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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 Amenorrhoea (primary and secondary) PCOS STIs and pelvic inflammatory disease Contraception The Peer Teaching Society is not liable for false or misleading information

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 Menstrual Cycle The Peer Teaching Society is not liable for false or misleading information 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 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 Menorrhagia Clinical definition: excessive menstrual blood loss that interferes with the womans 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

Fibroids (30%) Polyp (10%) Rare: Thyroid disease, haemostatic disorders (VWB), anti-coagulant therapy Irregular Cycle Idiopathic Chronic Pelvic Infection Ovarian tumours Cervical and Endometrial malignancy The Peer Teaching Society is not liable for false or misleading information Menorrhagia - investigations Check haemoglobin to assess effect of blood loss

Transvaginal Ultrasound 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 Menorrhagia - management When possible pathologies have been ruled out: 1st Line: IUS 2nd Line: i. Antifibrinolytics (tranexamic acid) can reduce blood loss by 50% with few S/E.

ii. NSAIDs (mefanamic acid) inhibits prostaglandin synthesis, can reduce blood loss by 30%. iii. COCP 3rd Line: iv. Progestogens cause amenorrhoea v. 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 Fibroids /leiomyomata benign tumours of the myometrium Symptoms/complications:

Occur in at least 25% of women. More common near menopause, AfroCaribbean 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. 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 Fibroids Investigations TVUS MRI may be required to distinguish from ovarian mass or adenomyosis. Treatment Medical Tranexamic acid, 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 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

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 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 Ovarian Cancer Management Surgery

Chemotherapy 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. 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 Endometrial Cancer Most common gynaecological carcinoma, usually >60 years >90% adenocarcinoma, adenosquamous carcinoma (poorer prognosis) Aetiology

Clinical Features High oestrogen:progesterone ratio: nulliparity, late menopause, PCOS, obesity. Unopposed oestrogens (HRT) and tamoxifen. COCP and pregnancy protective. PMB Premenopausal: irregular or IMB, recent onset menorrhagia. Cervical smear showing abnormal columnar cells: cervical glandular intraepithelial neoplasia CGIN 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 Endometrial Cancer Staging Surgical and histological FIGO

Histological grade: G1-3, G1 being a well differentiated tumour. Management 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

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 doesnt prolong survival. Prognosis 85% 5 year survival rate at stage 1. The Peer Teaching Society is not liable for false or misleading information CIN Cervical Intraepithelial Neoplasia: the presence of atypical cells within the squamous epithelium.

Dyskaryotic: large nuclei and frequent mitoses CIN I: mild dysplasia. CIN II: moderate dysplasia Atypical cells in the lower 2/3 of the epithelium CIN III: severe dysplasia

Atypical cells found in the lower 1/3 of the epithelium Can become CIN II/III but usually regresses on own Atypical cells occupy the full thickness of the epithelium. Carcinoma in situ: similar in appearance to malignant lesion 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 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 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 CIN - Screening Results: Mild Test sample for HPV If high risk strain +ve, colposcopy arranged If negative, returned to routine programme Colposcopy

Moderate Urgent colposcopy Severe CGIN Colposcopy If abnormality not found, hysteroscopy The Peer Teaching Society is not liable for false or misleading information 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 dont 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 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 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 1a(i) Cone biopsy Simple hysterectomy Laparoscopic lymphadenectomy and radical trachelectomy to preserve fertility 1a(ii)-1b(i) 1a(ii)-2a LNs negative: Wertheims hysterectomy (pelvic node clearance and removal of parametrium and upper 1/3 vagina too) or chemo-radiotherapy if older/medically unfit. LNs positive: Chemo-radiotherapy without surgery Chemo-radiotherapy wihtout surgery 2b-4

The Peer Teaching Society is not liable for false or misleading information Dysmenorrhoea Dysmenorrhoea Pain starts with menstruation No Organic Cause Pain precedes and is relieved by menstruation Deep dyspareunia, menorrhagia, irregular menstruation PRIMARY (50% women, 10% severe) SECONDARY

NSAIDS Ovulation Suppression - COCP Pelvic Pathology The Peer Teaching Society is not liable for false or misleading information 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 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 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 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 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 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 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 Categorising Infertility ANOVULATORY MALE INFERTILITY TUBAL The Peer Teaching Society is not liable for false or misleading information UNKNOWN Investigating Infertility

Day 21 progesterone (>30 indicates ovulation) Day 2 FSH & LH Rubella Immunity Oestrogen ADVISE ALL WOMEN Testosterone ABOUT WEIGHT, SMOKING SHBG AND FOLIC ACID Prolactin

