Obstetrics and

Gynaecology
Final Year Revision 2016
Roisin Ryan

Consent

Consent
1. Name of proposed procedure or
course of treatment

2. The proposed procedure

nature of the patients complaint
significance of the complaint,
extent of the planned surgery,
locations of incisions and
possible effects on fertility.
Explain the procedure as described in the
patient information
Explain additional safety measures, such
as abx and thromboprophylaxis.
3. Intended benefits
4. Serious and frequently occurring
risks
Serious
Frequent
5. Any extra procedures which may
become necessary during the procedure

6. What the procedure is

likely to involve, the
benefits and risks of any
available alternative
treatments, including no
Rx
7. Statement of patient:
procedures which should
not be carried out
without further
discussion
8. Preoperative
information

9. Anaesthesia

How do you know what will come

up?
Obstetrics
Maternal medicine
Fetal medicine
Labour ward
Antenatal clinic

Gynaecology
Urogynaecology
Gynae-oncology
Fertility
General gynaecology (inc. contraception)

UROGYNAECOLOGY

Stress incontinence

Stress incontinence

Involuntary leakage of urine on effort or

exertion
Urethral sphincter weakness
Coughing, laughing, sneezing

Risk factors

Multiparous
Instrumental deliveries
Long labour
Macrosomic babies
Increased intraabdominal pressure: ascites,
COPD
Chronic constipation
Obesity
Hysterectomy
Age

Ix

Exam

Sims speculum-look for prolapse

Left lateral decubitus, one leg extended, one
leg flexed

Urinalysis (UTI)
Urodynamic studies (Normal but ^^ vesicular
pressure on coughing)

Treatment

Bladder diary
Weight loss, Rx cough

Physiotherapy (works 50% time)

Pelvic floor exercises, 8 ocntractions 3x/day;

vaginal cones

Medications

Duloxetine (SNRI) (works 50% time.)

SE = Nausea, vom, abdo pain

Surgery
Tension free vaginal tape (Fewer Ses, better
outcome)
Trans-obturator tape SE: Bladder perforation, post
op voiding difficulty, bleeding, infection, urge
incontinence
Burchs colposuspension : Only for those finished
with families.

Urge incontinence
Mx
Urge incontinence (OAB + Loss of bladder
control)
Urgency, frequency, nocturia in the absence
of infection
OAB
35% female incontinence
Uncontrolled increase in detrusor
pressure increasing bladder pressure
beyond that of the normal urethra

Ix
Exam: vaginal exam to rule out cystocele,
stress incontinence
Urinalysis R/O UTI
Bladder Diary
US: exclude retention (urodymnamic studies
may be needed too)
Test for vaginitis
Cause:

Detrusor instability (infx / inflammation)

Brain damage (stroke, PK, dementia)

DM

Urethritis

Vaginitis

Med: Diuretics

Conservative

OAB: Bladder retraining. Hyponotherapy +

acupuncture

Medications

Beta 3 receptor agonist mirabegron

Anticholinergics e.g oxybutynin,
tolterodine

Other

Symps

Enuresis

Incontinence on hearing running water

Decrease fluid, caffeine,

carbonated beverage intake,
adjust drugs
Bladder retraining: education,
timed voiding, positive
reinforcement
If vaginitis: Oe3
Pads
Review diuretics/antipsychotics

Botox
Injected via cystoscopy into the
detrusor muscle
Effects last 6 months
Clam augmentation ileocystoplasty

Note: Contraindx to anticholinergics:

MG / Glaucoma / GI obstruction / Severe UC /
Urinary retention/ Outflow X

Overflow Incontinence

Constant dribbling, or perhaps they dribble a

lot after voiding.
May also behesitancy.
This results from a bladder that has avery
high residual volume(usually >300ml)

Causes include:

Urethral stricture such as perhaps kidney

and bladder stones.

Detrusor weakness this may be seen in

multiple sclerosis, where signals from the
bladder about bladder fullness are not
transmitted properly.Diabetesmay also
cause an autonomic neuropathy in a similar
manner.
Rarely seen in women- BUT ovarian tumours may
be a cause.

Anticholinergics will worsen the

symptoms in this type of incontinence

Rx:

Identify and eliminate the obstruction

Consider catheterisation

Pelvic Organ Prolapse

Symptoms
Something coming down
Dragging sensation
Bleeding PV
Recurrent UTIs
Urinary symptoms
Manual evacuation, constipation
Sexual dysfunction
Symps get worse on standing / towards end of day
Grade 3 / 4 => Lichenification + ulceration => bleed
Grading system

POP-Q

Grading of urogenital prolapse (BadenWalker classifi

cation)

1st degree: the lowest part descends halfway down

the vaginal axis to the introituse.

2nd degree: lowest part extends to the level of the

introituse and through the introituse on straining.

3rd degree: lowest part through introituse + lies outside

vagina.
(Procidentia)

Prevention:

Rx cough, chronic constipation

Avoid prolonged labour

Minimise damage on instrumental delivery

Weight reduction

Postnatal pelvic floor exercises- encourage persistence

Ix

Sims speculum
-Bimanual = exclude pelvic masses
-Assess pelvic floor muscle strength
(0-5, 0= no flicker, 5 = strong)

Quality of life assessment (ICIQ-VS questionnaire)

U SS to exclude pelvic/abdo mass (if suspected

clinically).
U rodynamics if urinary incontinence is present.
ECG, CXR, FBC, and U&E (if appropriate), to
assess fitness for surgery.

Rx

Conservative
Physiotherapy: Pelvic floor muscles with
Physios guidance
Pessary
Ring
Shelf e.g Gelhorn

Surgery
Anterior repair: cystocele
Posterior repair: rectocele
Hysteropexy or hysterectomy: uterine
prolapse
Colpopexy: vault prolapse

Prolapse

Serious risks of Prolapse Repair

Surgery:

Damage to bladder/urinary tract (uncommon)

Damage to bowel (uncommon)
Xs bleeding requiring transfusion/ return to theatre,
(common)
New or continuing bladder dysfunction (variable
related to underlying problem)
Pelvic abscess (uncommon)
Recurrence of prolapse (common)
although venous thrombosis (common) and
pulmonary embolism (uncommon) may
contribute to mortality, the overall risk of death
within 6 weeks is 37 women in every 100 000
(rare).

