GYNAECOLOGY Part 2

Dr Nina Cooper ST1 Obstetrics & Gynaecology Queen Charlotte’s & Chelsea Hospital North West Thames Deanery E: ninacooper@doctors.org.uk

Structure for Today:

There is MORE INFORMATION on the slides than I can explain in 45 minutes, so I will share the slides with the committee.

Session 1 •  Gynaecological cancers •  Urogynaecology 10 minute break Session 2 •  Benign gynaecology •  Reproductive medicine, subfertility and menopause care

To be covered at a later date: early pregnancy, acute gynaecology and gynaecological emergencies

DISCLAIMER

All questions have been written by myself and should not be copied, distributed or shared without prior permission. Every effort has been made for answers to be in line with national guidance, however you should follow guidance from your local medical school if any answer

conflicts with your teaching.

BENIGN GYNAECOLOGY Session 3:

Question 1

A 16 year old presents to her GP with absence of periods. She reports cylical lower abdominal pain however no bleeding. She has normal secondary sexual characteristics and normal growth. What is the most likely diagnosis? 1.  Imperforate hymen 2.  Asherman’s syndrome 3.  Turner’s syndrome 4.  Bicornuate uterus 5.  Kallmann’s syndrome

Question 2

A 33 year old woman is referred to gynaecology outpatients with heavy menstrual periods. A bimanual examination reveals a mobile uterus at 20 week size. A diagnosis of fibroids is suspected. She is keen to fall pregnant so would like to avoid treatment for now. Which of the following statements is false regarding fibroids in pregnancy? 1.  Women who have had breach of the cavity at myomectomy will require

a caesarean section 2.  Large fibroids in the upper uterine segment may cause obstructed

labour 3.  Women with submucosal fibroids are at higher risk of major obstetric

haemorrhage 4.  Fibroid degeneration may occur during pregnancy 5.  Most women with fibroids will have an uncomplicated pregnancy

QUESTION 3

A 25 year old girl is referred from her GP to gynaecology outpatients with severe dysmenorrhoea. She has tried mefenamic acid. Bimanual reveals a fixed, immobile 10-week sized uterus. A pelvic ultrasound demonstrates a globular uterus. What is the most likely diagnosis? 1.  Endometriosis 2.  Complex atypical hyperplasia 3.  Endometriosis with adenomyosis 4.  Endometrial cancer 5.  Adenomyosis

QUESTION 4

A 38 year old woman presents with mood disturbance during the week prior to her period. She reports increased tearfulness and irritability. Which of the following is not a treatment for premenstrual syndrome? 1.  Evening primrose oil 2.  Combined oral contraceptive pill 3.  SSRI 4.  CBT 5.  Hysterectomy and bilateral salpingo-oophorectomy

Question 1

A 16 year old presents to her GP with absence of periods. She reports cylical lower abdominal pain however no bleeding. She has normal secondary sexual characteristics and normal growth. What is the most likely diagnosis? 1.  Imperforate hymen 2.  Asherman’s syndrome 3.  Turner’s syndrome 4.  Bicornuate uterus 5.  Kallmann’s syndrome

DISORDERS OF REPRODUCTIVE DEVELOPMENT

Primary Amenorrhoea - when to suspect •  Girls who have not established menstruation by the age of 13 years

and have no secondary sexual characteristics (such as breast development).

•  Girls who have not established menstruation by the age of 15 years and have normal secondary sexual characteristics.

HPG Axis

HPG Axis

Question 2

A 33 year old woman is referred to gynaecology outpatients with heavy menstrual periods. A bimanual examination reveals a mobile uterus at 20 week size. A diagnosis of fibroids is suspected. She is keen to fall pregnant so would like to avoid treatment for now. Which of the following statements is false regarding fibroids in pregnancy? 1.  Women who have had breach of the cavity at myomectomy will require

a caesarean section 2.  Large fibroids in the upper uterine segment may cause obstructed

labour 3.  Women with submucosal fibroids are at higher risk of major obstetric

haemorrhage 4.  Fibroid degeneration may occur during pregnancy 5.  Most women with fibroids will have an uncomplicated pregnancy

