08. KFP: Women's Health Flashcards
(91 cards)
1
Q
Differentials for fidgety legs/leg discomfort?
A
- Restless leg syndrome
- Akathisia
- Nocturnal cramps
- Peripheral artery disease
- Peripheral neuropathy
- Parkinson’s disease
- Arthritis
- Iron deficiency
2
Q
What is restless leg syndrome?
A
Urge to move the legs when lying in bed or sitting down, particularly if the symptom occurs predominantly in the evenings
Diagnostic criteria:
- An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs
- Begin or worsen during periods of rest or inactivity such as lying or sitting
- Partially or totally relieved by movement
- Are worse in the evening or night than during the day
- Symptoms are not solely accounted for by another medical or behavioural condition such as leg cramps
Strong family history
3
Q
Questions to ask when working up fidgety legs/leg discomfort?
A
- Does the leg discomfort improve with movement? (RLS)
- Do you experience a general feeling of restlessness during the day? (Akathisia)
- Do you experience any leg cramping during the night? (nocturnal cramps)
- Do you experience leg pain on exertion? (peripheral artery disease)
- Is there numbness in the legs? (peripheral neuropathy)
- Have you noticed a tremor OR slowed movement? (Parkinson’s disease)
- Do you experience any pain in your knees OR hips OR ankles? (arthritis)
- Do you consume an iron-rich diet? (iron deficiency)
4
Q
What is akathisia?
A
- Inner sense of restlessness accompanied by an intense desire to move
- There is less relief from voluntary movement and less circadian rhythmicity compared with RLS
5
Q
What are nocturnal leg cramps?
A
- Unlike RLS symptoms, nocturnal leg cramps are sudden in onset, short in duration, and usually associated with a palpable muscle contraction
6
Q
Pneumonic for restless leg syndrome symptoms?
A
URGE
- Urge to move the legs (or arms) associated with an unpleasant sensation
- Rest induces symptoms
- Gets better with activity
- Evening and night time worsening
7
Q
Causes of secondary restless leg syndrome?
A
- Systemic iron deficiency
- Uraemia/renal failure
- Peripheral neuropathy (e.g. diabetes, alcohol, amyloid, motor neuron disease)
- Spinal cord disease
- Pregnancy
- Multiple sclerosis
- Parkinson’s disease
- Medications: Antihistamines (especially centrally acting/sedating), dopamine antagonists (e.g. metoclopramide)
8
Q
Initial investigations for suspected restless leg syndrome?
A
- FBC: anaemia
- Iron studies: low CNS intracellular iron can exacerbate RLS symptoms
- EUC: renal failure/uraemia
- Serum bHCG
Considering neuropathy:
- Diabetes
- Vitamin B12 and folate deficiency
- Hypothyroidism
- Autoimmune conditions
- Alcohol misuse
9
Q
Non-pharmacological management of restless leg syndrome?
A
- Cognitive distraction activities e.g. crosswords or puzzles during times of rest
- Particupate in regular moderate-intensity exercise for 30 minutes a day on 5 days per week
- Gently stretch the hamstrings OR calves for 5 minutes before bed
- Keep legs cooler than the body for sleep
- Undertake a trial of abstinence from alcohol
- Warm baths when symptomatic
- Massage legs when symptomatic
- Incorporate a gradual wind-down routine at bedtime
10
Q
Pharmacological management for restless leg syndrome?
A
- Gabapentin nocte PO OR pregabalin nocte PO
(for severe, persistent RLS)
11
Q
Distinguish between irritant contact dermatitis and allergic contact dermatitis
A
Irritant contact dermatitis:
- Sx: burning, pruritus, pain
- Surface appearance: dry and fissured skin. Less distinct borders
- Onset: usually minutes to hours
Allergic contact dermatitis:
- Sx: Pruritus is dominant symptom
- Surface appearance: vesicles and bullae, distinct angles, lines and borders
- Onset: Usually 24 to 72 hours
12
Q
Management of allergic contact dermatitis?
