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Women's Health Flashcards

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1
Q

When to stop contraception for women >50 y.o:
1) Mirena, Implanon, POP
2) Copper IUD/barrier contraception
3) Depot injection
4) COCP/vaginal ring

A

1) Amenorrhoeic for >12 mths - check 2x FSH levels, 6 weeks apart. If both >30 then only required for another 12 mths OR continue until age >55 y.o
2) Stop after amenorrhoeic for >12 mths
3) Not recommended >50, change to non-hormonal method until 24 mths amenorrhoea OR alternative POP method
4) Not recommended >50, change to non-hormonal method until 12 mths amenorrhoea OR switch to Mirena/implnanon/POP

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2
Q

Pregnancy - folic acid dose if low risk
High risk factors (4) & dose

A

0.4-0.5mg daily 1/12 before pregnancy –> 3/12 post-partum
5mg dose if
-BMI >30
-On anti-convulsant med
-Pre-pregnancy diabetes
-PHx/FHx of neural tube defect

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3
Q

Cervical Co-test indications (3)

A

Persistent/vaginal bleeding (post-coital, intermenstrual, post-menopausal)
Unusual unexplained discharge - bloodstained
Deep persistent dyspareunia (if accompanied by bleeding)

  • HPV test ONLY indications:
    ○ Other vaginal discharge - not bloodstained
    ○ Deep dyspareunia in absence of other symptoms
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4
Q

?Diagnosis/infection

  • > 80% of people with any sexual activity have been exposed to it
    ○ Common viral infection. Types detected on CST not a/w genital warts
    ○ Generally cleared by immune system within 12-24 months, no Rx required
    ○ Can persist in 10% of people - risk of high-grade changes
    ○ No need to test partners
A

HPV

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5
Q

Vaginitis DDx (8)

A

-Vulvovaginal candidiasis
-Bacterial vaginosis
-Herpes simplex
-Irritant dermatitis
-Localiesd provoked vestibulodynia (most common type of vulvodynia)
-Atrophic vaginitis
-Psoriasis
-Lichen planus

Thrush very uncommon in post-menopausal women

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6
Q

Vulvovaginal candidiasis Rx dose examples (4)

A

-Clotrimazole 1% cream 1 applicatorful nocte for 6 nights
-Clotrimazole 2% cream 1 applicatorful nocte for 3 nights
-Clotrimazole 100mg pessary intravaginally nocte for 6 nights
-Fluconazole 150mg stat

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7
Q

Lichen sclerosis complications (2)
Management

A

-Transformation into vulval SCC
-Anatomical distortion of vuvla –> labia minora fusion, stenosis of introitus

-Potent corticosteroind (dip 0.0% OV) BD until itch resolves, then daily until skin normalises
-ongoing maintenance steroids lifelone

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8
Q

Intermenstrual bleeding DDx (11)

A

-Pregnancy
-Mid-cycle bleeding w/ ovulation
-Hormonal (around menarche/perimenopause)
-HRT after menopause
-Contracetpion (COCP, Depot, IUD)
-Infections
-Polyps
-Fibroids
-Endometrial hyperplasia
-Endometriosis
-Malignancy

PALM COEIN = polyps, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, Endometrial, iatrogenic, not classified

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9
Q

General indications for a co-test (5)

A

-Unexplained intermenstrual bleeding
-Post-coital bleeding
-Post-menopausal bleeding
-Unexplained persistent unusual vaginal discharge
-Follow-up of previous high grade changes/post-LLETZ (test of cure)

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10
Q

Management aspects post-sexual assault (7)

A

-Assess safety and serious injuries
-Offer forensic medical examination at sexual assault service
-Give emergency contraception if needed
-Refer to sexual assault support service/1800 RESPECT
-Discuss STI screening baseline (chla/gono, consider trich)
-Discuss pregnancy test in 3 weeks
-Mental health risk

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10
Q

Sexual assault recommendations per timeline:
-72-120 hrs (3)
-4 weeks (1)
-6 weeks (1)
-12 weeks (1)

A

-72-120 hrs: assess immediate safety/wellbeing, emergency contraception. baseline STI testing
-4 weeks - pregnancy test
-6 weeks - HIV blood test
-12 weeks - repeat HIV, syphilis, Hep B blood tests

