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MRCOG Exam success part 1 part 2/3 study to prepare (Sumitra

Our mission

We are aiming to help medical students to get gold standards in the field of Obstetrics and Gynaecology throughout their journey beginning from the bottom. We help aspirants for MRCOG Exam Success part 1 part 2/3 study to prepare.

About our Expert

Dr. P.V. Sharma is an experienced, skilled and dedicated professional. She is holding extraordinary knowledge in this field.She has satisfied a number of patients with her skilled professional work.

She has gained national and international awards.She still continues the journey of learning as she believes that "A doctor is always a student". She is a leading IVF superspecialist, Obstetrician & Gynecologist.

She bagged many reputated degrees with her hard work i.e.

MRCOG (London),

MICOG,

FNB (Reproductive Medicine),

DNB (Obstetrics & Gynaecology)

MS (Obstetrics & Gynaecology),

MBBS

She has published a number of research work in renowned national and international journals and conferences.

She is also involved in mock exams conducting for MRCOG aspirants.

Introduction

Hello Friends,

It is highly appreciable that you have decided to follow the difficult but tricky path of getting MRCOG award which is gold standard in Obstetrics & Gynaecology field.

Why this title is important:

With this you will be able to do practice as a consultant in most of the countries in the world
It is recognised by Medical Council of India
You will get high standard knowledge in field of women’s health to serve them better
You will get support and guidance from the college whenever you need it
Highly skilled programme you can get to attend at concessional prices
Opportunity to get scholarship in highly advanced field like fetal medicine, urogynecology etc. sponsored by RCOG
You will be updated for recent advances in women’s health by the college
It is highly standard feather in your cap.

We help aspirants for mrcog exam success part 1 part 2/3 study to prepare

Registration with College

For starting the journey, follow the following steps:

Step 1. You have to register yourself with Royal college of Obstetrics & Gynaecology (RCOG) by visiting their website https://www.rcog.org.uk by using your e mail id and password as we are doing with any other website for making an account.

Step 2. After registration and before sitting an exam you have to get an Eigibility certificate from the college. For that you have to fill the form which is available on website.Make sure you have applied it quiet before the exam date as they take time to issue the certificate. Once you get the eligibility certificate, it is not necessary to get it before each exam.

Step 3. After getting eligibility certificate you have to fill Interest certificate every time before sitting the exam but it is not necessary to get the interest certificate result for booking the exam.

Booking the exam is on the basis of "First come & First serve",so be hasty to book the exam if the booking window is open especially for part 2 and part 3 exam to get your preferred centre.

Nowadays, Part 1 & Part 2 exams are being held on various places in online mode (by Pearson). Part 3 exams are being held in hybrid mode i.e. both online and offline depending upon the places and circumstances.

Journey to success ...step by step

How is the journey:

As expected, it is very exhausting and tricky. It takes a lot of your time from your busy schedule but we have to loose something to get a precious one. Here we have to do strict time management.Don’t loose the patience and never give up. Make a schedule to practice it 2 hrs per day if your exam is 6 months away and give at least 4 hrs daily if your exam is 2 months away.

About the exam:

This prestigious exam has 3 parts now and every 6 months college is conducting each part of the exam.

First part- College is conducting this exam in Jan/Feb and in June/July every year.

It is easy as compared to the other 2 parts. It contains 2 papers of 3/3 hrs duration having 100/100 single best answer (SBA).

It contains basics of obstetrics & gynaecology like anatomy, physiology, pathology, pharmacology, biochemistry, epidemiology and microbiology.

Each question will have more than one correct answer but you have to select single best. This answer will come with practice only. Trust me…

Second part- Congratulations…Time has come to proceed for part two. Before booking your place for part 2 you have to complete your Assessment of training(Aot) ,without that you will not be able to sit in the exam so complete it through the RCOG website in AoT section.

This exam is happening 2-3 days approximately after the part 1 exam each year in Jan/Feb and in Jun/Jul.

Unfortunately if you are not successful in this part ,you can attempt it for 6 times regardless of their date of first attempt. If you are still unable to be successful you may need letter from your college HOD or equivalent for further attempts.For UK based candidates they have to apply for part 2 within 7 years and for others within 10 years. UK council has decided to exclude 2020 and 2021 for counting the year due to pandemic.

This part is really a difficult one but with regular practice and hard work you will be master in it.This needs a lot of practice.

It contains 2 papers of 3/3 hrs duration having 100/100 Extended matching questions (EMQ).It means a single question will have at least 6-10 answers and you have to pick single best covering all answer of a particular situation.

Really tough…"But a skilled knight has keys for all difficult situations". Definitely, I mean it. You will do it with your hard work.You can have books for your help which I will suggest in suggested books section.Else you can have courses from experienced teachers.

I also will provide content later in this book.

Third part-Many congratulations !!! You have completed the two parts of this difficult exam.

Now in opinion of college you have enough knowledge to get the degree but they want to know with their this part of exam that Are you able to convey your knowledge clinically to your patients?

This is an exam of communication. This exam happens every year in May/Nov..You have 4 attempts to pass but unfortunately if you are not successful you have to give part 2 again.You have to take this exam within 7 years of completing part 2.

With clearing part 2 ,you are eligible to get entry into MIT before completing part 3.

Part 3 has 14 stations in a row which tests the candidate in five domains -

1.Patient’s safety

2.Information gathering

3.Communication with the colleague

4.Communication with patients and their relatives

5.Applied clinical knowledge

It is not necessary to pass in all domains but you have to the pass the cut off marks which is set for that exam. Usually it has 4-5 structured discussion (SD) with examiner and 9-10 patient based assessments.

In structured discussion, examiner has a set of questions, if you answer well then only it will lead to next question. Do not waste too much time on one question as there is only 10 minutes for that station and allow the examiner to ask all the questions which carry equal weightage.

In simulated pt case ,pt is instructed to ask set questions, answer them well and allow them to ask.

How to prepare

Make a schedule to practice it 2 hrs per day if your exam is 6 months away and give at least 4 hrs daily if your exam is 2 months away as I mentioned before.