A
- Wear skin protection
- Regular use of emollient
- Loratadine 10mg PO
- Betamethasone diproprionate 0.05% cream/ointment TOP until skin is clear
- Ice pack to affected regions to soothe itch
13
Q
First line therapy for acute localised otitis externa?
A
Flucloxacillin 500mg Q6hourly PO for 5 days
14
Q
Therapy for acute localised otitis externa if allergic to penicillin?
A
Cephalexin 500mg QID PO for 5 days
15
Q
What questions would you ask for a 3.5 year old girl presenting with language developmental concerns?
A
- Did she pass the statewide infant screening hearing test (SWISH) / history of recurrent ear infections or perforations or operations?
- Family history of hearing impairment or family history of developmental delay
- Ability to run or jump - gross motor development
- Ability to feed herself with utensils - fine motor development and vision
- Interest in playing with others - social development
- Difficulty sitting still hyperactivity can be a feature of ADHD although this could be normal for her age
- Snoring at night - obstructive sleep apnea may be associated with difficulty daytime behaviour
- Identify as Aboriginal or Torres Strait islander? - higher rates of otitis media
- Smoking exposure?
16
Q
What are some differentials for expressive language delay in a child?
A
- Hearing impairment e.g. from chronic otitis media
- Isolated language delay
- Anxiety
- Visual impairment
- Child abuse or family violence
- Autism spectrum disorder
- OSA
- Global developmental delay
- ADHD
17
Q
What examination findings would you seek for a 3.5 year old girl presenting with language developmental concerns?
A
- Otoscopy
- Plot current height/weight on age appropriate centile chart
- Observe ability to climb onto a chair or jump - gross motor
- Assess ability to pick up a pen or pencil - fine motor and vision
- Assess ability to articulate words clearly - speech and hearing
- Assess ability to engage in pretend or imaginative play - social
- Assess visual acuity using a Lea chart
18
Q
What visual acuity do you refer a 3-5 year old to an optometrist?
A
6/9 or less in either eye
19
Q
Non-pharmacological management for bilateral conductive hearing loss in a 3.5 year old paediatric patient?
A
- Refer to a speech therapist for speech therapy
- Refer to ear nose and throat specialist for consideration of tympanostomy tube insertion
- Recommend that visual instructions are given face to face / give instructions in a quiet environment
- Encourage shared book reading or storytelling - activities that stimulate speech and language
- Discuss the adverse effects of smoking on a child with otitis media with effusion
20
Q
What are some clinical signs of middle ear effusion?
A
- Loss of lucency of the tympanic membrane
- Visible grey-white or blue fluid
- An immobile tympanic membrane with dilated blood vessels on pneumatic otoscopy or tympanometry
21
Q
When does otitis media with effusion need a referral?
A
Effusion present for three months or longer
22
Q
What questions would you ask on history for an elderly male patient presenting with weight loss in the context of the death of his wife 6 months ago?
A
- Is the weight loss intentional?
- Depressed mood or anhedonia or memory loss - both major depression and dementia may affect energy intake
- Suicidal ideation - major depression
- Difficulty getting to the shops or cooking or finances - Intake/access issue
- Early satiety or epigastric pain - gastric cancer
- Difficulty swallowing or sensation of food getting stuck in the throat - oesophageal cancer, achalasia, esophageal stricture
- Heat intolerance or tremor - hyperthyroidism
- Polyuria or polydipsia - Poorly controlled diabetes mellitus
- Fevers or night sweats - occult malignancy or infection
- Difficulty chewing - neurological conditions such as stroke or motor neuron disease, or poor dentition
- Constipation or bowel habit change - Colorectal cancer
- Breathlessness on exertion or new leg swelling - heart failure
- Presence of reduced urinary flow or other stated lower urinary tract symptoms - prostate cancer
23
Q
Differentials for unintentional weight loss?
