A woman presents w/ intermenstrual bleeding (bleeding between periods). What are some differentials and therefore investigations you want to consider?
Infection –> do swabs
Cervical Ca –> speculum/smear
pregnancy –> urinary beta hCG
What are the 3 causes of (abnormal) vaginal discharge?
Physiological, infective, non-infective
Give some non-infective causes of vaginal discharge
physiological, foreign body (tampon), cervical ectropion, malignancy, cervical polyp, chemical vaginitis
How does physiological discharge vary during the menstrual cycle?
thick + sticky most of cycle
Becomes clearer and wetter + stretchy during ovulation
How can you differentiate normal from abnormal discharge?
Abnormal discharge is characterised by a change in colour, consistency, odour and smell AND have associated symptoms (itch, soreness, dysuria, pelvic pain or IMB or PCB)
Abnormal discharge most commonly caused by infection
What is the mechanism of action of the COCP?
MAIN: Negative feedback (suppresses FSH secretion + mid-cycle LH surge) –> inhibiting (follicle maturation) + ovulation (basically: INHIBITION OF OVULATION)
Also: cervical mucous thickening + prevents implantation
Give some SEs and risks of the COCP?
SEs: breakthrough bleeding, breast tenderness, mood swings…etc (progestogenic + oestrogenic)
Risks: VTE, stroke, MI, breast cancer ^ risk; maybe ^ cervical Ca (but may be due to ^ number of sexual partners)
Give some benefits of the COCP?
Reduces risk of ovarian and endometrial Ca
Give some absolute contraindications of the COCP? What would you give instead?
breast feeding, BMI >40, Smokers >30yo (>15 cigs/d), DM w/ vascular complications, Hx of VTE, Hx of IHD/cerebrovascular accident/severe HTN, pregnancy, migraine with aura
Give mini-pill
Give some oestrogenic SEs?
Nausea, heacahes, ^ mucous, fluid retention (vasodilator), weight gain HTN. breast tender, bleeding
How is the efficacy of contraceptives measures?
Pearl index (/100) –> i.e. if 2/100 then for every 100 women using it, 2 will get pregnant by the end of the year
If a woman is breastfeeding would you give her to minipill or COCP?
Minipill because the COCP reduces milk production
Why is the depo-provera injection not 1st line in adolescents and IBD?
Cuases reduced bone mineral density and so ^ risk of OP –> IBD already at ^ risk of OP
Give some other forms of combined contraception other than the COCP?
Transdermal patch, vaginal ring
who might the transdermal patch be useful in?
IBD (as malabsorption an issue w/ oral contraceptives)
How does the progestogen only pill work?
traditional: thickens cervical mucours (impenetrable to sprerm)
Desogestrel: also inhibits ovulation
What is the issue with the minipill? Is this always the case?
Has to be taken within 3 hours of the same time each day
However, DESOGESTREL has a 12 hour window
Give some SEs of the mini pill?
Acne, breast tenderness
Is the minipill as effective as the COCP?
No, only 92% effective
give some risks and benefits of the minipill
Benefits: no ^ risk of vte
risks: ECTOPIC, ovarian cysts
Which contraceptive ^ the risk of ectopic?
Minipill and IUS + IUD
What is the difference between the IUS + IUD?
IUD = copper
IUS = progestogen (e.g. Mirena)
How does the copper coil work (IUCD)?
inflammatory endometrial reaction –> prevents impantation
How does the mirena/other IUDs work?
Contain levenorgestrel –> cervical mucous thickening, reduces endometrial growth (prevents implantation)
N.b. doesn’t inhibit ovulation
What are the advantages of IUD, IUS, depot injection?
No need to remember to take the pill (helps w/ compliance)
Give some examples of barrier methods of contraception? What are their advantages over ?
Condoms (male + female), diaphragms, caps
reduced risk of STIs (not diaphragms/caps)
Give some complications of IUD/IUS?
