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Phase 3a Louise Cloney and Lucy Rigg

Gynaecology. Phase 3a Louise Cloney and Lucy Rigg. The Peer Teaching Society is not liable for false or misleading information…. Aims. Menstruation Physiology Disorders: menorrhagia, dysmenorrhoea , dysfunctional uterine bleeding. Infertility A menorrhoea (primary and secondary )

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Phase 3a Louise Cloney and Lucy Rigg

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  1. Gynaecology Phase 3a Louise Cloney and Lucy Rigg The Peer Teaching Society is not liable for false or misleading information…

  2. Aims • Menstruation • Physiology • Disorders: menorrhagia, dysmenorrhoea, dysfunctional uterine bleeding. • Infertility • Amenorrhoea(primary and secondary) • PCOS • STIs and pelvic inflammatory disease • Contraception The Peer Teaching Society is not liable for false or misleading information…

  3. Menstruation • Physiology • Puberty Hypothalamus Anterior Pituitary Thelarche: 9-11 years Menarche: 13 years Adrenarche: 11-12 years The Peer Teaching Society is not liable for false or misleading information…

  4. Menstrual Cycle The Peer Teaching Society is not liable for false or misleading information…

  5. Menstruation • Day 1-4: Menstruation • Endrometrium and myometrium contraction • Day 5-13: Proliferative Phase • Pulses of GnRH from hypothalamus cause release of FSH and LH which stimulate follicle growth. • Follicles release oestradiol and inhibin – negative feedback, FSH levels drop. Only the dominant follicle has enough receptors to continue developing under low levels of FSH. • Levels of oestradiol continue to increase and cause positive feedback producing LH and FSH surge = ovulation. • Oestradiol is responsible for proliferation of the endometrium: stromal cells proliferate causing it to thicken and the glands elongate. The Peer Teaching Society is not liable for false or misleading information…

  6. Menstruation • Day 14-28: Luteal/Secretory Phase • The surrounding follicular cells from the ovarian follicle becomes the corpus luteum(theca and granulosa cells) which produces oestradiol but mainly progesterone which is responsible for maintaining the endometrial lining. Levels peak at 21 days. • Progesterone is responsible for the secretory changes to the endometrium: stromal cells enlarge, the glands swell and the blood supply increases. • If the egg is not fertilised, the corpus luteum breaks down along with the endometrial lining and the cycle starts again. The Peer Teaching Society is not liable for false or misleading information…

  7. Menorrhagia Clinical definition: excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. (Objective: >80mL, never measured!) Menorrhagia Regular Cycle Irregular Cycle Idiopathic Fibroids (30%) Polyp (10%) Chronic Pelvic Infection Ovarian tumours Cervical and Endometrial malignancy Rare: Thyroid disease, haemostatic disorders (VWB), anti-coagulant therapy The Peer Teaching Society is not liable for false or misleading information…

  8. Menorrhagia - investigations • Check haemoglobin to assess effect of blood loss • TransvaginalUltrasound – assess endometrial thickness, exclude a uterine fibroid or ovarian mass and detect larger intrauterine polyps. • Endometrial biopsy if: • Thickness >10mm • Polyp suspected • 40+ with: recent onset menorrhagia or IBS or unresponsive to treatment • Exclude systemic causes: • TFT and coagulation screen only if history suggests. The Peer Teaching Society is not liable for false or misleading information…

  9. Menorrhagia - management When possible pathologies have been ruled out: 1st Line: IUS 2nd Line: • Antifibrinolytics(tranexamic acid) can reduce blood loss by 50% with few S/E. • NSAIDs (mefanamic acid) inhibits prostaglandin synthesis, can reduce blood loss by 30%. • COCP 3rd Line: • Progestogenscause amenorrhoea • GnRH agonists cause amenorrhoea. (unless HRT used, limited to 6 month use) 4th Line: Surgery – endometrial ablation, hysterectomy The Peer Teaching Society is not liable for false or misleading information…

  10. Fibroids • /leiomyomata – benign tumours of the myometrium • Occur in at least 25% of women. • More common near menopause, Afro-Caribbean women, FH • Less common in parous women, COCP, injectable progestogens • Growth is dependent on oestrogen. • During pregnancy, fibroids equally likely to grow, shrink or stay the same. • Symptoms/complications: • Asymptomatic • Menorrhagia • Dysmenorrhoea • Pain = torsion, red degeneration (particularly in pregnancy) or rarely sarcomatous change (0.1%). • Pressure effects – frequency, retention • Fertility impaired if preventing implantation • Pregnancy: premature labour, malpresentation, transverse lie, obstructed labour and PPH. The Peer Teaching Society is not liable for false or misleading information…