FIBROIDS

•  In pregnancy – associated wth preterm labour, malpresentation, transverse lie, obstructive labour and PPH

•  Menorrhagia and dysmenorrhoea symptoms more related to site rather than size

•  Submucosal can lead to menorrhagia or IMB

•  Can impair fertility due to distortion of uterine cavity, prevention of implantation or obstruction of the tubal ostia

MANAGEMENT OF FIBROIDS

None if asymptomatic Medical: •  TXA, NSAIDs, progestogens (give norethisterone for 5/7 usually) •  GnRH can be used to shrink prior to surgery but only for 6/12 as reduce BMD Surgical

•  Hysteroscopy: if small submucosal or polypoid •  Myomectomy: open or laparoscopic - if wishing to preserve fertility. Any uterine

incision can increase risk of uterine rupture during labour therefore should book for elective caesarean

•  Hysterectomy IR: uterine artery embolisation – can be considered in those wishing future pregnancy •  Potential risk of reduced placental blood supply or uterine rupture due to relative

myometrial ischaemia

QUESTION 3

A 25 year old girl is referred from her GP to gynaecology outpatients with severe dysmenorrhoea. She has tried mefenamic acid. Bimanual reveals a fixed, immobile 10-week sized uterus. A pelvic ultrasound demonstrates a globular uterus. What is the most likely diagnosis? 1.  Endometriosis 2.  Complex atypical hyperplasia 3.  Endometriosis with adenomyosis 4.  Endometrial cancer 5.  Adenomyosis

ENDOMETRIOSIS

Presence of endometrial tissue outside of the uterus Symptoms: chronic pelvic pain, dysmenorrhea affecting quality of life, deep dyspareunia, cyclical GI symptoms, period-related urinary symptoms, infertility Ix: pelvic USS (ideally TV), consider MRI if suspicion of bladder/bowel

involvement, diagnostic laparoscopy + staging

ENDOMETRIOSIS

ADENOMYOSIS

PHARMACOLOGICAL MANAGEMENT OF ENDOMETRIOSIS

https://www.nice.org.uk/guidance/ng73/resources

SURGICAL MANAGEMENT OF ENDOMETRIOSIS

•  Laparoscopy +/- excision of endometrial deposits/endometriomas +/- adhesiolysis

•  Hysterectomy

•  https://www.nice.org.uk/guidance/ng73/resources/algorithm-for-diagnosing-and-managing-endometriosis-pdf-4595719645

QUESTION 4

A 38 year old woman presents with mood disturbance during the week prior to her period. She reports increased tearfulness and irritability. Which of the following is not a treatment for premenstrual syndrome? 1.  Evening primrose oil 2.  Combined oral contraceptive pill 3.  SSRI 4.  CBT 5.  Hysterectomy and bilateral salpingo-oophorectomy

PMS

•  Mood disturbance associated with luteal phase of menstrual cycle

Symptoms •  mood swings •  feeling upset, anxious or

irritable •  tiredness or trouble sleeping •  bloating or tummy pain •  breast tenderness •  headaches •  spotty skin or greasy hair •  changes in appetite and sex

drive

PMS

REPRODUCTIVE MEDICINE, SUBFERTILITY AND THE MENOPAUSE

Session 4:

QUESTION 1

A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1.  Polycystic ovaries 2.  Physiological puberty 3.  Polycystic ovarian syndrome 4.  Virilising tumour 5.  Pituitary adenoma

QUESTION 2

A 32 year old woman has been trying to conceive for 14 months. Bloods and imaging are normal. She has a history of chlamydia which was treated at the age of 24. What is the most likely cause of her subfertility? 1.  Premature ovarian insufficiency 2.  Tubal scarring 3.  Congenital uterine structural anomaly 4.  PCOS 5.  Idiopathic

QUESTION 3

A 52 year old woman presents with a 1 year history of amenorrhoea, hot flushes and mood swings. What is the most likely pattern you would see on her bloods? 1.  Low FSH, high oestradiol 2.  High FSH, low oestradiol 3.  Low FSH, low oestradiol 4.  High FSH, high oestradiol 5.  Normal FSH, normal oestradiol