A
- Malignancy (e.g. gastrointestinal, lung, lymphoma, renal, prostate cancers)
- Non-malignant gastrointestinal diseases e.g. peptic ulcer disease, coeliac disease, inflammatory bowel disease
- Psychiatric disorders e.g. depression, eating disorders
- Endocinropathies e.g. hyperthyroidism, diabetes, adrenal insufficiency
- Infectious diseases e.g. HIV, viral hepatitis, tuberculosis
- Advanced chronic disease e.g. cardiac cachexia from heart failure, pulmonary cachexia, renal failure
- Neurological diseases e.g. stroke, dementia, Parkinson’s disease
- Medications/substances: alcohol, cocaine, amphetamines
- Side effects from medications: antiseizure medications, diabetes medications, thyroid medications
24
Q
What investigations are required for the evaluation of unintentional weight loss?
A
- FBC with peripheral film
- EUC
- Glucose
- HBA1c
- CMP
- LFT
- TSH
- ESR / CRP
- Urinalysis
- FOBT
- Serology for HIV, Hep C
- Chest XR
- Age appropriate cancer screening
25
What investigations are required for the evaluation of malnutrition?
* Full blood count and peripheral blood film
* Ferritin, folate and INR
* Blood biochem: Na, K, protein, albumin, glucose, urea, calcium, phosphate, magnesium, zinc, selenium
* Creatine kinase - check for statin myopathy
* Lipid profile
* Vitamin D and Vitamin A
26
Non pharmacological management for unintentional weight loss from psychological cause in an elderly patient?
* Referral to a psychologist
* Referral to a dietitian for further in-depth nutritional assessment
* Refer to My Aged Care for assessment for home support or Meals on Wheels
* Encourage small frequent meals / recommend increased dietary protein / recommend supplemental nutritional shake e.g. Resource/Sustagen
* Review in one month to track weight
27
List some nutritional support and advice for the elderly at risk of undernutrition
* Liberalise the patients diet (review dietary restrictions)
* Encourage use or flavour enhancers
* Recommend frequent small meals and snacks eg cheese and crackers, scrambled poached or boiled eggs, baked beans, Fortified soups, milk based puddings and drinks, sandwiches with high protein fillings
* Ensure ready availability of nourishing snacks eg nuts, yoghurt, cheese and crackers
* Ensure food texture suits chewing and swallowing ability
* Suggest ways to increase protein and energy intake by fortifying foods eg incorporate milk, butter or cheese in foods such as soups, sandwiches or mashed potato or add powdered nutritional supplements
* Consider high energyAnd protein nutritional supplements
* Ensure sufficient fluid intake
* Use a micronutrient supplement eg iron, folate, vitamin d
28
What questions do you ask on history for a patient presenting teary and overwhelmed?
* Depressed mood or anhedonia / fatigue or low energy / poor concentration or motivation - Major depression or organic disorder
* Presence of panic attacks / feeling anxious in social situations or in general or in open spaces - anxiety disorders
* Decreased need for sleep or excessive productivity - mania
* Hallucinations or delusions or ideas of reference - psychosis
* Intense fear of gaining weight - anorexia nervosa
* Unstable or absent sense of self identity / history of impulsive behaviour / history of breakdown of intense interpersonal relationships - borderline personality disorder
* History of trauma or exposure to a stressful event or situation - PTSD
* Palpitations or heat intolerance - hyperthyroidism
29
What is the diagnostic criteria for borderline personality disorder?
A pervasive pattern of instability of interpersonal relationships, self image, and affects and market impulsive iti, beginning by early adulthood.
Five or more of the following:
* Efforts to avoid real or imagined abandonment
* Unstable and intense interpersonal relationships
* Unstable self image
* Impulsivity
* Recurrent suicidal behaviour
* Marked reactivity of mood
* Chronic feelings of emptiness
* Difficulty controlling anger
* Stress related paranoid ideation or severe dissociative symptoms
30
What is different between complex post traumatic stress disorder and borderline personality disorder?
Complex PTSD:
* Severe but stable negative self concept
* Relational difficulties are characterised by a tendency to avoid
Borderline personality disorder:
* Shifts in self image between highly positive and highly negative
* Associated with rapid engagement followed by ups and downs or idealisation and devaluation of relationships
31
Non pharmacological management of borderline personality disorder?