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10
Q

Vulval lichen sclerosis non-pharm Rx (4)

A

-Vulval examination every 12 mths to monitor for vulval carcinoma
-Regular use of topical emollients
-Avoid use soap for cleansers
-Avoid tight clothing

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11
Q

Recurrent pregnancy loss DDx (7)

A

-Uterine fibroids
-Septate uterus
-Antiphospholipid syndrome (thrombophilias)
-T2DM
-Hypothyroidism
-Chromosomal abnormality
-Unexplained/idiopathic (up to 50%)

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12
Q

Deceased foetal movements - examination features (4)
-Management (1)

A

-Abdo palpation for uterine tone, foetal lie/presentation
-Symphyseal fundal hieght
-Maternal obs
-Doppler for foetal HR

-CTG within 2 hours (urgent referral to maternity unit), consider USS within 24 hours

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13
Q

Mastitis management aspects (8)

A

-Continue breastfeeding
-Fluclox/diclox 500mg QID for 5-10 days
-Feed from affected side first
-Paracetamol/pain relief
-Massage affected area
-Cold packs
-Check positioning/latching technique, lactation consultant
-Review 1-2 days

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14
Q

Management aspects to increase breastmilk supply (6)

A

-Ensure skin-to-skin contact & good attachment
-Frequent feeds, 2-3 hrly
-Express after breastfeeds for stimulation/drainage
-Compress/massage during feeding or expressing
-Switch feed - offer each breast twice
-Domperidone 10mg TDS

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15
Q

Post-menopausal bleeding - when to refer to gynae (3)

A

-Endometrial thickness >4mm
-Endometrial thickness <4mm but persistent bleeding or risk factors
-Women on tamoxifen

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16
Q

Vaginal bleeding in post-menopausal women
Risk factors for malignancy (7)

A

-Hx. of or PCOS a/wchronic anovulation
-Exposure to unopposed oestrogen
-Tamoxifen use
-Strong FHx of endometrial/colon ca
-Nulliparity
-Obesity
-Endometrial thickness >8mm

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17
Q

Other causes of raised CA-125 (8)

A

-Endometrial cancer
-Functional ovarian cyst
-Fibroids/adenomyosis/endometriosis
-Hepatitis/cirrhosis/liver cancer
-Pelvic inflammatory disease
-Bowel cancer
-SLE
-Other malignancies - pancreatic, breast etc.

If raised, repeat 4-6 weeks after initial test

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18
Q

Ovarian cancer examination findings (4)

A

-Adnexal/ovarian mass on bimanual exam
-Palpable liver mass/hepatomegaly
-Asciteis or shifting dullness
-Inguinal/cervical lymphadenopathy

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19
Q

Secondary amenorrhoea DDx (8)

A

-Pregnancy
-PCOS
-Primary ovarian insufficiency
-Pituitary tumour - hyperprolactinaemia
-Functional amenorrhoea
-Intrauterine adhesions
-Congenital adrenalhyperpasia, Thyroid disease
-Medications

Ix - pregnancy test, TSH, prolactin, LH/FSH, ultrasound

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20
Q

Progesterone only pill commencement - counselling (5)

A

-Strict time adherence - same time every day
-Need back-up contraceptive for at least 2 days if >3 hrs late
-Same with vomiting/severe diarrhoea within 3 hrs of taking
-Unscheduled intermenstrual bleeding
-Takes 3 days to start working

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21
Q

Menorrhagia treatment options

A

-Mefenamic acid 500mg TDS/other NSAIDs, just before period –> up to 5 days
-Tranexamic acid 1g TDS first 3-5 days of cycle
-Levonorgestral 52mg IUD
-COCP
-Norethisterone 5mg daily for same 12 days of cycle

Norethisterone dose 5mg TDS for 10/7 to stop acute heavy bleeding

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22
Q

Unsatisfactory sample on HPV or LBC test - next step

A

Return in 6-12 weeks for repeat HPV or LBC test (respectively)

