Lecture 21: Clinical Gynaecology Flashcards Preview

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Why is it important to promote woman's health?

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


Clinical gynecology of the female genital tract

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


Who invented the PAP smear?

Georgios Nicholas Papanicolaou


Cervical Screening

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


Timeline of the PAP smear

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


Who invented IVF?

Gregory Pincus
- also helped invent first combined oral contraceptive pill


Timeline of IVF

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


Process of IVF

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


Timeline of Development of Oral Contraceptive Pill

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)


Oral contraceptive pill

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


Gynaecology Work Stream

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


Impact of Loss of continence

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


Clinical Procedure for Gynaecology

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


Gynaecological History Taking

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


Presenting the complaint components of Gynaecological History Taking

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


Causes of continence problems

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


Features surrounding Lower abdominal pain

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


Components of Gynaecological examination

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)


Pelvic Examination illustrating infection

- 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


Gynaecological Investigations

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


Heavy Menstrual Bleeding

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


Uterine Fibroids

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


Treatment of Uterine Fibroids

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


Structural Causes of Heavy Menstrual Bleeding

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


Non-structural causes of Heavy menstrual bleeding

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


Treatment for Acute Heavy Menstrual Bleeding (HMB)

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)


Functions of Progestogens (on endometrium)

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


Function of Tranexamic Acid

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


Clotting diagram

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


Endometrial Ablation

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