We will learn (This is not theory but the key points to success)

1. Consent

2.Ethics

3.Learning assessment

4.Risk management

5.Early pregnancy

Assessment

Pregnancy of unknown location

Gestational trophoblastic diseases

Ectopic pregnancy

Miscarriage

6.Pregnancy complications

Small gestational age (SGA)

Multiple order pregnancy

Pre eclamptic toxaemia (PET)/HELLP

Hyperemesis gravidarum

Reduced fetal movements

7.Medical disorders during pregnancy

Aneamia

Renal diseases

Cardiac diseases

Diabetes

Pulmonary hypertension

Asthma

Urinary tract infection

Sickle cell disease

Epilepsy

Deep vein thrombosis

Pulmonary embolism

Thalassemia

Obesity

Pregnancy in elder women (>40 years)

Maternal collapse

Malaria

Perinatal mental health

8.Infections during pregnancy

Chicken pox

Sepsis

HIV

Syphilis

Hepatitis B

Genital herpes

Group B streptococcus (GBS)

9.Anomalies in fetus

Anencephaly

Down syndrome

Edward syndrome

Patau syndrome

Cystic hygroma

Turner syndrome

Diaphragmatic hernia

10.Labour management

Breech presentation

Shoulder dystocia

First stage

Second stage

Third stage

3rd/4th degree perineal tear

11.Postpartum

Normal changes

Postpartum Haemorrhage

11.Gynaecological disorders

Heavy menstrual bleeding (HMB)

Fibroid

Adenomyosis

Endometriosis

Polyp

Post menopausal bleeding

Postmenopausal ovarian cyst

Premenopausal ovarian cyst

Female genital mutilation (FGM)

Premenstrual syndrome

Premature ovarian insufficiency

Menopause

Hormone replacement therapy (HRT)

Pelvic inflammatory disease (PID)

Chronic pelvic pain

Vulval diseases

Lichen sclerosis

Lichen Planus

Vulval intraepithelial neoplasia (VIN)

Paget’s disease

Vulval atrophy

Candidiasis

Psoriasis

12.Subfertility

Ovarian hyperstimulation syndrome (OHSS)

In vitro fertilisation (IVF)

Intra cytoplasmic sperm injection (ICSI)

Polycystic ovarian syndrome (PCOS)

Hirsutism

Hypogonadotropic hypogonadism

13.Contraception

14.Urogynaecology

Prolapse

Urge incontinence

Stress urinary incontinence

15.Carcinoma

Breast

Ovary

Endometrium

Cervical intra epithelial neoplasia (CIN)

Cervix

Vulva

16.Operative Skills

Pre operative assessment

Post operative care

Abdominal hysterectomy

Vaginal hysterectomy

Laparoscopic hysterectomy

Hysteroscopy

Laparoscopy

External cephalic version (ECV)

Vaginal birth after cesarean (VBAC)

Forceps

Ventouse

Face presentation

Brow presentation

17.Teaching

Discharge summary

Growth chart

Neonatal resuscitation

Mechanism of labour

18.SBA/EMQ topic wise

19.How to prepare for Part 3

General precautions

Explanation for each station (14)

Syllabus

What to expect

Do’s & Don’t

Template case wise

Sample stations (14)

For MRCOG Part 1/2:

1.Early pregnancy assessment

2.Gestational trophoblastic tumor (GTD)

3.Premenstrual syndrome

4.Postmenopausal ovarian cyst

5.Premenopausal ovarian cyst

Rest of the content will be coming soon...

You can book it in advance through website

EARLY PREGNANCY ASSESSMENT

Early pregnancy

In early pregnancy (< 3 months),bleeding and pain are common
Most are normal
But in few cases, it may be an early sign of miscarriage (20%) or ectopic (1.1%)
In mild bleeding- Pt has to contact GP(General practitioner)/Midwife (as nurse in India) by calling on 111 (NHS-National health scheme)
In heavy bleeding-Pt has to contact EPAU (Early pregnancy assessment unit) or A & E Deptt. (Accident and emergency department)

It is very important to know what should we do immediately in normal and in emergency situation. So, you have to opt the correct answer on SBA after assessment of bleeding and haemodynamic stability of the pt as above i.e. if the pt is having mild bleeding and haemodynamically stable we should opt that she should call her GP/Midwife by calling on NHS number and if it is heavy bleeding opt for sending the pt to EPAU/ A & E Deptt.

Assessment of pt with bleeding in early pregnancy if haemodynamically stable

Urine test to confirm the pregnancy or beta HCG first step
Speculum examination to see the neck of the womb for the cause of the bleeding in the presence of chaperone (a person who acts as a witness for a patient and a health professional during a medical examination or procedure)
USG to see the location of the pregnancy by TVS(Transvaginal for Clearer view) or TAS(Transabdominal)
Test for chlamydia
Blood tests (Blood group and beta HCG)

Assessment of pt with bleeding in early pregnancy if haemodynamically unstable

Do resuscitation, according to ABCD guidelines, first then assess the pt if the patient stabilised.

Go for emergency surgery along with resuscitation if intra abdominal bleeding is continuing.

Causes

1.Threatened miscarriages: USG is normal with bleeding ,mostly healthy outcome, may need follow up

2.Early miscarriages: unfortunately common 20%,good chances of future pregnancy after the event

Ectopic pregnancy
Molar pregnancy: 1:714 incidence
Pregnancy of unknown location (PUL): positive urine pregnancy test and no findings in USG

It could be

a.Early pregnancy: as test is highly sensitive and USG findings comes @ 5 weeks

b.Early miscarriage: especially if bleeding now settled

c.Ectopic:20% of PUL

Gestational trophoblastic tumor (GTD)

Gestational trophoblastic tumor (GTD)

Incidence:

1:714 in UK

1:385 in Asia

1:20,000 after termination of pregnancy (TOP)

1:50,000 after a live birth

Recurrence:

1:80 (1.25 %)

After a molar pregnancy 98% chance of normal pregnancy & 2% chance of molar pregnancy (75% will be of same type) in future

Complete mole:

Diploid

80% due to sperm duplication after fertilisation with empty ovum

20% due to two sperm fertilised with empty ovum

Partial mole:

90% triploidy (2 sperm and 1 ovum fertilised)

10 % tetraploidy/mosaic

Sign & symptoms

Irregular vaginal Bleeding (most common)

Pain

Positive pregnancy test

Less common

hyperemesis,

excessive uterine enlargement,

hyperthyroidism,

early-onset pre-eclampsia and

abdominal distension due to theca lutein cysts.

Very rarely

haemoptysis or

seizures

due to metastatic disease affecting the lungs or brain.

Diagnosis

A.Pre evacuation diagnosis by USG

a. Complete mole-Easy to diagnose

Present with delayed miscarriage or anembryonic pregnancy

b. Partial mole- Difficult to diagnose

Present with

1. cystic spaces in placenta

2. Transverse/ Anteroposterior >1.5

3. B HCG > 2 mom

B. Post evacuation/confirmed diagnosis by Histopathological examination (HPE)

C.Biopsy of secondary deposits in the vagina can cause major haemorrhage and is not recommended.

Difference between complete and partial mole

CHARACTERISTICS COMPLETE MOLE PARTIAL MOLE
1.Evacuation method Suction & Evacuation, Suction & Evacuation

                                                              No medical                           Medical evacuation if increased size
2.Persistence                              More chances                               Less chances
3. Chances of chemotherapy             15%                                               0.5%
4.Requirement of Anti D                        No                                                      Yes

   after evacuation
5. Ploidy                                           Diploid                                  Triploidy/Tetraploidy
6. P57 Immunostain                           Positive                                  Negative

Suction & Evacuation

For all:

*Immediate cervical preparation before evacuation is safe

*Senior should be present

*If there is excessive bleeding, oxytocin can be used but balance it against the risk of embolisation in

life threatening situation

*1 in 7 may need repeat evacuation, except in situation of acute compromise, there should be

consultation with the relevant GTD referral centre before performing surgical management for the

second time in the same pregnancy.