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23
Screening (cervical) intervals for below populations: -Total hysterectomy for benign reason -Hysterectomy for HSIL -Subtotal hysterectomy (cervix present)
-Total hysterectomy for benign reason --No screening needed -Hysterectomy for HSIL --Annual co-test until 2 negative results -Subtotal hysterectomy (cervix present) --Screening as usual
24
Age for imaging cutoff for mammography PLUS uss (breast cancer)
35 y.o
25
Benign breast symptom/no breast lump/hormonal change - review timeframe Benign nipple discharge w/ normal clinical exam - recommendation/review timeframe
Review 6-8 weeks (immediately after period). If persisting problem --> imaging -Advise cease expression -Get imaging -Review in 2-3 months
26
Combined hormonal contraception MEC 3/4 criteria (10)
-0-6 weeks post-partum if breastfeeding (0-3 weeks PP if not BFeeding) -Age >35 + smoking -HTN w/ sBP >160 -IHD, stroke history, VTE history or current -AF/complicated valvular disease or cardiomyopathy -Major surgery w/ prolonged immobilisaton -Migraine w/ aura -Current/PHx of Breast Ca -FHx of VTE in 1st-degree relative <45 y.o -BMI >35
27
Implanon MEC 3/4 criteria (4)
-Current/PHx of breast Ca -Unexplained vaginal bleeding, suspicious for serious condition (before evaluation) -Severe liver cirrhosis -IHD/stroke or TIA *developing during use (for continuation)*
28
Mirena/Copper IUD MEC 3/4 criteria (5)
Current PID/chlamydia/gonorrhoea (for insertion) Postpartum 48 hours-4 weeks (*either insert immediately OR wait 4 weeks)* IHD/stroke or TIA *developing during use (for continuation)* (Mirena) Unexplained vaginal bleeding, suspicious for serious condition (before evaluation) Endometrial/Breast Ca hx or current
29
# (complications) Gestational Diabetes risks to mum (4), risks to neonate (4)
-Pre-eclampsia -Early delivery -Induction of labour -C-section -Macrosomia -Hypoglycaemia -Shoulder dystocia -Resp distress
30
Risk factors for developing gestational diabetes (7)
-Previous hyperglycaemia in preg -Age >40 y.o -FHx of diabetes -PCOS -BMI >30 -Previous macrosomia -Medications - steroids/antipsychotics
31
Gestation diabetes treatments (2), post-partum monitoring
1. Insulin - start 4-8 units daily, usually 1st choice 2. Metofmrin - no evidence of harm to mum/foetus OGTT from6 weeks to 3 months post-partum ?Annual HbA1c
32
Pre-conception checklist: * Diet ○ Supplements - folic acid ○ Iodine ○ Vit D ○ Calcium ○ Vit B12
○ Supplements - folic acid § 5mg for high risk (BMI>30, previous NTD, anticonvulsant med, GDM) - at least 4 weeks prior --> first 12 weeks gestation § 500mcg all other women, same duration § Prevents risk NTD + congenital heart disease ○ Iodine § 150mcg daily whilst pregnant + breastfeeding § Prevents subclinical hypothyroidism ○ Vit D § 1000 IU if 30-49, 2000 IU if <30 § 400 IU if normal levels § Prevents neonatal low Vit D, impaired skeletal development, hypocalcaemia ○ Calcium § At least 1g daily § Prevents hypertensive disorders and preterm labour ○ Vit B12 - consider if vegan/vegetarian
33
# PRE-CONCEPTION CHECKLIST * Weight * Exercise * Genetic screening * Smoking/alcohol/illicit drugs * Psychosocial * Medical conditions ○ Hypothyroidism ○ Hypertension ○ Epilepsy * Contraception/family planning * STI/Infectious Disease screen
* Weight ○ Measure BMI ○ Lose 5-10% of pre-pregnancy weight = realistic goal ○ Expect 11.5-16kg weight gain total normally during preg * Exercise ○ 150 mins per week/30 mins most days * Genetic screening ○ If indicated PHx/FHx/ethnic background * Smoking/alcohol/illicit drugs ○ Nicotine replacement therapy safe * Psychosocial ○ Screen for domestic violence ○ Screen mental health conditions * Medical conditions ○ Review and optimise current medications/conditions ○ Hypothyroidism - maintain TSH <2.5 in 1st trimester ○ Hypertension - switch to safe meds such as labetalol/methyldopa ○ Epilepsy - sodium valproate NOT recommended in pregnancy * Contraception/family planning * STI/Infectious Disease screen ○ MMR, Varicella, Hep B testing § Avoid pregnancy until 28 days after live MMR vaccine ○ DTP (20-32 weeks) and Flu Vax (any time) -Discuss TORCH