  11. Fibroids • Investigations • TVUS – MRI may be required to distinguish from ovarian mass or adenomyosis. • Treatment • Medical • Tranexamicacid, NSAIDs or progestogens (often ineffective) • GnRH agonists (+HRT) • Surgical • TCRF (hysteroscopic) – pretreatment with GnRH agonists 1-2 months to shrink • Myomectomy – preservation of reproductive function when medical treatment failed. GnRH agonists 2-3 months prior to reduce vascularity. Vasopressin injected into myometrium to reduce blood loss. Can increase risk of uterine rupture during labour if cavity opened – caesarian indicated. • Radical Hysterectomy – GnRH agonists 2-3 months prior. • Other • Uterine Artery Embolisation The Peer Teaching Society is not liable for false or misleading information…

  12. Polyps Intrauterine • Small, usually benign tumours that grow into the uterine cavity. • Common in women 40-50 years. • Menorrhagia, IMB, occasionally prolapse through the cervix. • Treated by resection with cutting diathermy Cervical • Benign tumours of endocervical epithelium • Most common in women >40 • Asymptomatic or IMB or PCB The Peer Teaching Society is not liable for false or misleading information…

  13. Ovarian Cancer • Causes most gynaecological cancer deaths – common in post-menopausal women • Epithelial (90%), Germ Cell, Sex Cord tumours • Aetiology • FH – BRCA1, BRCA2 or HNPCC • Related to number of ovulations - nulliparity, early menarche, late menopause increased risk. Pregnancy and use of pill protective. • Symptoms • Silent in early stages • 75% present in stages 3-4 • Abdominal distension or pain (bloating), loss of appetite, change in bowel habit. • Urinary frequency/urgency. • Pain or vaginal bleeding • Think new onset IBS symptoms in elderly woman! The Peer Teaching Society is not liable for false or misleading information…

  14. Ovarian Cancer • Transcoelomic spread directly within the pelvis and abdomen • Risk of Malignancy Index = UxMxCA125 (ultrasound score and menopause status) • Investigations • USS • CA 125 - if >35 IU/mL, ultrasound of pelvis and abdomen • CT • Alpha fetoprotien and hCG in <40 years for germ cell tumours • Staging • 1 Ovaries only. 1a one ovary; 1b both ovaries; 1c capsule broken with malignant cells in the abdomen • 2 Pelvis only • 3 Abdomen and Pelvis • 4 Distant, including liver , lung (Meigs’ syndrome) The Peer Teaching Society is not liable for false or misleading information…

  15. Ovarian Cancer Management • Surgery • Total hysterectomy, bilateral salpingoophorectomy and partial omentectomy. • Retroperitoneal lymph nodes sampled/removed in stage 2+ • Random biopsies of peritoneum. • To preserve fertility in ‘early’ or ‘borderline’ cases , uterus and unaffected ovary preserved with meticulous follow up. • Chemotherapy • Stages 1c+ • Palliative Care • Prognosis • CA125 useful to monitor • CT scans • Death commonly from bowel obstruction or perforation • <35% 5 year survival due to late presentation. The Peer Teaching Society is not liable for false or misleading information…

  16. Endometrial Cancer • Most common gynaecological carcinoma, usually >60 years • >90% adenocarcinoma, adenosquamous carcinoma (poorer prognosis) • Aetiology • High oestrogen:progesterone ratio: nulliparity, late menopause, PCOS, obesity. Unopposed oestrogens (HRT) and tamoxifen. • COCP and pregnancy protective. • Clinical Features • PMB • Premenopausal: irregular or IMB, recent onset menorrhagia. • Cervical smear showing abnormal columnar cells: cervical glandular intraepithelial neoplasiaCGIN • Investigations • If PMB: TVUS plus, if endometrium >4mm thick or multiple episodes, biopsy by pipelle or during hysteroscopy • If premenopausal: TVUS then biopsy if abnormal or change in periods and >40. • FBC, U&E, ECG – fitness for surgery The Peer Teaching Society is not liable for false or misleading information…

  17. Endometrial Cancer • Staging • Surgical and histological • FIGO • Stage 1: Lesions confined to the uterus – A <1/2 myometrial invasion; B >1/2 • Stage 2: Cervical stromal invasion, but not beyond uterus • Stage 3: Tumour invades through the uterus (A-Cii) • Stage 4: Further Spread – A in bladder it bowel; B distant metastases • Histological grade: G1-3, G1 being a well differentiated tumour. • Management • 75% present at stage 1: hysterectomy and bilateral salpingo-oophorectomy • External beam radiotherapy: for patients following hysterectomy at ‘high risk’ of lymph node involvement. • Vaginal vault radiotherapy: stage 2, reduces local recurrence but doesn’t prolong survival. • Prognosis • 85% 5 year survival rate at stage 1. The Peer Teaching Society is not liable for false or misleading information…

