SNI Gynaecology

Progress Notes

1 CA Cervix

2 CA Ovary Reassess types for prof

3 CA Endometrium

4 Endometriosis Correlate with pelvic in ammatory

disease and Adenomyosis if
questions don’t show up

5 PCOS Correlate with HMB

6 HMB Linked to endometriosis, PCOS and

broids

7 Ectopic
Pregnancy

8 Fibroids Correlate with HMB

9 Molar Pregnancy

10 UV Prolapse

11 Miscarriage Types need rethinking

12 Fertility Rethink Evaluation

13 Adenomyosis Questions missing

14 STIs Questions missing

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 CA Cervix SNI

A 50 years old lady presents in OPD with

history of inter menstrual and post coital
bleeding for 6 months. Now she has offensive
vaginal discharge for last 2 weeks. On
examination there is a 3cm fungating lesion
seen on anterior lip of cervix.

Vaginal walls are normal. On abdominopelvic

ultrasound no abnormality detected.
What is your provisional CA Cervix
diagnosis?
What investigations will be • Pap smear (Papanicolaou test)

carried out to con rm your • Cytology from the swab used as a rst
diagnosis and plan further line detection test.

management?
• Then the following assessment are indicated.

• Colposcopy and Biopsy

• First line after a positive pap smear

• Types of biopsy include

• Punch biopsy

• Wedge biopsy

• Ring biopsy

• Cone biopsy


• Conization of cervix


• Cystoscopy and Proctosigmoidoscopy

• Indicated if the tumour is bulky


• Barium enema studies are followed to

assess rectal involvement.

Staging workup

• Chest Xray to look for pulmonary metastasis

• Examination under anaesthesia

• Cystoscopy and radicalsigmoidoscopy

• CT scan of the abdomen and pelvis is

performed to look for metastasis in the liver,
lymph nodes, or other organs

• PET scan

• Surgical staging after nonsurgical staging and

FNAC fail to assess complete extent.
What is the stage of the Stage 1 as it is con ned to the cervix. The International
disease if all other Federation of
investigations are normal? Gynaecology and
Obstetrics (FIGO) staging
system is used to stage
cervical cancer:

• Stage 1: Con ned to

the cervix

• Stage 2: Invades the

uterus or upper 2/3
of the vagina

• Stage 3: Invades the

pelvic wall or lower
1/3 of the vagina

• Stage 4: Invades the

bladder, rectum or
beyond the pelvis

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What treatment you will
offer the patient according
to her stage of disease?
2
LLETZ or cone biopsy Management of cervical
cancer depends on the
Large loop excision of the transitional zone. stage and the individual
situation. The usual
treatments are:
• Cervical
intraepithelial
neoplasia and early-
stage 1A: LLETZ or
cone biopsy
• Stage 1B – 2A:
Radical
hysterectomy/
trachelectomy and
removal of local
lymph nodes with
chemotherapy and
radiotherapy
• Stage 2B – 4A:
Chemotherapy and
radiotherapy
• Stage 4B:
Management may
involve a
combination of
surgery,
radiotherapy,
chemotherapy and
palliative care
 CA Ovary SNI

A 50 years old, post-menopausal lady, Huga

smoker, nulliparous presented with
abdominal pain and distention for last 6
months associated with weight loss. Her
mother died of CA breast. On examination of
abdomen a hard mass of 18 weeks size is
palpable more on left side with reduced
mobility. Shifting dullness is positive. On
bimanual vaginal examination there is
fullness in left adnexa. Uterus and right
adnexa are normal
Which is the most likely CA ovaries

diagnosis in this patient?

What risk factors can you • Age (peak age 40- 60)
identify in her for this
condition? • BRCA1 and BRCA2 genes (consider the
family history)

• Increased number of ovulations

• Obesity

• Smoking

• Recurrent use of clomifene

• Early menarche and late menopause

• Workplace hazards like Asbestos

• Pelvic radiation
Justify the investigations The initial investigations in primary or
you will advise to con rm secondary care are:
the diagnosis.
• CA125 blood test (>35 IU/mL is signi cant)

• CEA

• B HCG

• Inhibin Alpha Feto Protein

• Base line bloods

• CP

• Urea

• Creatinine

• Elctrolytes

• LFTs

• RFTs

• Viral serology

• Pelvic ultrasound

• Trans Abdominal Ultrasound

• Trans Vaginal Ultrasound

Further investigations in secondary care

include:

• CT scan to establish the diagnosis and

stage the cancer

• Histology (tissue sample) using a CT

guided biopsy, laparoscopy or
laparotomy

• Paracentesis (ascitic tap) can be used

to test the ascitic uid for cancer cells

Staging

• Chest Xray to look for pulmonary metastasis

• Examination under anaesthesia

• Cystoscopy/ IVU and radicalsigmoidoscopy

• CT scan of the abdomen and pelvis is

performed to look for metastasis in the liver,
lymph nodes, or other organs

• MRI/PET scan

• Surgical staging after nonsurgical staging and

FNAC fail to assess complete extent.

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 Give the management plan Ovarian cancer will be managed by a specialist
for her gynaecology oncology MDT. It usually involves a
combination of surgery and chemotherapy.

Treatment is commenced after staging is done.

Total abdominal hysterectomy with bilateral
salpingo-oophorectomy

Stage 1a and 1b are explored with staging

laparotomy. Operate unilaterally to preserve
fertility

1c and more are also given adjuvant

chemotherapy.

Stage III and IV are given chemotherapy which is

platinum based and Bevacizumab.

Biopsy from lymph nodes and under surface of

diaphragm and send for histopathology.

Chemotherapy is 6 cycles at 4 weekly intervals.

Second look surgery at a later stage.

What is Risk Malignancy The risk of malignancy index (RMI) estimates Ultrasound

Index(RMI)? the risk of an ovarian mass being malignant, Multilocular cyst 1

taking account of three things: Solid areas 1

Metastasis 1

Ascities 1

• Menopausal status B/L lesions 1

• Ultrasound ndings 0 no ndings

1 for 1 nding

• CA125 level 3 for 2 or above ndings

Premanupausal 1

Ultrasound ndings X Menopausal status X Post menopausal 3

CA 125 levels.

