Lecture 20

Question 1

What is women’s health?

Answer 1

In the early part of the last century, women’s health was solely understood in the context or reproductive roles or of motherhood. However, over this time the definition has been broadened to address: non-pregnant women and girls, other health issues related to the female biology and structural factors of disadvantage.

Question 2

What does women’s health relate to?

Answer 2

Structures such as female genitalia and breasts or to conditions caused by hormones specific to, or most notable in, females.

Question 3

What are some women’s health issues?

Answer 3

1. menstrual cycle and menstruation issues.
2. Fertility and conception.
3. Contraception.
4. maternal health in pregnancy.
5. Child birth.
6. STD and pelvic infectious disease.
7. menopause.
8. Gynaecological and breast cancer.

Question 4

What are the socio-cultural factors of disadvantage from women’s health?

Answer 4

These factors prevent women and girls from benefiting quality health services and attaining the best possible level of health.

Question 5

What happens if women are given equal access education?

Answer 5

There is siginifcatn health benefits: decreased fertility rates, increased birth spacing, timely and appropriate health seeking behaviour, treatment adherence, reduced tobacco and alcohol consumption rates. Women with secondly school qualifications and above will have fewer experiences with sexual and gender-based violence.

Question 6

What is clinical gynaecology?

Answer 6

It promotes women’s health and well being across her lifespan.

Question 7

Why do women go to the doctor later than they should regarding their sickness?

Answer 7

Women will put their health last, and put their children, family and work before their health.

Question 8

Describe cervical screening

Answer 8

If you assemble fluid from the vagina (from the cervix) you could be able to detect cervical cancers. You do a PAP smear. Participation in the UK cervical screening programme by a woman aged 35-64 reduces her risk of cervical cancer over the next five years by 60-80%.

Question 9

What has the oral contraceptive been a breakthrough for?

Answer 9

For women’s health - for the first time women can choose when they get pregnant and when they have children. It also diminishes the duration and volume of menstrual bleeding.

Question 10

What do you see in the hospital in terms of gynaecology?

Answer 10

7714 in a year come in for the following:

1. Heavy menstrual bleeding.
2. Abnormal cervical PAP smear.
3. Early pregnancy complications.
4. Lower abdominal pain.
5. Continence and prolapse issues.

Question 11

What is the social restrictions of incontinence?

Answer 11

Women with incontinence have great fear of going out in public as they are embarrassed in losing control or urination.

Question 12

How do you do clinical gynaecology?

Answer 12

1. Take a proper history.
2. Do a gynaecology examination.
3. Order further investigations.

Question 13

Describe gynaecological history taking?

Answer 13

1. Presenting complaint: onset, duration, course, severity etc and lifestyle impact.
2. Specific complaint related history.

Question 14

Describe heavy menstrual bleeding?

Answer 14

Need to know the following:

1. Last menstrual period (LMP = 1st day of bleeding).
2. Cycle regularity (e.g. 7/28 days).
3. Flow (heavy,. light, painful).
4. Inter-menstrual bleeding (IMB).
5. Post-coital bleeding (PCB).
6. Medications.

Question 15

Describe continence problems?

Answer 15

1. Incontinence; stress, urge.
2. Micturition problems.
3. Prolapse.

Question 16

Describe lower abdominal pain?

Answer 16

1. site, character, radiation, aggravating/relieving factors.
2. Cyclicality (menstrual cycle).
3. Dyspareunia (pain with intercourse).

Question 17

Describe a pelvic examination?

Answer 17

1. Speculum - allows you to dilate the vaginal walls to see the cervix.

Question 18

Describe gynaecology investigations?

Answer 18

1. Urine.
2. Cervical smear.
3. Vaginal swabs.
4. Biopsy (pipelle).
5. Ultrasound.

Question 19

What is the epidemiology for heavy menstrual bleeding?

Answer 19

1 in 5 women in reproductive age will experience heavy menstrual bleeding. It will account for:

1. 5% of all visits to GP’s.
2. 35% of referrals to gynaecologists.
3. 30% of all gynaecology surgeries.

Question 20

What are the structural causes of heavy menstrual bleeding?

Answer 20

1. Polyp.
2. Adenomyosis.
3. Leiomyoma (fibroids).
4. Malignancy and hyperplasia.

Question 21

What is the epidemiology of uterine fibroids?

Answer 21

Present in 15-30% of reproductive

Question 22

Describe uterine fibroids?