  18. CIN • Cervical Intraepithelial Neoplasia: the presence of atypical cells within the squamous epithelium. • Dyskaryotic: large nuclei and frequent mitoses • CIN I: mild dysplasia. • Atypical cells found in the lower 1/3 of the epithelium • Can become CIN II/III but usually regresses on own • CIN II: moderate dysplasia • Atypical cells in the lower 2/3 of the epithelium • CIN III: severe dysplasia • Atypical cells occupy the full thickness of the epithelium. • Carcinoma in situ: similar in appearance to malignantlesion but there is no invasion. Malignancy ensues if they invade through the basement membrane. • If untreated, one third of women with CIN II/III will develop cervical cancer over next 10 years The Peer Teaching Society is not liable for false or misleading information…

  19. CIN • 90% cases in <45 years old, peak incidence 25-29 years. Aetiology: • HPV – 16, 18, 31 and 33. • Vaccination (16 and 18) reduces risk of pre-cancerous lesions. • Number of sexual contact, especially at an early age. • Oral conraceptives • Smoking • Immunocompromised more at risk of early progression to malignancy. Pathology: • Columnar epithelium undergoes metaplasia at the transformation zone to squamous epithelium. • Presence of HPV results in incorporation of vial DNA into cells – inactivate key cell tumour suppressor gene products and push cells into cell cycle. Mutations occur over time = carcinoma. • Viruses also hide cells from immune response so aren't destroyed, similar in immunosuppressed. The Peer Teaching Society is not liable for false or misleading information…

  20. CIN - Screening CIN causes no symptoms and is not visible on the cervix. Diagnosis identifies women at high risk of developing carcinoma of the cervix that could be treated before the disease develops. • Cervical Smears • All women from 25 years old, or after first intercourse if later, every 3 years until 49. • Between 50 and 65, 5 yearly. • From 65, those who have not been screened since 50 or who have had recent abnormal tests are screened. • Brush scraped around external os of cervix to pick up loose cells over transformation zone for Liquid Based Cytology. • Cellular abnormalities as only superficial cells sampled. Graded mild, moderate, severe dyskaryosis– relates to likely CIN to be found on biopsy. The Peer Teaching Society is not liable for false or misleading information…

  21. CIN - Screening Results: The Peer Teaching Society is not liable for false or misleading information…

  22. CIN - Screening Colposcopy • Acetic acid turns white on CIN • Diagnosis can only be confirmed with biopsy and histology • If CIN II or III is present: LLETZ – large loop excision of transformation zone with cutting diathermy. • Occasionally malignancy is diagnosed • ‘See and treat’ when don’t wait for histology of colposcopy more common. • S/E LLETZ – postoperative haemorrhage, uncommon. Risk of subsequent preterm delivery increased. • Significant false negative rate with cervical smears, dependent on both sampling and interpretation techniques. The Peer Teaching Society is not liable for false or misleading information…

  23. Cervical Cancer • 90% squamous cell carcinomas, 10% adenocarcinoma (worse prognosis) • Same risk factors as CIN as it is the preinvasive stage • Clinical Features: • None, found on LLETZ • PCB • Offensive vaginal discharge • IMB or PMB • Later stages: involvement of ureters, bladder, rectum and nerves, get uraemia, haematuria, rectal bleeding and pain. • On Examination: ulcer or mass may be visible or palpable on cervix. • Investigations: • Biopsy • Rectal and vaginal examination to assess size of lesion and parametrial or rectal invasion (under anaesthetic) • Cystoscopy detects bladder involvement • MRI detects tumour size, spread and LN involvement The Peer Teaching Society is not liable for false or misleading information…

  24. Cervical Cancer • Staging: • 1 Cervix: a(i) <3mm depth, <7mm across; a(ii) <5mm depth, <7mm across; b larger than 1a • 2 Upper Vagina also: a not parametrium; b in parametrium • 3 Lower vagina or pelvic wall, or ureteric obstruction • 4 Into bladder or rectum, or beyond pelvis. • Treatment The Peer Teaching Society is not liable for false or misleading information…