Frequent risks:

UTI, retention and/or frequency

Vaginal bleeding
Postop pain and difficulty +/or dyspareunia
Infx wound

GYNAE-ONCOLOGY

Cervical screening

Age 25-60
Q3 years 25-44
Q5 years 45-60
Use: Liquid based cytology
Results
Mild dyskaryosis
Moderate/severe dyskaryosis

Success

50% reduction in mortality from cervical cancer.

Regular cervical screening reduces the risk of

death from
cervical carcinoma by 75% (but does not eliminate
it).
Note on transformation zone:
Zone of squamous metaplasia- at the jnc between
glandular and squamous epithelium of cervix.
Area of high mitotic change
Vulnerable to HPV driven change. If persistent infx
CA.
Cancer takes 8-10 yrs of HPV to occur
Endo = glandular epithelium
Ectocervix = Stratified squamous
Transformational zone = ectocervical in women of
reproductive age. Endocervical in postmenopausal.

Mild dyskaryosis
Repeat smear in 6 months
Moderate/severe dyskaryosis
Refer to colposcopy
Speculum exam with colposcope
(magnification plus light)
Application of acetic acid to cervix to
visualise abnormalities
Biopsy transformation zone
See and treat

Colposcopy:
Magnified visual of TZ
After ascetic acid / Lugols iodine has been
applied
RFs for CIN
Persistent HPV
Multiple sexual partners
Smoking = promoter
Immunocompromised

2014 Q5

Describe the Irish National Cervical Screening

Programme.
Outline the evidence and rationale behind it

Describe:
Aim = To find Premalignant Lesions
Schedule : 1st smear at 25yrs
3 yearly, then 5-yearly from 49-60
Stop if normal at 60

Colposcopy Abnormality follow up

CIN 1 o Yearly Smears for 5 Years

CIN 2+3 o Colposcopy

o Ascetic acid and LLETZ.

o Yearly Smear for 10 Years

Procedure: Smear test at GP (liquid based cytology used

mostly. Papincolau= old test)
Best time to take smear = mid-cycle
If this is abnormal (borderline changes dyskaryosis),
Refer to colposcopy, at which time, they can be treated
if necessary
Advice is offered throughout the screening process by staff,
and all questions are answered

Rationale
Fulfils Wilsons criteria

An important health problem

the natural history of the condition is

understood

Test is easy to perform and interpret,

acceptable, accurate, reliable, sensitive and
specific

Theres an accepted treatment for the disease

treatment is more effective if started early

cost-effective

30-50% all CIN progress to invasive disease

Follow up protocol

Borderline or mild dyskaryosis o Test sample for HPV

Neg routine recall Pos colposcopy

Moderate dyskaryosis o Consistent CIN 2 Colposcopy

Severe dyskaryosis o Consistent CIN 3 Colposcopy
Inadequate samples x 3 Colposcopy

HPV is responsible for 5.2% of the cancer

burden worldwide.
It affects relatively young women, and is an
important cause of lost years. The recent pilots
in England showed robust evidence for cost
effectiveness in terms of life years saved
The effectiveness of screening programmes
based on cytological smears in reducing the
incidence of and mortality from carcinoma of
the cervix has been well established for some
decades as evidenced by experience in
Scandinavia in the 1960s and more recently and dramatically - in the UK

Cervical cancer

Cervical intraepithelial neoplasia

CIN 1, 2, 3

Colposcopy = Punch biopsy /

Definitive Rx
CIN = histological diagnosis made
after biopsy.

CIN on colposcopy:

Aceto-white epithelium

Vascular: mosaic, punctuation

Other indx for colposcopy:

Keratinizing cells

Glandular abnormality

PCB

Abnormal looking cervix

Mx

CIN 1: 90% cases will regress

spontaneously w/in 2 yrs

CIN 2/3 (3-5% + 20-30 CA w/in

10yrs)
50% CIN 2 will spontaneously regress
w/in 2 yrs

Biopsy
Repeat smear in 6/12
Colposcopy + cytology every 6 mos
LLETZ if persistent for >2yrs

Large loop excision of transformation

zone
Send for histology
Histology suggests 2/3-Repeat smear
in 6/12

Invasive cancer

Diagnostic cone biopsy and histology

Complications of LLETZ
Short term

Hge / Infx / Vaso-vagal reaction / Anxiety

Long term

Cervical stenosis (dysmenorrhoea and/or

difficulty in follow-up).

Cervical incompetence and premature delivery

(low risk)

Cervical cancer

Incidence 8/100 000

2 peaks of incidence: 30s and 80s
Human papilloma virus
16,18,31,33,45
16,18: 75% cervical ca
Gardasil: girls aged 13
6,11,16,18
6,11=genital warts

Symptoms BLEEDING!
PCB
IMB
Offensive discharge
PMB
Late: Pain
Asymptomatic, picked up on screening

Cervical cancer

FIGO classification
Clinical staging

1: Confined to cervix

1ai: Microscopic, <3 mm depth, <7mm

lateral spread
1a ii: Microscopic, <5mm depth,
<7mm lateral spread
1bi: Clinically visible <4cm
1b ii: Clinically visible >4cm

2: Invades upper vagina

2ai: Upper 2/3 vagina, <4cm

2a ii: Upper 2/3 vagina >4cm
2b: Parametrial invasion

3:
A Lower vagina,
b pelvic wall, hydronephrosis

4a: Bowel or bladder

4b: Distant metastases

Invx

U &E, LFTs, FBC.

CT abdo/pelvis (staging + preop assessment).
MRI pelvis (can be very accurate at staging
and examining for suspicious LNs
EUA:

bimanual, cystoscopy, hysteroscopy, and

PV/PR examination sigmoidoscopy

Can insert fiducial markers at clinical extent

of

tumour in advanced disease to aid radiorx

planning
5 year survival

Stage
1a 95%

1bi 90%

1bii 80%

Stage 2 75%

Stage 3 50%

Stage 4 20-30%

Cervical cancer

Mx
1ai: Conization (knife or
LEEP)

Hysterectomy types
Subtotal: uterus only
Total: Uterus + Cervix +/- ovaries
Radical: Uterus + Cervix + Upper vagina +
Parametrium
Wertheims: Radical + fallopians + ovaries +
LNs

Early

1a ii, 1bi, 2a
Surgical candidate
Radical hysterectomy
Radical trachelectomy +
lymphadenectomy
+/- chemo + pelvic
radiotherapy

Late/ >stage 2a

No radical surgery
Combo chemoradiation
Cisplatin

Trachelectomy

Upper vagina +80% cervix

Fertility conserving procedure
>50% chance pregnancy post
procedure

Compx of treatment
Wertheims hysterectomy and lymphadenectomy:

Bleed

Infx

DVT/PE

Lymphoedema

Lymphocysts

Ureteric fistula

Bladder dysfnc
Radiotherapy:

Acute bowel + bladder dysfnc (tenesmus, mucositis,

bleeding)

5 % late bowel and bladder dysfunction (ulceration,

strictures, bleeding, fistula formation)

Vaginal stenosis, shortening, and dryness.