Less 25 is low risk

25 to 200 is medium risk

More than 200 is high risk

A 60 years old postmenopausal lady, treated

case of HCV now PCR negative presented in
Gynae OPD, with complaints of progressive
distension of abdomen, loss of weight and
appetite for the last 6 months. On
examination a 34 weeks size rm, xed mass
with ill-de ned margins arising from pelvis is
found Ultrasound showed a complex right
adenexal cyst with papillary projection
What is your provisional CA ovaries

diagnosis?
How will you investigate The initial investigations in primary or
the patient? secondary care are:

• CA125 blood test (>35 IU/mL is

signi cant)

• Pelvic ultrasound

Further investigations in secondary care

include:

• CT scan to establish the diagnosis and

stage the cancer

• Histology (tissue sample) using a CT

guided biopsy, laparoscopy or
laparotomy

• Paracentesis (ascitic tap) can be used

to test the ascitic uid for cancer cells
Outline management plan Ovarian cancer will be managed by a specialist
of the patient? gynaecology oncology MDT. It usually involves a
combination of surgery and chemotherapy.

Treatment is commenced after staging is done.

Stage 1a and 1b are explored with staging

laparotomy

1c and more are also given adjuvant

chemotherapy.

Stage III and IV are given chemotherapy which is

platinum based and Bevacizumab.

A 50 yrs old, post-menopausal lady, P1

presented with abdominal pain and distention
for last 6 months associated with weight loss.
Her mother died of CA breast. On examination
of abdomen a hard mass of 18 weeks size is
palpable more on left side with reduced
mobility. Shifting dullness is positive.

On bimanual vaginal examination there is

fullness in left adnexa. Uterus and right
adnexa are normal.
Which is the most likely
diagnosis in this patient?

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 What risk factors can you
identify in her for this
condition?
Justify the investigations
you will advise to con rm
the diagnosis.
How will you manage her?

A 45-year-old nulliparous lady presents with a

history of abdominal distension and weight
loss and loss of appetite for six months.
Ultrasound shows bilateral adnexal masses
with moderate ascites. A sister died of CA
breast and mother died of ovarian cancer.
D/Ds • Distended Urinary bladder
• Pregnancy
• Uterine swelling and displacements
• Broad ligament cysts
• Fallopain tube swellings
• Pelvic abscess
• Endometriosis and adenomyosis
• Ascites
• Other complications
Investigations
Management
How do you calculate RMI

60 y/o post menopausal lady w abdominal

pain + wt. loss. O/E hard mobile is palpable in
right adenexa. Uterus and left adenexa are
normal
Name the common ovarian Thecoma/Thecal cell tumour
tumour in this age group
Investigations
Management

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 CA Endo SNI

A 63 years old Obese, diabetic and

hypertensive patient presented with irregular
vaginal spotting and pelvic pain after
menopause of two years. Her ultrasound
pelvis shows uterus 12x9 cm with distended
endometrial cavity with echogenic shadow.
MRI shows endometrial mass of 20 x 30mm
invading myometrium up to more than 50%.
What is the most likely CA Endometrium
diagnosis?
Identify the risk factors for • Increased age
this condition in the given
scenario? • Earlier onset of menstruation

• Late menopause

• Oestrogen only hormone replacement

therapy

• No or fewer pregnancies

• Obesity

• Polycystic ovarian syndrome

• Tamoxifen
What further There are three investigations to remember
investigations are required for diagnosing and excluding endometrial
to con rm the diagnosis? cancer:

• Transvaginal ultrasound for endometrial
thickness (normal is less than 4mm
post-menopause)

• Pipelle biopsy, which is

highly sensitive for endometrial cancer
making it useful for excluding cancer

• Hysteroscopy with endometrial biopsy

What is the stage of the
disease and what
treatment will be offered
according to stage?
The usual treatment for stage 1 and 2 The International
endometrial cancer is a total abdominal Federation of
hysterectomy with bilateral salpingo- Gynaecology and
oophorectomy, also known as a TAH and Obstetrics (FIGO) staging
BSO (removal of uterus, cervix and adnexa). system is used to stage
endometrial cancer:
• Stage 1a
• TAH BSO • Stage 1: Con ned to
the uterus
• Stage 1b, c
• TAH BSO+ Paraaortic & pelvic lymph • Stage 2: Invades the
node evaluation followed by adjuvant RT cervix

• Stage II • Stage 3: Invades the

• Surgery + adjuvant RT ovaries, fallopian
• Radical hysterectomy with pelvic lymph tubes, vagina or
adenectomy followed by radiotherapy or lymph nodes
RT alone
• Stage 4: Invades
• Stage III
bladder, rectum or
• Surgery + adjuvant RT
beyond the pelvis
• Laparotomy
• Debulking, omenectomy and lymph
adnectomy

• Stage IV
• Radiotherapy
• Chemoradiotherapy

Hormone therapy
• If possible debulking

A 63 years old obese diabetic and

hypertensive patient presented in irregular
vaginal spotting and pelvic pain after a
menopause of 2 yrs. Her US pelvis shows
uterus 12x9 cm and with distended
endometrial cavity with echogenic shadows
and ET of 14 mm.
What is the most likely
diagnosis?
Enumerate the risk factors
for this conditions?
What investigations will
you perform?
How will you manage the
patient?

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 Endometriosis SNI

A 26 years old lady nulliparous married for 6

years presented in Gynae OPD with history of
severe dysmenorrhea and dysparunia. On
examination uterus is retroverted xed with
nodularity on uterosacral ligament.
Ultrasound showed 4X3 cm cystic lesion in
left adnexal with internal echoes, CA 125 is 78
miu/l.
What is your provisional Endometriosis
diagnosis?
How will you investigate • Speculum examination

this patient? • Deposits in the vagina

• Bimanual examination

• Fixed uterus

• Tenderness

Pelvic ultrasound may reveal large

endometriomas and chocolate cysts. Ultrasound
scans are often unremarkable in patients with
endometriosis. Patients with suspected
endometriosis need referral to a gynaecologist
for laparoscopy.

Laparoscopic surgery is the gold

standard way to diagnose abdominal and pelvic
endometriosis. A de nitive diagnosis can be
established with a biopsy of the lesions during
laparoscopy. Laparoscopy has the added bene t
of allowing the surgeon to remove deposits of
endometriosis and potentially improve symptoms.

CA125

CT/MRI

What are the treatment Initial management involves:

options available for this
patient? • Establishing a diagnosis
• Providing a clear explanation
• Listening to the patient, establishing their
ideas, concerns and expectations and
building a partnership
• Analgesia as required for pain (NSAIDs
and paracetamol rst line)
 

Hormonal management options can be tried

before establishing a de nitive diagnosis with
laparoscopy:

• Danazol to trigger early menopause

• Combined oral contractive pill, which can
be used back to back without a pill-free
period if helpful
• Progesterone only pill
• Medroxyprogesterone acetate injection
(e.g. Depo-Provera)
• Nexplanon implant
• Mirena coil
• GnRH agonists
 

Surgical management options:

• Laparoscopic surgery
to excise or ablate the endometrial tissue
and remove adhesions (adhesiolysis)
• Presaccral neurectomy

• Hysterectomy
• TAH and BSO

Laparoscopic treatment may improve fertility.