* Refer to a psychologist for dialectical behaviour therapy
* Provide with the number for Lifeline or Mental Health Line
* Suggest replacing self harm with exercise or distraction
* Suggest a period of relaxing wine down time before bed or any other suitable sleep hygiene strategy
* Review in 48 hours to assess for safety
32
What psychological therapies are useful in the treatment of borderline personality disorder?
* Dialectical behaviour therapy: encourages patients to accept the way they are and change in order to move forward to reach personal goals
* Cognitive behavioural therapy
* Dynamic deconstructive psychotherapy
* Emotional regulation training
* Interpersonal psychotherapy
* General psychiatric management
* Mentalization based therapy
* Motive-oriented therapeutic relationship
* Psychoanalysis
* Psychoeducation
* Schema focused therapy
* Systems training for emotional predictability and problem solving
* Psychodynamic psychotherapy
33
List alternative strategies to replace self harm
* Holding ice cubes on your hand
* Use a red pen to draw on the areas you might normally cut
* Work it off with exercise
* Deep breathing and relaxation exercises
34
What would you include on a safety plan for a patient at mental health risk?
* Identification of warning signs or triggering events
* Suggestions to keep her environment safe or limiting access to harmful items
* Identifying reasons to live
* Developing coping strategies she can do by herself
* Learning socialisation strategies for distraction and support
* Identification of a trusted support person she can call when feeling overwhelmed
* Professional contact she can access for support
35
When should a patient stop non steroidal anti inflammatories before a high bleeding risk surgery?
3 Days before
36
When should a patient stop direct oral anticoagulant therapy before a high bleeding risk surgery?
Two days before
37
What modifiable risk factors increase the risk of complications for hip and knee replacements?
* Obesity
* Diabetes
* Tobacco use
* Opioid use
* Anaemia
* Malnutrition
* Poor dentition
* Vitamin d deficiency
38
What investigations are required before all major or complex surgery?
* Full blood count
* EUC- renal function and albumin as a surrogate marker for malnutrition
* Ecg
* HbA1c if diabetic (aim < 7%)
* Vitamin D (before arthroplasty)
39
What non pharmacological management steps would you take for a patient who presents with febrile neutropenia?
* Organise urgent ambulance transfer to a tertiary hospital for management or febrile neutropenia
* Contact haematologist to inform them of the clinical situation
* Provider phone hand-over to the clinical team at the emergency department
* Transfer patient to the treatment room
* Continuously monitor vital signs
40
What is the first line opioid analgesic choice in pallative care?
Morphine
41
What would you prescribe for pain relief in a patient in pallative care if they're not already on analgesia?
Morphine immediate-release 2-5mg orally, one hourly as required. Maximum 3 consecutive hourly doses or 6 choices in a 24 hour.
42
Why is oxycodone not the first line opioid for pain relief in palliative care?
Pharmacogenetic variability in the rate at which people metabolise oxycodone can cause wide inter-individual variability in the dose needed to control pain
43
Why are buprenorphine patches not commonly use in palliative care for analgesia?
* Transdermal buprenorphine patches are only suitable for patients with relatively stable opioid requirements, not for treating acute pain
* They are not appropriate for rapid dose adjustment
* Seven day buprenorphine transdermal patch reaches steady state after three days
44
What methods of step down therapy for PPIs is available?
* Halving the dose
* Alternate day dosing
45
What palliative care medication options are available?
* Pain/dyspnoea - morphine 2.5-5mg subcut Q1hourly PRN, hydromorphone
* Agitation - midazolam 2.5mg subcut Q1hourly PRN, clonazepam, haloperidol 0.5mg subcut Q4hourly PRN
* Nausea and vomiting - metoclopramide 10mg subcut Q4hourly PRN, haloperidol, cyclizine
* Secretions - Hyoscine butylbromide 20mg subcut Q4hourly PRN
46
What questions would you ask 19 year old male presenting with recurrent shortness of breath on exertion?
