Gynaecology cases

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Gynaecology cases

• Rehan Salim MD MRCOG
• Consultant Gynaecologist

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Case 1

• 34 year old
• Irregular periods
• No significant gynaecological problems
• 3 day history of pelvic pain

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Case 1

• Observations normal
• Urinalysis normal

Pregnancy test positive Ectopic pregnancy unless
proven otherwise
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Case 1

• Ultrasound scan
• No evidence of intrauterine or extrauterine
  pregnancy
• BHCG 400, progesterone 29

Called same day by EPU Come for a repeat bloods
in 2 days
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Case 1

• 2 days later
• More pain
• Repeat scan
• Small amount of blood in pelvis
• Right ectopic
• HCG 755

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Case 1

• Theatre
• Right salpingectomy
• Uneventful recovery

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Case1

• What is the effect on my fertility?
• Risk of another ectopic pregnancy?
• Why did it happen?

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Case 2

• 54 year old
• Fit and well
• Single episode of fresh vaginal bleeding

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Case 2

• Speculum
• Ultrasound
• Thick endometrium
• Pipelle
• Endometrial hyperplasia

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Case 2
Pathology Persistence Progression to complex atypical hyperplasia Progression to endometrial cancer Timescale Treatment
Simple with no atypia 18 3 1 10y Conservative
Complex with no atypia 22 4 10y Conservative
Complex atypical hyperplasia 29 4y Surgical
Up to 50 of patients with CAH have co-existent
endometrial carcinoma detected at histology of
subsequent hysterectomy
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Case 2

• Simple cystic hyperplasia without atypia
• progestagens such as norethisterone 5 mg bd for
  three out of four weeks.
• The treatment should last at least three months,
  then the biopsy should be repeated.
• In young women with polycystic ovaries, treatment
  with cyclical progestogens should continue or it
  can be replaced by long term combined oral
  contraceptive pill.
• In postmenopausal women the treatment may be
  stopped if the result of second biopsy is normal,
  but they should be advised to return if their
  symptoms recur.

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Case 2

• Adenomatous hyperplasia
• more likely to progress to cancer than cystic
  hyperplasia.
• However, the treatment is the same as in cystic
  hyperplasia.
• If abnormality persists after the therapy
  hysterectomy may be considered in older women.
• Complex hyperplasia
• may progress to atypical hyperplasia in 10 and
  to carcinoma in 4 of cases

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Case 2

• Atypical hyperplasia
• is believed to progress to cancer in up to 30 of
  cases depending on the degree of atypia.
• Severe atypia is often impossible to
  differentiate from cancer even on hysterectomy
  specimens.
• In postmenopausal women hysterectomy should be
  considered, whilst in young women treatment with
  oral progestagens or Mirena IUS are preferred
  options. All women managed conservatively should
  be followed up very closely.

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Case 3

• 21 years old
• Infrequent periods, hirsute
• BMI 34
• Fit and well otherwise

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Case 3
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Case 3
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Case 3
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Case 3

• Oligomenorrhoea
• Endometrial hyperplasia/ cancer
• Infertility
• Pregnancy
• Hyperandrogenism
• Cosmetic
• Long term
• NIDDM
• GDM
• Cycle control

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Case 3

• Weight loss
• COCP
• Endometrial protection
• Metformin
• Incremental dose
• 500md OD/BD/TDS ? 850mg BD
• Ovulation induction