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Gynaecology cases

Gynaecology cases. Rehan Salim MD MRCOG Consultant Gynaecologist. Case 1. 34 year old Irregular periods No significant gynaecological problems 3 day history of pelvic pain. Case 1. Observations normal Urinalysis normal. Pregnancy test positive Ectopic pregnancy unless proven otherwise.

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Gynaecology cases

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  1. Gynaecology cases Rehan Salim MD MRCOG Consultant Gynaecologist

  2. Case 1 • 34 year old • Irregular periods • No significant gynaecological problems • 3 day history of pelvic pain

  3. Case 1 • Observations normal • Urinalysis normal Pregnancy test positive Ectopic pregnancy unless proven otherwise

  4. Case 1 • Ultrasound scan • No evidence of intrauterine or extrauterine pregnancy • BHCG 400, progesterone 29 • Called same day by EPU • Come for a repeat bloods in 2 days

  5. Case 1 • 2 days later • More pain • Repeat scan • Small amount of blood in pelvis • Right ectopic • HCG 755

  6. Case 1 • Theatre • Right salpingectomy • Uneventful recovery

  7. Case1 • What is the effect on my fertility? • Risk of another ectopic pregnancy? • Why did it happen?

  8. Case 2 • 54 year old • Fit and well • Single episode of fresh vaginal bleeding

  9. Case 2 • Speculum • Ultrasound • Thick endometrium • Pipelle • Endometrial hyperplasia

  10. Case 2 Up to 50% of patients with CAH have co-existent endometrial carcinoma detected at histology of subsequent hysterectomy

  11. Case 2 • Simple cystic hyperplasia without atypia • progestagens such as norethisterone 5 mg bd for three out of four weeks. • The treatment should last at least three months, then the biopsy should be repeated. • In young women with polycystic ovaries, treatment with cyclical progestogens should continue or it can be replaced by long term combined oral contraceptive pill. • In postmenopausal women the treatment may be stopped if the result of second biopsy is normal, but they should be advised to return if their symptoms recur.

  12. Case 2 • Adenomatous hyperplasia • more likely to progress to cancer than cystic hyperplasia. • However, the treatment is the same as in cystic hyperplasia. • If abnormality persists after the therapy hysterectomy may be considered in older women. • Complex hyperplasia • may progress to atypical hyperplasia in 10% and to carcinoma in 4% of cases

  13. Case 2 • Atypical hyperplasia • is believed to progress to cancer in up to 30% of cases depending on the degree of atypia. • Severe atypia is often impossible to differentiate from cancer even on hysterectomy specimens. • In postmenopausal women hysterectomy should be considered, whilst in young women treatment with oral progestagens or Mirena IUS are preferred options. All women managed conservatively should be followed up very closely.

  14. Case 3 • 21 years old • Infrequent periods, hirsute • BMI 34 • Fit and well otherwise

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  18. Case 3 • Oligomenorrhoea • Endometrial hyperplasia/ cancer • Infertility • Pregnancy • Hyperandrogenism • Cosmetic • Long term • NIDDM • GDM • Cycle control

  19. Case 3 • Weight loss • COCP • Endometrial protection • Metformin • Incremental dose • 500md OD/BD/TDS → 850mg BD • Ovulation induction

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