1. Holly Tucker & Jessica Gray
Gynae Overview
Holly Tucker & Jessica Gray
The Peer Teaching Society is not liable for false or misleading information…

2. Contents Endometriosis PCOS Dysmenorrhoea Menorrhagia Amenorrhoea
Benign ovarian tumours
PID
Prolapse
Gynae oncology
Sporadic GUM
The Peer Teaching Society is not liable for false or misleading information…

3. Presentation: (think in 3s)
Endometriosis
‘When endometrial tissue grows outside the uterine cavity’
Presentation: (think in 3s)
1. CYCLICAL pain (hormone driven): Triple dysmenorrhoea – before, during, after menstruation.
2. Deep dyspareunia
3. Subfertility
O/E  adnexal tenderness, palpable nodule in posterior fornix (not always)
*Stress is often an exacerbating factor

4. Endometriosis (2) Investigations: Management:
Gold standard – diagnostic laparoscopy
(When endometrial tissue is seen on an ovary described as a ‘chocolate cyst’)
Management:
Aim – to suppress ovulation in order to stop growth of endometrial tissue will also cause already present endometrial tissue to atrophy
OCP – back to back no breaks
 Mirena or depot
2. Surgical  Ablation & fulguration or excision.
*remember to take into account fertility wishes – pregnancy improves Sx; no ovulation

5. SPOT DIAGNOSIS? Primary Syphilis – chancre, painless!
Ix – swab, HIV test, Treponemal enzyme immuneassay (EIA)
Causative organism – Treponem Pallidum
Tx: Benzathine penicillin IM
SPOT DIAGNOSIS?

6. PCOS
‘Polyfollicular’ – each month the follicle is expelled onto surface of ovary and turns into cyst
Pathophysiology – Ovaries are over stimulated (GnRH – LH) and produce excess amounts of testosterone which causes an increase in insulin levels and dyslipidameia.
Presentation: Classic triad:
+/- acne, subfertility,
male pattern balding,
acanthosis nigricans,
psychological distress.
Investigations:
Rotterdam criteria for diagnosis (need all 3)
USS  > 12 peripheral follicles or volume > 10cm3
Oligo or anovulation
Clinical or biochemical signs of hyperandrogenism
Test – Testosterone levels, TFT, Prolactin, Glucose, lipid levels
Anovulation
Obesity
Hirsutism

7. PCOS (2) Management: Metformin if BMI >25
Fertility – If BMI > 25 Clomiphene
BMI < 25 Ovarian drilling
3. Sx control – OCP
4. Hirsutism – Cyproterone (anti-androgen)+/- cosmetic tx
Treat any related HTN, DM, lipids as normal
Risk A/W PCOS:
> DM (do a GTT), CHD (tx lipids and obesity), HTN, Ovarian and endometrial Ca)

8. Primary Dysmenorrhea Pain with OUT organ pathology
Though to be due to an imbalance of Leukotrienes < Prostaglandins. ^ Uterine contractions = Pain.
RF: Smoking, obesity, early menarche, alcohol
Presentation:
Lower anterior pelvic pain a/w menstruation.
+/- nausea, diarrhoea, headache
Management:
Lifestyle advice +/- NSAIDs, Mefenamic acid,
2nd line; OCP
Secondary= fibroids, adenomyosis, endometriosis, PID, ov.tumours etc

9. Chlamydia Trachomatis  vulvovaginal swab (male urine) NAAT testing,
Normalise testing in at risk groups – always offer don’t wait for them to ask
Stat dose 1g Azithromycin, Doxycyline 100mg BD for 1 week
Treat contacts
Avoid sex for 1 week after finishing treatment
Only test to see if tx has worked if patient was pregnant

10. Menorrhagia Strictly meant to be > 80ml /cycle blood loss
Not practical, objective menorrhagia:
Wearing tampons and pads (hourly changes)
Passing clots
Anaemia
RF – IUCD, fibroids, endometriosis, adenomyosis, pelvic infection, polyps. *Vaginal examination
Ix:
> FBC (treat Fe def anaemia), TFT, Clotting (if clinically indicated)
> US and biopsy IF – persistent after Tx, abnormal examination, RF for Ca.
Management:
1st line – Mirena
2nd line – Tranexamic acid / Mefenamic acid (can do 1st if wanting pregnancy), OCP
3rd line – Norethisterone
Surgical – Hysterectomy or endometrial ablation
Mef = nsaid

11. Amenorrhea
Primary – Failure to start menstruation by 15 (14 if no other signs of puberty) Secondary – Previous menses, no menstruation for > 6 months and NOT pregnant.

