Lecture 21: Clinical Gynaecology

Question 1

What is clinical Gynaecology?

Answer 1

• Issues of discomfort and/or disease of the female genital tract.
• Prevention of disease eg; cervical screening.
• Reproduction and contraception.

Question 2

Cervical Screening is?

Answer 2

One of the most effective screening tests in reducing the incidence and mortality from cervical cancer. By 60-80%!!

HPV is the underlying cause, a vaccine has been introduced.

Question 3

IVF??

Answer 3

>5mill babies born by IVF

1. Stimulate via hormones the female ovaries so lots of follicles/eggs mature.
2. Puncture via abdominal wall, takes eggs our and mix in vitro with sperm
3. Find the best fertilised eggs, place them back in the womb

Question 4

What is the major breakthrough in womens reproductive health??

Answer 4

The Oral contraceptive Pill.
Currently used by >100 mill women.

Women could decide if/when they wanted to get pregnant!!!

Question 5

What kind of things do you see in terms of womens health in the community and/or emergency health system?

Answer 5

heavy menstrual bleeding

Abnormal cervical smears

Early pregnancy complication

Lower abdo pain

Question 6

Gynaecologic History taking

3 key history questions?

Answer 6

What’s the presenting complaint?

• onset, duration, course, severity
• impact on life

Specific complaint related history (exclude pregnancy)
-cervical smear, sexual health etc

1. mestrual history
2. contraceptive history
3. sexual history

Question 7

Gynacaelogical Examination

Answer 7

1. General Abdominal Examination
2. Pelvic Examination
   - Speculum &bimanual (checks cervix, cervical motion tenderness, uterus, adnexa)

IT MAY NOT EVEN BE A GYNACOLOGICAL PROBLEM

Question 8

What is a speculum examination?

checking for?

Answer 8

• Because in normal circumstances vaginal walls have collapsed, but speculum allows us to expand the walls and clearly view the cervix
• cervix size, motion, temderness, uterine movement

Question 9

Gynacaelogical Investigations

Answer 9

• Urine (pregnancy)
• Cervical smear
• Vaginal Swabs
• Biopsy (pipelle)
• Ultrasound (5-12mm)

Question 10

Uterine Fibroids are? Symptoms?

Answer 10

Very common cause of menstrual bleeding, benign SM tumor from uterine myometrium. Estrogen dependent and regress post menopause

Symptoms: abnormal bleeding, pelvic discomfort, no pain

Question 11

Uterine Fibroid Treatment?

Answer 11

Don’t treat unless the symptoms are really bad. If treatment is required, use drugs (eg NSAIDS) or surgery can be done.

These can grow in different places, eg; bladder

Question 12

Causes of Heavy menstrual bleeding?

Answer 12

Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia (PALM)

Non-Structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified (COEIN)

Question 13

Treatment for Acute HMB

Answer 13

Progestogens (high dose/ 10 days)

or Tranexamic acid

Question 14

Progestogens action on the Endometrium

Answer 14

• Stops the oestorgen induced growth of the endometrium
• Stabilizes endometrial Vasculature
• Initiates the clotting cascade
• inhibits matrix metallo proteinase activity

Question 15

What is Endometrial Ablation and when do we do it?

Answer 15

• Minor procedure, whole inner womb lining taken out
• Short recovery
• 80% satisfaction
• 25% repeat procedure

Only done if after 3 months medical management for HMB has failed!!

Question 16

How does Tranexamic Acid work?

Answer 16

Anti-fibrinolytic that prevents plasminogen activation.

It works by preventing blood clots from breaking down too quickly. This helps to reduce excessive bleeding.

Little bit of coagulation at the level of the uterus, restoring blanace of coagulating and anti-coagulating products.

Question 17

Types of Incontinence

Answer 17

..

Question 18

Dysmenorrhea

Answer 18

Pain during menstrual cycle

45-72% in menarche +3years

39% use analgenics

Question 19

Dyspareunia

Answer 19

pain during sex

Question 20

Endometriosis stats and associated pain types

Answer 20

1 in 10 women

Most painful condition, functional extra-uterine endometrium, only way to diagnose is a painful invasive procedure.

Dysmenorrhoea, dyspareunia, dyschezia (pain on opening bowels), dysuria

Question 21

Endometriosis treatment?

Answer 21

1. Pain management
2. Hormones
3. Surgery

But is is a chronic condition and will carry on within reproductive lifespan.

4. surgical - laprascopic excision of endometrial deposits
5. definitive surgery - hysterectomy and bilateral salpingo-oopherectomy