Ovarian cancer

80% cases in women>50

90% epithelial cell cancer
Serous adenocarcinoma
(50%)
Endometrioid
Mucinous (*pseudomyxoma)
Clear cell

Increased ovulation
Early menarche, late menopause
Nulliparity
Family: BRCA (BRCA1 especially),
HNPCC

Protective factors
OCP
Pregnancy
Lactation

Symptoms
Insidious, difficult to detect
IBS symptoms in a
woman>50
Bloating, distension
Discomfort/pain
Early satiety +/- anorexia
Urinary
symptoms:urgency/frequency

RFs (damage to ovary by ^^

ovulation)

70% diagnosed late: stage 3

or 4
UKCTOCS
Trial of screening for ovarian
cancer, Lancet 2015
MMS (multimodal screening)
may prevent 20% ovarian
cancer deaths

Ix:

Bloods: FBC, U+E, LFTs- espec albumin

Pelvic ultrasound
CXR: pleural effusion, lung mets
CT abdomen/pelvis: omental caking,
peritoneal implantation, liver mets,
para-aortic LNs
Markers: CA125
>35 IU/ml
If mucinous: CA 19-9
CEA: rule out colon cancer (a ddx)
AFP, LDH, hCG, inhibin, Oe3 = rarer
Ovarian cancers
Ascitic/pleural fluid for: Cytology,
Micro, U+E
Risk of malignancy index
Ultrasound score

1 feature, U=1
>2 features U=3

Menopausal status

1=pre menopausal
3=post menopausal

CA 125 level
USS x Menopausal x CA125

Ovarian
cancer
Features of malignancy
on ultrasound

Multiloculated cysts
Bilateral
Ascites
Metastases

5 year survival

Stage 1: 80%
Stage 2: 60%
Stage 3: 40%
Stage 4: <20%
Overall: <50%

Ovarian cancer
FIGO Staging

Mx
CT TAP
Surgery:
TAH+BSO+omentec
tomy+washings+as
sessment of
retroperitoneal LN
Chemotherapy:
paclitaxel,
carboplatin

Post menopausal bleeding (PMB)

10% risk endometrial cancer

Mx
History and exam

Including speculum exam

TVUS (96% endometrial CA

diagnosed this way)
Endometrial thickness>3mm
(>5mm if on sequential HRT)
Inpatient hysteroscopy
OP Pipelle biopsy to confirm dx

Exclude local causes

Take cervical smear if due
Refer for TVUS

Other causes

Atrophic vaginitis
Polyps
Ovarian or cervical ca
Cervicitis
PID

90% adenocarcinoma of columnar

endometrial cells
Vs Ovarian CA,
Stage: CT +/-MRI
75% present at Stage 1where 90% =
epithelial

FIGO staging
1: confined to uterus

1a: <50% myometrial invasion

1b: >50% myometrial invasion

2: Cervical stromal invasion

3: Beyond uterus

3a: invades serosa

3b: vaginal or parametrial involvement
3c: pelvic, paraaortic nodes

4a: bowel and bladder

4b: distant metastases
Present:

PMB

^^PV discharge
Invx:

Hx and exam: Bimanual, Vulval + vaginal +

speculum exam

TVUS

CT abdo/pelvis (pre-op staging), MRI pelvis (LNs

involved), CXR

Endometrial biopsy (if endometrium >/=4mm thick,

or <4mm but persistent bleeding, in which case, use
hysteroscoe for biopsy): Blind (pipelle) or
Hysteroscopy

Endometrial cancer
RFs
Unopposed oestrogen

Early menarche, late menopause

Nulliparity

Oestrogen only HRT

Tamoxifen

PCOS (no CL No progesterone = unpopposed Oe)

Obesity (peripheral conversion in adipose of

androstenedione Oe) + conditions predisposing to
obesity (hypoThy, DM2, HTN)

Oestrogen secreting tumours (granulosa cell tumour)

Protective:

COCP: 50% ** risk with 4yrs use

Parity: Pregnancy = High progesterone state

Rx

Stage 1
TAH+BSO+peritoneal washings+ omentectomy
No difference in route of surgery

Stage 2/3
Surgery
Carboplatin + doxorubicin + taxol
Radiotherapy

Gestational trophoblastic
disease
CUMH: National
Centre for GTD
Spectrum
1) Molar pregnancy:
complete mole, partial
mole
2) Choriocarcinoma
Malignancy of
trophoblastic tissue

3) Placental site
trophoblastic
tumour

1/714 live births

Risk factors

Molar pregnancy
Presentation

Irregular T1 vaginal bleeding

Large for dates
Hyperemesis
Abdo pain (large theca lutein
ovarian cysts because of ^^ hCG)
Early failed pregnancy
Rarely
Hyperthyroidism
Early onset PET

Ix
Ultrasound
Bunch of grapes
Snowstorm
May be fetal parts

hCG
Greater than twice normal for
complete moles.
May be within normal range for
partial moles

Rx
Rfs:
Previous molar pregnancy (10x risk)
Ethnicity: East Asian
Extremities of reproductive age

Evacuation-suction curettage
Medical rx if fetal parts are too
big for curettage (partial mole)
Excessive bleeding is a risk
Anti D is required

Complete mole

GTD

Partial mole

Diploid, 46 XY
Sperm fertilises an empty ovum
Risk of invasion 15%
Triploid
2 sperm fertilise an egg, 69 XXY
Risk of invasion 0.5%
Fetal parts

Follow up

Serial beta hCG

Watch it fall to <5
Follow up for 6/12 following normalisation of
hCG
Must check hCG 6-8 weeks after any future
pregnancy to exclude recurrence
Advised to not get pregnant until hCG has
been normal x6mos
Use BARRIER contraception. Hormonal is safe
after 6mos of normal hCG

