Lecture 21: Clinical Gynaecology Flashcards
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
- Discomfort (focus on the woman) and Disease
- Prevention of disease (cervical screening)
- 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
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
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
- Take a proper history
- Do a gynaecological examination
- Order further investigations
Gynaecological History Taking
- Presenting complaint
- Onset, duration, course, severity
- Lifestyle impacted (“and what is the impact on your life”) - Specific complaint related history
- Cervical smear
- Sexual Health
- Obstetric History
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
Causes of continence problems
Incontinence:
- Stress incontinence
- Urge –> constantly feel like you ahve to go
- Micturition problems
- Prolapse
Features surrounding Lower abdominal pain
- site, character, radiation, aggravating/relieving factors
- Cyclicity (menstrual cycle)
- Dyspareunia (pain with intercourse)
Components of Gynaecological examination
- General and abdominal examination
- Pelvic examination: Use Speculum —> distends vaginal cavity –> can look at cervix
- Bimanual (Cervix, cervical motion tenderness, uterus and adnexa)
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
Gynaecological Investigations
- Urine sample
- Cervical smear
- Vaginal swabs ( t. vaginalis, N. gonorrhoeae, C. trachomatia) Note: increasing resistance to diarrohea in auckland
- Biopsy (pipette): insert noting depth of fundus and withdraw plunger until “stopped” to create vaccum
- Ultrasound
Heavy Menstrual Bleeding
- Prevalence: 1/5 woman in reproductive age
- 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)
- 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
- Conservative: Expectant, unless significant menstrual bleeding problems, pressure symptoms and rarely infertility
- Medical: NSAIDS during menstrual period. Mirena if fibroids are small and not submucosal. GnRH analagous
- 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
COEIN
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet calssified
Treatment for Acute Heavy Menstrual Bleeding (HMB)
- Progestogens: high dose for 10 days
- Tranexamic acid:
a) 5x day Oral dose: 2x 500-625 mg tabs
b) IV dose: 10mg/kg bd - 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)
- Stops estrogen induced growth of the endometrium (stabilises)
- Stabilizes endometrial vasculature and blocks unrestrained vessel growth
- Initiates the clotting cascade (coagulation promoted)
- Homeostatic and anti-fibrinolytic action (PA-I pathway)
- 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
Options if initial HMB medical management has been compliantly followed, and no pathology, has failed for 3 months
- Endometrial ablation
2. Hysterectomy
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
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
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
Overflow incontinence
Urethral blockage –> Bladder unable to empty properly
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
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))
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
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
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)
Endometriosis Treatment
- Explanation and multidisciplinary approach
- Pain management - Holistic approach
- Medical: Progestogen hormonal suppression of endometrial cells –> Inhibit any further activation of endometriotic lesions
- Mirena - Surgical: Laparoscopic excision of endometrial deposits
- Definitive surgery: Hysterectomy and Bilateral Salpringo- oopherectomy
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
Endometriosis Prognosis
Tendency to progress and recur after medical treatment
May even recur after radical surgery, although rare
Regression in pregnancy and in postmenopause
Most common Gynaecological conditions
Heavy menstrual bleeding
Fibroids
Continence issues
Endometriosis
