Gynae1

Question 1

What is the relationship between HPV and Cervical cancer?

Answer 1

Persistent infection with oncogenic subtypes (10-15 years) can lead to cervical cancer

The oncogenic subtypes - 16 and 18 have increased risk of invasion and squamous intraepithelial lesions (SIL) (cervical and anal ca)

Question 2

What are the important HPV subtypes and what do they cause?

Answer 2

16 and 18 are oncogenic - they can cause cervical ca (And anal ca)

THey can cause invasion OR squamous intraepithelial lesions

6 and 11 - cause warts

Question 3

What are the risk factors for cervical cancer

Answer 3

1. No screening
2. DES exposure in utero
3. 5 years on OCP
4. Early pregnancy
5. More than 3 pregnancy
6. Smoking
7. Age 35 or higher
8. Immunocompromise

Question 4

What is the difference in regression of Low grade and High grade SIL (LSil and HSil)

Answer 4

low grade squamous intraepithelial lesions are faster to regress

high grade SIL is slower to regress

Must sample trasnformation zone during HPV testing.

Question 5

When does CST testing begin in Australia?

Answer 5

At the age of 25 or 2 years after first intercourse - whichever is LATER

If had Pap smear - then can have CST 2 years after last pap

eg pap at 28 can have CST at 30

For women UNDER 25 who had a Pap which was normal then can have their CST 2 years after OR at 25 which ever one is Later

HOWEVER

patient with symptoms - pain or bleeding can have a CST at any age

Question 6

What are the two components to the CST?

Answer 6

1. HPV testing
2. Liquid based cytology

Question 7

What are the risk factors for endometrial cancer

Answer 7

you are overweight or obese

you are over 50 years and have gone through menopause

your endometrium grows too thick (known as endometrial hyperplasia)

one or more people in your family has had endometrial, bowel, breast or ovarian cancer, or Lynch syndrome (known as hereditary non-polyposis colorectal cancer – HNPCC)

you take an oestrogen hormone replacement that does not have progesterone

you are taking the drug tamoxifen (which is used to treat breast cancer)

you have high blood pressure (known as hypertension) and diabetes

you have never had children -nulliparity

you have had pelvic radiation in the past to treat another cancer

you have a tumour in one of your ovaries - ovarian ca

you have polycystic ovary syndrome (PCOS).

Question 8

What is the difference between primary and secondary amenorrhea?

Answer 8

PRIMARY - no secondary sexual characteristics by 14. (year 9)

No menstruation by 16. (year 11)

Secondary - No menstruation for six months after a period of menstruation in the absence of pregnancy.

Question 9

Causes of Primary Amenorrhea

Answer 9

Imperforate hymen

Transverse vaginal septum

Mellerian agenesis (Female - has ovaries, but no uterus or vagina on u/s)

Androgen insensitivity (XY - genotypically male, grows up phenotypically female, external female sexual characteristics due to oestrogens in utero and b/down of testost - should have gonads removed as potentially carcinogenic)

Excessive exercise

Severe weight loss (anorexia nervosa)

Pitutaty adenoma - secreting prolactin

Turners Syndrome

Question 10

What are causes of secondary amenorrhea?

Answer 10

1. Prolactinoma is the commonest after pregnancy
2. PCOS
3. cervical stenosis
4. Asherman syndrome
5. Premature ovarian failure
6. Excessive exercise, severe weight loss, stress, anorexia nervosa - affects HPO axis
7. Hypopituitarism from destruction of pituitary eg craniopharygnioma, TB, sarcoidosis
8. Hypo and hyperthyroid
9. Sheehans syndrome (hypopituitarism caused by ischaemic necrosis of pituitary - blood loss during delivery or post partum/hypovolaemia
10. Use of illicit drugs eg cocaine
11. Medications - antipsychotics, antidepressants, antihypertensives

Question 11

What is the process for collecting a HPV molecular test with LBC?

Answer 11

1. Collect by inserting the central bristles of the collecting brush gently into the endocervical canal. (If lubricant is used for the speculum, use sparingly on the exterior surface and avoid applying lubricant to the tip of the speculum)
2. Gently Rotate 3-5 times to collect sample.
3. Rinse the bristles in the solution within the vial and tap the bristles against the base (Approximately 10 times) forcing bristles apart. Then discard the collecting device.
4. Document patients details on the vial and send to lab.
5. If for asymptomatic screening - write Cervical screening test on the form.

If Symptomatic - write Co-test (HPV and LBC)

Question 12

Once CST is done what are the possible outcome?

