Hashem Yaseen's Guide to Obstetrics and Gynecology

Hashem Yaseen, MBBS , 5th year resident in higher speciality degree in
obstetrics and gynecology, MRCOG P1
Jordan University of Science and Technology,
King Abdullah University Hospital,
Hashemmail@yahoo.com

Before we start…
Hashem Yaseen, MBBS,
MRCOG P1

Diagnostic strategy model
MRCOG P1

Outlines
MRCOG P1

zahra
Gracial
✓ Women with hirsutism
✓ Epilepsy
✓ Women over 35 years
✓ Menstrual disorders: menorrhagia/dysmenorrhoea
✓ Acne
MRCOG P1

The essential advice is ‘just keep going’ (i.e. take a pill as soon as possible and then
resume usual pill- taking schedule).
Also
If the missed pills are in week three, she should omit the pill-free interval.
Also
Condoms or abstinence should be used for 7 days if the following numbers of pills are
missed:
‘Two for twenty’ (i.e. if two or more 20 mcg pills are missed)
‘Three for thirty’ (i.e. if three or more 30–35 mcg pills are missed)
Also
Emergency contraception if sex within the last 5 days
MRCOG P1

Yuzpe method: use high oestrogen containing COC,for
example 50 mcg EO + 250 mcg LNG two pills initially,
then repeated 12 hours later. Failure rate: 2.6%.
MRCOG P1

Efficacy: IUCDs give 96–99% protection
against pregnancy.
Recommended use time: copper IUCD
6–10 years, Mirena 5 years.
MRCOG P1

i. What is the bleeding pattern?
ii. Should a complete blood count be performed?
iii.Should endometrial sampling be performed?
iv.Should a coagulation evaluation be performed?
v. Is bleeding related to a contraceptive method?
Initial tests
- Pregnancy test
- Complete blood count
Additional tests
- Endocrine tests
- Coagulation tests
- Tests to exclude cervical bleeding
MRCOG P1

➢After pregnancy has been excluded, endometrial sampling should be
performed in women with AUB :
●Age 45 years to menopause – In women who are ovulatory, any AUB,
including intermenstrual bleeding.
●Younger than 45 years – is indicated if AUB is persistent, occurs in the
setting of a history of unopposed estrogen exposure (obesity, chronic
ovulatory dysfunction) or failed medical management of the bleeding,
or in women at high risk of endometrial cancer (eg, tamoxifen therapy).
MRCOG P1

Menorrhagia
MRCOG P1

Dysfunctional uterine bleeding a diagnosis of exclusion
• Heavy bleeding: saturated pads,
frequent changing,
‘accidents’, ‘fl ooding’, ‘clots’
• Prolonged bleeding:
— menstruation >8 days
or
— heavy bleeding >4 days
• Frequent bleeding—periods occur
more than once
every 21 days
• Pelvic pain and tenderness are not
usually prominent
features
• Establish diagnosis by confirming symptoms and
exclude other pathology.
• Correction of iron deficiency or anaemia.
• Drug therapy is indicated if symptoms are
persistently troublesome and surgery is
contraindicated or not desired by the patient and
D&C doesn’t alleviate.
• Provide reassurance about the absence of
pathology, especially cancer, and give counseling to
maximise compliance with treatment.
• Consider surgical management if fertility is no
longer important and symptoms cannot be
controlled by at least 3–4 months of hormone
therapy.
• General rule:
<35 years—medical treatment
>35 years—hysteroscopy and direct endometrial
sample (diagnostic—sometimes therapeutic)
MRCOG P1

