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Conditions Flashcards

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1
Q

Postpartum contraception methods

A

Lactational amenorrhoea; 98% effective if;
- amenorrhoea
- <6/12 postpartum
- Baby fully breastfed and nil long intervals between feeds (<4hrs day, <6hrs night)
- BUT recommend additional contraception as variable night time feeding and ovulation may still occur
IUD; immediately postpartum
Progestogen-only pill; safe in breastfeeding
COCP; 6/52 postpartum (nil effect on BM from 6/52 onwards)

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2
Q

Ceasing contraception once 50yo

A

LNG-IUD, POP, implant
- amenorrhoeic for >=12/12
- 2x FSH 6/52 apart - if both >=30IU/L then only need contraception for another 12/12
- OR continue until >=55
Cu-IUD; cease amenorrhoeic 12/12

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3
Q

Contraception + epilepsy

A

Carbamazepine, phenytoin, lamotrigine -> reduce efficacy of COCP
LVG-IUD, copper IUD, depot are effective

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4
Q

Interacting drugs with contraception (excluding IUD/depot/Copper)

A

Antiepileptics: carbamazepine, oxcarbazepine, perampanel, phenobarbitone
Antiretrovirals for hiv
Antibiotics: rifampicin, rifabutin
Complementary: St John’s wort

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5
Q

Quick start indications

A

Irregular/long periods
If unintended pregnancy would cause harm
Difficulties accessing health care

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6
Q

Quick start contraindications

A

IUD
COCP with cyproterone (feminisation of foetus)

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7
Q

How to exclude pregnancy

A

Negative preg test + nil UPSI in last 3/52
Nil intercourse since period
Consistent with current contraception
within 5 days of start of period
21 days postpartum
5 days post abortion/miscarriage

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8
Q

COCP UMEK

A

Smoking
- >=35yo + >=15cig = 4
Obesity
- BMI >=35 = 3
HTN
- >=160/100 = 4
Vascular disease = 4
Previous CVA/IHD = 4
Hx VTE = 4
Fhx VTE = 3
Migraine + aura = 4
Current breast Ca = 4

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9
Q

Contraindications IUD

A

PID
STD
Unexplained PV bleeding
Cervical/endometrial Ca

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10
Q

LNG-IUD

A

52mg (menorrhagia/dysmenorrhoea/endo) or 19.5mg (dysmenorrhoea, reduce bleeding)
Contra; breast Ca, PID

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11
Q

Copper IUD

A

Immediately effective at any time
Complication; expulsion, PID, ectopic, perforation
Avoid sex 48hrs post insertion

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12
Q

Implanon

A

etonorgestrel 68mg every 3 years
Contra; breast Ca
Advantage
- cost-effective
- can quick start
- safe postpartum + breast feeding
- Amenorrhoea in 22%
- Improves dysmenorrhoea
Risks; infection, scarring, cysts

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13
Q

Mx bleeding on implanon

A

1st line; COCP continuously 3/12, mefenamic acid 500mg TDS 5/7, TXA 500mg BD 5/7
2nd line; norethisterone 5mg TDS 21/7

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14
Q

Depot medroxyprogesterone

A

Medroxyprogesterone 150mgcg 12/52ly
Consider; contraindication to COCP, drugs that induce liver enzymes, wanting discrete method
Risks; CVD risk, BMD
Contra; breast Ca
Precaution; IHD/CVA/TIA, CVD risk factors, avoid >50yo
Disadvantage; altered bleeding, low continuation rate, 20% have weight gain, loss of bone density, 18mo return of fertility

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15
Q

Late depo injection

A

up to 14/52 since injection is ok
14/52 + 1 or more days
- if UPSI within last 5/7 - need emergency contraception
- multiple UPSI >5 days ago and <=3/52 ago -> urine test needed

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16
Q

POP

A

Consider if oestrogen contraindication
Quick start = immediately effective - otherwise takes 3 pills before being effective
Contra; breast Ca
Precaution; unexplained PV bleed, Hx breast Ca, cirrhosis/liver disease, IHD/CVA/TIA that develops during use
Disadvantage; 3hr window, altered bleeding, low continuation rate, ectopic pregnancy,