Answer 12

1. RETURN for CST screening in 5 years - IF NO HPV IS FOUND.
2. REPEAT in 12 months - IF HPV is found (but not oncogenic) and Reflex LBC is either negative or shows pLSIL or LSIL. On the pathology form you would write FOLLOW UP HPV.
3. REFER TO COLPOSCOPY - if any oncogenic HPV is found (regardless of LBC result) OR if non oncogenic HPV but the reflex LBC demonstrates pHSIL or HSIL. (The colposcopy will determine whether biopsy etc is needed)
4. IF an UNSATISFACTORY SAMPLE was collected - the sample must be recollected within 6-12 weeks

Question 13

What are symptoms which are suggestive of cervical cancer?

Answer 13

• Abnormal bleeding (post coital, intermenstrual, post menopausal)
• Unusual vaginal discharge
• Pain during sexual intercourse

Question 14

How would you investigate a patient who has symptoms which might suggest cervical carcinoma?

Answer 14

CO-TEST - HPV and LBC

this means that regardless of the HPV result, they will also perform a liquid based cytology.

Write CO-test on the form and describe the symptoms eg abnormal bleeding.

Question 15

When is a co-test for cervical cancer required?

Answer 15

1. Symptomatic patients
2. Patients exposed to DES and if requested, their daugthers
3. Patients undergoing TEST OF CURE surveillance
4. Patients who have been treated for glandular abnormalities

Question 16

How do you perform a TEST OF CURE after a patient has been treated for high grade abnormalities?

Answer 16

These patients need a YEARLY CO-test

Until at least 2 consecutive negative co-test results

Then they can go back to 5 yearly screening

Question 17

A pregnant patient wants CST screening? What is important in regards to the procedure?

Answer 17

Can happen at any time provided that The correct equipment must be used. Certain brushes like the cytobrush can cause bleeding and so are not recommended. THe pathology provider can give information about appropriate device to use in this case.

Question 18

Self collected Vaginal sample tests for HPV - who is eligible and whats the process?

Answer 18

• MUST BE OVER 30 and declined clinician based collection AND
• OVERDUE for cervical screening by 2 years or longer

OR

• Have never screened

On the form write HPV ONLY (cos its a vaginal sample they cant do LBC)

NOT SUTIABLE IF - under 30, symptomatic, exposed to DES in utero, or had a total hysterectomy with hx of previous HSIL

Question 19

What’s the process after a self collected vaginal HPV test?

Answer 19

If HPV is detected (not oncogenic) - Encourage the patient to have a clinician collected cervical sample for LBC. If they REFUSE - then encourage a repeat HPV test - preferably by a healthcare provider in 12 months time.

If oncogenic HPV is detected - REfer to gynaecologist for colposcopy and they will collect a cervical sample for LBC at that visit.

Question 20

Would you offer CST to a woman who has had a total hysterectomy? A subtotal one (cervix not removed)

Answer 20

1. Total hysterectomy and prior screening has been documented as NORMAL - then no further screening is required.
2. IF total hysterectomy and previous High SIL was documented - then yearly CO- Test (Sample from the vaginal vault - write this on the form) taken yearly until 2 consecutive negative results. Then can stop screening.
3. IF Subtotal - cervix still in tact - then they continue 5 yearly screening as normal.

Question 21

What are the effectiveness rates of male condoms and female condoms? Correct use vs typical use

Answer 21

98Male —> 82 typical

95Female —> 79 typical

Question 22

A woman presents seeking emergency contraception

a) within 4 days of sex
b) within 5 days of sex

Answer 22

a) WITHIN FOUR DAYS

ORAL LEVENORGESTROL 1.5mg STAT

b) within FIVE DAYS

Copper IUD (Copper intra uterine device)

or Ulipristal 30mg orally stat

Question 23

What is the quick start method of contraception?

Answer 23

All contraception should be commenced within the first 5 days of the cycle.

If LATER than that when commencing contraception.

1) Use condoms for first 7 days
2) Repeat Pregnancy test in 4 weeks
3) Advice patient that there is a possibility of pregnancy in the current cycle

Question 24

What are the options for contraception in an adolescent female

Answer 24

IUCD
Implanon
Depo Progestogen injection

Question 25

What are the issues with prescribing contraception to an adolescent?

Answer 25

1. Confidentiality and consent to treatment Usually a child under 18 requires an adult to consent to medical treatment. However **common law states that if a patient is deemed 'GIllick competent' or a 'mature minor' then they can consent.** This requires clear documentation that the child has sufficient understanding and intelligence to make choices in regards to their own sexual health and contraceptive choices. This may include a **HEADSS assessment.** b) Its important to ascertain whether the **child is at risk**. For example if their partner is significantly older or in a postion of authority at which point we are impelled as a mandatory notifier to report this to **Child Protection.** c) If the situation is unclear - speak to **medical defence organisation**

Question 26

What combined hormonal contraceptive methods are available?