GTNeoplasia poor prognostic factors:

>40yrs,

Antecedent pregnancy = Term,

Antecedent pregnancy = >4mos ago,

large tumour burden, poor response to chemo

previously

Gestational trophoblastic neoplasia

50% follow molar pregnancy

25% follow normal pregnancy
25% follow TOP/miscarriage
Presentation

Persistent vaginal bleeding after

pregnancy
Amenorrhoea
If lung mets: Dyspnoea, haemoptysis
If perforates: Intra-abdo hge

Ix

Invasive mole
Known as choriocarcinoma if it
metastasises-lung, brain

Urine hCG
USS, CXR (snowstorm), CT chest + abdo

Rx

FIGO 2000 scoring system

Score<6: IM methotrexate + folic cid

Score>7: Multiagent IV chemo: MTX,

dactinomycin, etoposide

Cure rate 100%

Cure rate 95%

Rx until hCG normal and then for a

further 6/52

FERTILITY

Subfertility

85% couples having regular

unprotected intercourse
(>3/week) will be pregnant in 1
year
Of those who are not, about 50%
will become pregnant in a second
year
If woman<40
Refer after 1 year of trying
Refer earlier if history of PID,
known clinical cause of infertility,
woman >36
Previous PID
Malignancy
Severe endometriosis
Anovulatory cycles

Causes
Egg
Anovulation, 21%

Sperm, 25%
Passage 20%
Tubal blockage, MC
Cervical,
Sexual,

-Implantation
Incidence unknown

Unknown cause 30%

Endometriosis 8%

Infertility
Anovulation
Hypothalamus
Hypothalamic hypogonadism
Stress, weight loss, anorexia
Kallmanns

Pituitary
Prolactinoma
Tumour
Sheehans post partum
necrosis

Thyroid
Hyper or hypo

Adrenal hyperplasia
Ovarian
PCOS
Premature ovarian failure
Luteinised unruptured follicle
syndrome

Management
Hypothalamic hypogonadism
Moderate exercise, normal
BMI, reduce stress
Ovulation induction: GnRH
(goserelin), FSH/LH, hCG
Monitor for OHSS

Prolactinoma
Bromocriptine, cabergoline
Surgical: transsphenoidal
resection

Premature ovarian failure:

egg donation + IVF
PCOS: Weight loss, clomifene
citrate for ovulation
induction +/- metformin.
Ovarian drilling.

Infertility- Male reasons

Sperm

Semen analysis
Normal semen
Volume 1.5ml
Sperm count >15 million/ml
Oligospermia <15million/ml
Severe oligospermia<5million
Azoospermia no sperm

Motility ideally, >50%.

>32% = okay

Causes
Idiopathic
Primary testicular failure
Radiation, chemo

Drugs
Anabolics
Solvents
Alcohol, smoking

Varicocele
Antisperm antibodies (5%)
Post vasectomy reversal
See clumping on analysis

Infections

Asthenospermia=low motility

Morphology>14% normal
forms

Problem = <4%

Epididymitis
Mumps orchitis

Genetic: Klinefelters (47 XXY)

Chronic: Kallmanns hyperprolactinaemia, DM
Structural: Retrograde ejaculation
Absent vas deferens (CF)
Surgery: TURP

Infertility

Tubal damage
PID:

12% women infertile after 1 episode of PID

Endometriosis

Women with any grade of endometriosis

and subfertility should be offered surgery
as it improves fertility

25% subfertile women have endometriosis

Invx

Lap and dye: methylene blue (GOLD

STANDARD)
Dye: injected into uterus. Checks tubal
patency. If tubes are patent, will come out
open end and spill
into abdo cavity
Hysterosalpingogram (HSG): radioopaque
contrast

Previous surgery/adhesions

Laparoscopic adhesiolysis

Initial investigations for infertility

Invx: General exam

BMI

Signs of endocrine condition:

Hypo/hyperthyroidinm, hyperandrogenism,
PCOS, prolactinoma (homonymous
hemianopia)
Pelvic exam

Exclude local causes (bimanual, vaginal,

speculum)

Cervical smear

Chlamydia testing

Swabs: chlamydia, gonorrhea, NAAT

(nuclear acid amplifying test)
Rubella status
Day 21 progesterone
Hormone profile: Baseline Day 2-5 FSH/LH
TFTs, Prolactin, Testosterone
Semen analysis

Options
Unexplained subfertility
Intrauterine
insemination

Psychosexual problems
Physical disability
HIV +ve male
Same sex relationship
50% women < 40 will
conceive within 6 cycles
of IUI. Further 50% will
conceive after a further
6 cycles

Two year trial before

considering IVF
Live birth rate 35% per
stimulated cycle in
women <36
Method
Ovarian stimulation: GnRH
Ovulation + collection:
LH/hCG (LH analogue) injx
Fertilization + culture: to
blastocyst stage
Post transfer
Progesterone luteal phase
support to 8 weeks

Complications

Ovarian hyperstimulation
syndrome (OHSS)

33% women undergoing IVF

Multiple cysts release vasoactive
substances e.g VEGF
Mild: abdominal pain, bloating
Moderate: N+V, ascites on US
Severe: Clinical ascites, oliguria,
hypoproteinemia, Hct>45%
Critical: ARDS, thromboembolism,
anuria, tense ascites

Ovarian enlargement
Shifting of fluid intravascular
extravascular space.
Accumulates in peritoneal and pleural
spaces.
Intravascular fluid depletion, leading to:
haemoconcentration
hypercoaguability

<35
Previous OHSS
PCOS
Use of gonadotrophins
Low BMI
High antral follicle count, AMH

Prevention:

Path

Risk factors

Monitor FSH rx + Withold hCG during IVF

Use GnRH antag (degarelix) protocol, rather than
GnRH agonists (Nafarelin)
Cabergoline no pregnancy compromise. **
incidence

Rx:
D aily assessment of:

h ydration status (FBC, U&E, LFTs, and albumin)

c hest and respiratory function (pleural effusions)

a scites (girth measurement and weight)

l egs (for evidence of thrombosis).