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17
Q

Missed POP

A

1 pill missed
- immediately take, condoms until 3 consec pills
- consider EC if UPSI occurred in time since missed pill
>1 pill missed
- take most recent missed pill and condoms for 3 consec pills
- consider EC if UPSI occurred in time since missed pill

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18
Q

Oestrogen types in COCP

A

Estradiol
Ethyinylestradiol
Mestranol

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19
Q

Progestogen types in COCP

A

1st gen; norethindrone
2nd gen; levonorgestral, norethisterone
3rd gen (less androgen, more VTE)
- desogestral, etonogestrel
Unclassified; cyproterone acetate, drosperinone
- both antiandrogenic

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20
Q

COCP advantages

A

Tx
- acne
- menorrhagia
- dysmenorrhoea
- endometriosis
- PCOS
- PMS
Reduce risk
- endometrial/ovarian/bowel Ca

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21
Q

COCP disadvantages

A

high user involvement
VTE risk
MI/CVA risk
increase risk cervical/breast Ca
HTN
irregular bleeding

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22
Q

COCP contraindications

A

Breastfeeding <6/52 postpartum
Smoker >35 and >15 cig per day
Migraine + aura
HTN >160/110
>50yo
Hx VTE
Breast Ca
Cirrhosis/liver ca
Known thrombogenic mutations

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23
Q

Mx COCP ADR

A

Breakthrough bleeding
- Higher dose oestrogen or less androgenic progestin
- extending cycling
Breasts tenderness
- reduce oestrogen/progestogen dose
Nausea; take at night
Headache; reduce oestrogen
Bloating; reduce oestrogen or change to diuretic progestogen (drosperinone)

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24
Q

COCP missed

A

> 24hrs overdue
- take most recent
- condoms 7/7
- if <7 pills from placebo -> EC if UPSI in last 5/7
- <7 till next placebo - skip and take active