* Any chest pain
* Associate palpitations
* Associated cough or fever
* Episodes of non exertional shortness of breath
* Calf pain or calf swelling or haemoptysis or recent long distance travel
* Presyncope or syncope
* Wheeze or history of childhood asthma or history of eczema or hay fever
* Weight loss
* Family history of sudden cardiac death / premature cardiovascular disease
47
What does hypertrophic cardiomyopathy predispose a patient to?
Any cardiac arrhythmia, especially atrial fibrillation
48
What investigations are required for suspected hypertrophic cardiomyopathy?
* ECG
* Echocardiogram
* 24 hour Holter: identify subclinical arrhythmias
* Cardiac MRI: gold standard for ventricular volumetric assessment
49
Non-pharmacological management for a patient with newly confirmed hypertrophic cardiomyopathy?
* Urgent referral to a cardiologist
* Advise patient to temporarily stop high intensity exercise until review by a cardiologist
* Advise patient that if they develop chest pain or syncope, to immediately go to hospital for further investigations
50
Management options for pitted keratolysis?
Pharmacotherapy:
* Clindamycin 1% topical BD for 10 days
* Benzoyl peroxide (25-5%) topical daily - keratolytic with antimicrobial properties and can be used in conjunction with topical antibiotics
* Aluminium dichlorohydrate (20%) OR aluminium chloride (15%) topical daily - higher concentration antiperspirant
Non-pharmacological therapy:
* Wash regularly with antiseptic wash or soap (twice a day)
* Use antiperspirant on the feet
* Wash socks after wear at 60C with soap and water to eliminate bacteria
51
What is pitted keratolysis?
Condition of the feet caused by an overgrowth of bacteria that digest keratin
52
Clinical presentation and risk factors for pitted keratolysis?
* Unpleasant odour
* Shallow pitting of the skin on the soles
* Associated with plantar hyperhidrosis
* Predisposing factors: occlusive footwear (e.g. vinyl shoes, rubber boots), thickened skin on the soles and palms, insufficient foot hygiene, hot and humid weather, obesity, diabetes, immunodeficiency
* Higher risk occupations: farmers, athletes, sailors, fishing and industrial workers, military personnel
53
What level of creatine clearance is apixaban contraindicated?
CrCl < 25mL/min
54
What is the preferred method of anticoagulation in treating VTE for a patient with severe renal impairment?
* Warfarin (aim INR 2-3)
* Enoxaparin/clexane bridging until 1) INR is therapeutic for 2 consecutive days and 2) minimum of 5 days
55
Non-pharmacological management of end-stage chronic kidney disease without dialysis?
* Recommend writing an Advanced Care Directive or discussing health priorities / Recommend appointing a substitute decision marker
* Organise a review in 1-3 months to assess for clinical disease progression / Arrange monitoring of renal function or full blood count or parathyroid hormone at least Q3 monthly
* Referral to a dietitian for recommendations on a renal specific diet / Recommend a low salt diet <6g/day / Recommend adequate dietary protein intake of 0.75g/kg/day
* Recommend physiotherapy to design a safe exercise program involving gradual increase in physical activity levels
* Aim for weight loss to achieve BMI < 25
* Educate on avoiding nephrotoxic medications
* Aim for blood pressure < 130/80mmHg
* Offer a referral to a nephrologist for discussion about non-dialysis supportive care
56
What are some differentials for elderly patient presenting with confusion, vague lower back pain and BP 200/110mmHg after a recent hospital discharge on a background of end stage chronic kidney disease
* Pyelonephritis or urinary tract infection
* Aortic dissection
* Retroperitoneal bleed
* Uremic encephalopathy
* Subdural hematoma
* Cerebrovascular accident
* Hypercalcemia
* Renal colic
* Malignant hypertension
* Acute coronary syndrome
57
What are some risk factors for dementia you would ask for on history?
* Sedentary lifestyle or physical inactivity
* Excessive alcohol intake
* History of smoking
* History of head injury
* Infrequent social engagement or social isolation
* Family history of dementia
* History of depressed mood
* Exposure to air pollution
* Hearing impairment
* Low education level
* Hypertension
* Hypercholesterolemia
* Diabetes
* History of cerebrovascular accident
58
What are some appropriate initial investigations to find a cause of cognitive decline?
