Gynaecology The Peer Teaching Society is not liable for false or misleading information…

Topics to cover Amenorrhoea Gynaecological malignancies Infertility
Menorrhagia The Peer Teaching Society is not liable for false or misleading information…

Amenorrhoea What is the definition of amenorrhoea?
What are the causes of primary amenorrhoea? What are the causes of secondary amenorrhoea? What investigations would you do? Practice questions The Peer Teaching Society is not liable for false or misleading information…

Amenorrhoea Amenorrhoea Primary amenorrhoea Secondary amenorrhoea
The Peer Teaching Society is not liable for false or misleading information…

Absence or cessation of menses Primary amenorrhoea Secondary amenorrhoea The Peer Teaching Society is not liable for false or misleading information…

Absence or cessation of menses Primary amenorrhoea Failure to establish menstruation by the age of 16 years or by 14 years of age if no secondary sexual characteristics Secondary amenorrhoea The Peer Teaching Society is not liable for false or misleading information…

Absence or cessation of menses Primary amenorrhoea Failure to establish menstruation by the age of 16 years or by 14 years of age if no secondary sexual characteristics Secondary amenorrhoea Absence of menstruation for 6 consecutive months in a woman who has previously established regular menses The Peer Teaching Society is not liable for false or misleading information…

Amenorrhoea Amenorrhoea Oligomenorrhoea Absence or cessation of menses
Menses occurring less frequently than every 35 days The Peer Teaching Society is not liable for false or misleading information…

Amenorrhoea What is the biggest cause of amenorrhoea?

Amenorrhoea What is the biggest cause of amenorrhoea? Pregnancy!

Causes of primary amenorrhoea
Non-pathological Pregnancy Constitutional delay Pathological The Peer Teaching Society is not liable for false or misleading information…

Non-pathological Pathological Secondary sexual characteristics usually present Secondary sexual characteristics usually absent Ambiguous external genitalia The Peer Teaching Society is not liable for false or misleading information…

Secondary sexual characteristics usually present Mostly: genito-urinary malformation Imperforate hymen Transverse vaginal septum Absent vaginal Absent uterus Androgen insensitivity syndrome (46 XY, female) Endocrine: thyroid, hyperprolactinaemia, Cushing’s, PCOS (rare primary) The Peer Teaching Society is not liable for false or misleading information…

Secondary sexual characteristics usually absent Ovarian failure Hypothalamic dysfunction Other The Peer Teaching Society is not liable for false or misleading information…

Secondary sexual characteristics usually absent Ovarian failure Gonadal dysgenesis Turners (46, XO) Premature ovarian failure, chemo, pelvic irradiation Hypothalamic dysfunction Other The Peer Teaching Society is not liable for false or misleading information…

Secondary sexual characteristics usually absent Ovarian failure Hypothalamic dysfunction ↓ GnRH  ↓ LH, ↓ FHS Chronic systemic illness Eating disorders Weight loss Excess exercise Stress Depression Other The Peer Teaching Society is not liable for false or misleading information…

Secondary sexual characteristics usually absent Ovarian failure Hypothalamic dysfunction Other Head injury Infection Cranial irradiation Tumours of hypothalamus and pituitary) Kallman’s syndrome: congential gonadotrophin deficiency Anosmia and other cranial anomalies The Peer Teaching Society is not liable for false or misleading information…

Ambiguous external genitalia 5 alpha-reductase deficiency Genetically male, externally female Androgen-secreting tumour Rare Extreme virilisation (deep voice, extreme hirsutism) CAH Enzyme deficiency: 21-hydroxylase  excess androgen See: excess 17α-hydroxyprogesterone The Peer Teaching Society is not liable for false or misleading information…

Causes of secondary amenorrhoea
Physiological causes Pathological and iatrogenic The Peer Teaching Society is not liable for false or misleading information…

Physiological causes Pregnancy Lactation Menopause Pathological and iatrogenic The Peer Teaching Society is not liable for false or misleading information…

Physiological causes Pathological and iatrogenic Androgen excess No androgen excess The Peer Teaching Society is not liable for false or misleading information…

Physiological causes Pathological and iatrogenic Androgen excess Tumour (ovary or adrenal gland) Rare! Extreme virilisation No androgen excess The Peer Teaching Society is not liable for false or misleading information…