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25
COCP types
Microgynon ED; ethinyloestradiol 20mcg + levonorgestral 100mcg Levlen ED; ethinyloestradiol 30mcg + levonorgestrel 150mcg Microgynon 50; ethinyloestradiol 50mcg +levonorgestral 125mcg Brenda-35; ethinyloestradiol 35mcg + cyproterone 2mg Yaz; ethinyloestradiol 20mcg + drosperinone 3mg Yasmin; ethinyloestradiol 30mcg + drosperinone 3mg
26
Ulipristal acetate
30mg dose Best taken within 24hrs - but can use up to 5 days UPSI Contra; severe asthma, severe liver impairment If vomiting within 3hrs ingestion - repeat dose Delay resumption of contraception until 5 days after dose
27
Levonorgestrel EC
1.5mg PO within 72hrs if vomit <2hrs - repeat if on liver enzyme-inducing drug - take 3mg Avoid in obese due to risk of failure Resume contraception immediately within LNG-ECG
28
Minipill as EC
25x minipill 12 hrs apart (50 tab)
29
Copper IUD EC
Within 5 days UPSI Good option if taking liver enzyme inducers, BMI >30 Can keep in for ongoing contraception Need to screen for STI in high risk Need preg test 3/52 post UPSI
30
Copper IUD EC
Within 5 days UPSI Good option if taking liver enzyme inducers, BMI >30 Can keep in for ongoing contraception Need to screen for STI in high risk Need preg test 3/52 post UPSI
31
Signs of secondary dysmenorrhoea
Onset in third decade of life or later Dyspareunia Heavy menstrual bleeding Intermenstrual bleeding Post-coital bleeding Irregular periods Poor response to 3/12 tx Signs of endometriosis/fhx of same
32
Mx dysmenorrhoea
1st line; NSAID or COCP Ibuprofen 400mg TDS for 72hrs of menstruation Mefenamic acid 500mg TDS for 72hrs of menstruation Local heat Acupuncture Diet; thiamine, magnesium, fish oil
33
Secondary dysmenorrhoea causes
Endometriosis Pelvic infection Adenomyosis Fibroids Chronic PID Ovarian cysts Cervical stenosis
34
Abnormal uterine bleeding causes
PALM COEIN Polyps Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not classified
35
Primary amenorrhoea
Failure menses by age 16yo with normal secondary sex characteristics Causes - Hypothyroidism - HPRL - PCOS - Androgen insensitivity - Mullerian agenesis - Turner's - Low FSH; constitutional delay, pituitary failure, T1DM
36
Secondary amenorrhoea
amenorrhoea for 6/12 Causes - Pregnancy - Functional hypothalamic amenorrhoea (weight change, stress, eating disorder) PCOS Prolactinoma Premature ovarian failure Thyroid disease Exogenous androgen use Cervical stenosis Asherman's syndrome Sheehan syndrome Congenital adrenal hyperplasia
37
Secondary amenorrhoea Ix
bHCG FSH/LH Oestradiol/testosterone TSH PRL Pelvic USS
38
Premature ovarian insufficiency
<=40yo with irregular periods or amenorrhoea >=4/12 FSH >=25 on 2x occasions 6/52 apart confirms Dx Consider karyotyping - Fragile X or Turner syndrome Autoimmune screen with (ANA) - could be autoimmune POI Consequences - Menopause - Accelerated cognitive impairment - CVD - Inferility - Osteoporosis - Premature mortality
39
Asherman's syndrome
Adhesions inside uterus +/- endocervix Sx - light period, amenorrhoea, infertility, miscarriage Risk; curettage post miscarriage
40
DUB
Heavy/prolonged/frequent bleeding of unknown cause Tx - Cease smoking - Dietary iron - Exercise - Tranexamic acid - Naproxen / mefenamic acid - COCP - Oral progesterone - Depot - IUD
41
Heavy menstrual bleeding cause
Pregnancy PALM COEIN PCOS Hypothyroidism IUD Ginseng
42
HMB Ix
FBC Ferritin Coag TSH BHCG STD CST if due USS on day 5-10 cycle
43
HMB referral criteria
Refer if 6/12 ongoing sx despite tx Early referral - severe dysmenorrhoea - if wanting to conceive - fibroids >3cm - Endometrial polyp - Risk factors of endometrial ca
44
HBM tx
IUD TXA mefenamic acid COCP Depot PO medroxyprogesterone 10mg TDS day1-21 Uterine artery embolisation Acute severe heavy bleed - Medroxyprogesterone 10mg TDS until bleeding stops