What are the possible
causes of infertility in this
patient if her husband
semen analysis is normal?
Hormonal therapies may improve symptoms but
not fertility.
Adhesions around the ovaries and fallopian
tubes, blocking the release of eggs or kinking the
fallopian tubes and obstructing the route to the
uterus.

A couple comes to OPD with history of failure

to conceive for last 5 years.
Female partner has regular menstrual cycle
with severe dysmenorrhea and deep
dyspareunia. On pelvic examination uterus is
retroverted, with restricted mobility and is
tender.
What is the mostly likely
diagnosis and cause of
this problem?

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 How will you evaluate both
partners to reach a nal
diagnosis?
What are the management
options available for the
female partner if no
abnormality is detected in
male partner?

A. 26 years old lady, nulliparous married for 6

years, presented in Gynae OPD with history of
severe dysmenorrhea and dysperunia. On
examination uterus is retroverted xed with
nodularity on uterosacral ligament.
Ultrasound showed 4X3cm cystic lesion in left
adnexal with internal echoes.
What is your provisional
diagnosis?
What are the underlying
causes of infertility in this
patient if her husband
semen analysis is normal?
What further
investigations will you
carry out to con rm the
diagnosis and nd out the
cause of infertility?
What are the treatment
options available for this
patient?

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 PCOS SNI

A 26 years old lady presented with

oligomenoorhea for last 1 year. She is having
amenorrhea for last three months. She also
gives history of acne and hirsutism. Her BMI
is 36 KG/m 2. Her ultrasound revealed
bilateral enlarged ovaries. Right ovarian
volume is 12 cm3 and left ovarian volume is
11cm 3.
What is the provisional Polycystic Ovarian Syndrome
diagnosis?
Justify the investigations • Blood biochemistry
required for con rmation
of diagnosis. • NICE guidelines recommend the following
blood tests to diagnose PCOS and
exclude Other pathologies with similar
presentation:

• Luteinising hormone - raised

(LH:FSH will be raised)

• Testosterone - raised

• Sex hormone-binding globulin

• Follicle-stimulating hormone

• Prolactin (mildly elevated in PCOS)

• Thyroid-stimulating hormone

• Pelvic Ultrasound

• Transvaginal ultrasound - gold standard

for visualising ovaries.

• Follicles may be arranged around the

periphery of the ovary, giving a “string of
pearls” appearance. The diagnostic
criteria are either:

• 12 or more developing follicles in one

ovary

• Ovarian volume of more than 10cm3

• Screening for diabetes

• 2-hour 75g OGTT - screening test of choice

for diabetes in patients w PCOS.

• An OGTT is performed in the morning prior

to having breakfast. It involves taking a
baseline fasting plasma glucose, giving a
75g glucose drink and then measuring
plasma glucose 2 hours later.

• The results are:

• Impaired fasting glucose – fasting

glucose of 6.1 – 6.9 mmol/l (before
the glucose drink)

• Impaired glucose tolerance – plasma

glucose at 2 hours of 7.8 – 11.1
mmol/l

• Diabetes – plasma glucose at 2 hours

above 11.1 mmol/l

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 Outline the steps of • General management
management for this
patient? • Weight loss - Orlistat can be used if BMI>
30.

• Calorie-controlled diet

• Exercise

• Smoking cessation

• Antihypertensive medications where

required

• Statins where indicated (QRISK >10%)

• Regular assessment for associated features

and complications, such as: Endometrial
hyperplasia and cancer, Infertility, Hirsutism,
Acne, Obstructive sleep apnoea, Depression
and anxiety.

• Management of Infertility

• Weight loss

• Clomifene

• Laparoscopic ovarian drilling - multiple

holes are punctured in the ovaries using
diathermy or laser therapy. This can result in
regular ovulation and fertility.

• In vitro fertilisation (IVF)

• Women that become pregnant require

screening for gestational diabetes.
Screening involves an oral glucose tolerance
test, performed before pregnancy and at 24
– 28 weeks gestation.

• Hirsutism

• Weight loss

• Combined Oral Contraceptive Pills -

• Co-cyprindiol (Dianette)

• Topical e ornithine for facial hirsutism.

• Other options include:

• Electrolysis

• Laser hair removal

• Spironolactone (mineralocorticoid
antagonist with anti-androgen e ects)

• Finasteride (5α-reductase inhibitor

that decreases testosterone
production)

• Flutamide (non-steroidal anti-

androgen)

• Cyproterone acetate (anti-androgen

and progestin)

• Management of acne

• The combined oral contraceptive pill - 1st

line. Co-cyprindiol (anti-androgen e ects)
can be used

• Other standard treatments for acne

include:

• Topical adapalene (a retinoid)

• Topical antibiotics (e.g. clindamycin

1% with benzoyl peroxide 5%)

• Topical azelaic acid 20%

• Oral tetracycline antibiotics (e.g.

lymecycline)

• To reduce risk of endometrial CA

• Mirena coil for continuous endometrial

protection

• Inducing a withdrawal bleed at least every

3 – 4 months with either:

• Cyclical progestogens

• Combined oral contraceptive pill

What are the long term • Increased risk of Insulin resistance, DM and
consequences of this GDM

disease? • Acanthosis nigricans

• Cardiovascular disease

• Advanced atherosclerosis

• Hypercholesterolaemia - low HDL and high

TGL

• Endometrial hyperplasia and cancer

• Ovarian CA

• Breast CA

• Obstructive sleep apnoea

• Metabolic syndrome

• Depression and anxiety

• Sexual problems

• Infertility

A 30 years old married lady presented in OPD

with complains of failure to conceive,
oligumenorrhea and excessive hair growth on
chin and face for last 8 months. On
examination she is obese with BMI of 35Kg/
m2. Rest of the general physical and
abdominal examination is unremarkable.