12. 1⁰ Amenorrhoea Causes: > Constitutional delay (familial)
> GU malformation
> Hypothalamic failure – anorexia, Kallman’s syndrome (GnRH deficiency)
>Gonadal failure –Turners syndrome (X)
Ix:
hCG, FSH, LH, prolactin, TFT, karyotype, USS

13. 1⁰ Amenorrhoea Kallman’s Syndrome Turner’s Syndrome
> GnRH deficiency
45X (most common), 46XX,
Anosmia
Neck webbing
Cranio-facial abnormalities
Short stature
Affects males – cryptorchidism
Obesity
Colour blind / sensorineural deafness
Cardiovascular problems (ECG&Echo)
Primary amenorrhoea
Tx: Exogenous oestrogen and progesterone, for fertility GnRH pump
Tx; combine supplemental oestrogen and progesterone (start at normal age of puberty)

14. 2⁰ Amenorrhoea Causes: > Premature ovarian failure
(< 40y, amenorrhoea, high LH/FSH, low oestrogen)
> H-P-O axis failure – stress / exercises / weight
> Hyperprolactinaemia (suppress ovulation)
> Ovarian causes – PCOS, tumours, menopause
> Iatrogenic – depot, implant, post COCP
> Obstruction
Ix:
hCG, FSH, LH, day 21 progesterone, prolactin, TFT
Imperforate hymen or acquired eg Ashermans = adhesions
Bromocriptine for hyperprolactinaemia (D agonist)
Sheehans  necrosis of the pituitary gland after significant PPH

15. Benign Ovarian Tumours
FIBROIDS (Leiomyomas):
Pathophysiology – Growth is oestrogen dependent and to a lesser extent progesterone.
Clinically can cause:
Menorrhagia (30%)
Dysmenorrhoea
Press on bladder, block tubes
50% asymptomatic
Complications:
Torsion
Malignancy (rare 0.1%)
In pregnancy grows in 2nd trimester (can cause miscarriage)
Red degeneration – thrombosis in capsular vessels  Venous engorgement  Inflammation; abdo pain and vomiting  Resolves
Benign smooth muscle tumour of the uterus
Ix: USS +/- lap and biopsy
Management:
1. Mirena 2. Suppress oestrogen; Goserelin (GnRH agonist) 3. Surgery

16. Benign Ovarian Tumour (2)
Functional Cysts
 Enlarged persistent follicle or corpus luteum. Normal < 5cm, resolve after 2/3 cycles. Can cause pain and peritonitis sx if they bleed. COCP inhibits.
Mucinous Cystadenomas
 Massive. Unilateral, Appear solid, common in yr old, 15% malignant
Serous Cystadenomas
Most common epithelial tumour, commonly bilateral, 30-50yr old, 25% malignant
Dermoid cyst
 ‘mature cystic teratoma’, contain skin/hair/teeth most common cyst in < 30s. Bilateral 20/30%. Torsion most likely in dermoid cyst.

17. Rupture and Torsion
Rupture of ovarian cyst (mid cycle follicular most commonly)
Presentation:
Acute abdo pain (during exercise)
PV bleed
N&V
Circulatory collapse +/- weakness, syncope
Ix:
Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
Laparoscopy is diagnostic but usually get USS first
Management:
Stable  Analgesia
Bleeding / unstable  Surgery
Torsion occurs unilaterally in combination with a pathologically enlarged ovary.
RF – pregnancy, malformations, tumours, previous surgery
Presentation:
Acute abdo pain (during exercise) unilateral
Radiates back, thigh, pelvis
N&V
Fever (indicated necrotic ovary)
Ix:
Always rule out ectopic!! Urinary hCG and dip, FBC, swabs.
USS with colour Doppler analysis is diagnostic
Management:
Laparoscopy
+ Analgesia; NSAIDs, opiates

18. Bacterial vaginosis –
Vaginal pH >4.5, Gardenerella vaginalis
Ix – clue cells on microscopy, +ve whiff test (potassium hydroxide)
Tx – Metronidazole 500mg 5 days

19. PID
General term for infection of uterus, fallopian tube and ovaries. Most commonly due to ascending infection from the cervix.
Chlamydia
Gonorrhoea
RF – young, no barrier protection, multiple partners, BV (helps infection ascend), previous gynae surgery, IUD
Presents: (*can be asymptomatic do not present until fertility issues)
Cervicitis:
PV bleed +/- deep dyspareunia, bilateral abdo pain, post coital bleeding
Abnormal discharge
Salpingitis (more common with gonorrhoea)
Pain
Fever > 38
Spasm of abdo muscles
O/E – cervical excitation, adnexal tenderness, +/- peritonitis