45
Adenomyosis
Infiltration of endometrium into myometrium Risks - preterm labour - PROM - miscarriage - pre-eclampsia Sx - HMB, dysmenorrhoea, irregular bleeding Tx - LNG-IUD best - COCP, POPO - TXA/NSAID - If no longer wanting babies - endometrial ablation or hysterectomy
46
Endometriosis sx
Dysmenorrhoea Dyspareunia Dysuria Cyclical haematuria HMB Diarrhoea/bloating Infertility urinary sx
47
Endometriosis tx
1st line; NSAID, panadol Next; COCP, Progestogen, LARC Refer after 3/12 tx
48
Post-menopausal bleeding ddx
Endometrial ca Endometrial polyp Endometrial hyperplasia Vaginal atrophy Cervical polyp Endometrial fibroid
49
Endometrial Ca risks
Nulliparity Late menopause OBesity DM Unopposed oestrogen therapy Tamoxifen Endometrial hyperplasia
50
Normal endometrial thickness based on menopausal status
Post; <4mm Peri; <5mm Pre; <12mm
51
Hypogonadotropic hypogonadism
Cause - Functional; eating disorder, exercise - Acute illness - Chronic disease; DM - Nutritional deficiency - Medication; opioids, anabolic steroids - Contraceptive progestogens Ix - Normal LH/FSH with low oestradiol
52
Menopause sx
Vasomotor; hot flush, night sweats Urogenital; dryness, urinary freq, dysuria, nocturia, incontinence Insects crawling in skin Reduced libido Sleep disturbance Mood/memory issues Irregular PV bleeding
53
Menopause ddx
Thyroid Depression Anaemia Diabetes SSRI (cause flushes)
54
Menopause evaluation
Assess breast Ca, CVD, VTE, osteoporosis risk BMI CVD exam Thyroid exam Lymphatic exam - if concerns malignancy Cervical + vulvar exam Bimanual if indicated
55
Routine health screening for menopausal women
Exclude thyroid disease, diabetes, iron deficiency Vitamin D if risk CST + mammogram BP, cholesterol, FPG Smoking Bone health
56
Non-hormonal menopause tx
Use if contra-indication to systemic therapy or vulvovaginal sx only Good for sleep and vasomotor sx SSRI; escitalopram 5mg daily SNRI; venlafaxine 37.5mg PO Gabapentin 100-300mg nocte Clonidine 25-75mcg BD
57
Non-pharmacological mx of menopause sx
Psychologist for CBT Keep cool, air-conditioner, cool liquids Avoid triggers; stress, spicy food, caffeine, alcohol Smoking cessation Weight loss Pelvic floor exercises Vaginal lubricants; KY jelly
58
Types of systemic MHT
Most effective for hot flushes, night sweats, helps prevent osteoporosis - Oestrogen only MHT - Combination MHT; cyclical combined or continuous combined - Other; tibolone
59
Contraindication to systemic MHT/oestrogen
>=60yo Previous VTE Prev TIA/CVA/MI Uncontrolled HTN Oestrogen-dependent cancer Undx PV bleeding High breast Ca risk Significant liver disease Porphyria/SLE
60
Contraindication to oral oestrogen for menopause tx
VTE risk factors CVD risk factors Elevated TAG Liver/gallbladder disease If so -> use transdermal oestrogen If not - can use either transdermal or oral
61
Indication for addition of progestogen for transdermal/oral oestrogen for menopause tx
Intact uterus Endometrial ablation Subtotal hysterectomy If not -> oestrogen-only MHT
62
Mx menopause of contraception required
<50yo; CHC Or oestrogen PLUS LNG-IUD
63
Mx menopause if nil contraception required
POI/early menopause; cyclical combined or continuous combined Perimenopause; CHC (<50yo), oestrogen PLUS LNG-IUD, cyclical combined MHT Postmenopause; continuous combined MHT, tibolone
64
Oestrogen only MHT
Increases risk CVA/VTE Oestradiol valerate 0.5-2mg (progynova) PO Oestradiol 25-100mcg/24hr patch (Climara) Oestradiol 1.5mg 2x pumps gel (Estrogel)
65
Intravaginal oestrogen therapy
Most effective for vulvovaginal atrophy, reduce risk of UTI and improve some urinary sx Nil CVD/VTE/breast Ca risk - but if they have personal breast Ca risk then prefer non-hormonal therapy Estriol 1mg/g one applicatorful intravag nocte 2-3/52 then one or twice weekly
66
Cyclical combined MHT
