Female Pelvic Anatomy

Uterus Anatomy (1)

Structure:
• Fundus: the top, above the entry point of the uterine tubes
• Body: site for implantation of the blastocyst
• Cervix: the bottom, linking to the vagina

Position:
• Exact location varies with the degree of distension of the bladder
• Anteverted: rotated forward, towards anterior body surface
• Retroverted: rotated backwards, towards posterior body surface

Ligaments
• Broad: double layer of peritoneum attaching the sides of the uterus to the pelvis
• Round: remnant of the gubernaculum extending from the uterine horns to the labia majora via the inguinal
canal. Maintains the anteverted position of the uterus
• Ovarian: joins the ovaries to the uterus
• Cardinal: extends from the cervix to the lateral pelvic walls. Contains the uterine artery and vein
• Uterosacral: extends from the cervix to the sacrum
 Uterus Anatomy (2)
Layers of the Fundus and Body:
• Peritoneum: double layered membrane, continuous with the abdominal peritoneum
• Myometrium: thick smooth muscle layer. Cells of this layer undergo hypertrophy and hyperplasia during pregnancy
in preparation to expel the foetus at birth
• Endometrium: inner mucous membrane lining the uterus. Further subdivided into 2 parts:
• Deep stratum basalis: changes little throughout the menstrual cycle and is not shed at menstruation
• Superficial stratum functionalis: proliferates in response to oestrogens, and becomes secretory in response to progesterone. It is
shed during menstruation and regenerates from cells in the stratum basalis layer

Vascular Supply and Lymphatics

• Blood supply is via the uterine artery
• Venous drainage is via a plexus in the broad ligament that drains into the uterine veins
• Lymphatic drainage is via the iliac, sacral, aortic and inguinal lymph nodes

Innervation
• Sympathetic innervation: uterovaginal plexus (anterior and intermediate parts of inferior hypogastric plexus)
• Parasympathetic innervation: pelvic splanchnic nerves (S2-S4)
• Cervix innervation: inferior nerve fibres of the uterovaginal plexus
• Afferent fibres: ascend through inferior hypogastric plexus to enter the spinal cord via T10-T12 and L1 nerve fibres
Subfertility
Inability to conceive after 12 months of regular unprotected sexual intercourse
• Primary = woman is unable to ever bear a child. Includes miscarriages, ectopics, abortions and stillborns.
• Secondary = woman is unable to bear a child following a previous successful pregnancy

Causes
• Ovulatory Disorders (25%)
• Type 1: Hypopituitary Failure (can be caused by anorexia nervosa)
• Type 2: Hypopituitary Dysfunction (PCOS, hyperprolactinaemia)
• Type 3: Ovarian Failure (Premature Ovarian failure if under 40 yrs)
• Tubal Damage (20%)
• Pelvic Inflammatory Disease
• Previous tubal Surgery including tubal surgery for ectopic pregnancy.
• Endometriosis (tubal and uterine).
• Cervical mucus defect
• Uterine/peritoneal disorders (10%)
• Fibroids (uterine)
• Male factors (30%)
• Testicular (infection, cancer, surgical, congenital, undescended testes and trauma).
• Azoospermia with or without sperm antibodies
• Reversal of vasectomy
• Ejaculatory problems (retrograde and premature)
• Hypogonadism

• 40% of cases involve both male and female factors.

• Unexplained infertility (25%)
Assisted Conception
Intrauterine Insemination (IUI) – increase number of sperm reaching fallopian tube
• Sperm is separated in lab and slower speed sperm removed
• Sperm inserted into woman’s uterus via speculum and small catheter

In-vitro Fertilisation (IVF) – enable fertilisation

• Natural monthly hormone cycle is supressed with daily injections for about 2 weeks
• Daily gonadotrophins are given to boost egg supply
• Egg is fertilised outside the body then 1 or more are put back in
• Women < 40yr: 3 cycles
• Women > 40 yr: 1 cycle

Intracytoplasmic Sperm Injection (ICSI)

• Similar to IVF but 1 sperm is injected directly into an egg
• Indicated for couple whom previous IVF has failed
• ICSI improves fertilisation rates compared to IVF alone, but once fertilisation taken place, the pregnancy rate
is no better than with IVF
Bleeding in Early Pregnancy
Causes:
• Miscarriage
• Ectopic pregnancy
• Gestational trophoblastic disease
• etc
Miscarriage Early miscarriage is <12 weeks
Late miscarriage is 13-24 weeks
Stillbirth is >24 weeks
Recurrent is 3 or more in a row

Types: Symptoms:
• PV bleeding
• ± abdominal pain
• ± haemodynamic instability

History/Examination/Investigations
• LMP
• Quantify bleeding
• Site of pain
Causes:
• Early: genetic abnormality, placental problem, maternal age >45y • Abdominal exam
• Late: maternal chronic conditions, infections, food poisoning, PCOS • Speculum ± bimanual
• Recurrent: thrombophilia, prev misc, smoking, alcohol, caffeine • Urine HCG
• Serum HCG
Differential Diagnosis: • Transvaginal ultrasound (TVS)
• Ectopic pregnancy
• Hydatiform mole Management:
• Cervical/uterine malignancy • Conservative: pass POC naturally if expectant + safety net
• Ectropion • Medical: anti-D if >12 weeks,
• Polyp • Mifepristone 200mg PO (progesterone antagonist)
• Misoprostal 800mcg PV (prostaglandin analogue)
• Surgical: Evacuation of retained products of conception (ERPC)
Ectopic Pregnancy
Embryo implants outside the uterus

Risk Factors Investigations

• PMH: prev ectopic, PID, endometriosis • Pregnancy test
• Contraception: IUD, POP, implant, tubal ligation • Transvaginal USS
• Iatrogenic: pelvic surgery, assisted conception • Laparoscopy to confirm ± treat

Pathology Management
• Common sites – ampulla and isthmus of fallopian tube • SENIOR REVIEW
• Occasionally cornu, cervix, ovary, abdomen • Unstable = ABCDE
• Tubal implantation can lead to tubal rupture and • Stable:
intraperitoneal bleeding • Medical: Methotrexate (if <35mm, no heartbeat,
no pain, serum bHCG <1500IU/L, unruptured)
• Surgical: Salpingectomy/salpingostomy
Features • Anti-D (if Rh –ve)
• At 4-10 weeks of amenorrhoea
• Acute: collapse, abdo pain, bleeding, patient shock Complications
• Subacute: abdo pain, scanty dark bleeding, lower abdo • Haemorrhage
pain, cervical excitation • Repeat ectopic
• Subfertility
Gestational Trophoblastic Disease
Forms a group of disorders which range from molar pregnancies to malignant conditions
such as choriocarcinoma, persistence of GTD = gestational trophoblastic neoplasia (GTN)
Risk Factors Symptoms
• Age <16 and >45 years • Vaginal bleeding
• Previous molar • Hyperemesis – raised HCG levels
• Menarche >12 years • Hyperthyroidism – HCG stimulates thyroxine
• OCP • O/E: large for dates, soft boggy uterus
• Asian women • Rare: anaemia, respiratory distress

