Lecture 19: Clinical gynaecology Flashcards
At point does gynaecology health become important?
Its important across all her lifespan
Hospital and community settings for womans health issues are very different
What does clinical gynaecology involve?
- Education i.e whats normal, what to expect
- Prevention (Smear)
- Diagnosis and treatment of disease
- Managing symptoms
- Bening and malignant pathologies
When you have a young female come into a GP clinic, what are some things worth asking?
Note different ages have different needs
- Sexually active?
- Explore need for contraception
- Educate regarding family planning and sexual health
- Screen for family violence
- Offer cervical smear and self swabs for STI screen
What are some long acting reversible contraception options? discuss benefits
LARCs
- Effective, reversible, long lasting contraception
- Do not rely on patient compliance
- Failure less than 1%
- Cost effective
Methods:
- Subdermal contraceptive implant i.e jadelle, copper IUD, hormonal IUD, DEPO (lasts only 3 months tho)
Why cervical smear?
- Cervical cancer caused by HPV
- Slow progressive change over ten years
- Smear detects precancerous cervical change
- 20-69 y/o that are sexually active are invited to smear every 3 years
Note will be changing to HPV screening
Where does cervical cancer occur?
Majority of cancer developed within the transformative zone
= Area of maturing epithelium b/w current squamocolumnar junction and the original squamous epithelium
Describe the smear test:
- Use of speculum to visualise the cervix
- Cytobroom to sample cells from transformative zone
- 36 year Pacific woman sees GP with heavy periods lasting 10 days with ‘flooding’
- Menarche age 12, always had heavy periods, worse last 2 years, no IMB/PCB, no pelvic pain
- Feeling tired and exhausted
- Wants to get pregnant
- Normal smear history
How do you proceed with her tiredness?
•Screen and treat anaemia
- Iron deficiency anaemia confirmed (Hb 92, ferritin 6)
Treat : oral iron or iron infusion
- 36 year Pacific woman sees GP with heavy periods lasting 10 days with ‘flooding’
- Menarche age 12, always had heavy periods, worse last 2 years, no IMB/PCB, no pelvic pain
- Feeling tired and exhausted
- Wants to get pregnant
- Normal smear history
How do you exclude other pathologies?
Exclude pathology
- Normal gynaecological exam
- Normal pelvic ultrasound
- Normal endometrial sampling
- Negative pregnancy test
- 36 year Pacific woman sees GP with heavy periods lasting 10 days with ‘flooding’
- Menarche age 12, always had heavy periods, worse last 2 years, no IMB/PCB, no pelvic pain
- Feeling tired and exhausted
- Wants to get pregnant
- Normal smear history
What pre-pregnancy advice do you give?
•Pre-pregnancy advice
- Start folic acid and iodine, stop smoking
- BMI into healthy range if not already
How do you perform a gynae exam?
Abdo palpation - Pelvic masses i.e pregnancy, tumour
Speculum examination - Visualise cervix, swabs/STI screen, smear if indicated
Bimanual examination (fingers in vagina, push down on uterus) - uterine size and position, mobility and tenderness, adnexal masses (tubes)
How is pelvic ultrasound performed and what does it diagnose?
- Transvaginal or transabdo
- Visualise cervix, uterus, adnexae
- Diagnosis of polyps, fibroids, ovarian cysts, pelvic abscesses
What are the treatments for heavy menstural bleeding?
- Depends on age, fertility plans, choice i.e hormones (contraceptives) or surgery i.e hysterectomy or endometrial ablation
- Can manage with NSADIS and/or tranexamic acid to allow for pregnancy
What does tranexamic acid do?
- Tranexamic acid binds to plasminogen
- Blocks interaction of plasminogen with fibrin
- Prevents dissolution of fibrin clot
Write some notes on endometrial ablation:
- Day case procedure
- Short recovery time
- 2/3rds women satisfied
- 1/3rds require repeat procedure or hysterectomy
Insert probe into uterus and ablation of the endometrium
Whats the risk and prognosis for a hysterectomy?