Physiological causes Pathological and iatrogenic Androgen excess No androgen excess The Peer Teaching Society is not liable for false or misleading information…

Most common secondary causes with no androgen excess: PCOS Hypothlamic disfunction Premature ovarian failure Hyperprolactinaemia The Peer Teaching Society is not liable for false or misleading information…

Iatrogenic Contraception (which one takes a while to recover?) Chemo Radiotherapy Surgery (oophorectomy, hysterectomy, endometrial resection) Drugs causing hyperprolactinaemia Which ones? The Peer Teaching Society is not liable for false or misleading information…

Iatrogenic Contraception (which one takes a while to recover?) Chemo Radiotherapy Surgery (oophorectomy, hysterectomy, endometrial resection) Drugs causing hyperprolactinaemia Antipsychotics Metoclopramide Methyldopa Opiates Cocaine The Peer Teaching Society is not liable for false or misleading information…

Uterine causes Cervical stenosis Asherman’s syndrome (intrauterine adhesions) Ovarian causes Premature ovarian failure Chemo or pelvic irradiation Turner’s syndrome Hypothalamic dysfunction As before The Peer Teaching Society is not liable for false or misleading information…

Pituitary causes Prolactinoma Head injury Sheehan’s syndrome: pituitary infarction after major obstetric haemorrhage) Endocrine disorders PCOS Cushing’s syndrome Congenital adrenal hyperplasia (late onset) Thyroid disease Hypo and hyper The Peer Teaching Society is not liable for false or misleading information…

Amenorrhoea - Investigations
Beta-hCG Serum free androgen index - ↑ in PCOS FSH & LH ↑: ovarian failure (premature menopause) ↓: hypothalamic (constitutional delay, weight loss, anorexia, exercise, hypothalamic or pituitary tumour) PCOS: normal FSH and normal/ ↑ LH Prolactin ↑: stress, hypothyroid, prolactinomas, drugs TFT Testosterone ↑: androgen secreting tumour/CAH/Cushins/androgen insensitivity/moderate increase in PCOS Pelvic USS The Peer Teaching Society is not liable for false or misleading information…

Question 1 A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an 'early menopause'. How is premature ovarian failure defined? The Peer Teaching Society is not liable for false or misleading information…

Question 1 A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an 'early menopause'. How is premature ovarian failure defined? The onset of menopausal symptoms and elevated gonadotrophin levels before the age of: The Peer Teaching Society is not liable for false or misleading information…

Question 1 A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an 'early menopause'. How is premature ovarian failure defined? The onset of menopausal symptoms and elevated gonadotrophin levels before the age of: 40 Causes: idiopathic (commonest), chemo, autoimmune, radiation Symptoms: hot flushes, night sweats Infertility, secondary amenorrhoea Raised FSH, LH The Peer Teaching Society is not liable for false or misleading information…

Question 2 A 35-year-old woman presents as she has not had a period for six-months. Prior to this time she had a 28 day cycle with a five day bleed. Which one of the following investigations is least helpful initially? Thyroid function Serum gonadotrophins Serum prolactin Urinary beta-HCG Serum progesterone The Peer Teaching Society is not liable for false or misleading information…

Question 2 A 35-year-old woman presents as she has not had a period for six-months. Prior to this time she had a 28 day cycle with a five day bleed. Which one of the following investigations is least helpful initially? Thyroid function Serum gonadotrophins Serum prolactin Urinary beta-HCG Serum progesterone: doesn’t point to any particular diagnosis The Peer Teaching Society is not liable for false or misleading information…

Question 3 A 37 year old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative. What is the most likely diagnosis? The Peer Teaching Society is not liable for false or misleading information…

Question 3 What is the most likely diagnosis?
Premature ovarian failure Cessation of menses for 1 year before the age of 40 Can be preceeded by irregular menstrual cycles Symptoms: hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, irritability Strong risk factors FH, exposure to chemo/radiotherapy, autoimmune disease The Peer Teaching Society is not liable for false or misleading information…

Question 4 A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis? Mullerian agenesis Constitutional delay Turner syndrome Pregnancy Imperforate hymen The Peer Teaching Society is not liable for false or misleading information…