Clasification Investigations
Pre-malignant • Histology
• Complete – empty ovum fertilised by single sperm (no • Urine and serum HCG
foetus) • USS (snowstorm appearance)
• Partial – two sperm, one egg (foetal tissue)
Malignant Management
• Invasive – from complete mole, invades myometrium • Surgical – suction curettage, Anti-D if Rh neg
• Choriocarcinoma – malignancy of trophoblastic cells mother
• Placental site trophoblastic tumour (PSTT) • Follow up – serial HCG, specialist centre
• Epitheloid trophoblastic tumour (ETT) • Chemotherapy – GTN (persistent GTD)
Hyperemesis Gravidarum
Severe N&V  severe dehydration, weight loss, electrolyte disturbance

• More common in multiparous women

• In 1st trimester – usually resolves by 14 weeks

Investigations Management
• Obs • Exclude perdisposing conditions, esp UTI
• Urinalysis = ketonuria • Conservative: ginger
• Weight, • IV fluids (NOT dextrose)
• Bloods (inc U&E) • Antiemetics: metoclopramide, cyclizine, ondansetron
• Serum HCG • Thiamine (to prevent Wernicke’s encephalopathy)
• USS (exclude gestational trophoblastic disease, multiple
pregnancy) Complications:
• Wernicke’s encephalopathy
Indications for admission and IV fluids • Hyponatraemia
• <20 weeks – most common up to 12 weeks • Oesophageal tears
• Unable to tolerate oral food and drink • Malnutrition
• Ketonuria • Psychiatric disturbance
Infections in Pregnancy
Toxoplasmosis
Other
Syphilis
Hepatitis
HIV
Varicella-zoster virus
Parvovirus B19

Rubella
• Risky if in first trimester
• Sensorineural deafness, cong cataracts, PDA, purpuric rash, ‘salt and pepper’ chorioretinitis

Cytomegalovirus (CMV)
• Growth retardation, purpuric rash, sensorineural deafness, seizures

Herpes simplex virus (HSV)

Labour
Normal Labour
• The powers (contractions), the pelvis and the passenger (foetus) determine the course of labour
• Progress is assessed by cervical dilatation and descent of the head
• Labour is divided into stages:
• First is 0–10 cm dilation
• Second is 10 cm until delivery
• Third is from delivery of the baby until delivery of placenta
• The position of the head refers to its degree of rotation; the attitude refers to the degree of flexion.
• Most babies deliver flexed and in the occipito-anterior position; other positions (e.g. occipito-posterior) or extension
(e.g. brow) may cause obstruction

Management
• In nulliparous women slow progress is usually due to poor contractions and oxytocin is used to improve this
• In multiparous women oxytocin should be used with caution.
• Delivery of the foetus can be expedited by C-section (first stage) or instrumental vaginal delivery (second stage)
• Monitoring of the foetal condition principally involves heart rate auscultation or if this appears abnormal, and in high
risk cases, electronic cardiotocography (CTG).
• Foetal hypoxia in labour is an important cause of morbidity and mortality and could usually be prevented.
 Induction of Labour Membrane Sweep
• 40/41wk to nulliparous, and 41wk to multiparous women
• Gloved finger inserted through cervix and rotated against the fetal
Starting labour artificially membranes to separate chorionic membrane from the decidua.
• Separation helps to release natural prostaglandins
Indications: when it is safer for the baby and/or the mother • Classified as an adjunct of IOL. Performing it increases the
• Prolonged Gestation (40-42wk) – avoid the risk of stillbirth likelihood of spontaneous delivery, reducing the need for a formal
• Premature ROM (>37wk) – if not spontaneous labour in 24h induction
• Pre-eclampsia and other maternal Health Problems –
hypertension, diabetes, obstetric cholestasis Vaginal Prostaglandins (PGE2)
• Fetal Growth Restriction – deliver the baby prior to fetal • Prepare the cervix for labour by ripening it
compromise. • Role in uterine smooth muscle contraction
• Intrauterine Fetal Death – if mother is physically well with intact • Tablet/gel regimen: 1 cycle = 1st dose, plus a 2nd dose if labour
membranes has not started 6 hours later.
• Pessary regimen: 1 cycle = 1 dose over 24 hours.
Contraindications: generally the same as for vaginal delivery • Max 1 cycle in 24 hours (can take days)
• Cephalopelvic disproportion • Risk of uterine hyperstimulation
• Major placenta praevia
• Vasa praevia Rupture of Membranes (Amniotomy)
• Cord prolapse • Using an amnihook, resulting in release of prostaglandins
• Transverse lie • Only performed when cervix has been deemed as ripe (Bishop)
• Active primary genital herpes • Often done with an infusion of artificial oxytocin
• Previous C-section
Syntocinon
Bishop Score (“cervical ripeness”) • To increase the strength and frequency of contractions.
• ≥ 7 – suggests cervix ripe  high chance of response to induction • Start low and titrate up until there are 4 contractions every 10 min
• <4 – suggests labour is unlikely to progress • Can be reversed using terbutaline
Abnormal Labour: Operative Delivery
Used to shorten the 2nd stage of labour

Abdominal method = caesarean section

Vaginal assisted deliveries = forceps delivery and vacuum extraction

Indications:
• Foetal – presumed foetal compromise
• Maternal – to shorten and reduce the effects of the second stage of labour on medical conditions
• Inadequate progress
• Nulliparous – lack of continuing progress for 3 hours with regional anaesthesia, or 2 hours without regional
anaesthesia
• Multiparous – lack of continuing progress for 2 hours with regional anaesthesia, or 1 hour without regional
anaesthesia
• Maternal fatigue/exhaustion

Prerequisites:
• Cervix fully dilated and membranes ruptured
• Exact position of head known
• Head is deeply engaged (≤1/5th palpable)
• Adequate analgesia
• Empty bladder
Preterm Labour
Labour starting before 37 weeks gestation

Risk Factors Interventions

• Previous preterm labour • Progesterone supplement
• Previous late miscarriage • Cervical cerclage – stitch put in to prevent dilatation