* FBC - exclude anaemia and infection
* EUC
* LFTs
* Calcium
* TSH
* Fasting lipids
* Vitamin B12 & folate
* CRP
* BSL
* CT brain
Consider:
* Serology: syphilis, HIV
59
What is the management for mild cognitive impairment?
* Discuss limiting driving to less busy areas or consider conducting a licence medical to ensure fitness to drive
* Discuss appointing a substitute decision maker or enduring power of attorney or enduring guardian / Discuss preparation of advanced care directive
* Recommend 30 minutes of exercise per day on at least five days per week / recommend resistance training on two days per week
* Recommend eating 5 servings of vegetables per day / recommend eating two serves of fruit per day / recommend limiting intake of saturated fats
* Recommend regular cognitive training exercises or crosswords or sudoku or jigsaw puzzles
* Recommend finding a local activity group to form social connections
* Controlling blood pressure, lower cholesterol levels and stopping smoking
* Suggest counselling to explore strategies to compensate for memory deficits
60
What is mild cognitive impairment?
Mild cognitive impairment is generally defined as significant memory loss without the loss of other cognitive functions
61
Differentials for 11 month old with chronic wet cough and bilateral crepitations?
* Protracted bacterial bronchitis
* Primary ciliary dyskinesia
* Primary immunodeficiency
* Recurrent aspiration
* Alpha-1 antitrypsin deficiency
* Bronchiectasis
* Recurrent bronchiolitis
* Chronic pneumonia
* Congenital cardiac disease
* Tuberculosis - if appropriate travel history
62
How would you counsel parents with a young infant with a new diagnosis of cystic fibrosis who have two older children and they are concerned about future pregnancies?
* Explain that cystic fibrosis is an autosomal recessive condition, and therefore inherited a gene mutation from each parent
* Explain there is a one in four chance that future children will be born with cystic fibrosis
* Recommend that the other children undergo cascade testing to test for carrier status
* Refer for genetic counselling to discuss possible effects on future pregnancies
* Refer to a fertility specialist to discuss the possibility of preimplantation genetic testing for future pregnancies
63
What are some of the clinical presentations of cystic fibrosis?
* Chronic cough
* Meconium ileus - 20% of patients with cystic fibrosis present with meconium ileus
* Failure to thrive or faltering growth or slow weight gain / weight loss - infants and children / older children and adolescents
* Steatorrhea or excessive flatulence / pancreatic exocrine insufficiency - may present with bloating, abdominal cramps or pain
* Chronic rhinosinusitis / nasal polyposis
* Diabetes mellitus
* Rectal prolapse
* Infertility / azoospermia
* Hypochloremic hyponatremia alkalosis - caused by chronic hypokalemia with excessive lots of sodium and chloride in sweat with insufficient salt intake
* Osteoporosis
64
What are the priorities of a consultation where a 16F presents with concern about "catching something" after having unprotected sex last night with a boy from school of her year level?
* Emergency contraception
* Explain that what is discussed will remain confidential unless there is significant risk to herself or risk to others or if someone is harming the patient
* Encouraged patient to involve their parents to provide support or with another supportive adult
* Assess if the patient is Gillick competent
* Enquire if the sexual counter was consensual
* Discuss safe sex practises / discuss the risk of contracting sexually transmitted infections from unprotected sex / Recommend sexually transmitted infection screening
* Discuss the risk of pregnancy with sex without using reliable contraception / provide education on different forms of hormonal contraception
* Discuss why patient is concerned she caught something from the encounter
* Ensure that patient feels safe after her encounter last night
65
What are the options for emergency contraception?
* Levonorgestrel PO - single dose 1.5mg (can be used within 4 days after unprotected sex) [Australian TGA only approves up to 3 days]
* Ulipristal acetate PO - single dose 30mg (can be used within 5 days after unprotected sex)
* Copper intrauterine device - (can be inserted within 5 days after unprotected sex)
66
What is the most effective emergency contraception?