Follow up

*Weekly urine or serum B HCG till it becomes normal, usually it takes 56 days after evacuation and then weekly for 6 months (after uterine evacuation).

*If B HCG does not come normal within 56 days, follow up weekly till the normalisation of B HCG level and then weekly for 6 months (after B HCG normalisation)

*Follow-up for partial molar pregnancy is concluded once the hCG has returned to normal on two samples, at least 4 weeks apart.

*Register & Follow up with organisation (in UK,Charing Cross Hospital, London and Weston Park Hospital, Sheffield) as outcome is better and it is considered as minimum standard of care

*Inform every pregnancy and its outcome to the registered organisation

*Inform B HCG level 6-8 weeks after any pregnancy completion in women who had chemotherapy for GTN to registered organisation.

*Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event.

Special circumstances:

a.Ectopic molar pregnancy:

*Cases of women with ectopic pregnancy suspected to be molar in nature should be managed as any other case of ectopic pregnancy.

*If there is a local tissue diagnosis of ectopic molar pregnancy, the tissue should be sent to a centre with appropriate expertise for pathological review.

b. Twin pregnancy:

*If any doubt about the case, refer the patient to Fetomaternal unit (FMU)/GTD centre.

*If sure about the one molar pregnancy, counsel the women for,

-Prenatal test for karyotyping if there is any doubt about complete or partial molar pregnancy or any suspected placenta

-25% live birth rate (LBR)

-Increased preterm birth

-Increased perinatal morbidity & mortality

-PET

-Increased MMR(maternal mortality rate)

c.Placental site trophoblastic tumour (PSTT) and Epithelioid trophoblastic tumour (ETT):

*Recognised as variants of GTN

*Should be registered with and cared for within a GTD centre.

*Treated with surgery (hysterectomy) because they are less sensitive to chemotherapy.

d. Atypical placental site nodule (PSN) or where the local pathology is uncertain:

*Women should have their histology reviewed centrally.

*They will be discussed the existing data, perform staging investigations and to determine further management.

Women with typical PSN do not currently require further investigation or review.

Persistence of symptoms

Do USG and B HCG, if B HCG is < 5000 IU, Second evacuation may be offered after discussion with senior obstetrician

Persistence of increasing B HCG

There is chances of Gestational trophoblastic neoplasia

Calculate the risk by FIGO criteria:

FIGO Modified WHO Prognostic Scoring System as Adapted by FIGO(2000)

FIGO score

0 1 2 4

Age <40 >40

Antecedent pregnancy Mole. Abortion Term

Interval from index pregnancy <4 4–6 7–12 >12

months

Pretreatment hCG mIU/ml <1000 >1,000–10,000 >10,000–1,00,000 >1,00,000

Largest tumor size including

uterus,cm – 3–4 ≥5 –

Site of metastases

including uterus Lung Spleen, Gastrointestinal Brain,

kidney tract liver

Number of metastases identified – 1–4 5–8 >8

Previous failed chemotherapy – – Single drug Two or more

drugs

If low risk (score < 6)

-start single drug chemotherapy with injection Methotrexate and Folinic acid,alternate day for 1 week followed by rest for 6 days

-Continue same treatment till B HCG gets normal and then for 6 weeks (after normalisation of B HCG)

-Cure rate 100%

If high risk (score >7)

-start multiple drug chemotherapy with injections EMACO,

E- Etoposide,

M-Methotrexate,

A- Dactinomycin,

C- Cyclophosphammide &

O-Vincristine

-95% cure rate

-Increase the chances of secondary carcinoma i.e. colon carcinoma, acute myeloid leukaemia, melanoma and breast carcinoma, but if CT duration is <6 months there is no increased risk.

-Early menopause ~ 3 years, especially those approaching the age of 40 years, should be warned of the potential negative impact on fertility

If less common type- In case of Placental site trophoblastic tumor, surgery (hysterectomy)

Prevention:

*The histological assessment of material obtained from the medical or surgical management of all miscarriages is recommended to exclude trophoblastic neoplasia if no fetal parts are identified at any stage of the pregnancy.

*Women who receive care for a miscarriage should be recommended to do a urinary pregnancy test 3 weeks after miscarriage.

*No need of HPE following therapeutic abortion, provided fetal parts have been identified at the time of surgical abortion or on prior ultrasound examination.

*Refer all women to a GTD centre, with persistently elevated hCG either after an ectopic pregnancy has been excluded, or after two consecutive treatments with methotrexate for a pregnancy of unknown location.

*A urine hCG test should be performed in all cases of persistent or irregular vaginal bleeding lasting more than 8 weeks after a pregnancy event.

Planning of pregnancy after GTD:

-If not on the chemotherapy-avoid pregnancy till the follow up complete (for partial mole 2 normal level 4 weeks apart & for complete mole as advised above)

-If on the chemotherapy-avoid pregnancy for 1 year after the completion of chemotherapy,

if pregnancy occurs before 1 year,

a. Increase chances of miscarriage (in multi drug chemotherapy)

b.increase stillbirth (both CT)

c. Congenital anomaly~ general population

Contraception:

All methods can be used after evacuation

IUCD should not use as there is increased chances of perforation

HRT & Fertility drugs:

The use of exogenous estrogens,hormone replacement therapy (HRT) and other fertility drugs may be used once hCG levels have returned to normal.

Source:

https://doi.org/10.1111/1471-0528.16266

SBA ON GTD:

Coming soon…

PREMENSTRUAL SYNDROME (PMS)

Premenstrual SyndromeUsually confused with Bipolar disorder

Incidence

40%,5-10% severe, but 95% reproductive age women have premenstrual symptoms

Diagnosis

By making diary for two prospective cycles for menstrual problems by daily record of severity of problems (DRSP)

If diagnosis is inconclusive, make diary for one more month

If diagnosis is still inconclusive, give injectIon GnRha (total 3 months,1 month for GnRha to work and 2 months to see the effects on symptoms),if relieved, diagnosis confirmed

Another method-Premenstrual symptoms screening tool (PSST)-It is for screening, not for diagnosis as it is retrospective

No hormonal study should be done to diagnose PMS as same as in normal women

DIAGNOSIS SHOULD BE CONFIRMED BEFORE INITIATING ANY TREATMENT.