  25. Dysmenorrhoea Dysmenorrhoea Pain starts with menstruation Pain precedes and is relieved by menstruation Deep dyspareunia, menorrhagia, irregular menstruation No Organic Cause PRIMARY (50% women, 10% severe) NSAIDS Ovulation Suppression - COCP SECONDARY Pelvic Pathology The Peer Teaching Society is not liable for false or misleading information…

  26. Endometriosis • Growth of tissue similar to endometrium outside the uterus • Particularly found in uterosacral ligaments, pouch of douglas and on/behind the ovaries. • Endometrioma/’chocolate cysts’ due to accumulated blood • Causes inflammation with progressive fibrosis and adhesions –infertility • Theories: • Retrograde menstruation • Lymphatic or haematogenous spread • Metaplasia of coelomic cells Clinical Features: • Dysmenorrhoea • Dyspareunia • Cyclical or chronic pelvic pain • Subfertility • Less common symptoms include: • Cyclical rectal bleeding • Menorrhagia • Diarrhoea • Haematuria The Peer Teaching Society is not liable for false or misleading information…

  27. Endometriosis Investigations • Laparoscopy is the gold standard. Management • Medical: • COCP • Pain management • GnRH agonist • Mirena • Surgical: • Laparoscopic ablation/excision of cysts and adhesions • Bilateral oophorectomy, often with hysterectomy The Peer Teaching Society is not liable for false or misleading information…

  28. Adenomyosis • Presence of endometrium and its underlying stroma within the myometrium. • Associated with endometriosis and fibroids Clinical Features: • Painful, regular, heavy menstruation • Uterus mildly enlarged and tender Investigations: • MRI Management: • IUS • COCP • NSAIDs • Hysterectomy often required The Peer Teaching Society is not liable for false or misleading information…

  29. Amenorrhoea Hypothalamus GnRH Anterior Pituatry FSH & LH Ovary – Granulosa Cells Oestrogen Inhibin Ovary- Theca cells Androgens The Peer Teaching Society is not liable for false or misleading information…

  30. Amenorrhoea • Primary: failure to start menstruating by age 16 or 14 with no breast development • Causes: • PCOS • Delayed puberty • Turners Syndrome (45xo) – short stature, amenorrhoea and infertility • Gonadal Agenesis • Testicular Feminisation The Peer Teaching Society is not liable for false or misleading information…

  31. Amenorrhoea • Secondary = previously normal menstruation which ceases for >6 months, not due to pregnancy • Hypothalamic Hypogonadism (stress, anorexia), reduced secretion of GnRH subsequently  low FSH, LH and oestrogen. • Raised prolactin • Hypo or hyperthyroidism • PCOS • Premature menopause • Cervical stenosis The Peer Teaching Society is not liable for false or misleading information…

  32. Infertility • 1 in 6 couples UK • NICE definition: People who have not conceived after 1 year of regular unprotected sexual intercourse, should be offered clinical investigation: • Semen analysis • Ovulation assessment • Primary = never conceived before • Secondary = have previously conceived, but have not been able to since The Peer Teaching Society is not liable for false or misleading information…

  33. Categorising Infertility ANOVULATORY MALE INFERTILITY TUBAL UNKNOWN The Peer Teaching Society is not liable for false or misleading information…

  34. Investigating Infertility • Day 21 progesterone (>30 indicates ovulation) • Day 2 FSH & LH • Rubella Immunity • Oestrogen • Testosterone • SHBG • Prolactin • TFT • Glucose • Transvaginal US • Laparoscopy + Dye Test • Hysterosalpingogram • Vaginal US ADVISE ALL WOMEN ABOUT WEIGHT, SMOKING AND FOLIC ACID The Peer Teaching Society is not liable for false or misleading information…

  35. Anovulatory Causes of Infertility The Peer Teaching Society is not liable for false or misleading information…

  36. PCOS -Polycystic Ovarian Syndrome Rotterdam critera (2 of 3) • Oligomenorrhoea (>35 days apart) • Hirsutism • Clinical – acne/excess body hair (face) • biochemical – raised serum testosterone 3. PCO on US (transvaginal US showing multiple small follicles on an enlarged ovary) Increased levels of LH & Insulin (due to peripheral insulin resistance)  Ovarian androgen production increases, and reduced hepatic production of SHBG  increase in free androgens (testosterone)  irregular/absent ovulation O/E: obesity, acne, hirsutism, oligo/amenorrhoea subfertility, miscarriage, FH type II diabetes The Peer Teaching Society is not liable for false or misleading information…