Answer 26

1. cocp 2. Vaginal ring

Question 27

Which progestogen based methods are available for hormonal contraception?

Answer 27

Progestogen only pills 52mg Levonorgestrel IUD IM Depo Progestogen injections Sub Dermal Implant - Implanon

Question 28

Under what circumstances can lactation be used a birth control method?

Answer 28

Its only a reliable method of contraception if: The baby is younger than 6 months The mother is exclusively breast feeding She has yet to have a period If any of those factors change its very risky. Hence advice A **Progestogen Only contraceptive** if the mother is still breast feeding.

Question 29

Which COCP should you choose?

Answer 29

1. Most effective at controlling the cycle 2. Well tolerated 3. minimal ADR 4. Lowest possible dose of estrogen and progesterone

Question 30

Does the OCP help acne?

Answer 30

Most women find an improvement in their acne with OCP especillay if it contains **cyproterone (Brenda - 35 or DIane 35** - **ethinylestradiol 35 and Cyproterone 2000)** OR **desogestre**l - eg **Marvelon** (Ethinylestradiol 30, Desogestrel 150)

Question 31

What are some of the side effects of taking the COCP and how would you manage them?

Answer 31

Nausea Headaches Bloating and fluid retention Dysmenorrhea Breast tenderness - **REDUCE estrogen dose** For decreased libido - each COCP is as good as the otehr Breakthrough bleeding - normal in first three months (1/5 will have bleeds) - exclude cervical pathology (**Cervical exam, Co- TEst, Preganancy test and STI screening)** - If all clear then consider **increasing dose of oestrogen to 30 or 35** Or change to **triphasic** (From monophasic) or to **3rd gen progestorone**

Question 32

Which medications can cause failure of the OCP

Answer 32

Certain antiepilieptics - **carbamazepine**, phenytoin, Antimicrobials - **rifampacin**, ritonavir, griseofulvin Others - St Johns Wort, Topiramate

Question 33

How would initiate someone on the pill?

Answer 33

Hx for indications and contraindications and decide on combination of hormones Exclude Pregnancy - Pregnancy test Advice around commencement - within first five days of cycle OR need to do 7 days of barrier methods and Urine pregnancy test in 4 weeks. Explain -**e fficacy will be reduced** by - diarrhea and vomiting and meds like antiepileptics, rifampicin, st johns wort, topomax Explain **(plan for missed days)** - if only 24 hours - take the missed pill (take two on one day) then continue. If greater than 24 hours - Take the pill from the day previous (two on one day) then discard any other missed pills IF its been less than 7 days since the placebo pills in the pack and has had intercourse in last 5 days - consider emergency levenorgestrel 1.5mg stat. if less than 7 days till placebo pills - skip placebos and go straight to the active doses. Advice about potential ADR - headache, nausea, bloating/fluid retention, decreased libido, breakthrough bleeds for first 3 months Arrange to follow up and review progress

Question 34

Whats your approach to breakthrough bleeds on the COCP?

Answer 34

- normal in first three months (1/5 will have bleeds) After 3 months - history (compliance/meds/absorption?) and exam exclude cervical pathology (Cervical exam, Co- TEst, Preganancy test and STI screening) - If all clear then consider increasing dose of oestrogen to 30 or 35 Or change to triphasic (From monophasic) or to 3rd gen progestorone

Question 35

When is the vaginal ring indicated? Disadvantages?

Answer 35

INDICATIONS * Patient forgets to take the pill daily * Malabsorption/ IBD/ Diarrhoea * Breakthrough bleeds with COCP (more steady with ring hence less b/through) DISADVANTAGES * Needs to be comfortable with inserting a ring per vaginally * Needs to remember to remove at 21 days and then insert 7 days later. * Cost can be an issue *

Question 36

What is dysfunctional uterine bleeding?

Answer 36

Heavy or prolonged bleeding in the absence of recognisable pelvic pathology, systemic disease or pregnancy related bleeding Ovulatory - 35-45 Anovulatory - 12-16 or over 45

Question 37

When is a transvaginal ultrasound indicated for DUB?

