Lecture 21: Clinical Gynaecology Flashcards Preview

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Flashcards in Lecture 21: Clinical Gynaecology Deck (44):
1

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

2

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

3

Who invented the PAP smear?

Georgios Nicholas Papanicolaou

4

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

5

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

6

Who invented IVF?

Gregory Pincus
- also helped invent first combined oral contraceptive pill

7

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

8

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

9

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)

10

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

11

Gynaecology Work Stream

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

12

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

13

Clinical Procedure for Gynaecology

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

14

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

15

Presenting the complaint components of Gynaecological History Taking

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

16

Causes of continence problems

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

17

Features surrounding Lower abdominal pain

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

18

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)

19

Pelvic Examination illustrating infection

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

20

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

21

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

22

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

23

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

24

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

25

Non-structural causes of Heavy menstrual bleeding

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

26

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)

27

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

28

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

29

Clotting diagram

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

30

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

31

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

1. Endometrial ablation
2. Hysterectomy

32

Hysterectomy

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

33

Stress Incontinence

*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

34

Urge incontinence

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

35

Overflow incontinence

Urethral blockage --> Bladder unable to empty properly

36

Painful conditions of Gynaecology

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

37

Painful Gynaecological condition of Dysmenorrhea

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))

38

Endometriosis

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

39

Diagnosis of Endometriosis

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

40

Endometriosis Aetiology

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)

41

Endometriosis Treatment

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

42

When can you have endometriosis

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

43

Endometriosis Prognosis

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

44

Most common Gynaecological conditions

Heavy menstrual bleeding
Fibroids
Continence issues
Endometriosis