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Gynaecology cases
Rehan Salim MD MRCOG
Consultant Gynaecologist
Case 1
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34 year old
Irregular periods
No significant gynaecological problems
3 day history of pelvic pain
Case 1
• Observations normal
• Urinalysis normal
Pregnancy test positive
Ectopic pregnancy unless proven otherwise
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
Case 1
• 2 days later
– More pain
– Repeat scan
• Small amount of blood in pelvis
• Right ectopic
– HCG 755
Case 1
• Theatre
– Right salpingectomy
• Uneventful recovery
Case1
• What is the effect on my fertility?
• Risk of another ectopic pregnancy?
• Why did it happen?
Case 2
• 54 year old
• Fit and well
• Single episode of fresh vaginal bleeding
Case 2
• Speculum
• Ultrasound
– Thick endometrium
• Pipelle
– Endometrial hyperplasia
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
29%
4y
Surgical
Complex atypical
hyperplasia
Up to 50% of patients with CAH have co-existent endometrial carcinoma
detected at histology of subsequent hysterectomy
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.
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
Case 2
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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.
Case 3
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21 years old
Infrequent periods, hirsute
BMI 34
Fit and well otherwise
Case 3
Case 3
Case 3
Case 3
• Oligomenorrhoea
– Endometrial hyperplasia/ cancer
– Infertility
– Pregnancy
• Hyperandrogenism
– Cosmetic
• Long term
– NIDDM
– GDM
– Cycle control
Case 3
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Weight loss
COCP
Endometrial protection
Metformin
– Incremental dose
– 500md OD/BD/TDS → 850mg BD
• Ovulation induction