Answer 37

BEFORE MEDICAL Mx - 1. **Age over 40 with any dysfunctional bleeding** - regular or irregular 2. **Women under 40 with irregular** bleeds 3. Anyone with **risk factors for endometrial Ca** and have abnormal uterine bleeds 4. if uterus can be palpated abdominally 5. **palpable uterine mass** 6. **AND** anyone who has **failed medical management**

Question 38

What endometrial thickness is an endometrial biopsy indicated?

Answer 38

1. Pre-menopausal over 12mm 2. Peri menopausal over 5mm

Question 39

When would you test for coagulopathy in a patient with heavy uterine bleeding?

Answer 39

1. If present from Menarche 2. If FHx

Question 40

What surgical options are available for DUB that has failed pharmacotherapy?

Answer 40

1. Endometrial ablation 2. Hysterectomy

Question 41

Emergency management of acute severe bleeding?

Answer 41

1. IV tranexamic acid 10mg/Kg TDS 2. Oral tranexamic acid 1.5 g tds till bleeding stops 3. OR norethistrone 5mg 4hrly till bleeding stops

Question 43

What conditions must be considered if significant PAIN co-exists with dysfunctional uterine bleeding?

Answer 43

1. Exclude ectopic pregnancy 2. PID 3. Adenomyosis/Endometriosis 4. Fibroids

Question 45

Whats your approach to the management of dysfunctional uterine bleeding?

Answer 45

1. Exclude pelvic pathology, systemic causes, pregnancy related causes 2. If require contraception as well and have no CI's to COCP - commence OCP 3. Anovulatory - can also begin with a trial of of OCP 4. If CI's or ineffective - tranexamic acid 1.5 g tds for 3 to 5 days at the start of each cycle +/- ibuprofen 400mg tds prn for dysmenorrhea 5. If anovulatory DUB (12-16 or over 45) then will need 12/21 days of progestogen with the tranexamic acid 6. Trial for 3 to 6 months. 7. After 6 months needs referral to gynae 8. Further options include IUCD and for older patients or significant pelvic pathology - endometrial ablation or hysterectomy can be considered

Question 46

What are the contrainidications of tranexamic acid?

Answer 46

1. Previous VTE 2. Stroke 3. Acquired colour vision disturbance

Question 47

Whats your management approach to Irregular menstrual cycles?

Answer 47

Oligomenorrhea - consider causes of a **secondary amenorrhea** and investigate accordingly **U/S** in both under 35 and over 35 in under 35 trial of COCP if not contraindicated In **over 35** - **refer to gynae** for endometrial sampling and hysteroscopy

Question 48

Causes of intermenstural bleeding

Answer 48

Cancer till proven otherwise Endometrial Ca Cervical Ca Endometrial hyperplasia Endometrial/Cervical polyps Cervical ectropion (in patients on OCP or post partum) PID IUCD or OCP related bleeding

Question 49

Causes and management of Post-coital bleeding?

Answer 49

Cervical cancer till proven otherwise Cervical Ca Endometrial Ca Trauma to cervix or vagina Cervical ectropion Endometrial hyperplasia PID IUD or OCP endometrial or cervical polyps Management - Co -Test HPV and LBC - May need STI screening TVU/S and referal if recurrent

Question 50

Postmenopausal Bleeding - DDx and workup?

Answer 50

1. Ca till proven otherwise 2. **-endometrial Ca** 3. **Cervical Ca** 4. cervical ectropion 5. Atrophic vaginitis 6. Ovarian Ca must be considered 7. Endometrial hyperplasia 8. Endometrial/cervical polyps ALL need U/S and referral to Gynae - hysteroscopy and D&C

Answer 52

**Bleeding** – typically starts a few hours after taking misoprostol; bleeding usually heavier than regular menses, with clots, for 2–4 hours *Patients should be advised to seek help if they soak \>2 maxi pads per hour for \>2 consecutive hours, or feel dizzy or lightheaded, or have a racing heartbeat.* **Pain** – cramping and pain is expected before and at the time of expulsion In most cases, nonsteroidal anti-inflammatory drugs can be used to manage pain as needed. Mild opioid analgesics can be prescribed to be taken as needed. *Patients should be advised to seek help if severe pain during abortion is not controlled by analgesics*. **Prostaglandin effects** – nausea, vomiting, flu-like symptoms, diarrhoea, dizziness, headache, chills/fever Nausea can be treated with metoclopramide or ondansetron. Diarrhoea, fever and chills are usually self-limiting and can typically be managed with over-the-counter medications. *Patients should be advised to seek help if they experience fever \>38°C lasting \>6 hours, especially after the day of misoprostol administration, and if they experience flu-like symptoms, weakness/faintness, nausea, vomiting and diarrhoea in the days after abortion.*