Pain or cervical shock (^ vagal tone),
device expelled
perforation of uterus
heavier/more painful menstruation
If woman is asymtpomatic STI in cervix –> PID
If pregnancy occurs: ^ risk of it being an ectopic
Give some CI’es to the IUS?
Previous ectopic, Endometrial/cervical ca, undiagnosed vaginal bleeding, active/recent pelvic infection. current breast cancer (can use copper though)
What are two absolute forms of contraception?
Sterilisation (male + female)
What are some forms of emergency contraception?
1) (if <72hrs after unprotected sex): single dose levonorgestrel
2) (if <120 hours): ulipristal (selective progestogen receptor modulator) [like mifepristone used in abortion]
3) <5d: copper IUD
Why do you need to ask a woman about antibiotics before commencing the COCP?
reduces the absorption of the COCP as P450 inducers (and other drugs)
Examples: nitrofurantoin, penicillin, rifampicin
What are some of the problems associated with teenage pregnancy?
^ post-natal depression, infant mortality
less likely to finish education
delivering teenage births more risks
^ risk of poverty…etc
SAFEGUARDING ISSUE
^ pre-eclampsia / other things
Who must you offer a chlamydia screen to?
All sexually active <25s
What is gillick competence?
Term in medical law to decide whether a child <16 is able to consent to his or her own medical Rx, w/out the need for parental permission or knowledge
What is Fraser competence?
Specifically relates to contraception + sexual health
What are the 5 points to Fraser competence?
- Young person understands the advice
- Can’t be persuaded to inform parents or allow clinician to inform them
- Is likely they will continue to have sexual intercourse w/ or w/out the use of condoms
- their physical or mental health may suffer as a result of witholding contraception or treatment
- in the best interest of the young person for the clinician to provide contraceptive advise, treatment or both w/out parental
UPSSI
Understands, persuaded, still continue yo have sex, suffer (physical/mental health), best Interest
What is the vaginal pH like in vulvovaginal candidiasis (thrush)?
normal (<4.5)
What can be seen under microscopy in someone w/ BV?
Clue cells
What is needed for a diagnosis of BV?
3/4 of:
- +ve amine test (whiff test) - release of amine odour w/ 10% KOH
- vaginal pH >4.5
- Clue cells on microscopy
- Homogenous white-grey non inflammatory discharge
Describe the discharge seen in BV?
Homogenous grey/white discharge (thin)
Fishy/offensive
Describe the discharge seen in thrush?
White curdy discharge
Describe the discharge seen in Trichomoniasis? How does it differ from BV?
Yellow, green FROTHY discharge that is offensive/fishy
Distinguish from bv: other symptoms present (e.g. itching. vaginitis, dysuria)
What is trichomiasis caused by?
Trichomonas vaginalis = flegellated protozoan
How do you treat vaginal candidiasis?
topical antifungal (or pessary) - clotrimazole
OR oral fluconazole
What is the antibiotic of choice in BV + trichomoniasis?
metronidazole
What kind of swab is used for gonorrhoea / chlamydia?
Endocervical
can use vaginal [self sample] for chlamydia too
What is the high vaginal swab for?
trichomoniasis / other infections (NOT Gonorrhoea or Chlamydia)
How do you treat chlamydia?
Stat dose azithromycin
OR doxycycline
How do you treat gonorrhoea?
3rd generation cephalosporin: ceftriaxone
like meningitis
What are the SEs of the depot- injections
Weight gain
Reduced bone density (^ risk OP)
Unpredictable return of fertility
Menstrual irregularity
+ other progestognenic SEs
what is the problem with the depot injection?
Can take up to 12mths to return to normal fertility after stopping it
What does the transdermal contraceptive patch contain?
COMBINED
What vaginal infection is associated with high pH? (>4.5)
BV
Give 2 uses of ullipristal acetate
- Emergency contraception
- Fibroids