Indication; POI, perimenopausal (breakthrough bleeding occurs with continuous) Increases risk of; bresat Ca, CVA, VTE, CVD Component: oestrogen PO/transdermal PLUS PO progestogen Continuous oestrogen + progestogen 10-14/7 of cycle 1mg oestradiol/10mg dydrogesterone (Femoston) tablet Estrogel Pro; 1 pump 0.75mg oestradiol PLUS 2 capsules (200mg) progesterone PO 12/7
67
Continuous combined MHT
Indication; postmenopausal, POI, migraines Estradiol 1mg + drosperinone 2mg (Angeliq) PO Oestradiol 0.75mg 1 pump gel + progesterone 100mg (Estrogel Pro) 25/7
68
Counselling prior to commencing MHT for menopause
Discuss cyclical bleeding on cyclical MHT Discuss ADR; mastalgia, nausea, headaches Increase risk of breast ca Increase risk of VTE Use for max 5 years due to risks of cancer If develops breakthrough bleeding- needs review F/u in 3/12
69
Causes of PV itch
Lichen sclerosus Psoriasis Atopic dermatitis Atrophic vaginitis Candidiasis Lichen planus
70
Vulvodynia
Chronic vulvar discomfort in absence of other findings Sx - tender - burning/raw feeling - provoked by intercourse, tampons, tight clothing Mx - Topical lignocaine 2% gel prior to sex - Low dose TCA 1st line
71
Causes of vulvar pain
Infection; candida, bacterial, HSV Eczema/lichen simplex/contact dermatitis/psoriasis Atrophic vaginitis Vulval neoplasia TRauma Vaginismus
72
Primary vaginismus
Pain/difficulty of intercourse due to spasm of pelvic floor Sx - pain - difficulty with intercourse - fear of pain/penetration Mx - vaginal dilation - progressive desensitisation/relaxation - sex therapy to reduce fear - CBT - Pelvic floor physio for progressive desensitisation
73
Chronic vulvovaginal candidiasis
Sx - itch - burning/rawness - premenstrual pain / itch Mx - Avoid irritants; soap, wipes, panty liners, fabric softener, perfume - Candida suppression - prolonged course - prefer oral -> fluconazole 150mg weekly for 6/12
74
Bartholin gland mass
Small cyst <3cm; sitz bath, warm compress Abscess <3cm; I+D If 3rd episode - may need marsupialization + ABx
75
Candidal vulvovaginitis tx
Clotrimazole 1% cream intravaginally nocte 6/7 If can't tolerate - fluconazole 150mg PO stat Non-pharm - cotton underwear - unperfumed detergent - avoid tight pants - avoid soap - avoid douche Glabrata; Boric Acid 600mg pessary nocte 14/7 Can't use orals if pregnant - topical
76
Pelvic pain in women - exam
Vitals Peritonism External genitals - HSV lesion - Vulvar/perineal abscess - Imperforate hymen Speculum - discharge, open OS, POC Bimanual - Motion tenderness; PID, cystitis - enlarged uterus; pregnancy, fibroid - Painful adnexal mass; ectopic, tubo-ovarian abscess, ovarian cyst, torsion - Rectal exam; thrombosed haemorrhoids
77
Virilisation in woman (masculine)
DDx - adrenal/ovarian tumour secreting androgens - Congenital adrenal hyperplasia - PCOS - Exogenous androgen use - Severe insulin resistance Ix - FSH/LH - Oestradiol - PRL - Testosterone - Sex hormone binding globulin - DHEAS - Progesterone - TSH
78
Hx for ovarian mass
Fhx; breast / colon / uterus / ovarian Ca BRCA gene mutation Lynch syndrome Protective factors; parity, breast-feeding, COCP use Menopause status
79
Ovarian mass Ix
USS; TVUS + transabdominal Ca-125 <40yo; LHD + AFP + BCHG Risk malignancy index for postmenopausal women Premenopausal - Asymp + <5cm simple cyst - nil f/u - 5-7cm simple cyst; repeat USS 3/12 - >7cm refer gyn Postmenopausal - Simple unillocular cyst <5cm + low RMI - monitor - resolve by 3/12 - Mod-high RMI; refer gyn
80
Risk malignancy index ovarian mass component
= USS findings x menopause status x Ca125 (U/mL) USS finding Menopausal status (3 points if menopause) Ca125; Actual level
81
PCOS diagnostic criteria
Two or following and other causes excluded; - Menstrual disturbance - Clinical or biochemical hyperandrogenism - polycystic ovaries on USS
