Lecture 21: Clinical Gynaecology

Question 1

Why is it important to promote woman’s health?

Answer 1

Children, family and partners health are prioritised by the woman over her own health –> late presentation
Better female health improves everyone’s health

Question 2

Clinical gynecology of the female genital tract

Answer 2

1. Discomfort (focus on the woman) and Disease
2. Prevention of disease (cervical screening)
3. Reproduction and Contraception

Question 3

Who invented the PAP smear?

Answer 3

Georgios Nicholas Papanicolaou

Question 4

Cervical Screening

Answer 4

Prevention of disease of female genital tract
- Participation by a 35-64 yr old woman = 60-80% reduced risk of cervical cancer over the next five years = 90% reduced risk of advanced cervical cancer
PAP smear is one of the most effective screening tests ever
Major contributor in the significant reduction of both the Incidence and Mortality of cervical cancer

Question 5

Timeline of the PAP smear

Answer 5

1949: Conventional PAP screening (detects diseases cells. Note: prevention is still better)
2000 : HPV virus discovered (underlying cause of the sexually transmitted disease)
2006: HPV vaccine developed

Question 6

Who invented IVF?

Answer 6

Gregory Pincus

- also helped invent first combined oral contraceptive pill

Question 7

Timeline of IVF

Answer 7

1934: First in rabbits. Gregory Pincus suggest similar fertilisation is possible in humans
1978: First IVF in humans
2015: 2% of all births are IVF babies
Worldwide: > 5 million IVF babies currently alive

Question 8

Process of IVF

Answer 8

Stimulate female ovaries with hormones –> Eggs mature and are extracted –> Combine with sperm in lab & fertilisation occurs –> select optimal fertilised egg –> replace back into womb –> Intrauterine development –> birth

Question 9

Timeline of Development of Oral Contraceptive Pill

Answer 9

1957: Synthesize norethindrone, the first highly active progesterogen, that was effective when taken by the mouth (Carl Djerassl)
1960: This became the first successful combine oral contraceptive pill (Gregor Pincus and Dr John Rock)

Question 10

Oral contraceptive pill

Answer 10

used by more than 10 million woman worldwide
Uses vary by ocuntry, age, education, and marital status
Functions: decrease menstrual cycle pains, endometrial/ovarian cancer risk, duration and volume of menstrual bleeds –> preventing depletion of iron stores, hence decreased risk of female anaemia
-One of the main contributors to womans health
1/3 UK woman aged 16-49, currently used either Combined pill or Progesterone-only pill

Question 11

Gynaecology Work Stream

Answer 11

2014/15
Primary Care/Community : 7714
1.  Heavy menstrual bleeding
2. Abnormal cervical PAP smear
3. Early Pregnancy Complications
-4. Lower abdominal pain
-5. Continence and Prolapse issues
Emergency: 2236
1. Heavy Menstrual Bleeding
2. Early Pregnancy Complications
3. Lower Abdominal Pain

Question 12

Impact of Loss of continence

Answer 12

Social life impacted/restricted
- functionality
- embarrassment
Has to wear urinary incontinence pads daily
Negative impact on her work and mood

Question 13

Clinical Procedure for Gynaecology

Answer 13

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

Question 14

Gynaecological History Taking

Answer 14

1. Presenting complaint
   - Onset, duration, course, severity
   - Lifestyle impacted (“and what is the impact on your life”)
2. Specific complaint related history
3. Cervical smear
4. Sexual Health
5. Obstetric History

Question 15

Presenting the complaint components of Gynaecological History Taking

Answer 15

Rule 1: EXCLUDE PREGNANCY

a) Heavy menstrual bleeding:
1. Last menstrual period (LMP = 1st day of bleeding)
2. Cycle regularity (e.g. 7/28)
3. Flow (heavy, light, painful)
4. Inter-menstrual bleeding (IMB)
5. Postcoital bleeding (PCB)
6. Medications
b) Continence problems
c) Lower abdominal pain

Question 16

Causes of continence problems

Answer 16

Incontinence:

1. Stress incontinence
2. Urge –> constantly feel like you ahve to go
3. Micturition problems
4. Prolapse

Question 17

Features surrounding Lower abdominal pain

Answer 17

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

Question 18

Components of Gynaecological examination

Answer 18

1. General and abdominal examination
2. Pelvic examination: Use Speculum —> distends vaginal cavity –> can look at cervix
   - Bimanual (Cervix, cervical motion tenderness, uterus and adnexa)