Mechanisms Management
• Stretching of the myometrium – multiple pregnancy • Gestation
• Cervical thinning or shortening – previous LLETZ treatment • Foetus viable at 24 weeks
• Ascending infection • ≥ 24 weeks – consider antenatal corticosteroids for foetal
lung, tocolysis (nifedipine) and transfer to neonatal unit
Screening • Rupture of membranes
• No – tocolytics used if no infection
• Offered to those with risk factors
• Yes – suggests infection
• Transvaginal USS – measure cervical length
Presentation
Occipito-posterior
• usually resolves but may need C-section

Occipito-transverse
• Normal finding in 1st stage
• rotation with traction required (ventouse)

Brow
• presenting diameter too big to deliver
• C-section required

Face
• vaginal delivery possible if chin is anterior
(mento-anterior)
• C-section required if chin is posterior (mento-
posterior)
Obstetric Emergencies
Shoulder dystocia = normal downward traction fails to deliver the shoulders
• RF: maternal diabetes, macrosomia
• C: Erbs palsy, brain injury, brachial plexus damage
• M: leg hyperextension into abdomen (McRobert’s manoeuveure) + suprapubic pressure

Cord prolapse = umbilical cord descends below presenting part

• RF: preterm labour, breech presentation, polyhydramnios, twins, artificial amniotomy
• C: cord compression, foetal hypoxia
• M: push cord up, tocolytic (terbutaline), C-section or instrumental delivery

Uterine rupture = uterus tears, foetus extruded, uterus contracts and bleeds
• RF: previous CS, congenital uterine abnormality
• C: foetal hypoxia, massive internal maternal haemorrhage, cessation of contractions, maternal collapse
• M: IV fluid + blood resus, immediate laparotomy

Uterine inversion = fundus inverts into the uterine cavity

• RF: follows traction on the placenta
• C: haemorrhage, pain, profound shock
• M: push fundus up via vagina, replacement via saline hydrostatic pressure under GA
Perineal Trauma and Repair
Perineal Tear:
• First degree = skin only
• Second degree = involves perineal muscles
• Third degree = involves anal sphincter
• Fourth degree = involves anal sphincter and anal epithelium

Repair:
• Sutured under local anaeathetic
• 3rd and 4th may require spinal
• 3rd and 4th given antibiotics and laxatives
Medication During Labour
Analgesia
Syntocinon (oxytocin)
Entonox (NO + O2)
• Aid cervical dilatation in nuliparous
• Rapid onset, mild analgesia
• SE: light-headedness, nausea, hyperventilation • Only used in multiparous if malpresentation excluded

Epidural (fentanyl + local anaesthetic)

• delivered via indwelling epidural catheter Terbutaline (B2 agonist)
• into epidural space between L3-4 or L4-5 • Tocolytic use to suppress premature labour
• SE: transient hypotension, reduced sensation, spinal tap • Relaxes the uterus – anti-contraction
Spinal
• local anaesthetic injected as single dose into the CSF
• used for C-section
• SE: hypotension, total spinal with resp paralysis

Combined spinal and epidural (CSE)

• can be used in longer C-sections
• spinal gives rapid onset
• epidural top-ups provide longer-lasting effect
The Puerperium
The 6wk period following delivery, when body returns to pre-pregnant state

Changes
• Genital tract: uterus contracts, cervical os closes, lochia (discharge) turns bloodyyellow/white
• CV system: CO and plasma volume decrease, oedema reduces
• Urinary tract: dilatation reduces, GFR decreases
• Blood: U&Es return to normal, Hb and haematocrit rise, WCC falls, platelets and clotting factors rise

Management
• Encourage early mobilisation
• Daily checks: uterine involution, lochia, BP, T˚, HR, perineal wound

Problems
• Primary haemorrhage (24 hours) = atonic uterus or delivery trauma
• Secondary haemorrhage (6 weeks) = uterine infection
Pregnancy Induced Hypertension (PIH)
Blood pressure rises >140/90mmHg after 20wk

Pre-eclampsia hypertension + proteinuria (>0.3g/24h) Gestational hypertension without proteinuria

• Early onset = before 34wk  foetal growth restriction
• Late onset = late gestation  foetal damage or death Risk Factors:
Clinical signs: • x
• HTN
• Proteinuria (>0.3g/24h) Clinical signs:
• Often with face/hand/feet oedema • x
Management
• Control BP – labetalol Complications:
• Prevent seizures – MgSO4 • x
• Consider delivery – only cure
• Post partum monitoring

Complications:
• HELLP syndrome - haemolysis, elevated liver enzymes, low
platelets
• Eclampsia (seizures)  ABCDE  MgSO4  IV labetalol 
delivery
Intra-uterine Growth Restriction (IUGR)
Gestational Diabetes
Any degree of glucose intolerance with onset or first recognition during pregnancy

Aetiology Investigations
• Progressive insulin resistance with pregnancy (insulin requirements • Oral glucose tolerance test (OGTT)
rise by 30% during pregnancy) • Fasting glucose > 5.6mmol/L
• A woman with a borderline pancreatic reserve is unable to respond
to the increased insulin requirements, resulting in transient • 2hrs postprandial glucose > 7.8mmol/L
hyperglycaemia HbA1c
• Increased appetite and delayed gastric emptying in pregnant state
• Increased post-prandial glucose as insulin resistance increases Management
• Lifestyle advice should be given regarding diet and exercise
• After the pregnancy, insulin resistance falls – and the • Metformin – suitable in pregnancy and breast feeding
hyperglycaemia usually resolves.
• Insulin – at diagnosis if fasting >7, primal >6, post meal >7.5
Risk Factors for Poor Pancreatic Reserve • Glibenclamide – used if metformin is not tolerated (often due to GI
• BMI >30 side effects) and insulin has been declined.
• Asian ethnicity
• Previous gestational diabetes • Patients with gestational diabetes are looked after by a consultant
• 1st degree relative with diabetes throughout the pregnancy. Additional growth scans should be
• Polycystic ovarian syndrome performed at 28, 32 and 36 weeks, to monitor for the complications.
• Previous macrosomic baby (>4.5kg) The aim should be to deliver at 37 to 38 weeks if they are on
Foetal Complications of Gestational Diabetes treatment. They would be advised to consider delivery (induction of
• Glucose is transported across the placenta, but insulin is not  labour or caesarean section) before 40 weeks and 6 days if there is
foetal hyperglycaemia gestational diabetes managed by diet.
• Foetus will increase its own insulin levels to compensate 
hyperinsulinaemia
• Insulin promotes growth  macrosomia, cardiomegaly,
polycythaemia, polyhydramnios
• After delivery, the foetus still has high insulin levels, but no longer
receives glucose from its mother  hypoglycaemia
• High insulin can cause reduced surfactant production  transient
tachypnoea
Venous thromboembolism (VTE)
• Hypercoagulable state: increased coagulation factors, resistance to active protein C, fall in protein S,
impaired fibrinolysis
• Stasis: diminished venous flow in legs
• Endothelial damage: occurs during delivery
• Most VTEs occur in L side due to compression of L iliac vein by gravid uterus
Ante-Partum Haemorrhage (APH)
Vaginal bleeding after 24wk gestation