QUESTION 4

A 40 year old woman presents with a 2 year history of amenorrhoea. She complains of dyspareunia and hot flushes. What is the most likely diagnosis? 1.  Menopause 2.  Premature ovarian insufficiency 3.  Turner’s syndrome 4.  Hypothalamic hypogonadism 5.  Pituitary hypogonadism

QUESTION 1

A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1.  Polycystic ovaries 2.  Physiological puberty 3.  Polycystic ovarian syndrome 4.  Virilising tumour 5.  Pituitary adenoma

QUESTION 1

A 17 year old girl presents with acne, irregular menses and hirsutism. A pelvic ultrasound demonstrates a string of pearls sign on both ovaries. What is the most likely diagnosis? 1.  Polycystic ovaries 2.  Physiological puberty 3.  Polycystic ovarian syndrome 4.  Virilising tumour 5.  Pituitary adenoma

PCOS

Rotterdam criteria: •  Oligo/anovulation (> 2 years) •  Clinical or biochemical features of hyperandrogenism •  Polycystic ovaries on ultrasound (> 12 in one ovary measuring 2-9 mm

in diameter)

Hyperoestrogenic state à conversion to androgens Associated with insulin resistance

PCOS: Management

Conservative: weight loss Medical: •  Dianette COCP (androgenic symptoms) – contains cyproterone acetate

(anti-androgenic) •  Metformin

Can manage symptoms e.g. laser therapy for excessive hair If desiring pregnancy: •  Weight loss •  Clomiphene (SERM) +- metformin

•  Induce ovulation if subfertility is an issue; used for up to 6 month •  Laparoscopic ovarian drilling

QUESTION 2

A 32 year old woman has been trying to conceive for 14 months. Bloods and imaging are normal. She has a history of chlamydia which was treated at the age of 24. What is the most likely cause of her subfertility? 1.  Premature ovarian insufficiency 2.  Tubal scarring 3.  Congenital uterine structural anomaly 4.  PCOS 5.  Idiopathic

INVESTIGATING SUBFERTILITY

•  Blood hormones: day 2-3 FSH, LH and oestradiol. AMH demonstrates ovarian reserve

•  STI screening •  TVUS and antral follicle count •  Tubal assessment (HYSTEROSALPINGOGRAM or LAP+DYE) •  Semen analysis

TREATING SUBFERTILITY

Ultimately depends on cause

Cause Treatment Anovulation Ovulation induction (clomiphene)

Laparoscopic ovarian drilling Male factor IUI if mild

Donor insemination Tubal Failed IUI/ovulation induction

IVF ICSI

Lack off oocytes e.g. POI/Turner’s syndrome

Donor egg

Anatomical abnormality Surgical management e.g. adhesiolysis, myomectomy

QUESTION 3

A 52 year old woman presents with a 1 year history of amenorrhoea, hot flushes and mood swings. What is the most likely pattern you would see on her bloods? 1.  Low FSH, high oestradiol 2.  High FSH, low oestradiol 3.  Low FSH, low oestradiol 4.  High FSH, high oestradiol 5.  Normal FSH, normal oestradiol

QUESTION 4

A 40 year old woman presents with a 2 year history of amenorrhoea. She complains of dyspareunia and hot flushes. What is the most likely diagnosis? 1.  Menopause 2.  Premature ovarian insufficiency 3.  Turner’s syndrome 4.  Hypothalamic hypogonadism 5.  Pituitary hypogonadism

MENOPAUSE

Menopause: retrospective diagnosis, absence of menses for 12 months Premature ovarian insufficiency: before 42 years of age – can be idiopathic or

iatrogenic e.g. chemotherapy, BSO •  All women with POI require oestrogen replacement •  Cannot give oestrogen without progesterone if a woman has a uterus in situ •  Unopposed oestrogen à endometrial hyperplasia à cancer

HRT can be given orally/transdermally/locally Atrophic vaginitis: vagifem topical oestrogen Cyclical or continuous HRT •  Oestrogen: patch/pill/gel •  Progesterone: mirena IUS, pill •  Tend to give continuous to women who are definitely post-menopausal otherwise

can cause erratic bleeding in perimenopausal women

ANY QUESTIONS? END OF SESSION 2

https://forms.gle/wuJLUEUYLEMS8CD66