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 What is your provisional
diagnosis?
What criteria is used for
the diagnosis of this
condition?
The Rotterdam criteria are used for making a
diagnosis of PCOS. A diagnosis requires at least
two of the three key features:

Oligoovulation or anovulation, presenting with

irregular or absent menstrual periods

Hyperandrogenism, characterised by hirsutism

and acne

Polycystic ovaries on ultrasound (or ovarian

volume of more than 10cm3)
How will you manage this
case?
What are the early and late • EARLY

consequences associated • Anovulation

with this condition? • Oligoovulation

• Amenorrhoea

• Oligomenorrhoea

• Hyperandrogenism

• Hirsutism

• Acne

• Hair loss

• Obeisity

• LATE

• Increased risk of Insulin resistance, DM

and GDM

• Acanthosis nigricans

• Cardiovascular disease

• Advanced atherosclerosis

• Hypercholesterolaemia - low HDL and

high TGL

• Endometrial hyperplasia and cancer

• Ovarian CA

• Breast CA

• Obstructive sleep apnoea

• Metabolic syndrome

• Depression and anxiety

• Sexual problems

• Infertility

A 30 years old nulliparous female married for

last 7 years presented with history of
oligomenorrhea, weight gain. On examination
her weight is 85 kg. BP is 130/85 mmH and
has acne and hair growth on chin. She wishes
to conceive.
What is your provisional
diagnosis?
What criteria are used for
the diagnosis of this
condition?
How will you manage this
case?
what are the risk factors • Obeisity

associated with this • Positive family Hx

condition? • Sedentary life style

• Diet high in sugar and high glycemic index

• Insulin resistance and Diabetes

• Ethnicity - Caucasian, African-American,

South Asian women

A couple comes to OPD with history of

primary infertility for last 5 years. Female
partner is 28 years of age with history of
oligomenorrhoea and weight gain for last 4
years. On Examination her BMI is 32.
What is the probable Anovulation (PCOS)
cause of infertility in this
couple?
How will you further
evaluate the couple by
history and examination to
nd out other causes of
infertility?
What initial investigations
will you carry out in this
couple?

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Describe the drugs used • OVULATION INDUCTION

for ovulation induction?

• Antiestrogen drugs

• Clomiphene citrate

• Tamoxifen

• Letrozole

• Dopamine agonists

• Bromocriptine

• Cabergoline

• Gonadotrophins

• HMG

• GnRH analogues

• Metformin - insulin sensitising agent

• Other methods to induce ovulation include

laparoscopic ovarian drilling

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 Heavy Menstrual Bleeding SNI

A 40 years old patient para4+0 presented in

Gynae OPD with complain of heavy menstrual
ow and passage of clots for last two years.
She has cycle of 8/24 days. She also gives
history of dyspnea and easy fatiguability. Her
past medical & surgical history is
insigni cant. On examination she is very pale
and abdominal examination is unremarkable.
On vaginal examination uterus 8 week size
anteverted, mobile and bilateral adnexa free.
On USG no focal lesion is found.
What is the di erential • Polycystic ovarian syndrome Polyp

diagnosis? • Fibroids Adenomyosis

• Dysfunctional uterine bleeding (no Lyomioma Fibroid

identi able cause) Malignancy

• Extremes of reproductive age Coagulopathy

Ovulatory disorder PCOS

• Endometriosis and adenomyosis

Endometrial causes

• Pelvic in ammatory disease (infection) Iatrogenic Warfarin and

• Contraceptives, particularly the copper IUCD

coil No yet classi ed PID

How will you evaluate the
patient?
• Anticoagulant medications
• Bleeding disorders (e.g. Von Willebrand
disease)
• Endocrine disorders (diabetes and
hypothyroidism)
• Connective tissue disorders
• Endometrial hyperplasia or cancer
Pelvic examination with a speculum and
bimanual should be performed, unless there is
straightforward history heavy menstrual bleeding
without other risk factors or symptoms, or they
are young and not sexually active. This is mainly
to assess for broids, ascites and cancers.

Full blood count to look for iron de ciency

anaemia.

Outpatient hysteroscopy should be arranged if

there is:

• Suspected submucosal broids

• Suspected endometrial pathology, such as
endometrial hyperplasia or cancer

Pelvic and transvaginal ultrasound should be

arranged if the is:

• Possible large broids

• Possible adenomyosis
• Examination is dif cult to interpret
• Hysteroscopy is declined
 

Additional tests to consider in women with

additional features:

• Swabs/ endometrial
sampling(Diagnostic test) if there is
evidence of infection (e.g. abnormal
discharge or suggestive sexual history)
• Coagulation screen if there is a family
history of clotting disorders or periods have
been heavy since menarche
• Ferritin if they are clinically anaemic
• Thyroid function tests if there are
additional features of hypothyroidism

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 Outline the steps of Start by excluding underlying pathology.

management for this

patient? • Anaemia

• Fibroids

• bleeding disorders and cancer

• Where causes are identi ed, these should

be managed initially.

• For example, menorrhagia caused by a

copper coil should resolve when the coil is
removed.

The next step is to establish whether

contraception is required or acceptable.

When the woman does not want contraception;

treatment can be used during menstruation for
symptomatic relief, with: 

• Tranexamic acid when no associated

pain

• Mefenamic acid when there is associated

pain

Management when contraception is wanted or

acceptable:

1. Mirena coil ( rst line)

2. Combined oral contraceptive pill

3. Cyclical oral progestogens

This could be the progesterone-only pill or a

long-acting progesterone (e.g. depo injection or
implant).

Referral to secondary care for further

investigation and management is indicated if
treatment is unsuccessful, symptoms are severe
or there are large broids (more than 3 cm).

The nal options when medical management has

failed are endometrial ablation and
hysterectomy.

A 45 years old patient para4+0 presented in

OPD with complain of heavy menstrual ow
and passage of clots for last two years. She
has cycle of 8/24 days. She also gives history
of dyspnea and easy fatigability. Her past
medical & surgical history is insigni cant. On
examination she is very pale and abdominal
examination is unremarkable. On vaginal
examination uterus 8 week size anteverted,
mobile and bilateral adenexa free. On USG no
focal lesion is found
What is the probable
diagnosis?
How will you investigate
her?
What treatment will you
o er her?

A 60 years old obese, diabetic and

multiparous woman presents. in OPD with
complaints of heavy menstrual bleeding for
last 6 months. On examination the patient is
pale and abdomen is soft non tender. On
speculum examination, cervix appears normal
looking, the uterus is normal size and adnexa
are clear On pelvic ultrasound the uterus is
normal size with endometrial thickness of
12mm and there is no other pelvic pathology
on ultrasound.
What is the most likely
diagnosis?
What investigations you
will carry out to evaluate
this patient? Give one
justi cation for each.
Discuss the management
options available for her.
Keeping in mind her
clinical history. What
diseases do you expect?

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A 46 years old lady presented in gynae OPD
with complaint of heavy menstrual bleeding
for the last 8 months. On examination she is
pale, pulse is 90/min. Her abdominal
examination revealed soft non tender
abdomen. On pelvic examination uterus is
normal size and adnexa are clear. Pelvic
ultrasound revealed normal uterus with no
other pelvic pathology.
What is you provisional
diagnosis?
How will you evaluate the
patient?
What are the management
options available for the
patient?