Placenta praevia placenta implants into the lower uterine Placental abruption separation of part/all of the placenta
segment (appears “low-lying” at 20 wk) before delivery of the foetus (after 24 wk)
• Minor (I-II) = near/adjacent to cervical os • Revealed = blood tracks down from site of separation
• Major (III-IV) = partial/completely over cervical os • Concealed = bleeding remains in uterus

Risk Factors: Risk Factors:

• multiple pregnancy (large placenta) • intrauterine growth restriction (IUGR)
• high parity or age • pre-eclampsia
• scarred uterus (previous c-section) • pre-existing hypertension
• maternal smoking
Clinical signs: • previous abruption
• painless vaginal bleeding
• abnormal lie Clinical signs:
• painful bleeding
Complications: • “woody” hard uterus
• Haemorrhage = lower segment of the uterus is less able to • maternal collapse (shock)
contract and constrict the maternal blood supply. • coagulopathy
• Placenta accreta = placenta doesn’t separate • poor urine output / renal failure
• Placenta percreta = placenta penetrates through uterine wall
into surrounding structures eg. bladder Complications:
• Foetal death
• Haemorrhage
Post Partum Haemorrhage
Loss of >500ml blood <24h of delivery

Causes: Management
• Tone = uterus fails to contract • ABCDE approach
• Tissue = retained placental fragments • IV syntocinon (oxytocin)
• Trauma = tears to perieum, high vaginal, cervical • IM carboprost
• Thrombin = coagulopathy
Complications
Risk Factors: • Sheehan’s syn = pituitary undergoes ischaemic
• Antepartum haemorrhage necrosis, which can manifest as hypopituitarism
• Previous C section  lack of milk production, amenorrhoea
• Anticoagulant therapy
• Instrumental or C section delivery
• Multiple pregnancy
• Obesity
• Prolonged labour
Multiple Pregnancy
Dichorionic diamniotic (DCDA) – 2 placentas and 2 amniotic sacs
Monochorionic diamniotic (MCDA) – 1 placenta but 2 amniotic sacs
Monochorionic monoamniotic (MCMA) – 1 placenta and 1 amniotic sac

Common presentations: vertex – vertex , vertex – breech , breech – transverse

Twin-to-twin transfusion – artery of 1 foetus communicates with the vein of the other foetus, giving rise to a pressure gradient.
Blood flows uni-directionally from one to the other, resulting in fluid imbalance
• Donor (dehydration): oligohydramnios, foetal growth restriction
• Recipient (overload): polyhydramnios, cardiac failure
• Mother: sudden weight gain
• Amnioreduction – draining excess fluid from the recipient twin
• Laser ablation – closing communicating vessels
• Selective fetocide – closing off blood supply to one twin to aid survival of the other

Offer elective birth at:

• 37 wks for uncomplicated dichorionic twins
• 36 wks (+steroids), for uncomplicated monochorionic twins
• 35 wks (+steroids) for uncomplicated triplets
Termination of Pregnancy
Legal limit for termination in England and Wales is 24 weeks
Abortion is legal in GB if 2 doctors agree and sign the HSA1 form

There is no upper limit if there is: Pre-requisites:

• risk to the mother’s life • Confirm IUP and gestation (US scan, HCG)
• risk of grave, permanent injury to mother’s physical/mental health • Counsel to ensure decision is her own.
• susbstantial risk that child would be serious handicapped if born • Consider alternatives
• Methods of TOP
Types of termination:
• < 9 wk = medical (mifepristone RU486 norethindrone analogue)
or surgical (manual vacuum extraction)
• 9 to 12 wk = surgical (cervical dilatation and evacuation)
• > 12 wk = medical (misoprostol prostaglandin)
Antenatal Scans
Booking Counsel all regarding prenatal diagnosis options
(8 – 12 wk) Check rubella immunity to identify need for postnatal immunisation
Check Hep B to allow Ig administration to neonate
Check for syphilis infection and HIV status
Arrange genetic counselling ± later chorionic villus sampling or amniocentesis if risk
Dating USS – dating and check for twins
(10 – 14 wk) Advise regarding screening for chromosomal trisomies e.g. combined test
Counsel and offer CVS or amniocentesis if high risk or offer non-invasive prenatal testing
(NIPT)
Nuchal translucency and crown rump length
Anomaly USS – routine anomaly for structural abnormalities
(18 – 21 wk) Counsel and consider amniocentesis is abnormalities found
Offer cardiac scan if risk
Later Some abnormalities only visible later in pregnancy
USS – polyhydramnios, breech, suspected IUGR
Rhesus Blood Group in Pregnancy
Rhesus system consists of three antigens inherited as a triplet:
• C or c
• D or no D (D+ve or D-ve) D is dominant
• E or e

• D antigen is most important

• 80% of mothers without the D antigen will develop anti-D antibodies if exposed to it.