Question 4 A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis? Imperforate hymen Cyclical pain but no evidence of menstruation The Peer Teaching Society is not liable for false or misleading information…

Gynaecological malignancies

Endometrial Ca Type: Adenocarcinoma
Symptoms: Suspect in any postmenopausal woman with PV bleeding RF: Unopposed oestrogen (HRT non combined), obesity Treatment: Hysterectomy +/- chemo/radiothereapy The Peer Teaching Society is not liable for false or misleading information…

Cervical Ca Commonest cancer in young women, although it is rare Type:
Symptoms: IMB, PCB, dyspareunia often advanced if symptomatic Most picked up early on screening program RF: HPV (16,18,33), early sexual debut, >4 sexual partners The Peer Teaching Society is not liable for false or misleading information…

Cervical Ca - Screening
Age , every 3 years every 5 years Not good at detecting cervical adenocarcinomas Prevents deaths per year The Peer Teaching Society is not liable for false or misleading information…

Cervical Ca The Peer Teaching Society is not liable for false or misleading information…

Cervical Ca- Staging and treatment
0- Carcinoma in situ- Cryotherapy, LLETZ 1a and 1b- cancer at opening of womb 1a may have cone biopsy For 1b – radical trachelectomy if want to maintain fertility, hysterectomy if not 2- top of vagina 3- surrounding structures 4 spread outside of vagina and womb Chemo and radiotherapy in any stage above 1b The Peer Teaching Society is not liable for false or misleading information…

Cervical Ca The Peer Teaching Society is not liable for false or misleading information…

Vaginal cancer Risk factors: in-utero exposure to Diethylstilbestrol (clear cell), HPV Symptoms: bleeding, mass, pain on sex, pain in pelvis, dysuria Surgery is mainstay of treatment The Peer Teaching Society is not liable for false or misleading information…

Ovarian cancer 90% epithelial, others include germ cell tumours (younger age group) Risks: BRCA genes Many ovulations: early menarche, late menopause, nulliparious OCP and multiple pregnancy is protective Symptoms: notoriously vague, bloating, change in bowel habit, bleeding, early satiety, abdo pain Tests: Ca125, uss, CT scan Treat: platinum based chemo, oophorectomy, bevacizumab The Peer Teaching Society is not liable for false or misleading information…

Benign ovarian cysts… Physiological cysts (functional cysts)
Follicular cysts- commonest type of ovarian cyst due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle commonly regress after several menstrual cycles Corpus luteum cyst Usually corpus luteum breaks down if not pregnant, can fill with blood and persist as a cyst Benign germ cell tumours Dermoid cyst ( mature cystic teratomas) – all germ layers therefore contain hair and teeth etc Most common benign ovarian tumor in woman under the age of 30 years Fibroma – Meigs syndrome (ascites, pleural effusion Benign epithelial tumours Serous cystadenoma Most common benign epithelial tumour Bilateral in around 20% Mucinous cystadenoma They are typically large and may become massive pseudomyxoma peritonei The Peer Teaching Society is not liable for false or misleading information…

Infertility What is infertility? What are some causes of infertility?
How do you investigate infertility? PCOS – a quick tour The Peer Teaching Society is not liable for false or misleading information…

Infertility Definition: unable to conceive after 12 months of regular, unprotected sexual intercourse Types The Peer Teaching Society is not liable for false or misleading information…

Infertility Definition: unable to conceive after 12 months of regular, unprotected sexual intercourse Types Primary: never previously conceived Secondary: previously conceived The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes 25% no cause found 25% ovulation disorder
20% tubal damage 30% male factor 10% uterine or peritoneal disorders Other: coital problems, gamete/embryo defects, endometriosis The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes Ovulation disorders

Infertility – causes Ovulation disorders Premature ovarian failure
PCOS Hypothalamic-pituitary causes Pituitary adenoma, hypothalamic causes, Sheehan’s syndrome, Kallmann’s syndrome Thyroid Adrenal abnormalities Cushings, CAH Chronic debilitating disease The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes Tubal, uterine, and cervical factors

