH • Serum testosterone Hirsutism Trans-vaginal ultrasound • Polycystic ovaries • 12 or more small (2–8 mm) follicles in an enlarged (>10 mL volume) ovary *Lipids and diabetes screening because of increased risk

  45. Management Ovulation • Diet and exercise 5% weight reduction can lead to ovulation • Clomifene • Metformin • Gonadotrophins • Ovarian diathermy • In vitro fertilization (IVF) Cosmetic hair removal

  46. Pelvic inflammatory disease • Ascending infection of the genital tract • Endometris, Salpingitis, Tubo-ovarian abscess • Usually caused by STIs • Chlamydia (60%), gonorrhoea • Instrumentation in the vagina • Childbirth or miscarriage • Rarely descending infection • E.g appendicitis

  47. PID cont. Signs and symptoms • Asymptomatic • Subfertility • Chronic (6 month) pelivic pain • Acute signs of infection Investigations • EXCLUDE PREGNANCY • HVS, Endocervical swabs, MSU • USS if query tubo-ovarian mass

  48. PID cont. Management • Analgesia • Abx • Based on results of tests • ?drainage of abscess Complications • Sub-fertility • 6x more likely ectopic pregancy

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