• 15% of mothers are Rh-ve

• Rh+ve infant del to a Rh-ve mother = leakage – affects LATER pregnancy – crosses placenta  FOETAL
HAEMOLYSIS
Physiological Changes in Pregnancy
Weight gain 10 – 15 kg
Genital tract Uterus weight increases from 50g to 1kg
Muscle hypertrophy, increased blood flow and contractility
Cervix softens, may start to efface in late 3rd trimester
Blood Blood volume: 50% increase
Red cell mass: increase
Haemoglobin: decrease
White cell count: increase
CVS system Cardiac output: 40% increase
Peripheral resistance: 50% reduction
BP: small mid-pregnancy fall
Lungs Tidal volume: 40% increase
Resp rate: no change
Other Renal blood flow: GFR 40% increase, so Cr/Ur decrease
Reduced gut motility: delayed gastric emptying and constipation
Thyroid enlargement
Cardiotocography (CTG) Dr C BRaVADO
Define risk
Contractions
Baseline < 100 /min Increased foetal vagal Baseline Rate (110-160bpm)
bradycardia tone Variability (5-25bpm)
Maternal B-blocker use Accelerations
Baseline > 160 /min Maternal pyrexia Decelerations (early, late, variable)
tachycardia Chorioamnionitis Overall impression
Hypoxia
Prematurity
Loss of baseline < 5 beats/min Hypoxia
variability Prematurity
Early deceleration HR deceleration with onset of Usually innocuous
contraction and returns to normal feature, indicating head
when contraction ends compression
Late deceleration HR deceleration lags onset of Foetal ditress
contraction and doesn't return until Asphyxia
>30s after contraction ends Placental insufficiency
Variable Independent of contractions Cord compression
decelerations
Breast Feeding Drugs
Safe Unsafe
carbemazepine aspirin
cephalosporins lithium
warfarin ciprofloxacin
sodium valproate sulphonamides
levothyroxine tetracyclines
trimethoprim carbimazole
tricyclic antidepressants benzodiazepines
glucocorticoids amiodarone
antipsychotics sulphonylureas
theophyllines
digoxin
penicillins
beta-blockers
heparin
hydralazine
Medication in Pregnancy
Safe Unsafe
Analgesia (paracetamol) Tobacco (IUGR)
BAD:
Anticoagulants (heparin) Alcohol
Antibiotics (penicillin, cephalosporin, erythromycin, Fetal alcohol syndrome - epicanthic folds, short nose,
metronidazole) smooth philtrum, thin upper lip, Learning Disability
Vaccines (avoid LIVE vaccines) Cocaine- miscarriages, placental abruption.
Lithium- cardiac abnormalities, incompatible with life
ACE I + diuretics- CI
 Heroin, Methadone, Opiates  spontaneous
Drug Use in Pregnancy miscarriage, growth retardation, placental abruption,
SIDs
• No evidence of teratogenesis
• Placental vasoconstrictor so IUGR can occur
Tobacco  low birth weight, microcephaly, facial clefts • Neonatal withdrawal symptoms (requires
• Due to direct foeto-placental effect of nicotine and its naloxone) and respiratory depression
metabolites
• Reduced foetal oxygenation resulting in IUGR Cocaine  spontaneous miscarriage, facial and
skeletal anomalies, intestinal atresia, mental
retardation, growth retardation, placental abruption,
Alcohol (>80g/day)  foetal alcohol syndrome’
SIDs
• Mental retardation, growth retardation, facial and
structural anomalies • Particularly harmful in pregnancy
• No ‘safe’ amount – 14g/day suggested • Powerful vasoconstrictor
• Heavy drinkers – 30-50% risk • No neonatal withdrawal symptoms
• Early cessation may result in some reversal
Ecstasy & LSD
• No teratogenesis
• No adverse effects in pregnancy
• No neonatal withdrawal effects.
Menstrual Cycle

Normal cycle length 21-35 days

Oestrogen dominates proliferative

phase (1st half)

Progesterone dominates luteal phase

(2nd half)
 Intermenstrual bleeding
Menstrual Disorders • Endometrial cancer (USS, hysteroscopy), cervical cancer
(smears, colposcopy), cervical polyps, ectropion, fibroids, PID,
dysfunctional uterine bleeding, coil, progestogens

Mean loss = 35 – 45ml per cycle Oligomenorrhoea infrequent periods

• 10-15% of women lose >80ml • Most commonly PCOS
• 60% of those women are anaemia
• 70% of loss occurs in first 48h Amenorrhoea absent periods
• Must exclude pregnancy
Factors controlling menstrual loss • Primary = hypothalamic (idiopathic, radiotherapy, surgery,
• myometrial contractility craniopharyngomas, anorexia), chromosomal (Turner’s, XY
• haemostatic plug formation androgen insensitivity), endocrine (CAH), congenital (vaginal
• vasoconstriction (PGF2a) septum, absence of a uterus).
• Secondary = physiological (pregnancy, lactation, menopause),
Menorrhagia excessive cyclical bleeding (>80ml for >3month) hypothalamic, hyperprolactinaemia, PCOS, thyroid disease,
• Pelvic: fibroids, endometriosis, adenomysosi, PID, polyps, IUCD adrenal disease, premature ovarian failure, Sheehan syndrome,
• Clotting: thrombocytopenic purpura, VWD Asherman syndrome.
• Medical: thyroid disease, diabetes, Cushings
• Dysfunctional uterine bleeding Dysmenorrhoea painful periods
• Primary – no underlying pelvic pathology (physiological)
Metrorrhagia dysfunctional bleeding • Secondary – endometriosis, adenomyosis, PID, fibroids
• Uterine bleeding at irregular intervals
• Hormone imbalance, endometriosis, uterine fibroids Post-menopausal bleeding
• Less common is uterine cancer • Endometrial carcinoma (5%), endometrial hyperplasia, atrophic
vaginitis, cervical, vulval and ovarian carcinomas, urethral
Polymenorrheoa frequent periods caruncles, vaginal foreign bodies (pessaries), polyps
Menopause
Permanent cessation of menstruation due to loss of ovarian follicular activity
Average age is 47 to 52 years (median 51 years)
• Early = 40 to 45 years Diagnosis
• Premature = < 40 years • Triad of diagnostic features
• Typical symptoms
Climacteric Symptoms • 12 months amenorrhoea
• Changes in length of menstrual cycle • High FSH > 15iu/ml (peri-) or > 25 iu/ml
• Hot flushes and night sweats • Serum oestradiol levels – only useful over 45 yr (due to wide
• If menopause at 50yr, climacteric begins 1 yr earlier range of normality)
• If menopause ≤40yr, climacteric begins 4 yr earlier
• Bone mineral density – helps in diagnosis of osteoporosis
Short-Term Symptoms
• Vasomotor – hot flushes, night sweats, headaches, palpitations Lifestyle Management
• Psychological – depression, mood swings, insomnia, memory • CBT
loss, panic • Avoid smoking
• Urogenital – urinary frequency, dysuria, stress and urge • Healthy diet – low in fat, high in fibre
incontinence, vaginal dryness • Cut down salt
• Collagen – dry inelastic skin, brittle nails, hair loss, joint and • Avoid alcohol
muscle pains
• Ensure enough calcium and vitamin D in diet or supplement
Long-Term Symptoms
• Cardiovascular – hyperlipidaemia, ischaemic heart disease Post-Menopausal Bleeding
• Skeletal – osteopenia, osteoporosis
• Skin – inelastic thin skin, easy bruising • Vaginal bleeding occurring at least 12 months after LMP
• Genito-urinary – atrophic changes, prolapse, incontinence, • Endometrial cancer, cervical cancer and premalignant
depressed libido, dypareunia endometrial hyperplasia must be excluded
• Psychological – Alzheimer’s disease
Hormone Replacement Therapy
Replacing hormones that begin to fall leading to uncomfortable symptoms
Types: Side Effects
• No uterus = oestrogen only • Oestrogen: breast tenderness, leg cramps, nausea/bloating
• Uterus = oestrogen + progesterone • Progesterone: depression, headaches, abdominal pain
• Bleeding: at end of progesterone phase of cyclical HRT
• Temporary: heavy irregular bleeding, bloating, fluid retention and
• Loss of libido = testosterone weight gain
Indications HRT reduces menopausal symptoms (e.g. flushes, sweats, UG problems),
• Treat menopausal symptoms (benefit outweighs risk) osteoporosis and colorectal cancer
• Treatment of early menopause (until ~51yr)
• Osteoporotic fracture prophylaxis in women <60yr (when HRT increases:
non-oestrogens unsuitable) • Risk of breast cancer (if combined HRT and used >5yr)
• Endometrial hyperplasia  endometrial cancer (if oestrogen only)
• Risk of VTE (in 1st year – no risk with transdermal therapy)
Routes of administration: • Gallbladder disease
• Systemic: oral, transdermal patch, gel, implant
• Vaginal: cream, pessary, vaginal ring Non-hormonal treatments:
Bone protection:
Contraindications • Bisphosphonates and calcitonin  decrease osteoclast activity
• History of breast/endometrial cancer • Selective oestrogen receptor modulators (SERMs)
• History of VTE Menopausal symptoms:
• Clonidine (a2 receptor agonist) and venlaflaxine  reduce vasomotor sx
• Take calcium and vitamin D
• Endometriosis – may reactivate • CBT  for depressive symptoms
• Fibroids – may increase size
• IHD (stroke/MI/angina)
Uterovaginal Prolapse
Descent of the uterus and/or vaginal walls beyond normal anatomical confines