Ethology

Mainly due to more sensitivity to progesterone

Due to mediators serotonin/GABA which are mediated by Estrogen/Progesterone

Decrease level of Allopregnanolone (metabolite of progesterone)

Level of treatment

Initially under General physician (GP),If not relieved then

Gynecologist,If not relieved by GP

Multidisciplinary team if severe symptoms which include

GP
Gynecologist
Gynecologist who specialised in PMS
Psychiatrist

5. Dietician

History

Four things to ask

Symptoms cyclical or not/relieved by menses
Symptoms free week present or not
Effect on quality of life

4.Any additional factors (any psychological disorder self/family, hormonal treatment)

Classification

Type 1 (Physiological/mild PMS)

Only 1st symptom of above above mentioned symptoms present

Only counseling ,no treatment

Type 2 (Core menstrual disorder/PMS/Premenstrual dystrophic disorder)

Involve 5% of PMS

1st & 3rd symptom of above above mentioned symptoms present

Symptoms may be predominantly physical or psychological

Use all alternative approaches

Type 3 (Premenstrual exacerbation)

All symptoms of above above mentioned symptoms present

Treat the cause or suppress the ovulation or both

Type 4 (Premenstrual disorder with absent menstruation)

absent menstruation due to hysterectomy, ablation or IUD

1st & 3rd symptom of above above mentioned symptoms present

Treat as type 2

Type 5 (Progesterone induced premenstrual disorder)

History of progesterone treatment

1st & 3rd symptom of above above mentioned symptoms present

Change the type, dose and duration of the progesterone

Type 6 (Psychological disorder, no PMS)

Misattribution

Psychiatric referral

Type 7 (Premenstrual disorder due to non ovulatory ovarian activity)

Poorly understood

Treatment

First line

Exercise
Cognitive behaviour therapy (CBT) for 6 months, it has longer effects than Selective serotonin reuptake inhibitors (SSRI)
COC (containing drospirenone i.e Yasmin),continuously for 6 months,no 2nd generation COC,this is the first line treatment for PMS overall and for women who needs contraception too

4.Selective serotonin reuptake inhibitors(SSRI) i.e.tab Escitalopam 10 mg/Tab Citalopam during luteal phase (day 15 to day 28),it can be used during luteal phase (D15-D28) or

continuous with equal efficacy.

If using in continuous mode, it should be withdrawn gradually to prevent symptoms to reappear and

stop it during or before pregnancy as symptoms decreases in pregnancy from 2nd week onwards and there is small but unproven risk of congenital fetal malformation.

Side effects-decreased sexual function( decreased libido,anorgasmia)

It is not licensed in UK for this purpose.

Second line

1.Estradiol patches/gel(100 mcg) twice weekly or implant 100 mcg x 3 months with micronised progesterone 100 mg/200 mg (D17-D28) or levonorgestrel insert (LNG),or

Estradiol(20 mcg) 24 days and progesterone 4 days

as progesterone may cause symptoms to reappear, it should be used in minimal doses and should be micronised but low threshold for evaluating vaginal bleeding

Progesterone should not be used alone for PMS, use only with estradiol

Pt should be counselled about the side effects

Estradiol may effect breast and endometrial tissue ,insufficient data’s continue treatment on individual basis, no time period decided

Pt should be informed that it can not be used as contraception so use contraception by barrier or IUD methods to avoid the pregnancy

2.Selective serotonin re uptake inhibitors(SSRI) in increased doses (20-40 mg) i.e.tab Escitalopam mg/Tab Citalopam

Third line

GnRH agonist ,if > 6 months add back therapy with Hormone replacement therapy (HRT) I.e 1.continuous estradiol (50-100 mcg) oral/patches/gel with micronised progesterone 100 mcg/day or 2.Tab Tibolone 2.5 mg ,it will not affect the efficacy of GnRH

GnRH is for only severe cases &

For diagnosis

Yearly bone mineral density (BMD) should be checked, if decreased significantly then stop the treatment

Two yearly BMD should be done for natural menopause

2.Danazol 200 mg BD

Relieve especially breast symptoms, so used in cyclical mastalgia

More side effects

Especially affect lipid profile

Use contraception

Irreversible virilizing effects

Fourth line

Surgery (hysterectomy with bilateral salpingo-oophorectomy,BSO) + HRT

Isolated BSO is not recommended as HRT increases the risk of recurrence due to progesterone content and E2 only can not be used due to risk of cancer in remained uterus

Prior GnRH testing is necessary even surgery is done for other reason to test for cure and for tolerance to HRT

Start HRT after surgery especially in women <45 years

Complementary treatment

Especially in women who are not fit for HRT I.e. evening primrose

Calcium, vit D3, chasteberry (standard préparation is not available),magnesium, saffron and vitex agnus castus have some effect on PMS

Source:

https://doi.org/10.1111/1471-0528.14260

SBA on PMS

coming soon

POST MENOPAUSAL OVARIAN CYST

INCIDENCE

5-17%

Chances of malignancy

<1%,resolve in 3 months in > 50% cases

ASSESSMENT & MANAGEMENT

1.Whether symptoms present or not

If symptomatic and > 1 cm,surgery should be done according to diagnosis

2.Asses for risk of malignancy by RMI (Risk of Malignancy Index) calculation

RMI=CA 125 value x menopausal status x USG findings

Menopausal status:Premenopausal =1,Postmenopausal=3

USG findings:BAM2S(Mnemonic)

B-Bilteral,

A-Ascitis,

M-Multilocular,

M-Metastasis,

S-Solid

If no findings present give 0 point, if 1 finding present give 1 point, if >2 findings present give 3 points

3.Assess for need of surgery

a. Symptomatic @ any size > 1 cm

b. Non simple

c. Size > 5cm

d. Multilocular

e.Bilateral

If any one is present consider for BSO(Laparoscopically) only if with no spillage of content and retrieval through same umbilical port or vaginally and RMI < 200 by general gynecologist.

If just opposite to the above mentioned characteristics present plan for conservative treatment [repeat USG(TVS+ TAS) and CA 125 after 4-6 months].

During follow up if cyst resolve, discharge the patient

And if any changes occurs as mentioned above consider for BSO(Laparoscopically only if with no spillage of content and retrieval through same umbilical port or vaginally and RMI < 200

If cyst persist after 2 USG, individualise the treatment as per women’s preference

4.If RMI is > 200 or found malignant intra operative or later

-refer to oncologist and MDT

-CT SCAN (only for staging)

-need laparotomy/full staging laparotomy (if already done)

-If on evaluation, patient is found to be at high risk of malignancy full staging by oncologist should be done

-If at low risk do pelvic clearance (TAH+BSO+Omentectomy+peritoneal cytology+ pelvic/para aortic lymphadenectomy) by trained gynaecologist or leading clinician at cancer unit,should be done.

-If CT scan done and not clearly stated about the ca then do USG

-Any postmenopausal women with IBS(inflammatory bowel syndrome) for 12 months, do CA 125 and USG to evaluate for carcinoma.

-Fibroid, endometriosis, PID, peritoneal irritation by TB, pancreatitis, hepatitis and cirrhosis and ovarian cysts events increase CA 125 and caffeine, smoking and hysterectomy (CASH) decrease the CA 125.