Question 19

Pelvic Examination illustrating infection

Answer 19

Chlamydia

• inflamed cervix with white discharge
• 8% of woman (1/12)
• auckland has highest rates
• Ascends to tubes –> pelvic infectious disease –> chronic –> impact on future fertility
• therefore prevention via:
  1. Oral contraceptive pill
  2. Being aware that contraception isnt sufficient protection –> male Must use condom

Question 20

Gynaecological Investigations

Answer 20

1. Urine sample
2. Cervical smear
3. Vaginal swabs ( t. vaginalis, N. gonorrhoeae, C. trachomatia) Note: increasing resistance to diarrohea in auckland
4. Biopsy (pipette): insert noting depth of fundus and withdraw plunger until “stopped” to create vaccum
5. Ultrasound

Question 21

Heavy Menstrual Bleeding

Answer 21

1. Prevalence: 1/5 woman in reproductive age
2. Health care use: 5% of all GP visits (increasing as people dont know what to do). 35% of all referrals to Gynaecologists. 30% of all gynaecological surgeries (to alleviate/stop heave menstrual bleeding)
3. Structural Causes: PALM (diseases can effect the shedding of the uterus lining)
   - Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy and hyperplasia

Question 22

Uterine Fibroids

Answer 22

Type of structural cause of heavy menstrual bleeding
1. Epidemiology: Common (15-20%) reproductive age. Estrogen dependant. Regress into postmenopause. OCP proteins (can interfere with fertility?)
2. Pathophysiology: Benign leiomyomata arising from the uterine myometrium
- interfer with blood flow from the uterus
-1:3 woman over 35 years
3. Symptoms: Abnormal uterine bleeding, pelvic discomfort, No pain
–> Fibroids are only a problem if you are EXPERIENCING Pain
Note: Anterior fibroids can affect the bladder

Question 23

Treatment of Uterine Fibroids

Answer 23

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 analagous
3. Invasice: a) Myomectomy (fibroid resection)(Hysteroscopic, Abdominal/Laprascopic) b) Hysterectomy c) Uterine Artery Embolisation
   Note: Treatment can differ b/w public and private healthcare, purely due to money insentives

Question 24

Structural Causes of Heavy Menstrual Bleeding

Answer 24

Structural Causes: PALM (diseases can effect the shedding of the uterus lining)
- Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy and hyperplasia

Question 25

Non-structural causes of Heavy menstrual bleeding

Answer 25

COEIN - Coagulopathy - Ovulatory dysfunction - Endometrial - Iatrogenic - Not yet calssified

Question 26

Treatment for Acute Heavy Menstrual Bleeding (HMB)

Answer 26

1. Progestogens: high dose for 10 days 2. Tranexamic acid: a) 5x day Oral dose: 2x 500-625 mg tabs b) IV dose: 10mg/kg bd 3. 3 months of: (continue cycle regulation for 3x months until have stopped bleeding) a) Oral contraceptive (days 0-22 of cycle) b) Progestogens (day 5-25 of cycle)

Question 27

Functions of Progestogens (on endometrium)

Answer 27

1. Stops estrogen induced growth of the endometrium (stabilises) 2. Stabilizes endometrial vasculature and blocks unrestrained vessel growth 3. Initiates the clotting cascade (coagulation promoted) 4. Homeostatic and anti-fibrinolytic action (PA-I pathway) 5. Inhibits matrix metallo-proteinase activity

Question 28

Function of Tranexamic Acid

Answer 28

Normal: Anticoagulation/anti-clotting release occurs in initial days of menstruation --> allows clot breakdown so inner lining can be shed --> blood easily flows out HMB: Excessive Anticoagulation/anti-clotting factor release --> Excessive clot breakdown --> Excessive HMB Therefore HMB Clotting treatment: (decreased clot breakdown) HMB --> prescribe Tranxemic acid (anti-fibrinolytic) --> decreased plasminogen conversion into plasmin --> decreased degradation of fibrin clot --> decreased ease of blood flow --> HMB

Question 29

Clotting diagram

Answer 29

Fibrinogen --Thrombin --> Fibrin clot | Fibrin Clot -- (Plasminogen --> Plasmin) --> Fibrin Degradation