Strict fluid balance with careful maintenance of
intravascular volume.
Thromboprophylaxis: compression stockings,
consider heparin.
Paracentesis for symptomatic relief (+/ IV
replacement albumin).
Analgesia and antiemetics

GENERAL GYNAECOLOGY

PCOS

Rotterdam Criteria

1)
2)
3)

At least 2 of the following 3:

oligo- or amenorrhea
Hyperandrogenism,
polycystic ovaries by ultrasound
>12 follicles 2-9mm OR
^^ ovarian volume
(>10mm)
Other criteria: NIH, Androgen excess
society

Hyperandrogenism
Hirsutism, acne, male pattern
baldness,
elevated testosterone or
DHEA-S

Metabolic disorders
Metabolic syndrome
Insulin resistance
Central obesity

PCOS
Pathogenesis
Not well understood
Increased androgens
Converted in
periphary by
aromatase to
oestrogens
Chronic high estrogen
state feeds back more
to FSH than LH
Low FSH-follicles fail
to mature
High LH (relatively)drives ovaries to
produce androgenspositive feedback loop

Investigation
History
Exam

BP
BMI
Waist circumference
Hirsutism-Ferriman Gallwey (04)
Acanthosis

Labs

Total/free testosterone
FSH/LH
DHEA-S
Prolactin, TSH (r/o other causes
amenorrhea
HbA1C
Lipid panel
Consider 17-OH P for non
classical CAH if suspicious

Pelvic ultrasound
Assess ovaries
Assess endometrial thickness

PCOS

Clomiphene: ovulation
induction
80% will ovulate with
clomid
6 course trial

Aims of treatment
Reduce symptoms of
hyperandrogenism
Address risk of T2DM and
CVD
Address infertility/subfertility
Prevent endometrial
hyperplasia/cancer

Metformin
Most useful in overweight
patients

Gonadotrophins
May be beneficial in
patients who do not
respond to clomid and
metformin

Treatment
Hirsutism
Conservative-bleaching
,waxing, laser+eflornithine
OCP: Thought increase SHBG
and so decrease free
testosterone
Spironolactone, flutamide,
finasteride (not very effective
with significant risk profiles)

Infertility

Weight loss

increases ovulation

Ovarian drilling with laser

Preventing endometrial
hyperplasia
Any cyclic progesterone
will balance the high
estrogen state

Menorrhagia
Def: Excessive bleeding in
an otherwise normal cycle
>80ml
Affects womans quality
of life
Ix

Speculum exam
Smear
TVUS
FBC
If >41yo, hysteroscopy or
pipelle biopsy
TFTs, coag as indicated

Causes
Anatomic

Fibroid (30%)
Cervical polyp (10%)
Endometrial polyp
Adenomyosis
Infx: PID
CA:Endometrial cancer
Cervical cancer
Ovarian cancer

Systemic causes
Hypothyroidism
Von Willebrands disease

Management
Mx
Treat anaemia
Rule out local causes
and malignancy
Treat symptoms

Always consider the

patients
contraceptive needs
and family plans

Medical
First line:
Mirena IUD
Decreases BL 50-80%

Second line
NSAIDs: inhibit PG
synthesis, decrease BL 30%
Tranexamic acid: anti
fibrinolytic, decrease BL
50%
COCP

Surgical
Endometrial ablation
Microwave

Dysmenorrhea

1ary dysmenorrhea
No underlying pathology
Abnormal PG ratios nervous sensitization
Pain begins with onset of period
2ary dysmenorrhea
Typically precedes the period
May be associated with dyspareunia
Causes
Endometriosis
Adenomyosis
PID
Adhesions
Developmental abnormalities: vaginal
septum, partially imperforate hymen

Exam
Enlarged tender, boggy uterus in
adenomyosis
Finding of endometriosis
Partially imperforate hymen
Vaginal septum
Chandelier sign (cervical excitation) =
PID

Ix
High vaginal swab, endovervical swabs
(chlamydia, Gonorrhoea)
Pelvic/TV ultrasound
Laparoscopy

Mx
NSAIDs
Mefenamic acid

Mirena
Danazol (GnRH antagonist) (anbonist)
Leuprolide acetate GnRH agonist

Fibroids

Management

Oestrogen dependent leiomyoma

25% women
Incidence higher in Afro Caribbean
women

Categories
Submucosal
Intramural
Subserosal

Symptoms

50% asymptomatic
30% menorrhagia
IMB
Subfertility (submucosal)
Pressure effects (abdo discomfort,
bloating, urinary frequency /
retention, dyschezia)
Usually do not cause dysmenorrhea

Conservative
Medical
GnRH analogs (leuprolide)
Ullipristal acetate
6/12 therapy, decreases size by up to
50%

Uterine myomectomy
Uterine artery embolisation

Indications for removal

?Subfertility
12 week uterus
Severe menorrhagia

Complications
Enlargement
Red degeneration
Outgrow blood supply
Pain, haemorrhage, necrosis
Increased risk in pregnancy

During pregnancy

PTL
Breech, transverse lie
Obstructed labour
PPH

Endometriosis

10-12% women
Oestrogen dependent benign
inflammatory condition
Ectopic endometrial glands and
stroma
Hx

Deep dyspareunia (uterosacral

ligament involvement)
Dysmenorrhea (pre menstrual)
Dyschezia
Urinary symptoms
Subfertility
Chronic pelvic pain

Exam

DRE

Bimanual Pelvic
Tenderness
Ovarian mass
Uterus fixed in retroversion
Nodules in POD
Speculum exam (rarely visible)
Nodules in rectovaginal septum

Ix

Gold standard: laparoscopy + biopsy

Gunshot lesion/Powder burn/ Clear vesicles

Endometrioma chocolate cysts
If >3cm, biopsy
Classify severity

MRI / barium enema / IV urography

Grading: American Soc of
Reproductive Medicine
Check out extent of bladder, rectovaginal,
ureteric or bowel involvement

Takes into account: Location, Size,

Depth of infiltration, Adhesion: Colour,
form, texture, extent of enclosure
Indx for laparoscopy:

Minimal / Mild / Moderate / Severe

Pain days of school/work

Infertility
NSAID resistant abdo pain/ dysmenorrhoea

Endometriosis

Mx
Symptomatic
Analgesia-NSAIDs
Ovarian suppression
COCP
Progestogens
Second line:
GnRH agonists e.g decapeptyl
Mirena (levonorgestrel (Prog))

Surgery
Helica electromagnetic
wave
First line to improve fertility
20-50% will have recurrent
symptoms
Mirena may increase time to
recurrence