-MRI should be done only when USG is inconclusive, contraindicated in pt with pacemaker/cochlear implant,constrast MRI is better than CT/MRI (noncontrast)

-Ascitis is the best indicator of malignancy

International ovarian tumour analysis (IOTA) group-

There is B rules 7 M rules according to USG appearance of the ovarian cyst

In B rules, cyst is

1.unilocular

2.Presence of solid component max <7 mm

3.Presence of acoustic shadowing

4.Smooth multilocular cyst <10 cm

5.No blood flow

M Rules

1.Irregular solid tumour

2.Ascitis

3.At least four papillary structures

4.Irregular multilocular >10 cm

5.Very strong blood flow

Statistical significance of different methods:

RMI WITH CUT OFF >200 RMI WITH CUT OFF >250 IOTA GROUP

SENITIVITY (%) 78 70 95

SPECIFICITY (%) 87 90 91

-Aspiration of ovarian cyst should be done only in post menopausal symptomatic women who are unfit for surgery. Twenty five (25%) percent will recur within 1 year.

-For patient with borderline tumour, even on suspicion, refer them to oncologist as 20% cases have simple USG findings.

FLOWCHART FOR POSTMENOPAUSAL OVARIAN CYST MANAGEMENT (FROM RCOG GREEN TOP GUIDELINES)

PRE MENOPAUSAL OVARIAN CYST

Incidence:

10 % women have surgery in lifetime due to ovarian mass

10% non ovarian in adnexal mass

0.1% malignant in symptomatic cyst in <50 years of age

0.3%(3X) malignant in symptomatic cyst in >50 years of age

Causes: Adenexal mass

Ovarian

Benign

Functional cyst

Endometriotic cyst

Serous cyst adenoma

Mucinous cyst adenoma

Mature teratoma (Dermoid cyst)

Malignant

Primary

Epithelial cell tumour

Sex cord tumour

Germ cell tumour

secondary

Predominantly breast and gastrointestinal carcinoma.

Non Ovarian

Paratubal cyst

Hydrosalpinges

Tubo ovarian abscess

Appendices access

Diverticular abcess

Pelvic kidney

Peritoneal pseudocyst

Dermoid cyst

Benign germ cell tumour (GCT)

Most common pathological cyst in premenopausal women

10-20% bilateral

3-4% recurrence

Grow @ 1.7-1.8 mm/year

Have no or little effect on fertility

It only stretches the ovarian cortex and not damaging the follicles

Repeated surgeries may decrease the AMH (Anti mullerian hormone) and hence fertility

Surgery at large size decreases more AMH and hence fertility, so do surgery at smaller size(<5 cm is cut off)

Endometriomas

15-45% of women with endometriosis

30% bilateral

Recurrence 15-30% after 2-5 years of follow up in same ovary mainly and in contralateral ovary

Growth at 0.48 cm/month if not using any hormonal treatment

Affect all aspect of fertility i.e. oocyte, embryo,fertilizzation

Increased spontaneous fertility in women with proved infertility, so surgery should not be done in women with with endometriomas who have no proven infertility

Haemorrhagic cyst

Due to haemorrhage into follicular/corpus luteal cyst

Looks like endometriomas

Differentiated by histopathological examination(HPE)

NO EFFECT ON FERTILITY

If mistaken for endometrioma followed by surgery, decrease fertility

Ovarian cystadenoma

May be serous or mutinous

Both are benign epithelial neoplasm

Serous variety is more common in menopausal women

Occurs in 30’s-60’s of age

Unilateral

Large 15-30 cm

No effect on fertility as such but due to increased size there is increased chances of oophorectomy and surgical spill and hence adhesions and infertility

In children & adolescent

75% oophorectomies due to benign cyst

45% adnexal abnormalities are functional

55% neoplasm (50% teratoma,1% immature teratoma)

Consult with MDT

Clinical assessment:

Patient can present as

-Pain lower abdomen

-Decreased appetite

-Distension

-Frequent micturition

-Frequent defecation

-Dyspareunia

-Abnormal periods

-Acute events i.e. torsion, rupture, heamorrhage

-Difficulty in getting pregnant if endometriosis

-Take history for risk factors i.e.

1.personal/family h/o of breast cancer, ovarian cancer, colon cancer

2.age >50 years(80%)

3.increased BMI

4.Nulliparity/late menopause(pregnancy/OCPs prevent it)

5.BRCA I/II mutation(10% cases)

6.Other high risk genes RAD51C, RAD51D, BRIP1, PALB2 and Lynch syndrome genes

-Symptoms of endometriosis

Do examination

Investigation-TVS-if simple cyst, no further tests

No CA 125 should be done in premenopausal women with simple cyst in USG

LDH,AFP & HCG should be only if complex cyst present in USG

RMI-can be done in premenopausal women also, if CA 125 can not be used do IOTA assessment

Management:

A.If CA 125(IU/ml) done & it is

<200-search for benign diseases and its trend ,if rapid increase, it may be cancer

>200- discuss with oncologist

B.If size

<50 mm-no follow up

50-70 mm-yearly USG,if persist, do surgery

>70 mm-do MRI or Surgery

C. For large(size not decided yet) dermoid cyst with solid components laparotomy(cystectomy) should be done

0.2% chances of chemical peritonitis on spillage

If occurs lavage with warm saline

D.No aspiration should be done as it is equivalent to expectant management

Recur 50-80%

E. Endometrioma >3 cm

do endometriotic cystectomy by enucleation

Rare chances of malignancy

If suspicion discuss with MDT

Take consent of oophorectomy if needed

F. If any M rule (out of 6) along with ovarian mass

Refer to Gynae oncologist

Surgery

Usually laparoscopic cystectomy should be done unless very large or any chances of cancer ,in that case do laparotomy

During surgery

Only cyst to be removed not ovary unless cyst is

1.very large and very less ovarian tissue remained,

2.suspicion of cancer or

3.infarcted ovary

After surgery fertility remains

OCPs decreases new cyst formation

Cyst in pregnancy-do only scans ,do surgery only when it is painful

ALL RECOMMENDATIONS ARE FOR ASYMPTOMATIC CYST,IF SYMPTOMATIC,SURGERY SHOULD BE DONE ACCORDING TO DIAGNOSIS

SCREENING FOR OVARIAN CANCER

*Family history can be used to define women who are at increased risk of ovarian cancer.In cases where ovarian cancer risk assessment appears complex or difﬁcult, it is important to seek advice from a specialist with greater expertise, such as a clinical geneticist or gynaecologist/gynaecological oncologist with special interest in genetic risk assessment or hereditary cancer risk management.