- Major procedure with significant risks:Bleeding, Infection, Damage to bladder/bowel/ureter,Re-operation, Chronic pelvic pain/adhesions, Blood clots
- Requires 6-8 weeks recovery (regardless of route)
- High satisfaction rate overall
- 52 year old Asian women with night sweats and hot flushes since her periods stopped 18 months ago
- Unable to concentrate at work due to tiredness, feeling low and wanting to reduce her working hours
What are you going to do?
Educate regarding menopause, check for other symptoms, discuss treatment options :
- Explain she is now postmenopausal (Definition of menopause =1 year from LMP)
- Outline physical and psychological symptoms
- Mean duration of vasomotor symptoms is 2 years for majority of women
- Screen for depression/mental health
•Health promotion: mammogram & cervical screening history, advice regarding breast awareness, PMB, bone health, CVS risk
What is menopause and what symptoms are common?
- ‘Normal’ life transition stage-not disease
- 10% women need medical assistance
- Vasomotor symptoms due to loss of oestrogen, self-limiting
- 50% women experience local genital symptoms which persist-pain with sex, bladder urgency and recurrent UTI’s-treatable with local oestrogen cream/pessaries
What are the treatment options that can help with menopause?
- Symptom control!!
- Lifestyle measure to reduce hot sweats/CVS/prevent osteoporosis: weight loss if obese, weight-bearing aerobic exercise, reduce caffeine/alcohol, stop smoking
- Non-hormonal treatment includes SSRI/SNRI, gabapentin (Vasomotor), CBT
- Hormone treatment-if no contraindications-use lowest dose for shortest duration
Whats the risk of hormone replacement therapy?
DVT, stroke, gallbladder disease
- 28 year old women with increasing pelvic pain, worse just before period starts, with pain on having sex (dyspareunia)
- Pelvic examination reveals deep vaginal tenderness to right side, pelvic ultrasound a 3cm right ovarian cyst
What are you going to do?
- Discuss potential diagnosis and treatments..
- Discuss symptoms of endometriosis
- Severity of symptoms and impact on life (work, relationship, mood)
- Plans for having children
- Medical versus surgical treatment options
What are the symptoms of endometriosis?
- Painful periods
- Painful sex
- Pain on opening bowels
- Pain on passing urine
- Mid cycle / ovulatory
- Chronic pelvic pain
- Delayed conception
How does endometrioma (endometriosis of the ovary) appear on ultrasound?
Grainy appearance of cyst contents due to altered blood
What are the facts of endometriosis?
- Affects 1 in 10 women in reproductive years
- Chronic condition, Progresses.
- No pain to severe, i.e spectrum
- 40% of women with infertility have endometriosis
- No known cause, genetic predisposition
Whats the pathology of endometriosis?
- NOT normal endometrium displaced into ‘wrong’ place RATHER deposits of glandular tissue that cause chronic inflammation, scar tissue and smooth muscle infiltration
- Inflammation promoted by hormonal cycles
- Sites involved: peritoneum, ovaries, tubes, bladder, bowel, rectovaginal septum
- Diagnosis requires laparoscopy with biopsies
How is endometriosis managed?
- Manage pain
- NSAIDS and hormonal suppression (Hormonal contraceptives) reduces inflammation
- Surgery aims to excision deposits of endometriosis, not always possible due to location (e.g. close to ureters/bowel) - must consider fertility wishes
- Surgery often repeated, increasing complexity
NB: Hysterectomy is not curative
What are ovarian cancers?
Not one disease but many
- 90% cases are malignant epithelial tumours
- Non-specific symptoms…. so high index of suspicion required
- 90+% cases have elevated Ca125 levels
- Most present with advanced disease
Whats the usual treatment for ovarian cancer?
Major surgery and chemo
What can be done for the early detection and prevention of ovarian cancer?
- Combined pill for five years reduces risk by 50%
- Pregnancy <26 years and breastfeeding reduces risk
- Awareness of family history and genetic referral
What is familial ovarian cancer?
BRACA 1 and 2 predispose people to ovarian cancer
Serum tumour marker Ca125 and pelvic US can serve as screening
Prophylatic removal of both ovaries and tubes ones family is complete
