Gynae2 Flashcards
(46 cards)
How does vaginal candidiasis present?
Thick curdy, white discharge
PH LESS THAN 4.5
Amine odor test with KOH - NEGATIVE
Wet mount - WBC’s, spores, pseudohyphae
Differences between medical and surgical abortion?
Medical abortion
Avoids surgery
Can occur in the privacy of the patient’s own home
Can take days to complete
Somewhat and variably painful; ≥95% success rate within 1–3 weeks
Generally much heavier bleeding than a period
Typically 2–3 office visits plus ultrasonography and blood tests
Surgical abortion
Surgical procedure
Day hospital admission
Completed in 5–10 minutes followed by 30 minutes to one hour of observation time
Usually less painful anaesthesia is available
99% success rate
Light bleeding
Typically 1–2 office visits
Requires a support person to drive depending on anaesthesia
What advice should you give women seeking abortion?
Reassure patients that having an abortion is not associated with increased risk of infertility, breast cancer or mental health issues.
- Provide information about the differences between medical and surgical abortion (including the benefits and risks; refer to Table 2), taking into account the patients’ needs and preferences. Do this without being directive, so that patients can make their own choices.
- As early as possible, provide patients with detailed information to help them prepare for the abortion. Discuss what is involved and what happens afterwards, including how much pain and bleeding to expect and what follow-up is required.
- Provide information in a range of formats, such as video (www.howtouseabortionpill. org) or written information (www.betterhealth.vic.gov.au/health/HealthyLiving/abortionprocedures-medication).
- Ask patients if they want information on contraception; if so, provide information about the options available to them
. • For patients who are having a medical abortion, explain that they may see the products of pregnancy as they are passed, and that this will generally look like large blood clots
. • For patients who are having a medical abortion, explain how to be sure that the pregnancy has ended.
• Provide patients with information on signs and symptoms that may indicate they need medical help after an abortion, and whom to contact if they do
What are the regulations for prescribing medical abortion in Australia?
In Australia, MS-2 Step (a composite pack containing Mifepristone Linepharma 1 × 200 mg tablet and GyMiso misoprostol 4 × 200 mg tablets) (a synthetic steroid and prostaglandin analogue) is indicated under the PBS for medical termination of an intrauterine pregnancy of up to 63 days of gestation. Women can only obtain an authority prescription for MS-2 Step from doctors who are registered prescribers.
What is the differential diagnosis for a vulvar mass?
Cysts - bartholins cyst, cyst of the canal of nuck, inclusion cyst, sebaceous cyst
Inflammatory - Fibroma, Fibroadenoma, granuloma, hidradenitis suppurativa
Traumatic - Vulvar Haematoma
Infective - Bartholins abcess, folliculitis
Malignancy
What is a bartholins cyst/abcess? CLinical features? Mx
Occurs due to obstuction of the bartholin duct
Usually painless labial/vulvar swelling
If infected - very painful, difficult to walk, dyspareunia
Mx - SITZ BATHS
- Surgial drainage of abcess
- Oral antibiotics if infected
- Marsupialisation for recurrent
Whats your approach to Amenorrhea?
- Is it primary or secondary?
If Primary - U/S - check for uterus - if none - ?Mullerian agenesis vs Androgen insensitivity so do a karyotype
If Uterus is present - check FSH and LH
- if High (over 40) then recheck in 4 to 6 weeks. Two Elevated = Primary ovarian insufficiency - Genetic - Turners/ Fragile Xpremutation FMR1, Autoimmune - addisons, DM, Iatrogenic - oophorecotmy, radiation. –> Treat menopausal sx and discuss long term sequelae.
If Low - Functional - exercise, weight loss, anorexia, underyling illness,
If Normal - outflow obstruction - vaginal septum, imperforate hymen
If Secondary
Pregnancy test, FSH, LH, Prolactin, TSH
High prolactin, normal TSH - Prolactinoma? MRI
Normal prolactin, Abnormal TSH - Thyroid? Further investigate
If normal TSH and Prolactin
Check FSH and LH
If High (FSH over 40 - repeat in 4-6 weeks)
If low (Functional or hypopituitarism - sheehans syndrome, pituitary destruction)
Normal - Outlet obstruction - cervical stenosis, fibroids, ashermans syndrome - intrauterine scarring post op,
or Hyperandrogenism - PCOS
Approach to Primary Amenorrhea?
If Primary - U/S - check for uterus - if none - ?Mullerian agenesis vs Androgen insensitivity so do a karyotype
If Uterus is present - check FSH and LH
- if High (over 40) then recheck in 4 to 6 weeks. Two Elevated = Primary ovarian insufficiency - Genetic - Turners/ Fragile Xpremutation FMR1, Autoimmune - addisons, DM, Iatrogenic - oophorecotmy, radiation. –> Treat menopausal sx and discuss long term sequelae.
If Low - Functional - exercise, weight loss, anorexia, underyling illness,
If Normal - outflow obstruction - vaginal septum, imperforate hymen
Approach to Secondary Amenorrhea?