High risk ( >10% risk)

A woman is defined as being at high risk( with an estimated 10% or more lifetime ovarian cancer risk ) of ovarian cancer if she has a first-degree relative (mother,father,sister,brother, daughter or son) affected by cancer within a family with:

● two or more individuals with ovarian cancer, who are first-degree relatives of each other (2 OC in 1 degree)

● one individual with ovarian cancer at any age and one with breast cancer diagnosed under age 50 years who are first-degree relatives of each other(1OC+1 BC <50 years)

● one relative with ovarian cancer at any age and two with breast cancer diagnosed under age 60 years who are connected by first-degree relationships(1 OC+2 BC<60 years)

● three or more family members with colon cancer, or two with colon cancer and one with stomach, ovarian,endometrial,urinary tract or small bowel cancer in two generations.One of these cancers must be diagnosed under age 50 years and affected relatives should be first-degree relatives of each other (> 3 CC or 2CC +1 stomach, ovarian,endometrial,urinary tract or small bowel cancer)

● one individual with both breast and ovarian cancer. (OC+BC)

Intermediate risk(5–10% )

one or two ﬁrst-degree relatives with ovarian cancer

RAD51C, RAD51D, and BRIP1 gene mutation(5–13% lifetime ovarian cancer risk)

PALB2

*A woman is also considered at increased risk of ovarian cancer if

she is a known carrier of relevant cancer gene mutations (e.g.BRCA1,BRCA2,mismatch repair genes{MLH1,MSH2,MSH6}),
she is an untested first-degree relative of an individual with a relevant cancer gene mutation,or
she is an untested second-degree relative,through an unaffected man,of an individual with a relevant cancer gene mutation

*Where family history is significant,referring the woman to the Regional Cancer Genetics service should be considered.

*BRCA I gene is at chromosome 17

*BRCA II gene is at chromosome 13

Category of risk of lifetime ovarian cancer

High risk if >10% risk

Intermediate risk 5–10%

Association with other cancers

BRCA I/II- Breast/Prostate/Fanconi anemia/Pancreatic/Melanoma
RAD51C/RAD5ID-Fallopian tube/primary peritoneal cancer
Mismatch repair genes{MLH1,MSH2,MSH6}/Lynch syndrome-Endometrial

What to do if women is at high risk/intermediate risk of ovarian cancer (RRSO + Hysterectomy)

Risk Reducing Salpingo Oophorectommy (RRSO) has been traditionally offered in BRCA1/BRCA2carriers and in women with Lynch syndrome (mismatch repair gene [MLH1, MSH2 or MSH6] mutation carriers).

Concomitant hysterectomy is undertaken in those with

1.Lynch syndrome as they also have a 40–60% lifetime risk of endometrial cancer.

2.It may be appropriate in a small number of other women for independent gynaecological indications, such as ﬁbroids and adenomyosis.

3.Few studies have reported an increased risk of serous (subtype) endometrial cancer in BRCA1 carriers. This comprises a small proportion (approximately 7%) of endometrial cancers, with the overall population-based lifetime risk for endometrial cancers being 2.4% in the UK and 2.9% in the USA.

Moreover, the number of reported serous endometrial cancer cases are small, conﬁdence intervals wide, and the absolute lifetime risk is low (around 3%), and total endometrial cancer risk is not increased in BRCA1 carriers. Endometrial cancer risk is not increased in BRCA2carriers.

Therefore, more corroborating data and precision around endometrial cancer risk are needed before hysterectomy in BRCA1 or BRCA2 carriers can be routinely advocated

Selection criteria for prophylactic surgery.

A.In the UK, given the historic restricted access to genetic testing, RRSO has been offered to women from high risk families, who were unable to access gene testing.

B.RRSO has been shown to be cost-effective at lifetime ovarian cancer risk thresholds of more than 4–5%

RRSO can therefore also be offered to women with moderate risk gene mutations including

1. RAD51C, RAD51D, and BRIP1(5–13% lifetime ovarian cancer risk),

2.selected women with a signiﬁcant family history of ovarian cancer(e.g. one or two ﬁrst degree relatives with ovarian cancer)

3.PALB2 has been conﬁrmed as a moderate risk ovarian cancer gene, with some now supporting RRSO in these women, while others cite the limited evidence for this. RRSO can be considered for women with PALB2mutations following a non-directive counselling process taking into account additional risk and protective factors, and preferably carried out near/after menopause

Timing of RRSO

RRSO decision making is a complex process, and timing needs to be individualised following informed counselling of the pros and cons & taking into account clinical factors and personal preference.

RRSO is usually offered once a family is complete.

There are occasional exceptions when women undergo IVF and have embryos stored prior to RRSO in order to complete their family later.

In women with early onset cancers in the family it may also be undertaken from up to 5 years before the earliest recorded age of onset of ovarian cancer in the family.

It is typically offered

from 35–40 years for BRCA1 carriers,
40–45 years for BRCA2 carriers,
40–50 years for RAD51C/RAD51D carriers, and
nearer/after menopause (aged above 45–50 years) for PALB2 carriers.
In BRIP1 carriers and mutation-negative, intermediate risk women (5–10% lifetime ovarian cancer risk) with a strong family history, it maybe delayed until 45–50 years .

Need for HRT

A signiﬁcant number of women undergoing RRSO will end up with premature iatrogenic menopause (with the average age of natural menopause being 51 years) requiring HRT.

Clearly the issue of risk and age of surgery needs to be individualised and there must be informed discussion with women regarding the consequences of iatrogenic surgical menopause, beneﬁts of HRT, and its risks and limitations so they can make informed decisions.

Research suggest that unlike older women,HRT for women with early menopause does not increase the risk of breast cancer including in those with BRCAI/II carrier,who have preventive surgeries done.

Who will care these women

Women are best cared for in dedicated high risk clinics or multidisciplinary teams involving gynaecologists/gynaecological oncologists with speciﬁc interest in care of women at high risk, a psychologist, and clinical nurse and menopause specialists.

There should also be links to clinical genetics, breast and colorectal teams.

SBA

BRCA I/BRCAII genes are located on chromosome

A. 10/11

B. 11/12

C. 09/10

D. 13/17

E. 17/13

2.A women with ovarian cancer with NO gene mutation related to ovarian cancer wants to know about the lifetime risk of ovarian cancer in her daughter. It will be:

A. <10 %

B. >10 %

C. <4%

D. 13%

E. Can’t be predicted

3.A women with ovarian cancer with BRCA I gene mutation, wants to know about the lifetime risk of ovarian cancer in her daughter. It will be

A. 1:25

B. 1:50

C. 1:75

D. 1:1

E. Can’t be predicted

4.Lynch syndrome is associated with

A. Ovarian cancer

B. Endometrial cancer

C. Both A & B

D. Breast cancer & ovarian cancer

E. Fallopian tube cancer

5.What prophylactic surgery should be done in women with BRCA I mutation

A. Risk Reducing Salpingo Oophorectommy (RRSO) from 35-40 years

B. Risk Reducing Salpingo Oophorectommy (RRSO) from 40-45 years

C. Risk Reducing Salpingo Oophorectommy (RRSO) & hysterectomy from 35-40 years

D. Risk Reducing Salpingo Oophorectommy (RRSO) & hysterectomy from 35-40 years

E.None of the above

6.A women had undergone Risk Reducing Salpingo Oophorectommy(RRSO) at 37 years of age due to high risk family history of ovarian cancer and she is found to have BRCA I mutation.Few months later she has severe menopausal symptoms not responding to any non hormonal treatment.To start HRT