20. PID (2) Ix: Management: Complications:
Triple swab, hCG,
Management:
If very unwell (more likely if due to gonorrhoea) then admit for cultures and IV Abx.
Inpatient  Ceftriaxone IV + Doxy PO
 reduce to Doxy PO and Metronidazole 14d
Outpatient  Ceftriaxone IM stat dose + Doxy + Metronidazole PO 14 d
*** Important to treat sexual partners***
Complications:
Ectopics, chronic pelvic pain, subfertility
Triple swab – high vaginal, cervical, endocervical

21. Prolapse Vaginal vault prolapse post-hysterectomy
Apical or uterine prolapse
ICS POP scoring! (0-4)

22. Prolapse (2)
Causes inc. vaginal delivery, pregnancy, menopause, obesity, chronic factors eg. High intra-abdominal pressure, iatrogenic factors or congential
Features asymptomatic, ‘lump’, ‘dragging’, see a bulge, urinary incontinence/infections, LBP/ constipation
Management
Lose weight/ stop smoking/ avoid straining
Pelvic floor exercises
Oestrogen for post-menopause
Pessaries (6-9 months)
Surgery: ant./post. wall repair, hysteropexy/sacrocolpopexy, sacrospinous fixation
?TVT + TOT + Burch colposuspension

23. Trichomonas vaginalis  Flagelaated protozoan
Trichomonas vaginalis  Flagelaated protozoan. On wet microscopy (done in gum clinic)
Discharge is common – different from BV because its usually yellow and frothy . Strawberry cervix o/e
Mx – Metronidazole 500mg 7 dyas or stat 2 g dose. Tx partner at same time

24. Ovarian Ca
Most common histological type; Epithelial  Serous adenocarcinoma (50%)
RF: increased risk with increased number of ovulations – early menarche and late menopause, null parity. BRCA1 (40% lifetime risk) BRCA2 (25% lifetime risk) and HNPCC. (Protective: COCP + having children)
Presentation:
Persistent abdo bloating
Early satiety
Urinary urgency / frequency
PV bleed
Lower abdo pain/ back pain or dyspareunia
*** ANY > 50 presenting with new IBS type sx must have Ca125 done***
80% of cases in over 50s  think germ cell line if under 30y/o

25. Ovarian Ca(2) Ix: (used to work out the Risk of Malignancy Index RMI)
USS (score 2-5  U=3)
Menopausal status (1 point pre, 3 post)  If x together score > 250 refer urgently to MDT + CT and laparoscopy for staging
Staging - Spreads transcoelomic and lymphatic routes.
A= alone
B= both
C= capsule not intact
2= pelvis
3= beyond pelvis
4= beyond abdo

26. Endometrial Ca RF: Oestrogen only HRT, Tamoxifen, Presents:
Oestrogen dependent ca. At increased risk when endometrium is exposed to unopposed oestrogen.
RF: Oestrogen only HRT, Tamoxifen,
Presents:
POST MENOPAUSAL BLEEDING
+/- watery discharge
Ix:
Hysteroscopy with endometrial biopsy
(Biopsy any endometrium > 4mm)
Management:
Stage I + II  Total hysterectomy and Bilateral salpingo-oophrectomy
Stage III  ‘’ + Post op vault radiotherapy
IF unsuitable for surgery  radiotherapy + progestogens Medroxyprogesterone
Tamoxifen is antagonist in breast but agonist in uterus

27. Cervical Ca
Primary RF is HPV 16,18,31,33,45. Most commonly a squamous cell carcinoma.
RF: HPV, multiple partners, smoking, COCP, immuno-suppressed pts
Prevention: Gardasil to y/o
Presentation:
Vaginal discharge
PV bleed – postcoital/micturating/defecating
Late sx – painless haematuria, chronic urinary freq, altered bowel habit, leg oedema, pelvic pain.

28. Cervical Ca (2) Screening Treatment
Smear - Targets transformation zone (squamous-columnar jct), both types of cell must be in sample. + HPV testing
Aged / 3 yearly
Aged / 5 yearly (NB if at high risk e.g. HIV then yearly)
Results:
Refer to colposcopy IF:
Borderline dyskaryosis AND HPV +ve
Moderate or severe dyskaryosis
Treatment
Dysplasia  laser therapy/ cryotherapy  LLETZ/ cone biopsy
Stage 1B+  surgery with chemo therapy
Stage 2B+  ?chemoradiation

29. Thank you! Questions? Contact us at: jlgray1@sheffield.ac.uk

30. Not covered Disorders of urinary tract Sexual medicine
Menstruation cycle
Breast + malignancy
Vulval + vaginal malignancies