Submitted by : Nitu  oommen

Reference -Tog 

  • Most frequent in pre menopausal and multiparous women
  • Dyspareunia worsened by sex, throbbing pain afterwards in contradiction to EM where there is deep dyspareunia.
  • Selective venography is the gold standard investigation.Scan- tortuous pelvic vein dia >6 mm and blood flow ≤3cm/sec
  • Medical management- 1st line. Endovascular treatment with embolotherapy may be preferred since less invasive and min complications.
  • Nutcracker syndrome-left ovarian vein compressed btwn superior mesenteric artery and aorta

Submitted by : Satarupa 

TOG Prevention and treatment of postmenopausal osteoporosis

  • DXA standard method to evaluate BMD of the spine, hip and forearm. Used to diagnose osteoporosis and monitor patients on or off therapy
  • Forearm BMD may be useful in patients with hyperparathyroidism
  • Women older than 65 or or younger postmenopausal with major osteoporotic fracture risk >9.3,%,- recommended FRAX . FRAX not to be used in premenopausal women, women under 40 or on pharmacological therapy 4.Vit D recommendation – 800IU daily, Calcium,-1000 mg daily
  • Recommended goal of vit D- 75 mmol/l
  • 30% of older adults fall each year and 5% of these falls result in fractures  or hospitalisation
Submitted by : Nai queti
Reference-Tog in Hirustism 

1. How dose COCP act to reduce hirsutism?

Progesterone component suppress LH ——> ovarian androgen, estrogen component increase SHBG production Thus decrease free androgen

2. What are androgenic causes of hirsutism?

PCOS , androgen secreting tumor congenital adrenal hyperplasia nonclassical , thyroid dysfunction ,acromegaly Cushing syndrome , hyperprolactinemia ,hyper androgenic insulin resistant acanthosis nigricans syndrome , drugs like testosterone,  Danazol, anabolic steroid

3. What is the most common cause of androgenic hirsutism?


4. What’s the most important  hormone regulate hair growth and how does it work?

Androgen testosterone in the hair follicle under five alpha reductase converted to dihydrotestosterone + weak Androgens (androstenedione /dehydroepiandrosteron)  Metabolised in the skin into testosterone stimulate hair growth.

5. Examples of less androgenic progesterone?

Norgestimate and desogestrel.

6. What are the advantages and disadvantages of COCP in woman with the PCOS?

Advantages : decrease hirsutism, regular cycle contraceptive , protect endometrium disadvantages : affect metabolism increase long-term metabolic side effect diabetes type two cardiovascular disease.

7. How can we differentiate by investigation between the androgenic causes of hirsutism?

Free testosterone level if more than 1.5 – 2 ng/ml (very high) —> tumor.

—>DHEAs  if high mainly adrenal (ovary not produce).

17 alpha hydroxyprogesterone (early morning test sample) —> increased—> congenital adrenal hyperplasia if more than 200 ng/L

If less than 200ng/l —> PCOS considered —->  do ultrasound ultrasound(polycystic ovaries)

8. How do Yasmin and Dianette act to treat hirsutism?

Yasmi contain drospirenon progesterone act as antiandrogenic.

Dianette contain cyproterone acetate progesterone —> decrease LH thus Androgens and  peripherally by Androgens receptors antagonist.

9. What is the hormonal treatment for hirsutism, mood of action and side effects for each one?

Hormonal therapy

COCP , Cyproterone acetate (mentioned above),spironolactone( Weak competitor for dihydrotestosterone), finastride( inhibit five alpha reductase), flutamide( Block androgen receptor’s —-> decrease androgen production,

insulin sensitizers metformin (decrease insulin level by inhibiting hepatic production of glucose and increased number of insulin receptors)

Submitted by : Satarupa 

Tog.. Understanding Precocious Puberty

1. Precocious Puberty – development of secondary sexual characteristics before 8 years

2. Median age of menerche in British teenagers is 13 years ( 12 years and 11months)

3. Classified as

A. Central, true or gonadotropin dependent

B. Peripheral, pseudo or gonadotropin independent

C. Isolated variants

4.GnRH stimulation test is the gold standard for diagnosing CPP

LH>8 iu/l are considered diagnostic of CPP

5.A suppressed LH response to GnRH testing indicates that the therapy is having the desired effect and can be used to evaluate treatment efficacy

Submitted by : Dr Santoshi 

TOG 2009 – 

✍️Adenomyosis sub basalis – superficial disease

✍️ Women with Adenomyosis – 80% will have associated lesions

✍️ Endometrial cancer can be associated with Adenomyosis – no affect on the prognosis or cancer survival

✍️ Carcinoma limited to adenomyotic foci – does not make the prognosis worse than if confined to endometrium proper

✍️ 35% women asymptomatic

✍️ Severity correlates with pelvic pain and dysmenorrhoea

✍️ HSG honey comb appearance low sensitivity and specificity

✍️ TVS sensitivity 55-90%

Specificity 50-99%

✍️ MRI superior to TVS when associated pathology present

✍️ Maximum JZ thickness to myometrial thickness ratio > 40% in MRI

✍️ Long term low dose mifepristone causes anovulation, reduces pain, proves endometriosis scores

✍️Treatment – nsaids, mefenamic acid, coc, gnrh analogue, Lngius

Lap myometrial electrocoagulation, UAE, uterine artery ligation, endometrial ablation for superficial disease and hysterectomy

Submitted by : Rati 

1. Pain is one of the most debilitating symptoms of endometriosis

2. Suspect endometriosis with 1 or more of following symptoms

#chronic pelvic pain

#period pain affecting QOL

#Deep pain after or during sexual intercourse

#periods related or cyclical bowel or urinary symptoms

#infertility associated with any 1 of the above

3. Refer to GYNAEC SERVICE for ULTRASOUND if they have persistent recurrent symptoms of endometriosis pelvic signs of endometriosis

4. Refer to SPECIALIST ENDOMETRIOSIS SERVICE if they have suspected deep endometriosis involving bowel bladder or ureter

5. DO NOT uae CA125 ORMRI as primary investigation to diagnose endometriosis

6. Consider PELVIC MRI to assess EXTENT of deep endometriosis involving bladder bowel ureter

7. Consider OUTPATIENT FOLLOWUP for women with confirmed endometriosis who donot wish surgery if they have

# deep endometriosis involving bladder bowel ureter

# one or more endometrioma more than 3 cm

8.A short trial of paracetamol NSAIDS for 3 months

9. During laparoscopy to diagnose, consider treatment if

#peritoneal endometriosis NOT involving bladder bowel ureter

#uncomplicated ovarian endometriomas

10. For deep endometriosis consider GNRH agonists 3 months .before surgery

11. Consider excision rather than ablation to treat endometriomas if fertility not a priority

12. If fertility is a priority offer

# excision or ablation plus adhesiolysis to women with endometriosis not involving bladder bowel ureter

# offer laparoscopic cystectomy to women with endometriomas