Infertility – causes Tubal, uterine, and cervical factors
Previous pelvic surgery Previous cervical surgery Submucosal fibroids Endometriosis Previous sterilization The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes Other
Drugs: spironolactone, chemotherapy and cytotoxic, neuroleptic, recreational drugs Occupation and environment: pesticides, solvents Stress: effect on libido/intercourse The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes Male factors
44% no cause found other than reduced sperm count, reduced motility, and abnormal shape (with no explanation) Primary spermatic failure Testicular causes (chemo, maldescent, absence of testes) Chromosome abnormalities (Klinefelters – 47, XXY) Varicoceles The Peer Teaching Society is not liable for false or misleading information…

Infertility – causes Male factors Obstructive azoospermia Hypogonadism
Epididymal obstruction (infection/surgery) Vas deferens obstruction, ejaculatory duct obstruction Hypogonadism Deficient androgen secretion Kallmann’s, hyperprolactinaemia from pituitary adenoma Anabolic steroids Drugs Sulfasalazine, chemo, androgens/anabolic steroids Other Stress, ejaculation disorders, erectile dysfunction The Peer Teaching Society is not liable for false or misleading information…

Infertility - investigations
First: talk about stress, sex, smoking, weight Then Mid-luteal phase progesterone (when?) The Peer Teaching Society is not liable for false or misleading information…

First: talk about stress, sex, smoking, weight Then Mid-luteal phase progesterone (7 days before expected period; day 21 in a 28 day cycle) FSH, LH Thyroid function Prolactin Screen for chlamydia! The Peer Teaching Society is not liable for false or misleading information…

First: talk about stress, sex, smoking, weight Then Male Semen analysis Chlamydia screening The Peer Teaching Society is not liable for false or misleading information…

First: talk about stress, sex, smoking, weight NICE: Do not recommend Basal body temp charts Use of ovulation predictor kids The Peer Teaching Society is not liable for false or misleading information…

Couple decides to do assisted conception. What problem might the GP see after assisted conception (eg clomifene and gonadotrophin ovulation induction)? The Peer Teaching Society is not liable for false or misleading information…

Couple decides to do assisted conception. What problem might the GP see after assisted conception (eg clomifene and gonadotrophin ovulation induction)? Ovarian hyperstimulation syndrome Ectopic pregnancy Pelvic infection (from egg extraction) Multiple pregnancy The Peer Teaching Society is not liable for false or misleading information…

Ovarian hyperstimulation syndrome (OHSS) Iatrogenic, potentially life threatening Hyperstimulated ovaries produce vasoactive products – can  thrombosis, renal/liver dysfunction, resp distress syndrome Risk factors: young, lean physique, PCOS Symptoms and signs Mild: abdominal bloating and mild pain Moderate: n&v, increased pain Severe: oliguria, generalised oedema, abdominal pain Critical: oligo/anuria, tense ascites or large hydrothorax, thromboembolism, acute resp distress syndrome The Peer Teaching Society is not liable for false or misleading information…

PCOS Definition PCO PCOS

PCOS Definition PCO: 12+ small follicles (2-9mm) within at least one ovary, or enlarged ovarian volume (>10mL) seen on transvaginal USS PCOS: 2/3 of PCO on USS Oligomenorrhoea Hirsutism Clinical: acne, excess hair And/or Biochemical: increased serum testosterone The Peer Teaching Society is not liable for false or misleading information…

PCOS Complications The Peer Teaching Society is not liable for false or misleading information…

PCOS Complications Impaired glucose tolerance and type 2 DM
Infertility due to anovulation The Peer Teaching Society is not liable for false or misleading information…

PCOS Complications Findings on investigation
Impaired glucose tolerance and type 2 DM Infertility due to anovulation Findings on investigation The Peer Teaching Society is not liable for false or misleading information…

PCOS Complications Findings on investigation
Impaired glucose tolerance and type 2 DM Infertility due to anovulation Findings on investigation Total testosterone: normal to mod ↑ Sex hormone-binding globulin: normal to mod ↓ Free androgen index: normal or ↑ The Peer Teaching Society is not liable for false or misleading information…

PCOS Management The Peer Teaching Society is not liable for false or misleading information…