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 Ectopic Pregnancy SNI

34 year old nulliparous patient presented in

Gynae OPD with pain lower abdomen and
vaginal spotting. She has been married for the
last 8 years and has taken ovulation induction
several times. She has history of recurrent
attacks of pelvic in ammatory disease. Her
cycles are regular but she gives history of
intermenstrual bleeding in previous cycle. Her
urine pregnancy test is positive and her
ultrasound shows adnexal mass of 30 mm
and thickened endometrium measuring
18mm. She is clinically stabie
What is her provisional Ectopic pregnancy
diagnosis?
What additional • USG (TVS, TAS)

investigations would you • Adnexal mass moving separate to ovary

perform to con rm the (sliding signs) or adnexal mass
diagnosis? separately moving to the ovary
compressing a gestational sac and fetal
pole (with or without heart beat)

• An empty uterus or collection of uid

with in uterine cavity.

• Free uid in peritoneal cavity or POD.

• ß hCG (serum human chorionic gonadotropin)

• Laparoscopy

• Colpocentesis/colpotomy

• Serum progesterone

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 What management options Perform a pregnancy test in all women with
are available for her? abdominal or pelvic pain that may be caused by
an ectopic pregnancy. Women with pelvic pain or
tenderness and a positive pregnancy test need to
be referred to an early pregnancy assessment
unit (EPAU) or gynaecology service.

All ectopic pregnancies need to be terminated.

An ectopic pregnancy is not a viable pregnancy.

There are three options for terminating an ectopic

pregnancy:

• Expectant management (awaiting
natural termination)
• Medical management (methotrexate)
• Surgical
management (salpingectomy or salpin
gotomy)
 

Criteria for expectant management:

• Follow up needs to be possible to ensure

successful termination
• The ectopic needs to be unruptured
• Adnexal mass < 35mm
• No visible heartbeat
• No signi cant pain
• HCG level < 1500 IU / l
 

Women with expectant management need

careful follow up with close monitoring of hCG
levels, and quick and easy access to services if
their condition changes.

Criteria for methotrexate are the same as

expectant management, except:

• HCG level must be < 3000 IU / l

• Con rmed absence of intrauterine
pregnancy on ultrasound

Methotrexate is highly teratogenic (harmful to
pregnancy). It is given as an intramuscular
injection into a buttock.

Women treated with methotrexate are advised

not to get pregnant for 3 months following
treatment.

Surgical Management

Most patients with an ectopic pregnancy will

require surgical management. This include those
with:

There are two options for surgical management

of ectopic pregnancy:

Laparoscopic salpingectomy 

Laparoscopic salpingotomy

There is an increased risk of failure to remove

the ectopic pregnancy
with salpingotomy compared
with salpingectomy. NICE state up to 1 in 5
women having salpingotomy may need further
treatment with methotrexate or salpingectomy.

Anti-rhesus D prophylaxis is given to rhesus

negative women having surgical management of
ectopic pregnancy.

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 How will you manage the Management to stabilise the patient involves:
case if on day 4 of her
medical management she • Resuscitation with an ABCDE approach
suddenly collapses with
vitals of puise, 120/min, BP • Lie the woman at, keep her warm and 

60/40 mmH and communicate with her and the partner
ultrasound showing free
uid in pelvis? • Insert two large-bore cannulas

• Bloods for FBC, U&E and clotting screen

• Group and cross match 4 units

• Warmed IV uid and blood resuscitation as 


required

• Oxygen (regardless of saturations)

• Fresh frozen plasma is used where there 


are clotting abnormalities or after 4 units of
blood transfusion 

In severe cases, activate the major
haemorrhage protocol. Each hospital will
have a major haemorrhage protocol, which
gives rapid access to 4 units of
crossmatched or O negative blood. 


A 34 ye. r ld nulli para patient presented in

Gynae OPD with pain lower abdomer. and per
vaginal spotting. She has been married for
the last 8 years and has taken ovulation
induction several times. She has history of
recurrent attacks of pelvic in ammatory
disease. Her cycles were regular but she
gives history of mild spotting in previous
cycle. Her urine pregnancy test is positive
and her ultrasound shows adnexal mass of 30
mm and thickened endometrium measuring
18mm
What is her provisional
diagnosis?
What additional
investigations would you
perform to con rm the
diagnosis?
What management options
available for her?
How will you manage the
case if on day 4 of her
medical management she
suddenly collapses with
vitals of pulse, 120/min,
BP 60/40 mmH and
ultrasound showing free
uent in pelvis

A 32 years old woman with history of

previous 1 lower segment caesarian section
reported in ER at gestational amenorrhea of 8
weeks with severe lower abdominal pain, mild
vaginal bleeding and vertigo. On examination
she has cold clammy skin and sweating. Her
pulse is 110/min, BP 90/60 mmEg and she has
tenderness on right iliac fossa.
What is your provisional
diagnosis?
How will you investigate
this patient?
What will be your
management plan?
What are the
complications of this
condition?

A 32 vears old lady has reported in

emergency at gestational amenorrhoea of 6
weeks with severe lower abdominal pain and
mild vaginal bleeding, On examination her
pulse is 110/min, BP 90/60 mmg. Abdominal
examination revealed marked tenderness in
right iliac fossa
What is your provisional
diagnosis?
How will you evaluate this
patient to con rm your
diagnosis?

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 Discuss your management
plan?
What are the risk factors
of this condition?
What are the • Tubal Rupture
• Previous ectopic pregnancy
• Previous pelvic in ammatory disease
• Previous surgery to the fallopian tubes
• Intrauterine devices (coils)
• Older age
• Smoking

complications of this • Tubal abortion

condition? • Tubal mole

• Abdominal pregnancy

young healthy patient G3P2+0, Gestational

Amenorrhoea of 10 weeks, presents in
emergency with two days history of moderate
vaginal bleeding and lower abdominal pain.
Discuss the differential • Spontaneous miscarriage
Pelvic in ammatory disease

diagnosis. • Ovarian cyst

Pregnancy molar

• Corpus luteal haemorrhage

Corpus luteal haemorrhage

• Acute pelvic in ammatory disease

Ovarian cyst

• Appendicitis
Spontaneous miscarriage

• Sub-serous broid
Sub serous broid
• GIT & Urinary tract problems
Describe investigations
required to con rm the
diagnosis.
How will you manage if
missed miscarriage is
con rmed?

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 Fibroids SNI

A 20 ears old hulliparous patient has reported

in OPD with history of heavy menstrual
bleeding, lower abdominal heaviness, and
felling of mass in lower abdomen for last ten
months. On examination she is pale and there
is a 16 weeks size rm mass arising from
pelvis.
What is your differential Uterine Fibroids
diagnosis?
Justify the investigations Hysteroscopy is the initial investigation
required for con rmation for submucosal broids presenting with heavy
of diagnosis? menstrual bleeding.