Answer 22

They are oestrogen dependent, they regress in post menopause and they are OCP protective. They are benign leiomyomata’s arising from the uterine myometrium.

Question 23

What are the symptoms of uterine fibroids?

Answer 23

1. Abnormal uterine bleeding.
2. Pelvic discomfort.
3. No pain.

Question 24

What is the treatment for uterine fibroids?

Answer 24

1. Conservative = expectant, unless significant menstrual bleeding problems, pressure symptoms and rarely infertility.
2. Medical = NSAIDS during menstrual period, mirena if fibroids are small and not submucosal, GnRH analogues.
3. Invasive = Myomectomy (fibroid resection) - hysteroscopic, abdominal/laparoscopic - hysterectomy, uterine artery embolisation.

Question 25

What are the non-structural causes of heavy menstrual bleeding?

Answer 25

1. Coagulopathy. 2. Ovulatory dysfunction. 3. Endometrial. 4. Latrogenic. 5. Not yet classified.

Question 26

How do you treat heavy menstrual bleeding?

Answer 26

1. Progestogens - at high doses for 10 days. | 2. Tranexamic acid - two 500-625mg tablets for 5 days OR 10mg/kg bd for dose IV.

Question 27

Why do you use progestogen?

Answer 27

It stops the oestrogen-induced growth of the endometrium. it stabilises the endometrial vasculature and blocks unrestricted vessel growth. It also initiates the clotting cascade, haemostat and anti-fibronlytic action (PAl-1 pathway). It also inhibits matrix metallo proteinase activity.

Question 28

Why do you use ttranexamic acid?

Answer 28

It is an anti-fibrinolytic that prevents plasminogen activation - restores proper balance between coagulation and anti-coagulation. That is why you only use for the first three days of the menstrual period.

Question 29

What other treatment can you use for heavy menstrual bleeding?

Answer 29

You will only use surgery if for at least three months the medical management has failed. You will do an endometrial ablation.

Question 30

What is an endometrial ablation?

Answer 30

Removal of the endometrium. It is a minor procedure, with short recovery time. There is a 80% satisfaction rate and 25% have a repeat procedure of subsequent hysterectomy.

Question 31

What is a hysterectomy?

Answer 31

It is a major procedure where they completely remove the uterus. There are significant possible consequences: bleeding, infection, re-operation, and chronic pelvic pain. It requires 6-8 weeks' recovery (regardless of route). there is a high satisfaction rate overall.

Question 32

What are the types of incontinence?

Answer 32

1. Stress - there is a relaxed pelvic floor however there is an increased abdominal pressure. 2. Urge - the bladder is oversensitive from infection, and it is a neurological disorder.

Question 33

what are the painful conditions in gynaecology?

Answer 33

1. Dysmenorrhea - pain during menstrual period. 2. Dyspareunia - pain during sex. 3. Ovulation bleeding. 4. Ectopic pregnancy. 5. Torsion of the ovary. 6. Miscarriage. 7. Endometriosis.

Question 34

What is dysmenorrhea?

Answer 34

These are painful menstrual periods. The prevalence is 45-72% of women in their first three years after onset of menstruation. 40% of women with dysmenorrhea will need to use analgesics (ibuprofen and paracetamol).

Question 35

What is endometriosis?

Answer 35

Endometrial tissue outside the womb. It occurs in 1 in 10 women in reproductive age. It is the most painful condition in gynaecology.

Question 36

What are the pain types associated with endometriosis?

Answer 36

1. Chronic pelvic pain. 2. Dysmenorrhoea. 3. Dyspareunia. 4. Dyschezia. 5. Dysuria.

Question 37

What is the cause of endometriosis?

Answer 37

During the menstrual period the endometrial lining will spread to the cervix however, some will travel up the tubes and end up in the intra-abdominal cavity. The cells can implant themselves in the intra-abdominal cavity and start to cycle in the same way as if they were in the womb.

Question 38

How do we treat endometriosis?

Answer 38

1. Explanation and multidisciplinary approach. Pain management is a holistic approach. 2. Medical - hormonal suppression of endometrial cells. 3. Surgical - laparoscopic excision of endometrial deposits. 4. Definitive surgery - hysterectomy and bilateral salpingo-oopherectomy.

Question 39

What is the prognosis of endometriosis?

Answer 39

Endometriosis will tend to progress and recur after medical treatment. It may even recur after radical surgery, although rare regression in pregnancy and in post menopause.