• Urethrocele = lower anterior vaginal wall, involving urethra only

• Cystocele = upper anterior vaginal wall, involving the bladder (± urethra)
• Apical prolapse = uterus, cervix and upper vagina
• Enterocele = upper posterior vaginal wall (pouch often contains small bowel loops)
• Rectocele = lower posterior vaginal wall and anterior wall of the rectum

Baden Walker classification

• 0 = no organ descent with straining
• 1 = doesnt descend below 1cm above hymenal ring
Treatment:
• 2 = extends 1cm above to 1cm below hymenal ring
Physiotherapy
• 3 = extends >1cm below hymenal ring
Ring or shelf pessaries
• 4 = complete vaginal eversion (complete procidentia)
Surgery
Examination: • Uterine – hysterectomy or hysteropexy
• Using a Sim’s speculum • Vault – sacrocolpopexy or sacrospinous fixation
• Patient lies on LHS with legs up • Vaginal wall – anterior and/or posterior repair
Incontinence
• Parasympathetic nerves aid urine voiding
• Sympathetic nerves prevent voiding

• Overactive bladder = increases in detrusor and therefore bladder pressure beyond that of the normal
urethra
• Stress incontinence = increased intra-abdominal pressure transmitted to the bladder but not abnormally
placed urethra
• Investigations: urine dipstick, urine diary, urodynamics

Treatment:
• Overactive - bladder training, anticholinergics, botulinum toxin, oestrogen (after menopause)
• Stress – physiotherapy, duloxetine, surgery (TVT or TOT)
Pelvic Inflammatory Disease (PID)
Common causes: Chlamydia trachomatis, Neisseria Investigations
gonorrhoeae, Mycoplasma genitalium, and anaerobes • High vaginal swab: check for chlamydia and gonorrhoea
• Pelvic USS: to exclude ovarian cyst or abscess
Symptoms: • Laparoscopy: with fimbrial biopsy and culture
• Bilateral lower abdominal pain
• Recent onset deep dyspareunia Management
• Irregular bleeding pattern, eg postcoital bleeding • Analgesia: paracetamol
• Abnormal discharge, often purulent • Antibiotics: ceftriaxone 1g IM STAT + doxycycline PO
100mg BD + metronidazole PO 400mg BD for 14 days
Risk factors:
• Young age (under 25 years) Complications
• Sex without a condom • Fitz-Hugh-Curtis syndrome: perihepatitis involving
• New partner in the last 3 months adhesions between liver and anterior abdominal wall
• Multiple partners • Infertility: tubular
• Previous STI or previous PID • Chronic pelvic pain
• Instrumentation of the uterus: termination of pregnancy, • Ectopic pregnancy
insertion of a uterine device in the last six weeks,
hysterosalpingography, or in vitro fertilisation.
Pelvic Pain and Masses
Contraception
Combined pill Progesterone pill Diaphragm/ Patch
Condom Rhythm method
(oestrogen + progesterone) (progesterone) Spermacide (oestrogen + progesterone)

Physical barrier Inhibit ovulation Thickens cervical mucus Perfect use: 99% Perfect use: 92% Perfect use: >99%
Perfect use: 98% Thickens cervical mucus Perfect use: >99% Typical use: 76% Typical use: 71-88% Typical use: 91%
Typical use: 82% Perfect use: >99% Typical use: 91%
Typical use: 91%
Protect from STIs Lighter, less painful periods Smokers and >35y can use No physical SEs Regular, lighter, less painful
Safe when breastfeeding Useful in planning pregnancy periods
May split or slip off Increases VTE risk Pills can be missed Need to avoid sex at fertile Need to have the right size May be seen
Breast/cervical cancer risk V&D effect effectivity times Need extra spermacide if Skin irritation
NOT when breastfeeding Irregular bleeding have sex again
Mirena IUS Injection
Implant Copper IUD Sterilisation Vaginal ring
(progesterone) (progesterone)
Inhibits ovulation Decreases sperm Thins endometrium Inhibits ovulation Fails in men: 1 in 2000 Works for 3 weeks
Thickens cervical mucus motility/survival Thickens cervical mucus Thickens cervical mucus Fails in women: 1 in 500 Perfect use: >99%
Lasts 3 years Lasts 5 or 10 years Lasts 3 or 5 years Lasts 12 weeks Typical use: 91%
Perfect use: >99% Perfect use: >99% Perfect use: >99% Perfect use: >99%
Typical use: >99% Typical use: >99% Typical use: >99% Typical use: >94%
Used if Hx migraines + aura Lighter, shorter periods Permanent with no serious
SEs
Requires small procedure Heavier, longer periods Irregular bleeding for first 6 Cant be removed Cant be reversed Fiddly to insert and remove
NOT if history of PID months
Increases risk of ectopic