  37. Investigations Diagnostic: • Day 2 LH (raised) • Testosterone (raised) • SHBG (reduced) • Transvaginal US Other (exclude other causes of infertility) • Day 21 progesterone (>30mmol/L = ovulating) • Day 2 FSH • Prolactin • TFT • Rubella immunity • Hba1c (may have DM II) The Peer Teaching Society is not liable for false or misleading information…

  38. Treatment 1. Weight loss (diet and exercise) + smoking cessation 2. CLOMIFENE = anti-oestrogen to induce ovulation, use upto 6 months. SE: endometrial thinning 3. Metformin (alone or with clomifene) 4. Gonadotrophins (if resistant to clomifene) 5. Laparoscopic diathermy For those not wishing to get pregnant – Co-cyprindol for hirsutism COCP to control mestrual irregularity and hirsutism Metformin The Peer Teaching Society is not liable for false or misleading information…

  39. Hypothalamic Causes Hypothalamic Hypogonadism – Reduced GNRH  reduced FSH & LH  reduced oestrogen Common causes = anorexia, athleticism, stress Aim: try and maintain a good normal weight Kallmans Syndrome – GnRH secreting neurones don’t develop Also present with anosmia Treat: Gonadotrophins/ GnRH pump The Peer Teaching Society is not liable for false or misleading information…

  40. Pituitary Causes Hyperprolactinaemia – Raised prolactin  reduced GnRH Causes: • Pituatary adenoma • Pyschotropic drugs • Hypothyroidism • Stress • Breastfeeding Oligo/amenorrhoea, Galactorrhoea, Headache + bitemporal hemianopia (if tumour) Treat: Dopamine Agonist e.g. Bromocriptine Surgical Excision (if tumour) Sheehans Syndrome- post-partum hypopituatarism, where GNRH is normal, but FSH and LH are low due to pituatry damage. The Peer Teaching Society is not liable for false or misleading information…

  41. Tubal Causes • Infection: PID  adhesions • Endometriosis • Previous Surgery/ sterilisation causing adhesions Needs surgical intervention, adhesiolysis The Peer Teaching Society is not liable for false or misleading information…

  42. Pelvic Inflammatory Disease • Causes: • CHLAMYDIA • Gonorrhoa • Miscarriage • Termination • Laparoscopy • Nulliparous • RF: • Low social class • Sexually active • Young • Investigations: • Endocervical swabs • FBC, CRP, Blood cultures • Transvaginal US • Laparoscopy • Protective Factors: • COCP • Mirena The Peer Teaching Society is not liable for false or misleading information…

  43. Pelvic Inflammatory Disease The Peer Teaching Society is not liable for false or misleading information…

  44. Male Subfertility AZOOSPERMIA = no sperm OLIGOSPERMIA = <15million SEVERE OLIGOSPERMIA = <5million ASTHENOSPERMIA = low motility TERATOSPERMIA = reduced morphology • Stop smoking • Stop drinking • Avoid tight fitting boxers The Peer Teaching Society is not liable for false or misleading information…

  45. Causes of male subfertility • Idiopathic • Alcohol/smoking • Anabolic Steroids • Infection – epidydimitis • Kleinfelters (XXY) • Kallmans • Hyperprolactinaemia • Retrograde Ejaculation (TURP, Diabetes) • Cystic Fibrosis The Peer Teaching Society is not liable for false or misleading information…

  46. Assisted Conception 1. IUI – intrauterine insemination 2. IVF 3. ICSI (if male problem – intracytoplasmic sperm injection) 4. Egg donation 5. Surrogacy Complications: multiple pregnancy, ectopicsperinatal mortality, procedural haemorrhage The Peer Teaching Society is not liable for false or misleading information…

  47. Gynaecological Infection Girl presents in the GU clinic with a new fishy smelling grey/white discharge…. The Peer Teaching Society is not liable for false or misleading information…

  48. Gynaecological Infection • BV- bacterial vaginosis • Gardnerella & MycoplasmaHominis • Grey/white discharge • Fishy smell • Clue cells • Raised PH • Treat: Metranidazole The Peer Teaching Society is not liable for false or misleading information…

  49. Gynaecological Infection 36 year old diabetic woman, just finished course of antibiotics, noticed a thick white discharge and has noticed pain during intercourse and itching down below The Peer Teaching Society is not liable for false or misleading information…

  50. Gynaecological Infection • Candidiasis (Thrush) • Candida Albicans • Cottage cheese thick white discharge • Inflamed/red vulva • Pruritis vulvae • Superficial dyspareunia • RF: abx, pregnancy, diabetes, COCP, HRT • Treat: Clotrimazole cream + pessary • Fluconazole oral tablet if reccurent The Peer Teaching Society is not liable for false or misleading information…

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