Hysterosalpingography

Pelvic ultrasound is the investigation of choice

for larger broids. Both trans abdominal and
transvaginal.

MRI scanning may be considered before

surgical options, where more information is
needed about the size, shape and blood supply
of the broids.

Laparoscopy is done if broids are associated

with infertility. This is to better visualise.
What are the management For broids less than 3 cm, the medical
options if broid uterus is management is the same as with heavy
con rmed? menstrual bleeding:

• Mirena coil (1st line)

• Symptomatic management with NSAIDs

and tranexamic acid

• Combined oral contraceptive

• Cyclical oral progestogens

• Danazole

Surgical options for managing smaller broids

with heavy menstrual bleeding are:

• Endometrial ablation

• Resection with hysteroscopy

• Hysterectomy

Surgical options for larger broids are:

• Uterine artery embolisation

• Myomectomy

• Hysterectomy

GnRH agonists, such as goserelin (Zoladex) or

leuprorelin (Prostap), may be used to reduce
the size of broids before surgery.

Uterine Artery Embolisation

The interventional radiologist guides a catheter
to the uterine artery under X-ray guidance.
Once in the correct place, particles are injected
that cause a blockage in the arterial supply to
the broid.

Myomectomy 

Surgically removing the broid

via laparoscopic surgery or laparotomy.

Hysterectomy involves removing the uterus and

broids. Hysterectomy may be by laparoscopy,
laparotomy or vaginal approach. The ovaries
may be removed or left depending on patient
preference, risks and bene ts.
What complications do • Haemorrhage

you anticipate if she opts • Infections

for surgery? • Adhesions

• Infertility

• Intestinal obstruction

• Recurrence

A 35 years old P1 came in OPD with

complains of menorrhagia for the last 02
years with abdominal distension. On
abdominal examination a midline pelvic mass
of 26 weeks size is palpable. Her Hb is 6 g/dl.
What is your provisional
diagnosis?
What is your D/D? • Dermato broma

• Dermatologic Manifestations of Glomus Tumor

• Dermatologic Manifestations of
Neurilemmoma (Schwannoma)

• Mastocytosis
How will you investigate
her?
What are the management
options?

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 A 28 years old pulliparous patient has
reported in OPD with history of heavy
menstrual-bleeding, lower abdominal
heaviness, and frequency of micturition for
last lo6 month. She recently got married and
is concerned about her fertility. On
examination she is pale and there is a 16
weeks size mass in hypogastrium arising
from pelvis, rm in consistency, and non-
tender, mobile, smooth and regular margins.
On biranual examination the mass seems to
be uterine in origin and bilateral adnexa are
clear.
What is your provisional
diagnosis?
How will you di erentiate
between an ovarian and a
uterine mass on clinical
grounds?
Justify one investigation
that will help you to
con rm your diagnosis.
What options of treatment
will you o er your patient?
Enlist complications that
you will anticipate if she
opts for surgical
management.

A 37 years old P6 came in OPD with

complains of menorrhagia for the last
(02 )vears with abdominal distension. On
abdominal examination a midline pelvic mass
of 26 weeks size is palpable. Her Hb is 6 g/dI.
What is your provisional
diagnosis?
What is your D/D?
How will you investigate
her?
What are the management
options?

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 Molar Pregnancy SNI

A 23 year old C2P1 presented with

amenorrhea of 14 weeks with PV bleeding
and passage of vesicles for 2 days. On
examination SFH is 18 cm. USG shows
intrauterine cluster of grapes (Snow storm
appearance)
What is your provisional Molar pregnancy
diagnosis?
What general and speci c Diagnosis is based on clinical presentation and
investigations would you Ultrasound.
perform this patent
Molar pregnancy behaves like a normal
pregnancy. Periods will stop and the hormonal
changes of pregnancy will occur. There are a few
things that can indicate a molar pregnancy
versus a normal pregnancy:

• More severe morning sickness

• Vaginal bleeding
• Increased enlargement of the uterus
• Abnormally high hCG
• Thyrotoxicosis (hCG can mimic TSH and
stimulate the thyroid to produce excess T3
and T4)

 Laboratory studies

The following laboratory studies may be used to

evaluate patients with suspected hydatidiform
mole:

• Quantitative beta-human chorionic

gonadotropin (hCG) levels

• Complete blood cell count with platelets

• Clotting function studies

• Liver function tests

• Blood urea nitrogen (BUN) and serum

creatinine levels

• Blood type and Rh factor

• Thyroxine level

• Serum inhibin A and activin A levels

Ultrasound of the pelvis shows a characteristic

“snowstorm appearance” of the pregnancy.

Provisional diagnosis can be made

by ultrasound and con rmed with histology of
the mole after evacuation.
How would you manage • Management involves evacuation of the
this patient? uterus to remove the mole.

• The products of conception need to be sent for

histological examination to con rm a molar
pregnancy.

• Patients should be referred to a tertiary setup

for management and follow up.

• The hCG levels are monitored until they return

to normal.

• Occasionally the mole can metastasise, and

the patient may
require systemic chemotherapy.
What will be the best Oral contreceptives
method for contraception
in this case?

A 25 years old G3 PI+1 presents at 11 weeks

of gestation with vaginal spotting for 3 days.
On examination abdomen is soft and non-
tender with SFH of 16cm. On ultrasound the
uterus is lled with cystic structures and no
fetal pole is seen.
What is your provisional
diagnosis?
Discuss the investigations
to con rm the diagnosis.
Discuss the managenient
of this patient in detail.
Write down the follow up • Patients should be referred to a tertiary setup
plan for her. for management and follow up.

• The hCG levels are monitored until they return

to normal.

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 What are the risk fastors • Mother's age

for this disease? • Previous abortion

• History of previous mole

• Ethnicity

• History of OCP

• IUD

• Blood group

• Radiation

• Socioeconomic status

• Infertility

• Arti cial insemination

A 23 years old female has come to emergency

room with amenorrhoea of 10 weeks, and
vaginal spotting. On GPE her thyroid is
enlarged. On abdominal examination SFH is
20 weeks size. On ultrasonography fetus is
present with absent cardiac activity and
placenta has multiple soft tissue shadows
appearance.
What is your provisional
diagnosis?
Investigations
fow will you treat her once
diagnosis is con rmed?
What follow up plan you
will make for this patient?
What contraception is
suitable for her and for
how long?