TFT Glucose Transvaginal US Laparoscopy + Dye Test Hysterosalpingogram Vaginal US The Peer Teaching Society is not liable for false or misleading information Anovulatory Causes of Infertility OVARIAN PCOS Premature Ovarian failure Gonadal Dysgenesis HYPOTHALAMIC Hypothalamic hypogonadism Kallmans Syndrome PITUATRY

- Sheehans Syndrome - Hyperprolactinaemia OTHER Hypothyroidism Hyperthyroidism Diabetes Smoking Turners (45XO) The Peer Teaching Society is not liable for false or misleading information PCOS -Polycystic Ovarian Syndrome Rotterdam critera (2 of 3) 1. Oligomenorrhoea (>35 days apart) 2. 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 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 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 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 dont develop Also present with anosmia Treat: Gonadotrophins/ GnRH pump The Peer Teaching Society is not liable for false or misleading information 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 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 Pelvic Inflammatory Disease Nulliparous RF: Low social class Sexually active Young

Investigations: Endocervical swabs FBC, CRP, Blood cultures Transvaginal US Laparoscopy Causes: CHLAMYDIA Gonorrhoa Miscarriage Termination Laparoscopy Protective Factors: COCP Mirena The Peer Teaching Society is not liable for false or misleading information Pelvic Inflammatory Disease

ACUTE Severe Bilateral lower abdo pain Abnormal bleeding discharge Tachycardia. Pyrexia Cervical Excitation Bilateral Adnexal Tenderness Unwell patient Treat: ABC, analgesia IM Ceftriaxone + Doxycycline + Metranidazole (IV or PO depending on severity) Comp: chronic pid,abcess CHRONIC Chronic lower abdo pain Dysmenorrhoea Deep dyspareunia Menorrhagia

Chronic discharge Subfertility Investigate with Transvaginal Us/ Laparoscopy adhesions, tube obstruction, hydrosalpinx Treat: analgesia, abx, adhesiolysis, salpingectomy? The Peer Teaching Society is not liable for false or misleading information Male Subfertility SPERM ANALYSIS VOLUME >1.5 ML SPERM COUNT >15 MILLION/ML

PROGRESSIVE MOTILITY >32% MORPHOLOGY >4% PH ALKALINE >7 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 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 Assisted Conception 1. IUI intrauterine insemination 2. IVF 3. ICSI (if male problem intracytoplasmic sperm

injection) 4. Egg donation 5. Surrogacy Complications: multiple pregnancy, ectopics perinatal mortality, procedural haemorrhage The Peer Teaching Society is not liable for false or misleading information 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 Gynaecological Infection BV- bacterial vaginosis - Gardnerella & Mycoplasma Hominis - Grey/white discharge - Fishy smell - Clue cells - Raised PH

- Treat: Metranidazole The Peer Teaching Society is not liable for false or misleading information 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 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 Gynaecological Infection 19 year old girl presents in clinic, following a drunken one night stand a couple of weeks before, she has noticed some burning when weeing, and abnormal discharge since The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Chlamydia - Chlamydia Trachomatis - More often asymptomatic than not - Discharge - Urethritis - Dyspareunia - Complications: PID, reiters, subfertilty

- Treat: single dose Azithromycin 1g The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection 28 year old man who has recently split from his partner and has been making the most of his situation presents in clinic with sore red ulcers in his groin and around his penis, he notices a burning pain when weeing, and feels generally unwell The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Genital Herpes - Herpes Simplex Virus 2 - Multiple painful vesicles/ulcers - Dysuria - Fever -Vesicles must be present for tranmission

- Lie dormant in CNS, and can reactivate, usually related to stress/infection - Treat: Aciclovir The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Woman presents in clinic with a frothy offensive green discharge, and pain on intercourse The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Trichomonas Vaginalis - Flagella Protozoa - smelly, frothy, green discharge - Irritation - Strawberry cervix - Superficial dyspareunia - Polymorphonuclear leucocytes on wet film

microscopy - Treat: Metranidazole The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Young man presents in clinic with some discharge from his penis and burning sensation when weeing, swabs reveal a gram negative diplococcus The Peer Teaching Society is not liable for false or misleading information Gynaecological Infection Gonorrhoea - Neisseria Gonorrhoea - Gram negative diplococcus - Asymptomatic or - Discharge and urethritis - Treat: IM ceftriaxone 250mg or oral cefixime 400mg

The Peer Teaching Society is not liable for false or misleading information REMEMBER Look over breast disease in the handbook provided on Minerva! The Peer Teaching Society is not liable for false or misleading information

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