PCOS Management Advice on weight loss
Regulate menstruation and treat hirsutism: COCP Clomifene: first line ovulatory drug 6 months, at start of cycle Anti-oestrogen (prompting release of FSH and LH) Watch out for OHSS! Metformin Gonadotophin Give FSH/LH daily subcut  follicular growth The Peer Teaching Society is not liable for false or misleading information…

Question 1 A couple in their 20s come into their GP after failing to conceive despite having regular sexual intercourse for 6 months, and ask you for advice. What is the most appropriate course of action for you to take? The Peer Teaching Society is not liable for false or misleading information…

Question 1 A couple in their 20s come into their GP after failing to conceive despite having regular sexual intercourse for 6 months, and ask you for advice. What is the most appropriate course of action for you to take? Wait until they have been having regular intercourse for 12 months The Peer Teaching Society is not liable for false or misleading information…

Question 2 A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant. She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill. Despite stopping the pill 6 months ago she is still not having regular periods. Her body mass index is 28 kg/m^2. Apart from advising her to lose weight, which one of the following interventions is most effective in increasing her chances of conceiving? The Peer Teaching Society is not liable for false or misleading information…

Question 2 A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant. She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill. Despite stopping the pill 6 months ago she is still not having regular periods. Her body mass index is 28 kg/m^2. Apart from advising her to lose weight, which one of the following interventions is most effective in increasing her chances of conceiving? Clomifene The Peer Teaching Society is not liable for false or misleading information…

Question 3 During a subfertility clinic you are asked to take a menstrual cycle history from a 30-year-old in order to establish on what day her mid-luteal progesterone level needs to be done. You clarify that the woman has a regular 35 day cycle. On which day would you carry out mid-luteal progesterone level? The Peer Teaching Society is not liable for false or misleading information…

Question 3 During a subfertility clinic you are asked to take a menstrual cycle history from a 30-year-old in order to establish on what day her mid-luteal progesterone level needs to be done. You clarify that the woman has a regular 35 day cycle. On which day would you carry out mid-luteal progesterone level? Day 28 The Peer Teaching Society is not liable for false or misleading information…

Question 4 A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely spaced nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear? The Peer Teaching Society is not liable for false or misleading information…

Question 4 A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely spaced nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear? Systolic, loudest over aortic valve The Peer Teaching Society is not liable for false or misleading information…

Question 4 A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely spaced nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear? Systolic, loudest over the aortic valve Turners: bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation The Peer Teaching Society is not liable for false or misleading information…

Menorrhagia Causes: Structural: fibroids, bicornate uterus/ uterine abnormality, endometriosis, adenomyosis Endocrine: Thyroid, adrenal Age: Beginning or end of reproductive life Iatrogenic: Copper coil (IUD), anticoagulants Coagulopathy: clotting disorder e.g. haemophilia, VW Malignancy: endometrial carcinoma Infective: PID The Peer Teaching Society is not liable for false or misleading information…

Menorrhagia- Treat 1st line is …. MIRENA COIL (AKA the answer to every gynecological problem) 2nd line: tranexamic acid, mefanamic acid, other NSAIDS, COC 3rd line: prostaglandins, GnRH analogue, - Surgical options: endometrial ablation, embolisation, hysterectomy Obviously treat the cause if systemic The Peer Teaching Society is not liable for false or misleading information…

Endometriosis Multiple theories about how it happens: retrograde flow, endometrial tissue in circulation Diagnosis: laparoscopy Treat: NSAIDs, COC, progestogens e.g. medroxyprogesterone acetate GnRH analogues IUS MIRENA Only ablation has improved fertility The Peer Teaching Society is not liable for false or misleading information…

Fibroids Benign smooth muscle tumours
More common in African Caribbean women (50%) Symptoms: pain, heavy periods, palpable mass, infertility - Severe pain if red degeneration (happens in pregnancy) Treatment: Guess who… Mirena! Tranexamic acid, coc etc GnRH short term shrinkage prior to surgery Surgery: myomectomy, ablation, hysterectomy, embolisation The Peer Teaching Society is not liable for false or misleading information…

Gynaecology The Peer Teaching Society is not liable for false or misleading information…

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Gynaecology The Peer Teaching Society is not liable for false or misleading information…

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Presentation on theme: "Gynaecology The Peer Teaching Society is not liable for false or misleading information…"— Presentation transcript:

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