Complications
** quality of life
Small ^^risk
endometrioid/clear cell
ovarian ca
Subfertility
25-50% women with
endometriosis have infertility
25-50% women with infertility
have endometriosis
Causation not established
Remove endometriomas
>3cm by cystectomy.
Medical treatment does not
help subfertility

Primary amenorrhea
Ix: 16 + secondary sexual characteristics
14 if no secondary sexual characteristics
First investigation: Pelvic exam + U/S

Uterus present

Uterus Absent

FSH

Karyotype + serum
testosterone
; MRI to confirm
normal urinary tract
and spine

Elevated: ovarian
pathology
Turners most common
(45 XO)

Low: cranial pathology

MRI to rule out
Kallmanns (anosmia)
or malignancy
Constitutional most
common cause

Mullerian duct
abnormality e.g Maryer
Rokitansky
Androgen insensitivity
syndrome (46XY)

Secondary amenorrhea
Invx

History
Exam -BMI
Beta hCG
Prolactin
TFTs
FSH/LH
Testosterone
Hx of uterine procedures: progestin
stimulation test

No withdrawal bleed:
Hysteroscopy + HSG to
R/O Ashermanns
Withdrawal bleed: FSH/LH
Elevated FSH/LH: PCOS,
premature ovarian failure
Low FSH/LH: history,
consider MRI if suspicious

Causes

Pregnancy, Lactation
Premature menopause
Hyperprolactinaemia
Hyperthyroidism/hypo
thyroidism
PCOS
Stress
Exercise
Weight loss
Ashermans

Menopause

Median age of onset: 51

Cessation of menstruation
due to ending of ovarian
function
Diagnosed retrospectively
as 12 months after a
final period
Climacteric:
perimenopausal period.
From the start of
symptoms to 12 months
after the final period.

Symptoms
Early
Psychological
Including sexual dysfunction

Vasomotor: 70% women

Night sweats
Hot flushes
Classically last 5 years
Most common indication for
HRT

Intermediate
Vaginal atrophy
Urogenital atrophy
Skin atrophy (collagen)

Late
CVA
CVS: IHD
Osteoporosis

Menopause

Ix
Elevated FSH (d2-5)
(>30IU/L)
Decreased AMH

Mx
Conservative
Reassurance

HRT
Oestrogen: oral, patch,
implant, gel
Progesterone
Must be given if the
patient has a uterus

Continuous therapy
Alternatives to HRT:
Vasomotor:

SSRIs (fluoxetine, Paroxetine)

SNRIs (Venlafaxine)
Osteoporosis

Bisphosphonates, Ca, Vit D, SERMs

Urogenital

Oestrogen cream, vaginal lubricant

Risks of HRT
^^ risk :
Endometrial cancer
Breast cancer: extra 4/1000
cases after 5 years Rx
VTE (transdermal HRT = lower risk of
VTE than oral)

GB disease
Ovarian cancer if taking Oe
ALONE for >10yrs

Benefits of HRT
** vasomotor symps
** urogenital dysfnc
Improves sexual fnc
**risk colorectal cancer
** risk Osteoporosis

Causes

Vaginal
discharge

Physiological
Most common

Infection

Chlamydia (AD)
Obligate intracellular bacteria
No cell wall
Clear discharge
Associated urethritis, cervicitis
Invx: NAAT (nucleic acid amp test)
Rx: azithromycin 1g single dose OR
Doxycycline 100mg bd x7days
Contact tracing
Rx pregnant: Erythromycin 500mg bd 10-14d

Candida

Yeast like fungus

Creamy cottage cheese like discharge
Itch
Oral nystatin, topical clotrimazole

Bacterial vaginosis

Not sexually transmitted

Gardnerella most common
White/grey watery discharge
Fishy smell
Clue cells on microscopy
pH >4.5
Rx: metronidazole

Trichomonas

Green frothy discharge

Offensive smell
Invx: Motile trophozoites on microscopy
May be sexually transmitted
Rx: metronidazole

Gonorrhea (CA)
Gram negative diplococcus
Purulent discharge
Associated urethritis, cervicitis
NAAT
Rx: ceftriaxone 500mg IM STAT (OR
spectinomycin 2g IM)
+ azithromycin PO 1g stat
Contact tracing
Pregnancy RX = same
Other causes:

Foreign body, Atrophic vaginitis, Malignancy

Invx:

Vulvovaginal/ Endocervical swab

Vaginal pH measurement

Saline wet mount microscopy + gram staining (if

available)

Colposcopy: If abnormal cervical appearance

NAAT: Chlamydia, Gonorrhoea

STDs
Chlamydia compx

PID

Perihepatitis (Fitz Hugh Curtis)

Reiters syndrome

Tubal Infertility

Ectopic risk

Pregnancy compx:

PROM,

Preterm delivery,

Neonatal pneumonia + conjunctivitis

Gonorrhoea compx

PID

Bartholins abscess

Tubal infertility

Ectopic

Disseminated disease:
Fever, pustular rash,
septic arthritis,
migratory polyarthritis

Pregnancy:

PROM

Preterm delivery

Chorioamnionitis

Ophthalmia neonatorum

Contraception Station
Most effective methods (>99%) =

Implanon Adv: Effective 3 yrs. Fertile once stopped.

Safe whilst breastfeeding

Disadv: Weight gain, depression, irreg periods

MOA: x Ovulation. ^^ cervical mucous viscosity

Moderate Efficacy (75-90%)

Diaphragm must be fitted by provider
Condom male/female
Fertility awareness methods

Least Effective:
Spermicide
Contraind
to
Common
Withdrawal

Mirena (IUD with progestin)

Adv: Effective 5 yrs. Fertility once stopped.
Breastfeeding safe. Lighter periods, less cramp
Disadv: Spotting <6 months. Acne. Perforation
1/1000
MOA: Inflammation rxn. Cervical thickening +
endometrial decidualization
Copper T wire (IUD):
Adv: 10 yr effective, Fertility when stopped. Breastfeed
Disadv: ^^ cramping + bleed. Uterine puncture
1/1000
MOA: Inflammation rxn. Copper = spermicide
Surgical sterilization:
Adv: Permanent effective. Safe breastfeeding
Disadv: Tubal ligation- Irreversible. ^^ectopic preg
Vasectomy- Failure. Usually because didnt
wait for 2 negative sperm samples

Very Effective (90-99%):

OCPs:
Adv: ** risk ovarian and endometrial CA

Predictable, lighter, less painful periods.