Unbooked 40 years pt. PG presented to OPD

at GA of 14 w w PV bleeding w passage of
vesicles like tissue. O/E dehydration ++ Abd
exam = 20 cm uterus is palpable, soft non-
tender

PG at 8 w of pregnancy came to ER w h/o

vaginal spotting + lower abdominal pain. O/E
uterus is 12 size. On USG = small fetus +
absent heart + placenta snow storm
apperance

A young healthy pt. G3P2+0, gestational

ammenhorrhea of 12 weeks presented to ER
w 2 days Hx of moderate vaginal bleeding +
lower abdominal pain
D/Ds Multiple pregnancy
M4

Missed miscarriage
F

Menohhragea
P4

Metastasis from any tumour

T

V
Fibroids

Polyhydraminios

Pregnancy with broids

Pregnancy with ovarian cyst

Preeclampsia

Threatened miscarriage

Vomiitng

Investigations to con rm
molar pregnancy
Rx if molar

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 UV Prolapse SNI

60 y/o P4 presented to OPD w h/o something

coming out of vagina and di culty passing
urine for 2 years
60 y/o P4 presented to OPD w h/o something
out of her vagina for 5 years. She has urine
retention and o but no bowel complaints
55 y/o multiparous lady w h/o something
coming
out of vagina for 3 years grade 1. She is
hukka
smoker, past obs h/o good sized babies +
di culty
passing stool and urine
58 y/o parous woman has grade 3 prolapse
Uterus
+ no urine or bowel complaints

Diagnosis Uterine Prolapse

How will you evaluate her Diagnosis is based on clinical examination.
to con rm your diagnose
• Ideally, the patient should empty their bladder
and bowel before examination of a prolapse.

• When examining for pelvic organ prolapse,

various positions may be attempted, including
the dorsal and left lateral position. 

• A Sim’s speculum examination can help

assess the complete extend of the prolapse

• The women can be asked to cough or “bear

down” to assess the full descent of the
prolapse. 
Management options you There are three options for management:
can o er
1. Conservative management
2. Vaginal pessary
3. Surgery
 

Conservative management

• Physiotherapy
• Weight loss
• Lifestyle changes for associated stress
incontinence, such as reduced caffeine
intake and incontinence pads
• Treatment of related symptoms, such as
treating stress incontinence with
anticholinergic mediations
• Vaginal oestrogen cream
 

Vaginal pessaries

Prosthesis are inserted into the vagina to provide

extra support to the pelvic organs.Types include

• Ring pessaries are a ring shape, and sit

around the cervix holding the uterus up

• Shelf 
• Cube 
• Donut 
• Hodge 

Try a few types of pessary before nding the

correct comfort and symptom relief.

Surgery

There are many methods for surgical correction

of a prolapse, including hysterectomy and pelvic
organ prolapse surgery.
De ne UV prolapse Uterine prolapse is where the uterus itself
descends into the vagina.
Causes of UV prolapse
• Multiple vaginal deliveries
• Instrumental, prolonged or traumatic
delivery
• Advanced age and postmenopause status
• Obesity
• Chronic respiratory disease causing
coughing
• Chronic constipation causing straining

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 Note on Grades of UV The severity of a uterine prolapse can be graded
prolapse using the pelvic organ prolapse
quanti cation (POP-Q) system:

• Grade 0: Normal
• Grade 1: The lowest part is more than 1cm
above the introitus
• Grade 2: The lowest part is within 1cm of
the introitus (above or below)
• Grade 3: The lowest part is more than 1cm
below the introitus, but not fully descended
• Grade 4: Full descent with eversion of the
vagina

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 Miscarriage SNI

A G7P6 at 12 weeks of gestation presents in

Emergency with history of lower abdominal
pain, fever and vaginal bleeding for 3 days. On
exam: pulse 100/min, temp= 100 F, RR-20/
min. Abdominal exam reveals tenderness in
lower abdomen. On vaginal exam: os admits 1
nger with moderate bleeding. On
investigation her UPT is positive.
What is the most probable Septic Miscarrige
diagnosis?
How would you investigate • Blood and urine biochemistry

this patient? • Complete blood picture

• Beta HCG levels

• Blood type and crossmatching for RH

incompatibility

• DIC pro le

• Urineanalysis

• Cultures

• Blood

• Urine

• High Vaginal Swab

• Imaging

• Ultrasound studies

• Procedural

• D and C
Outline the management Less Than 6 Weeks Gestation
plan
Women with a pregnancy less than 6 weeks’
gestation presenting with bleeding can be
managed expectantly provided they have no
pain and no other complications or risk factors

More Than 6 Weeks Gestation

• referral to an early pregnancy assessment

service (EPAU) and admission to hospital.

• Ultrasound will con rm the location and

viability of the pregnancy.

Expectant Management

• Expectant management is offered rst-line for

women without risk factors for heavy bleeding
or infection. 1 – 2 weeks are given to allow the
miscarriage to occur spontaneously.

• A repeat urine pregnancy test should be

performed three weeks after bleeding and pain
settle to con rm the miscarriage is complete.

• Persistent or worsening bleeding requires

further assessment and repeat ultrasound, as
this may indicate an incomplete miscarriage
and require additional management.

Medical Management

• Misoprostol is a prostaglandin analogue,

meaning it binds to prostaglandin
receptors and activates them.

• Prostaglandins soften the cervix and stimulate

uterine contractions.

• Medical management of miscarriage involves

using a dose of misoprostol to expedite the
process of miscarriage. This can be as
a vaginal suppository or an oral dose.

• The key side effects of misoprostol are:

• Heavier bleeding
• Pain
• Vomiting
• Diarrhoea
 

Surgical Management

Surgical management can be performed under

local or general anaesthetic.

There are two options for surgical management

of a miscarriage:

• Manual vacuum aspiration

• Electric vacuum aspiration 

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 What are the long term Infertility

sequelae? Chronic pelvic pain

Renal failure

DIC and endotoxic shock

29 y/o lady MF 6 h/o 3 recurrent pregnancy

losses
1 trimester of pregnancy. She is at present 6
w pregnant
Enumerate causes of
recurrent abortion
Investigations
Management options

35 y/o female G3P2 presented to ER w h/o

amenorrhea for 9 weeks + brown PV
discharge, on USG: CRL 9 w, Foetal cardiac
activity is present
Diagnosis Threatened miscarrige
Investigations
Treatment

34 y/o G3P2+0 gynae OPD amennhorhea of 11

w
On USG: CRL is 6 mm + cardiac activity
Diagnosis Threatened miscarrige
Investigations
Treatment

A young female G3P2+0 presented to ER.