Emergency: Breastfeeding:
• Copper IUD – within 5 days of UPSI, or within 5 days of ovulation • Lactational amenorrhoea
• Levonelle (levonorgestrel) – within 3 days of UPSI • Any time: implant, POP, injection
• ellaOne (ulipristal acetate) – within 5 days of UPSI • 6wk: COCP, patch, ring
Contraception: COCP First Pill Counselling
Full medical & gynae hx, medication, exclude pregnancy, patient choices, MOA, adv, disad, consider alternatives

UKMEC : Age (>50), BMI >35, smokers, migraine, postnatal, CVD risk, BP vascular disease, congenital heart disease,
cardiomyopathy, hx or current VTE, FHx, of VTE , prolonged immobility, AF, liver cancer, cirrhosis, gallbladder disease /
cholestasis, SLE, thrombogenic mutation, liver enzyme inducing medication

• 21 days on pill, start on day 1 of period, 7 days off

• 3 month follow up (BP, weight)

Missed Pill Rules

• 1 pill: Take missed pill asap, take remaining pill at regular time
• >1 pill: Take last missed pill asap, then remaining pill as usual. Consider contraception
• Week 1 – Consider emergency contraception if UPSI
• Week 3 – NO pill free interval
Cervix
Functions
• Facilitates the passage of sperm into the uterine cavity (dilation of the external and internal os)
• Maintains sterility of the upper female reproductive tract (frequent shedding of the endometrium, thick
cervical mucus and a narrow external os)

Structure
• Ectocervix – portion of the cervix that projects into the vagina (stratified squamous non-keratinized)
• External os – opening in the ectocervix  transition from the ectocervix to the endocervical canal
• Endocervical canal (endocervix) - inner part of the cervix (mucus-secreting simple columnar epithelium)
• Internal os – end of the endocervical canal  transition into the uterine cavity
Cervicitis
Chronic inflammation and infection of the cervix

Cervicitis is probably the most common of all gynaecological disorders, affecting half of all women at some
point in their lives.
It can be caused by any sexually transmitted disease - gonorrhoea, Chlamydia and herpes.
A chronic cervicitis associated with papilloma virus is heavily implicated in the aetiology of cervical carcinoma.

Presentation:
• Usually asymptomatic
• Pelvic pain, vaginal discharge, postcoital bleeding and dyspareunia may be present.
Complications
• PID
• Infertility - blockage of mucus ducts and cyst formation
Cervical Ectropion
Columnar epithelium of endocervix is visible on the cervix surface (red)

• Normal finding in younger women, particularly those who are pregnant or taking COCP

• Ectocervix = squamous epithelium

• Endocervix = columnar epithelium

• With ectropion, you get eversion of the columnar epithelium of the

endocervix to the surface of the cervix

Symptoms:
• normally asymptomatic
• vaginal bleeding
• post-coital bleeding

Treatment:
• Cryotherapy (freezing)

Complications:
• Exposed columnar epithelium is prone to infection
Cervical Intraepithelial Neoplasia (CIN)
Presence of atypical (dyskaryotic) cells within the squamous epithelium

Histological diagnosis:
• CIN I (mild) = atypical cells in lower 1/3
• CIN II (mod) = atypical cells in lower 2/3
• CIN III (carcinoma in situ) = atypical cells in full epithelial thickness

Risk Factors:
• Human papilloma virus (HPV) 16, 18, 31 and 33
• Vaccination: targets 16 and 18
• Oral contraceptive use
• Smoking

Immunocompromised patients are at increased risk of early progression to malignancy.

Cervical Screening
• Every 3 years from ages 25 – 49
• Every 5 years from 50 – 64

• First line – HPV

• If high-risk HPV is present or cytology shows moderate or severe dyskaryosis then colposcopy is performed
to diagnose and treat CIN

Colposcopy
• Looks for any abnormal changes in the cervix which may indicate precancerous changes (CIN).
• Acetic acid is applied abnormal areas turn white (acetowhite).
• Iodine solution normal tissue stains dark brown but pre-cancerous cells will not take up stain
• ?Biopsy
Cervical Cancer
Squamous cell carcinoma Treatment:
• cancer of the epithelial lining of the ectocervix 1a(i) – cone biopsy or loop excision
• most common 1a(ii) – 1b(i) – radical trachelectomy and lap lymphadenectomy
Adenocarcinoma 1a(ii) – 2a – radical hysterectomy + chemoradiotherapy
• cancer of the glands lining the cervix 2b onwards – chemoradiotherapy

Stages:
• 1a(i) – in cervix, <3mm deep and <7mm wide
• 1a(ii) – in cervix 3-5mm and <7mm wide
• 1b(i) – in cervix <4cm wide
• 1b(ii) – in cervix >4cm wide
• 2a(i) – spread to top of vagina and <4cm
• 2a(ii) – spread to top of vagina and >4cm
• 2b – spread to tissues surrounding cervix
• 3a = tumour spread to lower 1/3rd of vagina but not pelvic wall
• 3b = tumour gone through pelvic wall or is blocking a ureter
• 4a = metastasis to bladder or rectume
• 4b = metastasis further to lungs, liver etc
Benign and Malignant Ovarian Masses
Primary neoplasms:
• Epithelial tumours = derived from epithelium covering ovary. Most common in post-menopausal women
• Serous adenocarcinoma = can be benign, borderline or malignant. Most common type of malignant and is high grade
• Endometroid carcinoma = 10% of ovarian malignancies
• Clear cell carcinoma = 10% of ovarian malignancies, with a particularly poor prognosis
• Mucinous adenocarcinoma = 3% of ovarian malignancies. Rare ‘borderline varient’ is pseudomyxoma peritonei
• Germ cell tumours = derived from undifferentiated primordial germ cells
• Dermoid cyst (teratoma) = common, benign, most often in premenopausal women
• Yolk sac tumour = highly malignant and present in children or young women
• Dysgerminoma = most common ovarian malignancy in younger women
• Sex cord tumours = derived from stroma of the gonad
• Granulosa cell tumour = slow growing, malignant, secrete high levels of oestrogens and inhibin
• Thecoma = rare, usually benign, can secrete oestrogens and/or androgens
• Fibroma – rare, benign. Can cause Meig’s syndrome = ascites, (R) pleural effusion and ovarian mass
Ovarian cancer risk factors:
Secondary malignancies • BRCA1
Ovary is a common site of metastases, particularly from breast and GI tract • BRCA2
• HNPCC
Tumour-like conditions
• Endometriotic cysts = blood accumulates to form “chocolate cysts”
• Functional cysts: Biomarker: CA125
• Follicular cyst = persistently enlarged follicle
• Lutein cyst = persistently enlarged corpora lutea
Vulva Anatomy
External genital organs
• Act as sensory tissue during sex
• Help micturition, by directing flow of urine
• Defend the internal female reproductive tract from infection