** acne. Immed fertility on cessation

Disadv: Must take daily. Thromboembolism risk

Breakthrough bleeding 10-30%

MOA: X FSH/LH X ovulation.

^^ cervical mucous and endometrial

decidualisation

Contraceptive Methods

Oe-containing (OCPs,
Nuva ring, Ortho Evra)

IUDs Mirena, Copper T

Pregnancy
Unexplained abN vaginal
bleed.
CA: Breast/endometrium
hx
Liver neoplasm
Stroke/DVT hx
>35 and smoker

Pregnancy
Unexplained vaginal bleed
CA: Cervical/uterine
Heart valve replacement
hx
Artificial joint hx
Purulent cervicitis
Confirmed symp
actinomycosis
PID- active or recurrent
2 atypical pap smears
Uterus bicornuate/septate
Mirena alone
Levonorgestrol intolerence
Breast CA
Liver neoplasm
Copper T alone
Copper intolerence
Severe dysmennorhoea
Severe menorrhagia

Contraception
First I need to ask you about your health and
relationship status to figure out which contraception
method will suit you best.
Age
Relationship: Single or multiple sexual partners: Need
barrier method to prevent STD transmission
Menstrual hx: Cycle length/Regular/IMB/Menorrhagia.
Hormonal contraception can make periods lighter
Prev contraception: Current/Side effects/Try similar
PMHx: Liver disease, PV bleed, Breast CA
Drugs: ** OCP efficacy:Anti-epileptics (Phenytoin,
Carbamazepine, Phenobarbital, Ethosuximide), Rifampin, St.
Johns wort, Anti-fungals, Vaccines: HPV, Hep, Pap smear
(>25)
Contraind COCP: Smoking
FHx of Clots/Migraine with aura/Breast CA/Cervical CA
What they like and know
Hopes: What do you want to get out of this consultation
Preferences
Preferred delivery
Forgetful- Mirena, Implant, Injection
Like injections?
Starting family soon?:Avoid injx as fertility can take 6mos to
return
Describe method
How it works
How to take/Treatment course
Efficacy
Side Effects
Positive vs Negative

Mention Alternatives- Briefly discuss

End:

Ill let you think about it. Im here to advise you if

youd like to discuss it again.
Summarise
Leaflets and websites

To note:

Contraception

Combo OCP
Who?

Anyone EXCEPT: >35 yr old smoker, BMI>40m, Hx of CVA, venous thromboembolism, HTN, inherited
thrombophilia, Current breast CA, on enzyme inducers.

Failure

Pearl index (x/100 women in 1 year): Perfect use PI of 1.

effective

Mode of
Action

X ovulation. Thickens cervical mucous (mechanical sperm barrier). Thins endometrium

How to use

3 weeks on, 1 week placebo, beginning day 1 of cycle

Rare major
Ses

DVT, CVA, IHD, HTN, Breast + cervical CA

Common
Ses

Breast tenderness, bleeding, headaches, nausea

Benefits

Cycle control. Controls dysmenorrhoea and bleeding.

Reduces risk of fibroids, and ovarian, cervical and endometrial CA

Typical use = PI of 5

99%

Drawbacks
User dependent efficacy. Major Ses and contraindications.
Progestogen only
pill#
(e.g.
minipill)
Comment
If miss
1: Take
it ASAP,
even with next pill. If miss 2 pills = 7 day condom rule.
IfForgetful,
on enzyme
inducing
drugs
(anti-fungals,
some abx)7 day condom rule
Who?
Liver
disease,
Breast
CA, Undiagnosed
PV bleed.
Failure

Perfect use: PI of 1.

Typical use: PI of 5

99% effective

Mode of
Action

^^ cervical mucous. Thins endometrium. In women, also X ovulation.

How to use

Take at same time every day (3 hrs), NO BREAK. If you miss the window, take the pill ASAP and
wear a condom for the next week.

Common
Ses

Vaginal spotting, weight gain, PMS-like symps.

Benefits

Few Ses and contrainds.

Not affected by broad spectrum antibis

Drawbacks

Compliance and failure rates ^^

Progestogenic Depot
Who?
Epi
Failure

Those with compliance issues .

Contraind: Liver/Breast/Genital CA, Undiagnosed PV bleed, Liver disease.
PI = 0.5

MOA

^^ cervical mucous. Thins endometrium. Most= X ovulation

How to
use

Depot IM. Depo-Provera = 1/3months.

Nexplanon = 1/3 yrs

Commo
n Ses

Progestogenic (vaginal spotting, weight gain, PMS-like symps).

Depo-Provera Prolonged amenorrhoea, reversible bone loss

Benefits

No user dependent failures

Drawba
cks

Progestogenic Ses. Cant remove once given, so Ses will

Continue LT.

Noristerat = 1/8wks.

Condoms
Who?

Any, casual sex. Contraind = allergy

Failure

PI of 2 (perfect use).
PI 15

How to
use

New condom each time have sex

Benefits

Safe. Protects against STIs. Nonhormonal

Typical use=

Drawbac Failure rates. Poor technique.

ks
Diaphragm Inconvenience. Some lubricants not
compatible
Who?
Motivated women, usually monogamous

Contraception
Sterilization
Who?

Older. Finished with family

Failure

Female 1/200 lifetime incidence. MALE

1/2000

How to
use

Female: Laparoscopic clips

Male: Vasectomy = Ligation + removal of
segment of vas deferens through cuts in
scrotum. Local anaesthetic. Takes 20 mins

Ses

F:Anaesthetic risk, bleeding, bruising

M:Bleed, bruise, infx, chronic testicular pain
(1-3%), sperm granulomas form if leaks

Failure

Perfect use PI = 5. Typical use PI = 15

How to
use

Put on before sex with spermicide. Remove 6

hrs later.
Benefits

Benefits

Non-hormonal. Woman in control

Drawbac

Failure rates. Limited STI protection.

Drawba
cks

Permanent
Expensive and difficult to reverse with varied
success.