•Primary amenorrhoea is the failure of the menses to start by 16 years of age.
•Secondary amenorrhoea is the absence of menses for over 6 months in a woman
who has had established menstruation.
•delayed puberty: no signs of sexual maturation by age 13.
Amenorrhoea and oligomenorrhoea
Investigations:
FSH (2nd day hormonal profile) – to ro POI
LH (2nd day hormonal profile) – indicators for insulin resistant
and long-term DM
Prolactine – to exclude Hyperprolactinemia
TSH – to exclude Hyper – Hypothyroidism
Testosterone – if clinical hyperandorgenism
DHEAs – if very high testosterone, or hyperandorgenism with
normal testosterone
Ro pregnancy lactation contraception
MRCOG P1

For practical purposes patients with irregular menstrual cycles can be divided into those
under 35 and those over 35 years.
Patients under 35 years:
• the cause is usually hormonal, rarely organic, but keep malignancy in mind
• management options:
— explanation and reassurance (if slight irregularity)
— COC pill for better cycle control—any pill can be used
— progestogen-only pill (especially anovulatory cycles) norethisterone (Primolut N)
5–15 mg/day from day 5–25 of cycle.
Patients over 35 years should be referred for investigation for organic pathology, usually
by endometrial sampling and/or hysteroscopy. If normal, the above regimens can be
instituted.
Cycle irregularity
MRCOG P1

Menopause: Definitions
• Clinically: Amenorrhoea of 12 months
• WHO: permanent cessation of menstruation,
resulting from the loss of ovarian follicular activity
• The Climacteric phases ?
• Surgical menopause ?
• At 50 years (standard deviation + / - 4 years)
• Early menopause: before 45 years ~Risk factors ??
• Premature ovarian failure (POF): before 40 years ??
• Osteoporosis: reduced bone mass per unit volume
MRCOG P1

Clinical approach: History
1. Age
2. Menstrual history
3. Menopausal symptoms
4. Mental state symptoms
5. Sexual history
6. Use of contraception
7. Urinary symptoms
8. Social history ( smoking, relationships…)
9. Medical history ( liver disease, SLE, migrane, CVD, VTE, or HTN)
10. Surgical history(gyne operations)
11. Family history ( cancers, CVD, or osteoperosis)
MRCOG P1

Clinical approach: Physical
examination
1. Blood pressure
2. Weight and hight
3. Breast palpation
4. Abdominal palpation
5. Vaginal examination
6. Pap smear
MRCOG P1

Clinical approach:
Investigation
1. Pap smear
2. Urine analysis
3. Full blood count
4. Lipid profile
5. Thyroid function test
6. Liver and kidney function tests
7. Mamography ( all women, preferably before and annually)
8. Diagnostic hysteroscopy wih bx ( undiagnosed vaginal bleeding)
9. Bone density study
10. If diagnostic in doubt: serum FSH & Estradiol
MRCOG P1

When to refer
✓All cases of ‘unexplained infertility’
✓ All teenagers with dysmenorrhoea sufficient to interfere with normal school, work or
recreational activities, and not responding to prostaglandin inhibitors
✓ Patients with dysmenorrhoea reaching a crescendo mid-menses
✓Patients with dysmenorrhoea and unexplained bowel or bladder symptoms
MRCOG P1

Acute pain vs Chronic pain
MRCOG P1

Diagnostic criteria for acute PID
MRCOG P1

Practice tips
MRCOG P1

Vaginal discharge
MRCOG P1

• Initial induction therapy with fluconazole 150 mg every 72
hrs for 3 doses followed by fluconazole 150 mg once
weekly for 6 month ( maintenance therapy )
• If relapse occurred : reinduction therapy with maintenance
therapy for 1 year
• Minority of women persist in relapsing ( fluconazole
dependent recurrent VVC) , symptoms in these patient can
be controlled by months or years of weekly fluconazole
❖ Alternative approaches : treat each recurrent episode with
longer duration of therapy ( topical azoles for 7_14 days /
fluconazole 150 mg for 3 doses 72 hrs apart )
Defined as 4 or more episodes
MRCOG P1

Hashem Yaseen's Guide to Obstetrics and Gynecology

Hashem Yaseen's Guide to Obstetrics and Gynecology

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