Pregnancy test, FSH, LH, Prolactin, TSH
High prolactin, normal TSH - Prolactinoma? MRI
Normal prolactin, Abnormal TSH - Thyroid? Further investigate
If normal TSH and Prolactin
Check FSH and LH
If High (FSH over 40 - repeat in 4-6 weeks)
If low (Functional or hypopituitarism - sheehans syndrome, pituitary destruction)
Normal - Outlet obstruction - cervical stenosis, fibroids, ashermans syndrome - intrauterine scarring post op,
or Hyperandrogenism - PCOS
How would you manage a woman with primary ovarian insufficiency/failure
Manage Menopausal symptoms and Long term Sequelae.
Menopausal (PVU)
- Psychoaffective - Sleep - insomnia, Mood - irritability and Lability of Mood
- Vasomotor - Hot flushes, Night sweats
- Urogynaecological - vaginal dryness, decreased libido, dyspareunia
Long term sequelae:
- Increased cardiovascular risk
- manage risk factors, regular screening, early initiation of HRT is recommended - Osteoporosis
- Monitor Bone density, ensure adequate calcium and Vitamin D intake, early inititation of HRT is recommended - Infertility - referal to fertility specialist (Assisted reproduction options -,may need donor egg, fitness for pregnancy)
What are some of the causes of primary ovarian failure (insufficiency)
- Genetic - Turners, Fragile X pre mutation carrier (FMR1)
- Autoimmune - Addisons, DM
- Iatrogenic - Chemo, Radio, Oophorectomy, Ashermans syndrome,
What history questions would you ask someone with Amenorrhea?
- Length of amenorrheic period. How heavy the bleeding is.
- When did Menarche occur
- Abdominal pain - cyclical or constant?
- Possiblity of pregnancy? Sexually active?
.5 Exercise/Stress/ Weight loss/
- History of pelvic surgery ? oopherectomy
- Previous pregnancies? Bleeding? Complications?
- History of Thyroid disorder - neck lump, cold intolerance, weight gain, fatigue
- History of chronic illness - PCOS, TB, Sarcoid
- Any visual symptoms, loss of libido, sexual dysfunction
Examination findings in amenorrhea?
- Secondary sexual characteristics, Height - turners
- Hirsutism, BMI - ?PCOS,
- Visual Fields
- Neck lump, signs of hyper/hypothyroid
- Abdomen - scars of previous pelvic surgery, uterus palpable, fibroids?
- Pelvic examination - Cervical stenosis, imperforate hymen,
What is MittelSchmerz
Recurrent Mid cycle abdominal pain in women with normal ovulation cycles.
- Caused by normal enlargement of a follicle just prior to ovulation or to normal folliculr bleeding at the point of ovulation.
Unilateral severe pain, sudden onset (horse kick). Radiates to centre.
otherwise well.
(Ruptured Graffian follicle pain)
What are potential complications of ovarian cysts?
- Rupture of cyst.
- Torsion of ovary - Severe pain, nausea and vomiting in a woman with an adnexal mass (mass greater than 5cm is a risk factor for torsion) - Requires urgent referral for gynaecological review
Severe pain, nausea and vomiting in a woman with an adnexal mass
Ovarian Torsion
What are the phases of the female reproductive cycle (re: menopause)
Regular cycles - PREmenopause
Change in cycle frequency - Early PERImenopause
Cycles 3-12 months apart - Late PERImenopause
Date of last Period - Menopause (around 51)
Greater than 12 months after last period - Post menopause
BASED on symptoms only, not bloods unless young
Non pharmacological treatments for hot flushes
- Dress in layers, natural fibres
- Reduce weight
- reduce alcohol
- Reduce caffeine
- Healthy diet
Treatments for vaginal dryness in Menopause?
- Oestriol cream 1mg/g 500mcg intravaginally daily at bedtime for 3 weeks then 1-2 times weekly.
- Oestriol pessaries
- Vaginal Moisturiser 2 x week
- Lubricant during intercourse eg Astroglide
What are contraindications to MHT?
Breast cancer
High risk endometrial Cancer
Thrombophillia and Previous VTE
Undiagnosed vaginal bleeding
Active Liver disease
HTN
Cardiac disease or risk factors
Who is a candidate for MHT?
- Women experience menopausal symptoms (peri or post)
- Women with primary ovarian insufficiency
- Women under 60 with Osteoporosis
- Women with 5-10 years of last period experiencing Vasomotor symptoms
What is an alternative to MHT?
Venlafaxine 37.5mg to 75mg daily
What MHT options exist for woman with a uterus with early menopause (before age of 45) or premature menopause (before age of 40)
- Continuous oestrone + cyclical or continuous progesterone
(Oestrogen dose will be high due to age).
- Tibolone
- COCP if no contraindications
What MHT options exist for a woman in perimenopause (at the menopausal transition)?
Here remember there’s a risk of pregnancy so
Combined low dose contraceptive (if no contraindications)
OR
Continuous oestrogen + cyclical progestogens (10-14 days each month) + barrier contraception
OR
Continous Oestrogne + levonorgestrel IUD