34
Recurrent pregnancy loss Ix Female (4) Male (1)
Female: karyotype, USS + sonohysterography, TFTs, acquired thrombophilia screen Male: karyotype
35
Post-menopausal bleeding DDx (6)
-MHT -Endometrial Ca -Atrophic vaginitis -Endometrial hyperplasia -Cervical/endometrial polyps -Cervical Ca
36
Vulvodynia management aspects (5)
-Lubrication for sexual activity -Topical lignocaine gel 2% prior to sex -Physiotherapy for pelvic muscle dysfunction -Avoid irritants- soaps/pads/perfumes -Low dose TCAs, duloxetine/venlafaxine
37
# OCP Late pill definition + Rx Missed pill definition + Rx Missed early cycle pill Rx Late cycle missed pill Rx
-Late - between 24-48 hours, take late pill ASAP and continue as reg -Missed - >48 hours sinc last pill, take missed pill ASAP + continue as reg + *condoms for 7 days* -Missed early - missed during first days of pack after a hormone break - emergency contraception if unprotected sex in last 5 days - (LG can continue pill as reg, UP need to stop for 5 days before pill, condoms for 12 days in this case) -Late missed - skip inactive pills, use condoms 7 days as precaution
38
Which mood stabilisers safe in preg (2) Which are contraindicated (2)
-Lithium (small risk foetal heart defect - foetal echo, UEC/TFTs and lit level. Can't breastfeed) -Lamotrigine -Sodium valproate -Carbamazepine
39
How to manage irregular bleeding whilst on a LARC (4)
-Adding on COCP continuously/cyclically for 3 months -5 day course of NSAID (e.g mefenamic acid 500mg BD) -5 day course of tranexamic acid (500mg BD) 2nd line option -Norethisterone 5mg TDS 21 days
40
Tests to order for early pregnancy loss (3)
-serial b-HCG (falling bhcg after 48-72 hrs = non-viable, but not determinant of location) -Transvaginal USS (rule out ectopic) -Blood group (Rh-ve needs Anti-D)
41
Management options for early pregnancy loss (3)
-Expectant 6-8 weeks -Medical - misoprostol -Surgical
42
Ovarian cysts in pregnancy - advice/management aspects (4)
Usually incidental finding, 50% resolve ○ Repeat 12-14 weeks to ensure resolution ○ CA-125 only if mass is suspicious for malignancy on USS appearance ○ >7cm usually needs further Ix
43
Secondayr dysmenorrhoea causes (4)
Endometriosis Pelvic fincetion Adenomyosis Fibroids
44
Ix for menorrhagia/AUB (8)
FBE iron studies B-hCG TFTs coags CST/co-test Gonorrhoea/chlamydia PCR Transvaginal USS day 5-10 of cycle
45
Vaginismus (genito-pelvic pain/penetration disorder) management aspects (5)
Vaginal dilation + progressive desensitisation + relaxation education CBT Sex therapy Pelvic floor physio
46
SCOFF Questionnaire for eating disorder screening
Do you make yourself **S**ick w/ feeling uncomfortably full Lost **C**ontrol **O**ne stone (6.3kg) in past month Belief that they are **F**at Does **F**ood dominate your life
47
Eating disorder physical examination findings (10)
-Dorsal finger callouses -Stress fractures -Muscle cramps/weakness (squat test) -Dental caries -Parotid enlargment -Irregular menses/amenorrhoea -Dry hair/skin -Lanugo hair -Hypercarotenaemia -Postural hypotension
48
Primary amenorrhoea DDx (6)