82
Clinical features of PCOS
Obesity Insulin resistance Subfertility Irregular periods Hirsutism Oligo/Anovulation; cycles <21 or >35 days indicate this
83
PCOS Ix
Hyperandrogenism; wait 3/12 post cessation oestrogen (can falsely elevated SHBG) - Total serum testosterone; 2x upper limit - Free androgen index; total serum test / SHBG x 100 -> best measure of hyperandrogenism - Serum 17-hydroxyprogesterone; measure during follicular phase - if elevated then indicates congenital adrenal hyperplasia - LH/estradiol/progesterone; confirms in follicular phase to avoid misinterpretation of serum 17-hydroxy - TSH Exclude other causes - PRL - TSH - Cortisol - Vitamin D; deficiency can increase testosterone USS - >=12 follicles per ovary +/- vol >=10ml (not to be done if <8yo from menarche as will always have polycystic ovaries) - do in 1st week of cycle
84
PCOS mx
Weight loss 5% Exercise COCP; regular period, suppress androgen - if COCP contraindicated -> medroxyprogesterone 10mg 12 days of each month Mirena 52mg IUD good for menstrual regulation Metformin 250mg IR BD; subfertility (doesn't tx androgen)
85
PCOS infertility
1st line; exercise + 5% weight loss 2nd line; specialist referral for letrozole Metformin; can induce ovulation but not effect. can trial whilst awaiting specialist Laparoscopic ovarian drilling IVF
86
PCOS monitoring
Lipid 2 yearly BP annual OGTT 1-3 yearly Mental health Monitor OSA Fertility
87
Ovarian cancer risk factors
Age Caucasian Premature menarche Late menopause Never taken COCP Post-menopausal HRT Use of IUD in past Smoking Fhx
88
Ovarian Ca sx
Abdominal pain Bloating Dyspareunia Altered bowel habits Anorexia Nausea Vaginal bleeding Urinary freq Weight loss Fatigue
89
Ovarian ca exam
Abdominal exam - masses, organomegaly Bimanual exam Lymph node exam
90
Endometrial ca risk factors
Chronic anovulation Unopposed oestrogen PCOS Tamoxifen Lynch syndrome nulliparity Obesity Endometrial thickness >8mm
91
Incontinence risk factors women
Age Obesity Parity Vaginal delivery Fhx Smoking Caffeine Diabetes Menopause Genitourinary surgery
92
Types of incontinence
Stress Urgency Mixed Overflow; chronic retention and leakage
93
Incontinence hx
Urgency Stress Nocturia Incomplete emptying Overflow Haematuria Lower limb weakness Pelvic prolapse Constipation Alcohol/caffeine intake Medication
94
Incontinence exam
Vulvovaginal exam; atrophic vaginitis Pelvic exam; adnexal mass Pelvic organ prolapse Pelvic floor weakness Anal tone Constipation on exam Lower limb neurology Cardiac; volume status, CHF
95
Incontinence Ix
UMCS FPG Bladder diary
96
Incontinence mx Non-pharm
- Weight loss - Diet; reduce EtOH/caffeine/spicy food - Tx constipation - Avoid heavy lifting - Smoking cessation - Bladder training (scheduled voiding) - Physio for pelvic floor rehab - Fluid restriction 8 cups per day
97
Incontinence pharmacological mx
Vaginal oestrogen; vagiefem pessaries weekly Oxybutynin 5mg TDS Mirabegron (Betmiga) 25mg daily Botox in bladder wall SNRI - duloxetine 30mg (good for stress)
98
Pelvic organ prolapse risk factors
Menopause Smoking Chronic cough Vaginal deliveries Obesity Fhx Chronic constipation
99
Pelvic organ prolapse mx
Non-pharm - Avoid lifting - tx constipation - pelvic physio - weight loss - educate condition is mechanical and minimal long term health impacts Vaginal pessary via O+G Local oestrogen cream in menopausal women Referral - failed conservative - voiding issues or obstructed defecation - recurrent prolapse post surgery - ulceration of prolapse or irreducible
100
Mx postcoital bleeding flowchart
Do Co-test If co-test negative - and single episode + normal cervix - nil further Ix - recurrent / persistent bleed -> refer gyn If co-test positive -> refer to gyn

Gynaecology (1 decks)

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