A. HRT should not be started as she is BRCA I positive and at increased risk of breast cancer

B. HRT can be started without increasing the risk of breast CA

C. HRT can be started with increased risk of breast CA due to severe menopausal symptoms

D. HRT can not be started as it will not improve the symptoms

E. HRT up to 51 years of age is recommended post RRSO in the absence of any contraindication

ANSWERS

1.E,

2.A-As daughter is having only one first degree relative with ovarian cancer, she comes under intermediate risk (5-10%)

3.B-As BRCA mutations are dominant one hence inheritance would be 1:50

4.C

5.A

6.E

HEAVY MENSTRUAL BLEEDING

Heavy menstrual bleeding (HMB)

This term replaced the term menorrhagia

Women having HMB should be evaluated by

1. Menstrual history,

2. Related symptoms (persistent inter menstrual bleeding, pressure symptoms or pelvic pain with high risk of fibroids, uterine cavity abnormality, adenomyosis),occasional symptoms are common

3.Associated co morbidities (Hypertension, diabetes, carcinoma)

If HMB is not associated with any related symptom, there is no need for physical examination unless planned for LNG IUS.Medical treatment can be started immediately.

If related symptoms present do physical examination before planning any investigation

Women at high risk of malignancy:

1.Declined or failed to have adequate treatment

2.Age >45 years

3.Pathology suspected on history and examination

4.HMB with regular or irregular cycles

5.HMB with dysmenorrhea

6.HMB with pelvic mass

7.HMB with pressure effects on gastrointestinal or genitourinary tract

8.Inter menstrual or postmenopausal or postcoital bleeding

Indication for secondary referral:

1.If red flag sign present

2.Moderate to severe anemia on FBC

3.Any abnormality detected during treatment

4.Treatment failure i.e. 3 months duration for medical treatment and 6 months duration for LNG-IUS

Investigations

A. Full blood count (FBC)-first line investigation and should be done for women with HMB with any treatment offered

B. Transvaginal scan (TVS)-it can be first line investigation if 1. Physical examination shows pelvic mass

2. Uterus palpable abdominally

3.Medical treatment fails

4. Examination inconclusive i.e. obese

USG detects fibroid better than hysteroscopy and hysteroscopy detects intrauterine abnormality (i.e. polyp/endometrial disease) better than USG.

If TVS declined by the women offer TAS or MRI pelvis with explanation of its limitations

C.Coagulation profile-if

1.HMB present since first period

2.personal or family history present

D.Serum ferritin-not routinely done

E.Hormonal tests-not routinely done

F.Thyroid function test-only if symptoms present

G. Hysteroscopy-if

1. Intra cavitary abnormalities are suspected by history (fibroid, polyp, carcinoma)

2.persistent inter menstrual bleeding

3.risk factor for endometrial pathology present

Hysteroscopy should be organised so that if pathology present, one can see & treat

If woman decline hysteroscopy in outpatient, plan it under general/regional aneasthesia

If decline hysteroscopy, offer pelvic scan and explain its limitation to detect uterine pathology

H.Endometrial biopsy-

-No blind dilatation & curettage for HMB for diagnostic tool

-only during hysteroscopy if-high risk for endometrial pathology (i.e. irregular bleeding on HRT)

-HMB with PCOS or Obese or on Tab Tamoxifen

-HMB with persistent inter menstrual bleeding

-HMB with > 45 years of age

-HMB with treatment failure

-HMB with ineffective treatment

*Do not use Saline hystero-salpingography and MRI as first line investigation

Management

*Inform pt regarding the treatment, its consequences and future fertility

*If use LNG-IUS-irregular bleeding may last >6 months

-wait for 6 cycles for benefits

-Effect is equivalent to ablation which in turn equivalent to hysterectomy

-at 1 year of use 70% women continue and 30% ask for hysterectomy

-At 5 years of use 60% women continue and 40% ask for hysterectomy

-it is licensed for- 1.Menorrhagia with no cause found (hormonal)

2.uterine protection with HRT in peri and post menopausal women

3.Contraception

-it is not licensed for-

1.endometrial adenomyosis

2. Endometrial hyperplasia

3.Endometraial carcinoma

4.Fibroids

5.Endometrial protection with Tab Tamoxifen

*Procedures retaining the fertility- 1. Myomectomy

2.Uterine artery embolisation (UAE)

*Procedures not retaining the fertility-1.Ablation:avoid subsequent pregnancy

2. Hysterectomy

*for deciding the treatment of HMB consider:

1.Woman’s preference

2.Any comorbidity

3.Presence or absence of fibroid/polyp/endometrial pathology

A. Treatment in women with: 1. No identified pathology

2. Fibroid <3 cm

3.suspected or diagnosed adenomyosis

1.LNG-IUS:first line, if declines

2.Non hormonal treatment (Trenexamic acid/NSAIDS)- no Ethamsylate for HMB

- do not use in combination initially

-use NSAIDS if dysmenorrhea present

3.Hormonal (COC,Cyclical oral progesterone)

*Use oral treatment for 3 cycles to confirm efficacy

*If all treatment fails, refer to specialist care for

A.Repeat investigation

B. Alternate treatment

i.another pharmacological options which were not tried before

ii. Surgical options:a.Ablation (2nd generation),preferred over hysterectomy if uterus size <10

weeks

b. Hysterectomy

c. Submucosal fibroid-outpatient hysteroscopic removal, if decline then do

under general or regional anaesthesia. If decline hysteroscopy do USG after

explaining its limitations.

B. Treatment in women with: 1. Severe symptoms

2. Fibroid >3 cm-Treatment depends on size and location of fibroid

*Start NSAIDS/Trenexamic acid to relieve the symptom before investigation and definite diagnosis and as long as woman find it beneficial.

In this group of patients we can give if not tried before:

1.Non hormonal treatment (Trenexamic acid/NSAIDS)- no Ethamsylate for HMB

- do not use in combination initially

-use NSAIDS if dysmenorrhea present

2..Hormonal (COC,Cyclical oral progesterone)

3.Uterine artery embolization (UAE)-ONLY FOR FIBROID

-Fertility outcome poor, lacking evidence, explain risk & benefits

-Outcome equivalent to myomectomy

-According to Cochrane study, if a woman desires for fertility do

myomectomy than UAE as effects of UAE on fertility and

pregnancy are uncertain though successful pregnancies are

possible in women undergoing UAE.

-40-70% reduction in volume of fibroid

-80-90% asymptomatic/drastic improvement comparable to

surgical treatment (hysterectomy/myomectomy) after 1 year

Indications-

1. Symptomatic fibroid, if adenomyosis also present, less effective, but can be used

2.Woman’s desire

3. Adenomyosis

4.Medically unfit for surgery

5.Who are unwilling for blood transfusion if needed (Jehovah’s witness)

6.Prior unsuccessful surgery

Contraindications-

1.Current/recent pelvic infection

2. Inadequate diagnosis of fibroids

3.Asymptomatic fibroids

4. Pregnancy

5.Size of fibroid is not a contraindication

Prerequisites-

Confirmed diagnosis

-Rule out sarcoma

-Urine pregnancy test to rule out pregnancy

-Can be done anytime of menstrual cycle

-Rule out infection by history & examination

-Single dose antibiotic prophylaxis at the discretion of local hospital policy

-If increased risk of venous thromboembolism (VTE),Heparin prophylaxis

-Prior GnRH treatment to reduce size and vascularity, also leads to smaller uterine artery with spasm and technically more challenging to catheterise, especially (shown in a trial EMMY) if UAE done within 60 days of treatment, but UAE done after 60 days do not improve outcome

Recent trial suggests that it enhances technical outcome of UAE for large fibroids.So,GnRH treatment deferment is also at local discretion.