Question 30

Endometrial Ablation

Answer 30

Endometrial Ablation is required if no pathology and compliant medical management has failed for atleast 3 months - Minor procedure: destroys (abalates) the uterine lining / endometrium - Short recovery time - 80% satisfaction rate - 25% have repeat procedure or subsequent hysterectomy

Question 31

Options if initial HMB medical management has been compliantly followed, and no pathology, has failed for 3 months

Answer 31

1. Endometrial ablation | 2. Hysterectomy

Question 32

Hysterectomy

Answer 32

Endometrial Ablation is required if no pathology and compliant medical management has failed for atleast 3 months - Major procedure (removes all/majority of uterus) - Significant possible consequences: Bleeding, infection, Re-operation, Chronic Pelvic pain - Required 6-8 weeks recovery (regardless of route) - High satisfaction rate overall

Question 33

Stress Incontinence

Answer 33

* Increased intra-abdominal pressure --> external intra-abd pressure exceeds outwards pressure of uterine wall --> *Relaxed pelvic Floor --> bladder closing mechanism not working well --> urine leaks - repair can occur - increased abdominal pain - e.g. netballers, bballers, women lifting something - 45-50 year old woman

Question 34

Urge incontinence

Answer 34

Infection --> Neurological disorder --> Bladder has become over sensitive --> Constant feeling of needing to/urge to pee - Alcohol and Drugs = take away irritability of nerve which regulate bladder function

Question 35

Overflow incontinence

Answer 35

Urethral blockage --> Bladder unable to empty properly

Question 36

Painful conditions of Gynaecology

Answer 36

``` Dysmenorrhea (period pain) Dyspareunia (sex pain) Oculation bleeding Ectopic pregnancy Torsion of the overy (180 degrees --> blood supply closed) Miscarriage Endometriosis ```

Question 37

Painful Gynaecological condition of Dysmenorrhea

Answer 37

Painful menstrual periods Prevalance 45-72% Menarche + 3 years: first three years of menstrual cycle = 1/2 of young girls have dysmenorrhea Analgesics 39% (NSAIDS: ibprofen))

Question 38

Endometriosis

Answer 38

``` Upto 1/10 women which MUST BE IN REPRODUCTIVE AGE - Most painful condition on Gynaecology 6x pain types assoc w. endometriosis: 1. Painful periods (dysmenorrhoea) 2. Painful sex (dyspareunia) 3. Pain on opening bowels (dyschezia) --> Bloating 4. Pain on passing urine (dysuria) 5. Mid cycle/Ovulatory 6. Chronic Pelvic Pain ```

Question 39

Diagnosis of Endometriosis

Answer 39

Can only diagnose Endometriosis via an Invasive procedure under general anaesthetic (Lasparoscopy) - Black spots are typical for endometriosus Want to avoid invasive procedure --> therefore try and confirm via other methods that it is actually endometriosis - Oral contraceptive pill for atleast 6 months - No elevation: Is either 1. Pain due to a Non-gynaecological cause 2. Endometriosis assoc. pain

Question 40

Endometriosis Aetiology

Answer 40

``` Disease characterised by function extra-uterine endometrium i.e. Endometrium sheds --> but some travels through uterine tubes (instead of towards cervix) and inserts into abdominal cavity --> implantation --> tries to cycle/develop in same way as it's brother/sister cells do in the womb ( functional extra-uterine endometrium) RETROGRADE menstruation (VASCULAR/LYMPHATIC spread) ```

Question 41

Endometriosis Treatment

Answer 41

1. Explanation and multidisciplinary approach 2. Pain management - Holistic approach 3. Medical: Progestogen hormonal suppression of endometrial cells --> Inhibit any further activation of endometriotic lesions - Mirena 4. Surgical: Laparoscopic excision of endometrial deposits 5. Definitive surgery: Hysterectomy and Bilateral Salpringo- oopherectomy

Question 42

When can you have endometriosis

Answer 42

When you are within Reproductive lifespan (for however long within the life span) - therefore not before menarche or after menopause - Chronic condition

Question 43

Endometriosis Prognosis

Answer 43

Tendency to progress and recur after medical treatment May even recur after radical surgery, although rare Regression in pregnancy and in postmenopause

Question 44

Most common Gynaecological conditions

Answer 44

Heavy menstrual bleeding Fibroids Continence issues Endometriosis