Copper intrauterine device
67
What is the most effective oral emergency contraceptive and why?
Ulipristal, because it can prevent ovulation even when the luteinising hormone surge has started
68
What clinical scenarios make the copper IUD particularly suited for emergency contraception?
* If the patient is taking drugs that induce liver enzymes
* If the patient has a body mass index > 30 or weighs more than 85kg
* If the patient wants ongoing contraception with the copper IUD
69
When do you repeat a urine pregnancy test after copper IUD insertion for emergency contraception?
3 weeks after the last episode of unprotected sexual intercourse
70
Can you restart hormonal contraception immediately after using ulipristal as emergency contraception?
No. You must wait five days before restarting or initiating a hormonal methods of contraception
71
Non pharmacological management steps for a 16F pregnant and positive chlamydia test?
* Inform her of the requirement of contact tracing for all partners from the last six months
* Advise to avoid sexual contact for seven days after treatment is administered
* Advise to avoid sexual contact with partners from the last six months until they have been tested and treated
* Notify the department of health
* Inform her she will need to have a test of cure in four weeks time
* Organise follow up appointment in one week to assess response to treatment or confirm contact tracing has occured
72
Pharmacological management for a 16F pregnant and positive chlamydia test?
Azithromycin 1g PO STAT, as a single dose
73
When is doxycycline safe in pregnancy?
* If used during the first eighteen weeks of pregnancy ( 16 weeks post conception)
* After this period, they are contraindicated as tetracyclines can inhibit bone growth in the foetus and discoloured deciduous teeth
74
Pharmacological management options aside from menopausal hormone therapy for the management of hot flushes?
* SSRIs/SNRIs: escitalopram, citalopram, fluoxetine (not if using tamoxifen), paroxetine (not if using tamoxifen), desvenlafaxine, venlafaxine - hot flushes and concurrent mood symptoms
* Gabapentin / Pregabalin - gabapentinoids are reasonable options if hot flashes are worse at night and associated with poor sleep or neuropathic pain
* Clonidine - consider if also needing migraine prevention
* Oxybutynin - may be useful in patients who also experience overactive bladder and urge incontinence symptoms
75
How long does it take non hormonal drug therapy to work for vasomotor symptoms in menopause?
Onset of action is usually within four weeks at an effective dose but may take 8 weeks to have full effect
76
77
Non pharmacological management options for vasomotor symptoms of menopause?
* Cognitive behavioural therapy (either self guided or in a group) reduces vasomotor symptoms and improves mood
* Hypnosis weekly for five weeks
* Weight loss in overweight or obese postmenopausal individuals
* Mindfulness based stress reduction
* Stellate ganglion block reduces vasomotor symptoms for six months
78
What history would you ask before prescribing menopausal hormonal therapy / contraindications to menopausal hormonal therapy?
* History of hypertension - uncontrolled hypertension is a contraindication to any systemic menopausal hormone therapy. Controlled hypertension is a contraindication to oral oestrogen but transdermal oestrogen may be considered
* History of venous thromboembolism
* Previous transient ischemic attack or stroke or myocardial infarction
* Current or past endometrial cancer or breast cancer - oestrogen dependent cancers can worsen or relapse with menopausal hormonal therapy
* Family history of breast cancer - high familial breast cancer risk requires specialist advice prior to prescribing menopausal hormonal therapy
* History of liver disease - patients with only mild liver disease may be able to use transdermal oestrogen
* Porphyria - may be exacerbated by oestrogen
* Systemic lupus erythematosus - may be exacerbated by oestrogen
79
Contraindications to all forms of systemic oestrogen for menopausal hormonal therapy?
* Age 60 years or older
* Previous venous thromboembolism
* Previous transient ischemic attack, stroke or acute myocardial function
* Uncontrolled hypertension
* Oestrogen dependent cancer (eg endometrial or breast cancer)
* Undiagnosed vaginal bleeding (may indicate oestrogen dependent cancer)
* High risk of breast cancer
* Significant liver disease
* Porphyria or systemic lupus erythematosus (may be exacerbated by oestrogen)
80
Contraindications specially to oral oestrogen as menopausal hormone therapy?