Contraception
Implanon (Progesterone Implant)
Contraind

Liver/genital/breast CA, Liver disease, Undiagnosed PV bleed, Enzyme

inducing drugs

Failure

99% effective

MOA

X ovulation. Thickens cervical mucous. Thins endometrium

How to
Use

Lasts 3 yrs

Ses

Hormonal Ses (Weight gain, acne, mood changes, headache)

Insertion risks (bruising, infx, scarring, expulsion)
Periods can stop/ilonger/irreg

Benefits

Forget about it

Drawback
s

Can feel it

Note

Inserted under local

anaesthetic,
into inner-upper arm (4cm long)
Merena
Coil (IUS)
Contrai
nd

Pelvic infx, PID <3mo, Small uterine cavity, Gynae Ca, Undiagnosed PV
bleed,

Failure

BEST! >99% efficacy

MOA

X ovulation. ^^cervical mucous. Thins endometrium

How to
use

Lasts 5 yrs.

Ses

Coil insertion risks (Infx <3wks, perforation, bleeding, vasovagal).

Spotting for first 6mo, then light/stop

Benefits

Can forget about it. ** period severity

Drawba
cks

Check for string monthly. STI check before insertion.

Note

Can insert at any time if not had sex since period, OR insert within first
5 days of start of period.
Can stay in place until
menopause if fitted >45

Contraception
IUDs (copper wire)
Who?
Contraind

Older, multiparous, monogamous

Pelvic infx, PID <3mo, Gynae CA, Copper allergy, Undiagnosed PV bleed,
Small uterine cavity

Failure

PI <1 depending on type (Mirena PI = 0.1)

MOA

Spermicide + Inflammation uterus X implantation and fertilisation

How to use

Implant into uterus. Lasts 5 yrs

Ses

Coil insertion risks: Infx <3wks, Bleed, Perforation, vasovagal)

Periods heavier

Benefits

Can forget about it.

Drawbacks

Pelvic infx. Check for string monthly. STI check before insertion

Note:

Put in anytime if no sex since period/ within first 5 days of period. Can stay
in place until menopause if fitted >40.

Contraception
Contraceptive options
Barrier
Condom
Diaphragm+spermicide

Hormonal

COCP
POP
Depo-provera
Implanon
IUD: IUCD, Mirena, Jaydess

Permanent
Sterilisation (male and female)

Non-hormonal
Rhythm method
Basal temperature method

Pearl Index
Number of
pregnancies/100
womaN/ year
Condoms: 2
Mirena: <0.01
COCP: 1

Combined OCP
Contains both
oestrogen and
progesterone
1st generation: 50mcg
oestrogen
2nd generation: 20-30
mcg oestrogen
3rd generation: new
progesterones
(gestodene,
desogestrel)

Indications
Contraception
Cycle control
Menorrhagia
Dysmenorrhea
Acne/hirsutism
Yasmin
Dianette
(cyproterone
acetate)

Combined OCP
Absolute
contraindications (MEC
4)
Hx stroke or CVA
Hx IHD, MI, hypertension
Hx DVT/PE
BMI>40
>35 +smoking>15/day
Hx breast ca
Hx migraine with aura
Liver disease

Risk of non fatal VTE

(/100k women/year)

Background risk:5
2nd gen pill: 15
3rd gen pill: 25
Smoking + pill: 60
Pregnancy: 60

Risk greatest in first

3/12 (exception:
cyproterone)

COCP
Side effects
Increased risk
IHD/MI
Hypertension
Breast cancer
Cervical cancer
Focal migraine
CV
Jaundice

Oestrogenic side effects

Nausea (most common)
Vascular headache
Hypertension

Progesterone side
effects
Breast swellling and
tenderness
Weight gain and bloating
Mood swings
Acne
Breakthrough bleeding

COCP
Missed pill rule
Miss one
Take when you
remember
No extra precautions
needed

Miss >2
Use precautions or
abstain for next 7 days
Day 1-7: get emergency
contraception
Day 14-21: start the next
pack without a break

Drugs that
interfere with COCP
metabolism
Some antibiotics:
rifampicin
CYP450 inducers
Anti-epileptics:
Ethosux, Phenytoin,
Phenobarbital

IUD

Copper
Prevents fertilisation-copper is
toxic to sperm
Prevents implantation
May be used as emergency
contraception for 5 days post
exposure
Insertion: during 1st half of
cycle. May be inserted in
puerperium
Lasts up to 10 years

Contraindications
Endometrial ca
Cervical ca
Undiagnosed vaginal
bleeding
Active/recent infection
Pregnancy

Risk
Cervical shock
(parasympathetic-pelvic
splanchnic nerves)
Uterine rupture
Expulsion
Infection (actinomyces
israelii)
Ectopic pregnancy
Menorrhagia

Mirena/Jaydess
Mirena
Levenorgestrel
Lasts 5 years
Action: alters
cervical mucus and
uterotubal fluid
Prevents
implantation

Risks
As for IUD-except,
decreased risk of
menorrhagia

Indications
Contraception
Menorrhagia
Progesterone
component of HRT

LARC
Depo Provera
Medroxyprogesterone
acetate
IM, 3/12
Max duration of Rx 2
years

Disadv:
Increased risk
osteoporosis
Delayed return to
fertility: 6-18 months

Implanon

Lasts 3 years
Subdermal implant
Slow release
Irregular bleeding

EXTRA OBSTETRICS
NOTES

High risk pregnancies

Outline the visit schedule for a patient carrying MCDA
twins
Monochorionic twin gestation should be regarded as highrisk
Consultant-led dedicated obstetric clinic
Counsel about possible structural anomaly
Offer anatomy scan at 20 weeks
Screen every 2-3 weeks from 16 weeks
Screen every 1-2 weeks from ~ 32 weeks
Threshold for significant birth weight discordance, i.e. that
associated with an increase in perinatal morbidity, is 18%
both for dichorionic twins and for monochorionic twins without
twin-twin transfusion syndrome (ESPRiT study Ireland)
Target delivery @ 37 weeks (C-section or induction)
Earlier if signs of maternal or fetal demise

High risk pregnancies

Infant identified as
SGA
Scan every 2-4
weeks
Increase visits as
per umbilical artery
doppler scores
See obstetrics
lecture for in depth
timeline

GDM booking visits

Pre existing
diabetes visits
See attached slides

T1: Bloods, US 710wks

T2: US 18-20wks,
Compx

T3: 2xUS,
Macro/polyhydra
m
Foetal
movements
Anaesthetic
review

Bishops Score
https://
en.wikipedia.org/wi
ki/Bishop_score