Gestational age is 12 w, PV bleed last 24
hours + lower abdominal pain
D/Ds Miscarriage

Ectopic pregnancy

Hydatid mole
How will you manage if There are two options for surgical management
incomplete miscarriage is of a miscarriage:
diagnosed
• Manual vacuum aspiration
• Electric vacuum aspiration 

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 Sub fertility SNI

A couple married for last ve years, comes to

OPD with complain of failure to conceive. The
male partner works in a steel industry and is a
Smoker On examination BMI of female
partner is 30kg/m2,
What is your provisional Subfertility - failure to conceive after regular
diagnosis? sexual intercourse for 1 year

What are the risk factors • HUSBAND

present in history for both • Occupation - steel industry

partners? • Hx of smoking

• WIFE

• Obesity (BMI 30 kg/m2)

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 How will you evaluate this Initial investigations, often performed in primary HISTORY

couple for the said care:

problem? • Length of time
spent trying for
• Body mass index (BMI) (low could
pregnancy

indicate anovulation, high could • Any previous

indicate PCOS) pregnancy

• Chlamydia screening • Coital frequency

• Semen analysis • Occupation

• Female hormonal testing (see below) • Medical and

• Rubella immunity in the mother surgical Hx

  • Speci c to female -
Menstrual Hx, Hx
Female hormone testing involves: of PID, previous
fertility Rx, Cervical
smear Hx

• Serum LH and FSH on day 2 to 5 of • Speci c to male -

the cycle Hx of mumps or
• Serum progesterone on day 21 of measles

the cycle (or 7 days before the end of

the cycle if not a 28-day cycle). EXAMINATION

• Anti-Mullerian hormone
• Thyroid function tests when • Female - GPE,
symptoms are suggestive Abdominal
• Prolactin (hyperprolactinaemia is a examination, Pelvic
examination

cause of anovulation) when symptoms

• Male - GPE,
of galactorrhea or amenorrhoea Testicular
examination

• Ultrasound pelvis to look for polycystic

ovaries or any structural abnormalities in
the uterus INVESTIGATIONS

• Hysterosalpingogram to look at the FEMALE

patency of the fallopian tubes

OVULATION

• Laparoscopy and dye test to look at the

patency of the fallopian tubes, adhesions Assessment of ovulation -

Serum progesterone on day

and endometriosis
21 of the cycle in a woman
who has 28 days menstrual
cycle. Level of 30 n mol/L or
• Patients with abnormal semen results are more is suggestive of
referred to a urologist for further ovulation.

investigations. Further investigations that may

be considered include: If cycle is irregular

Follicular phase FSH, LH

• Hormonal analysis with LH, FSH and TSH

testosterone levels Prolactin

• Genetic testing
Assessment of ovarian
• Further imaging, such as transrectal Reserve -

ultrasound or MRI Antral follicle count

• Vasography, which involves injecting < 4 - low reserve

contrast into the vas deferens and >16 - high reserve

performing xray to assess for obstruction AMH: marker of ovarian

• Testicular biopsy reserve

FSH

< or equal to 4 low reserve

> or equal to 8.9 high

reserve

TUBAL FACTORS

Hysterosalpingography

to see patency of fallopian

tubes

Radio–opaque dye
(urogra n) is used

Spillage of dye in to the

peritoneal cavity can be
seen on uoroscopy.

Laparoscopy

◦ Gold standard for tubal

test

◦ Methylene blue insu ation

test

◦ Co-existing pelvic
pathology can also be

detected like endometriosis

UTERINE FACTORS

Hysterosalpingography -
Intrauterine adhesions,
Submucous broids, uterine
malformation can

be detected.

Hysteroscopy

MALES

Semen analysis - to check

sperm count, volume,
motility, vitality, pH

If sperm count very low or

azoospermia

o FSH /LH - low level

indicates
hypogonadotrophic
hypogonadism, high level for
primary testicular failure

o Screen for Cystic Fibrosis

o Karyotyping

o Testicular Biopsy

Antisperm Antibodies:

Present in semen, cervical

mucous and serum of both
partners.

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 Outline the management • MEDICAL MANAGEMENT

plan for a successful

pregnancy? • OVULATION INDUCTION

• Antiestrogen drugs

• Clomiphene citrate

• Tamoxifen

• Letrozole

• Dopamin agonists

• Bromocriptine

• Cabergoline

• Gonadotrophins

• HMG

• GnRH analogues

• Laproscopic ovarian drilling

• ASSISTED REPRODUCTION TECHNIQUES

• Intrauterine Insemination

• In vitro fertilization

• SURGICAL SPERM RETRIEVAL

• In the absence of naturally ejaculated

sperm patient will undergo SSR under GA
or sedation.

• Retrieved sperms are used in IVFor ICSI

cycle.

• SURGICAL TREATMENT

• Operative laparoscopy - for endometriosis,

ovarian cysts etc

• Hysteroscopy - for Sub mucus broids,

Intrauterine adhesions, Uterine septum

• Tubal reconstructive surgery - to open

blocked fallopian tubes amenable to repair
by microsurgical procedures

• OTHER OPTIONS

• Oocyte & Sperm donation

• Surrogacy

• Adoption

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 MP and HRT SNI

A 48 years old lady had total abdominal

hystrectomy and bilateral salpingo
ophrectomy due to heavy menstrual bleeding
and multiple broids. Now she is complaining
of hot ushes and mood changes.
What do you think she is Menopausal symptoms
su ering from?
What is the cause of this Menopause is caused by a lack of ovarian
condition in this patient? follicular function, resulting in changes in the
sex hormones associated with the menstrual
cycle:

What other side e ect she
• Oestrogen and progesterone levels are
low
• LH and FSH levels are high, in response
to an absence of negative feedback from
oestrogen
• Hot ushes 7 dwarfs of menopause

can have in future? • Emotional lability or low mood Itchy

• Premenstrual syndrome Bitchy

• Irregular periods Sleepy

• Joint pains Sweaty

Bloated

• Vaginal dryness and atrophy

Forgetful

• Reduced libido Psycho

What are the management
options for her now and
for her future
complications?
• No treatment 
• Hormone replacement therapy (HRT)
• Tibolone, a synthetic steroid hormone that
acts as continuous combined HRT
• Clonidine, which act as agonists of alpha-
adrenergic and imidazoline receptors
• Cognitive behavioural therapy (CBT)
• SSRI antidepressants, such as uoxetine
or citalopram
• Testosterone can be used to treat
reduced libido
• Vaginal oestrogen cream or tablets, to
help with vaginal dryness and atrophy (can
be used alongside systemic HRT)
• Vaginal moisturisersReplens and YES

De ne menopause Menopause is a retrospective diagnosis, made

after a woman has had no periods for 12
months. It is de ned as a permanent end to
menstruation.

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Adenomyosis SNI

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STIs SNI