Complications-

A.Perioperative:

1. Hematoma

2. Thrombosis

3.Aneurysm

4.Reaction to contrast media

5.Vasospasm-use vasodilator through catheter

6.Non target embolisation

B. Early (<30 days)-

1.Post embolisation syndrome-a.Pain

b.Nausea

c.Fever

d. Malaise

2.Self limiting infection

3.Urinary tract infection (UTI)

4.Deep venous thrombosis (DVT)

C. Late (>30 days or after 1 year)-

1.Hysterectomy is needed in 2.9% cases

2.Early ovarian failure/Amenorrhea ,1.5 % cases,especially if age >45 years

3.Needs reintervention after ~5 years in 30 % cases

4. Vaginal discharge-may be due to infection or fibroid expulsion

5.Fibroid expulsion or impaction in 10 % cases, managed expectantly or hysteroscopic removal

6.Infection

7.Sexual function-improved in 26%,worse in 10 % and unchanged in remainder

Effect of above mentioned treatments is limited in this group of patients.

4.Surgical-

a. Myomectomy- Use USG for description of fibroid, if needed do MRI,MRI is superior to USG,MRI

alters management in as many as 22% cases

-Use GnRH pretreatment if size is large and uterus is distorted

b. Hysterectomy-Usually 2nd line treatment but it is a first line treatment in small group of patients

-Total or subtotal,

- Via laparoscopy/laparotomy/vaginal

-Depends upon 1.patient’s choice

2.size of the uterus

-Removal of ovaries-if needed, take patient’s preference with risk and benefit.

c. Ablation- if woman meet the criteria of manufacturer

-if no pressure symptoms present

-no blind ablation, only hysteroscopic

-decrease 80% blood loss

-if submucosal fibroid>3 cm/polyp present, remove before ablation

First line treatment in this group is surgical, UAE can be considered but removed now due to its temporary effects.

In either group, mentioned above, if treatment unsuccessful:

1.Re evaluate the cause of HMB

2.Opt for other treatment modalities which were not used before

Effectiveness of treatment on HMB (reduction of blood loss in percentage):

1.Traxenamic acid - 40%

2.NSAIDS - 30%

3.COC -40%

4.Qlaira -30%

5.POP. -60%

6.LNG-IUS -70-100% (50% amenorrhea & 30% decrease in size of fibroid)

7.GnRH -60-100%(80-90% amenorrhea,30% decrease in size of fibroid)

8.Implant/injection -30-100% (15-20% amenorrhea)

(progesterone)

9.Ablation -80%

Best treatment according to patient’s choice and conditions:

A.Ablation:If all present

1.Severe impact on the quality of life

2. No desire to conceive

3. Uterus size is <10 cm, but microwave can be used with 14 cm long uterus

And/or

4.small fibroid <3 cm

If any pathology present i.e. endometriosis, chronic pelvic pain etc. hysterectomy/UAE may be the first line treatment.

B. Hysterectomy: if all present

1.Other treatment failed/contraindicated/declined

Don’t remove heathy ovaries 2.Desire for amenorrhea

3.Fully informed and requested for this treatment

4. No desire to retain uterus/fertility

C.Severe impact on quality of life with fibroid>3 cm

1.Hysterectomy,Don’t remove heathy ovaries

2. UAE

3. Myomectomy

a. Submucous: 1.Transcervical endometrial resection-80-100% decrease in blood loss

2. Hysteroscopic removal-65% decrease in blood loss

-60-90% success rate in long term

-20% need repeat surgery in 4 years and 0% thereafter

b. Subserosal/Not defined:Laparoscopic myomectomy -30% decrease in blood loss

c. Focal fibroid:1.MRI Guided Ultrasonic therapy-60% decrease in blood loss,

-20% decrease in size at 2 years

-30 % secondary treatment

-10% complications

-Fertility may increase or decease or have no effect, but effect is not known if age

is >41 years

2.Radio frequency ablation-50% decrease in blood loss,

-65% decrease in size

d.Global fibroid:

1. UAE-80% decrease in blood loss

-30% decrease in size

-95% benefit in < 3 months

-25% re treatment at 5 years

-Fertility may increase or decease or have no effect but effect is not known if

age is >41 years

2.Laparoscopic uterine artery occlusion:

-55% decrease in blood loss,

-25% decrease in size

3. Doppler guided transvaginal uterine artery occlusion:

-50% decrease in blood loss,

-25% decrease in size

e. Abdominal myomectomy: 1.> 80% decrease in blood loss,

2. Increase fertility if no cavity encroachment

3. Re treatment at 2-5 years in 20%

4. Conversion to hysterectomy in <1%

SBA

1.A woman 30 years, has attended her general physician for heavy bleeding during her periods with no other symptoms. She is also planning to have some contraception for short period of time as she wishes to have pregnancy soon.

A.Take thorough history, do physical examination and plan for treatment

B.Take thorough history, do physical examination and plan for LNG IUS

C.Take thorough history, do physical examination and plan for COC

D.Take thorough history and start COC if no contraindication

E.Take thorough history and start non hormonal treatment

2. What first investigation would you offer to women with HMB

A.Pelvic scan

B.Full blood count

C.Coagulation profile

D.Liver function test

E.Thyroid function test

3.A 40 years woman attends the GP clinic with heavy menstrual bleeding with persistent inter menstrual bleeding for last 6 months.On examination,GP found bulky and tender uterus.What investigation would you like to offer her on first line:

A.FBC

B.TVS

C.FBC & TVS

D. Endometrial biopsy pipelle

E. Hysteroscopic guided Endometrial biopsy

4.A woman,45 years, presenting to GP clinic with heavy menstrual periods alongwith inter menstrual bleeding. On evaluation, she was found to have intramural fibroid ~ 5 cm in anterior wall of uterus. She has tried COC for last 3 months but now it is not working. What is the best treatment for her:

A. Hysterectomy

B. Myomectomy

C. Uterine artery embolisation

D. Ablation

C. Non hormonal treatment

5.A woman,33 years, presenting to GP clinic with heavy menstrual bleeding during periods with pain.She wants further pregnancy.On examination,GP found bulky, irregular and non tender uterus.Scan shows intramuaral fibroid ~6 cm in anterior wall but not encroaching the cavity.She tried COC but now it is not working for her.GP referred the case to you.What is the best treatment for her?