* Risk factors for venous thromboembolism, including obesity, smoking and thrombophilia
* Risk factors for cardiovascular disease, including previous cardiovascular disease, insulin resistance, diabetes, obesity, hypertension (even if controlled), smoking
* Elevated triglycerides
* Liver disease or gallbladder disease
Note: if any of these are present, transdermal oestrogen is recommended
81
Options for menopausal hormonal therapy when prescribing for a woman with no contraindications, uterus intact and less than 12 months since LMP?
Combination MHT (oestrogen plus an agent for endometrial protection)
* Transdermal continuous oestrogen and cyclic progestogen
* Oral continuous oestrogen and cyclic progestogen
* Transdermal oestrogen plus cyclic oral progestogen
* Transdermal or oral oestrogen plus levonorgestrel IUD
82
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Options for menopausal hormonal therapy when prescribing for a woman with no contraindications, uterus intact and more than 12 months since LMP?
Combination MHT (oestrogen plus an agent for endometrial protection)
* Transdermal continuous combined oestrogen and progestogen
* Oral continuous combined oestrogen and progestogen
* Transdermal or oral oestrogen plus levonorgestrel IUD
* Oral oestrogen plus SERM (TSEC)
* Tibolone
83
Options for menopausal hormonal therapy when prescribing for a woman with no contraindications, and previous hysterectomy?
Ostrogen only (transdermal or oral)
84
When should menopausal hormone therapy be reviewed once commenced?
Review severity of menopausal symptoms 6 to 8 weeks after starting MHT, then again at 6 months; continue to review every 6 to 12 months
For persistent vasomotor symptoms:
* Consider malabsorption of oral MHT, or confirm that the patient is applying the patch or gel correctly
* Increase oestrogen dose; if not effective, consider other causes and the need for specialist referral
* Review progestogen dose to ensure adequate endometrial protection if increasing the oestrogen dose in continuous combined MHT
85
How do you manage unscheduled vaginal bleeding in cyclical combined MHT?
If the expected withdrawal bleed occurs before day 10 of progestogen and has not settled within 2-3 months, endometrial protection against hyperplasia and cancer may not be adequate
* Increase the duration of progestogen (e.g. from 10 days to 12 or 14 days) or increase the progestogen dose
Prompt investigation of vaginal bleeding is only needed if bleeding is heavy, irregular, postcoital or occurs in individuals at increased risk of endometrial cancer
86
How do you manage breast tenderness secondary to menopausal hormone therapy?
Options:
* Reduce oestrogen or progestogen dose
* Change route or type of progestogen
* Change to tibolone or conjugated oestrogens + bazedoxifene
87
How do you manage nausea secondary to menopausal hormone therapy?
Options:
* Reduce oestrogen dose
* Change from oral to transdermal therapy
* Consider other causes
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What checks are involved with routine surveillance for a patient on systemic MHT?
* Weight
* Blood pressure
* Breast examination
* Fasting lipids
* Diabetes screening
* Age appropriate cancer screening e.g. mammogram, cervical screening test
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Non-pharmacological recommendations to prevent osteoporosis?
* Recommend smoking cessation
* Consume a diet containing at least 1300mg calcium per day (no more than 500-600mg in supplements per day) / recommend consumption of at least 3 servings of calcium-containing foods each day
* Recommend no more than 10 standard drinks of alcohol per week
* Recommend regular participation in weight bearing impact loading exercises (jogging, jump rope) / recommend participation in moderate intensity resistance exercises at least 2 days per week
* Aim to maintain a normal body weight
* Recommend adequate sunlight exposure as a source of vitamin D or oral supplementation
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What are some risk factors for the developement of osteoporosis?
Non-modifiable:
* Female
* Early menopause
* Older age
* Certain medication conditions
* Genetic predisposition
Modifiable:
* Lack of weight-bearing exercise
* Poor calcium intake
* Vitamin D deficiency
* Low or high body weight
* Cigarette smoking
* Excessive alcohol intake
* Long term use of corticosteroids
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