Vascular Supply and Lymphatics

• Blood supply is by the paired pudendal arteries (internal branch mostly)
• Venous drainage is via pudendal veins (engorge during sex to increase
size of clitoris)
• Lymphatic drainage is to the superficial inguinal lymph nodes

Innervation
• The external female genitalia receives sensory and parasympathetic
nervous supply
• Sensory innervation can be split into anterior and posterior sections:
• Anterior vulva: ilioinguinal nerve, and the genital branch of
the genitofemoral nerve
• Posterior vulva: pudendal nerve, and the posterior
cutaneous nerve of the thigh
• Clitoris and vestibule: also receive parasympathetic innervation
from the cavernous nerves, derived from the uterovaginal plexus
Common Vulval Disorders
Vulval Cancer
• Vulval intraepithelial neoplasia – a premalignant condition. 2 type –usual and differentiated
• Vulval cancer
• usually squamous cell type
• associated with: VIN, lichen sclerosis, immunosuppression, smoking
• Treatment: wide local excision and lymph node removal

Infection of Bartholin’s Glands

• Bartholinitis – infection and inflamation of the Bartholin gland
• Bartholin’s cyst – blocked glands, without infection, filled with fluid

Sexually Transmitted Infections

• Herpes simplex – (Type II virus) localised itching and burning, with formation of painful red vesicles ~3 days after
infection. These may ulcerate and last up to 2 weeks, sometimes with recurrent attacks.
• Genital warts – (HPV) benign growths of epithelium. Infection can spread to the vagina and cervix, and is readily
transmitted via sexual activity. Certain strains of HPV may predispose affected individuals to dysplastic changes in
the cervix, vagina and/or anus which can potentially lead to carcinoma.
Bartholin’s Cyst
Fluid-filled sac within one of the Bartholin’s glands of the vagina

Risk Factors Management

• Nulliparous women of child-bearing age • Small/asymptom  warm baths
• Previous Bartholin’s cyst • Large/painful  treatment
• Sexually active (STIs)
• History of vulval surgery Word catheter
• Incision made an catheter inserted. tip inflated
Clinical Features and left 4-6wk to allow epithelisation of
• Small = often asymptomatic surgically created tract.
• Large = pain when walking/sitting) • SE: infection, recurrence, dyspareunia, scarring
and superficial dyspareunia Marsupialisation
• Spontaneous rupture  sudden relief of pain. • Incision made behind hymenal ring to allow
• On examination – unilateral labial mass drainage. Cyst wall is everted and
• Cyst = typically soft, fluctuant and non-tender approximated to the end of the vaginal
• Abscess = typically tense and hard, with mucosa
surrounding cellulitis • SE: bleeding, dyspareunia, infection

Cyst can become infected: E coli, MRSA, STIs

Fibroids (leiomyoma)
Benign tumours of the myometrium
• Most common benign tumours in women
• Estimated incidence of 20-40%.
• Growth is thought to be stimulated by oestrogen

Position:
• Pedunctulated – on a stalk
• Subserosal – bulge outside the uterus
• Intramural – in the myometrium (most common)
• Submucosal – under the endometrium, bulge into uterine cavity

Symptoms: Risk Factors:

• Asymptomatic • Obesity (oestrogen)
• Menorrhagia/erratic bleeding • Early menarche (<11yr)
• Pain • Age (reproductive – shrink after menopause)
• Pressure symptoms
• Subfertility • Family history
• Ethnicity (AFC and Asian)
Treatment:
• Medical: tranexamic acid, GnRH anaogue (Zolidex), IUS
• Surgical:
• Transcervical resection (TCRF) – removal hysteroscopically – for submucosal fibroids
• Myomectomy – removal by laparoscopy or laparotomy – for intramural and subserosal fibroids
• Uterine artery embolisation (UAE) – shrinks fibroids but only used for women who don’t want more children
• Hysterectomy – removal of the uterus
Adenomyosis
Presence of endometrium in the myometrium
Endometriosis
Presence of endometrium outside uterine cavity

Presentation:
• Cyclical pelvic pain / dysmenorrhoea Treatment:
• Menorrhagia • NSAIDs – for pain
• Dyspareunia • COCP (4x with no break to slow down the cycle)
• Subfertility • Mirena (IUS)
• Laparoscopy + removal
Investigations:
• Bimanual examination – pelvic tenderness, mass, fixed Complications:
(retroverted) uterus • Subfertility
• Laparoscopy – chocolate cysts, adhesions, peritoneal
deposits

Treatment:
• NSAIDs – for pain
• COCP (4x with no break to slow down the cycle)
• Mirena (IUS)
• Laparoscopy + removal
Endometrial Carcinoma
Pathology
• >90% adenocrcinomas
• Type 1 = less aggressive, oestrogen dependent
• Type 2 = more aggressive, not oestrogen dependent

Risk factors
• Nulliparity, late menopause, PCOS, obesity, tamoxifen
• COCP and pregnancy protective

Clinical features
• Post-menopausal bleeding
• Premen: change in bleeding – irregular, heavier, intermenstrual

Treatment
• Total laparoscopic hysterectomy and bilateral salpingo-oopherectomy
• Radiotherapy if lymph node involvement
PCOS
Hyperandrogenaemia + oligomenorrhoea + polycystic ovaries

Polycystic ovaries = > 12 follicles per ovary on ultrasound

Presentation
• Menstrual disturbance (oligomenorrhoea, amenorrhoea)
• Infertility
• Hirsutism, acne, male-pattern hair loss, central obesity
• Acanthosis nigricans

Diagnosis
• Raised LH with normal FSH
• Raised androgens (e.g. testosterone) ± reduced SHBG
• >12 follicles per ovary on ultrasound

• Exclude thyroid dysfunction, hyperprolactinaemia, androgen-secreting tumours…

Management:
• Oligomenorrhoea – COCP, progestogens (prevent endometrial hyperplasia)
• Infertility = Metformin / Clomifene
• CV risk and Obesity = diet, exercise.