-Constitutional delay -Hypothalamic (e.g functional - stress/exercise/nutritional def.) -Prolactinoma/hypopituitarism -Premature ovarian insufficiency -Turner syndrome -Mullerian agenesis/imperforate hymen
49
Secondary amenorrhoea DDx (9) -Initial Ix
-Pregnancy! -Perimenopause -PCOS -Hypothalamic (e.g functional) -Prolactinoma -Hypopituitariusm -Primary ovarian insufficiency -Intrauterine adhesions - Asherman's syndrome -Medications -hCG, FSH/LH, TSH, prolactin, androgen levels, ?oestrogen/progesterone
50
Frequent loose/green/frothy stools (Ddx 1)
lactose overload - complete feed on one side of breast (↓foremilk) ## Footnote Others; UTI, pyloric stenosis. Very unlikely = GORD, cow's milk protein intolerance, colic, lactose intolerance
51
Ovarian cyst management: -Premenopausal ○ Asymptomatic <5cm cysts ○ Cyst 5-7cm ○ Cyst >7cm * Post-menopausal ○ Simple, unilateral, unilocular ovarian cyst <5cm + low risk malignancy ○ If moderate to high RMI ○ If malignancy suspected
* Pre-menopausal ○ Asymptomatic <5cm cysts - no f/u - resolve within 3 cycles ○ Cyst 5-7cm - repeat USS ○ Cyst >7cm - consider surgical intervention * Post-menopausal ○ Simple, unilateral, unilocular ovarian cyst <5cm + low risk malignancy - conservative. 50% resolve within 3 mths ○ If moderate to high RMI - refer gynae ○ If malignancy suspected --> oophrectomy ## Footnote Ovarian torsion - needs urgent gynae review
52
Antenatal bloods must do + to consider
** ○ FBE, Blood group/Ab, Rubella, Hep B, Hep C, Syphilis serology, HIV serology** ○ +/- iron studies, TSH, Vit D, Vit B12/folate, Urine PCR gonorrhoea/chlamydia, CST
53
PCOS Rx aspects (6)
○ Lifestyle - weight loss 5%, calorie restriction, exercise (150 mins weekly) ○ COCP/Mirena - effective for menstrual regularity ○ Metformin - insulin resistance, improved frequency of ovulation/fertility ○ Vit D supplementation ○ Anti-androgen added on to COCP (e.g cyproterone, spironolactone) ○ Letrozole - anovulatory infertility (refer Gynae), clomifene
54
PCOS monitoring aspects (4)
○ Lipids 2 yearly ○ BP annually ○ OGTT 2 yearly ○ Co-morbid mental health
55
Indications for tubal testing for tubal disease (5) Imaging modalities used (2)
Long-standing ingertility Prior pelvic surgery Endometriosis Adenomyosis STI/pelvic infection hx Hysterosalpingography (HSG) or HyseroSalpingo Contrast Synography (HyCoSy)
56
Infertility history questions (8)
-Frequency and timing of intercourse -Menstrual history -CST previous results -Previous pregnancies -Pelvic infection -Medication/contraceptive use -Vaccination - Rubella, varicella, Hep B/influenza -Smoking/alcohol/drug use
57
Female infertility Ix: (7) Male infertility Ix: (4)
-FSH/LH -Oestradiol -TSH -Prolactin -Transvaginal USS -HSography/HyCoSy -AMH FSH, LH, serum testosterone, semen analysis
58
Nipple trauma DDx (5)
○ Suboptimal fit and hold ○ Breast pump trauma/misuse ○ Nipple bacterial infection ○ Blocked/plugged nipple duct ○ Tongue-tie ## Footnote * Tongue tie - not expected to have an impact on breastfeeding high rate false positives for nipple swab MCS - normal flora on skin/baby's mouth
59
Perceived low milk supply DDx (6)
○ Poor fit and hold ○ Top-up feeds --> longer durations between feeds ○ PCOS ○ Hypothyroidism ○ Meds - COCP, bromocriptine -Smoking/eTOH
60
Bacterial vaginosis 1st line Rx (2)
-Metronidazole 0.75% gel 1 applicatorful intravaginally nocte for 5 nights -Metronidazole oral 400mg BD for 7/7
61
Pre-eclampsia high risk risk-factors (5) Prophylaxis (2)
-Chronic HTN -Chronic kidney disease -PHx of hypertensive disease in pregnancy -Diabetes -Autoimmune disease Aspirin 100-150mg daily + calcium 1.5g daily

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