Contraception + HRT

Question 1

Implantable devices

Answer 1

Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.

Question 2

Advantages of implantable devices

Answer 2

• Most effective form of contraception
• Long lasting: 3 years
• Doesn’t contain oestrogen so can be used if there is a past history of thromboembolism, migraine etc
• Can be inserted immediately following a termination of pregnancy

Question 3

Disadvantages of implantable devices

Answer 3

• Additional contraception is needed for the first 7 days if not inserted on day 1 to 5 of a women’s menstrual cycle
• Irregular/heavy bleeding
• Progesterone effect: headache, nausea, breast pain
• Interactions: antiepileptics and rifampicin reduce efficacy, should take other contraception for 28 days
• Contraindications: breast cancer, ischaemic heart disease/stroke, unexplained/suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer

Question 4

Starting the POP

Answer 4

• if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
• if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
• Should be taken at the same time each day without a pill free break unlike the COCP

Question 5

POP: missed pills

Answer 5

• if < 3 hours* late: continue as normal
• if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 6

POP: disadvantages and advantages

Answer 6

Disadvantages= Irregular vaginal bleeding
Advantages= doesnt contain oestrogen

Question 7

Lichen sclerosus

Answer 7

An inflammatory condition that usually affects the genitalia and is more common in elderly women. Leads to atrophy of the epidermis with white plaques forming

Question 8

Features and diagnosis of Lichen sclerosus

Answer 8

Features
* White patches that may scar
* Itch is prominent
* May result in pain during intercourse or urination

Diagnosis is mainly made on clinical grounds but a biopsy can be performed if there are atypical features

Question 9

Lichen sclerosus: management

Answer 9

Management: topical steroids and emollients
Follow up: increased risk of vulval cancer

Question 10

Lichen sclerosus- Biopsy is needed if:

Answer 10

• there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions;
• the disease fails to respond to adequate treatment;
• there is extragenital LS, with features suggesting an overlap with morphoea;
• there are pigmented areas, in order to exclude an abnormal melanocytic proliferation

Question 11

Mastitis: treatment

Answer 11

The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’.
The first-line antibiotic is flucloxacillin for 10-14 days, the most common organism causing infective mastitis is Staphylococcus aureus. Breastfeeding or expressing should continue during treatment.

Question 12

Fetal/neonatal effects of cytomegalovirus

Answer 12

Vertical transmission to the fetus occurs in 40%. Approximately 10% of infected neonates are symptomatic at birth, with IUGR, pneumonia and thrombocytopenia; most of these will develop sever neurological sequelae such as hearing, visual and mental impairment, or will die. The asymptomatic neonates are at risk (15%) of deafness.

Question 13

Diagnosis of CMV during pregnancy

Answer 13

• Ultrasound abnormalities such as intracranial or hepatic calcification are evident in only 20%, and most infections are diagnosed when CMV testing is specifically requested.
• CMV immunoglobulin M (IgM) remains positive for a long time after infection, which could predate the pregnancy; titres will rise and IgG avidity will be low with a recent infection.
• If maternal infection is confirmed, amniocentesis at least 6 weeks after maternal infection will confirm or refute vertical transmission

Question 14

Management of CMV during pregnancy

Answer 14

Most infected neonates are still not seriously affected; close surveillance for ultrasound abnormalities amy help determine those at most risk for severe sequelae. There is no prenatal treatment, and termination may be offered. Because most maternal infections do not result in neonatal sequelae and amniocentesis involves risk, routine screening is not advised. Vaccination is not available.

Question 15

Primary and secondary failure to conceive

Answer 15

Primary - female partner has never conceived
Secondary - female partner has conceived before but the pregnancy ended in miscarriage or termination

Question 16

Induction of ovulation

Answer 16

If PCOS:
- Weight loss and lifestyle changes. If inappropriate/fails …
- Clomifene or metformin (or letrozole). If fails…
- Clomifene and metformin
- Gonadotrophins
- Ovarian diathermy. If fails…
- In vitro fertilization (IVF)

If hypothalamic: Restore weight
If hypogonadism: Gonadotrophins if weight normal
If hyperprolactinaemia: Bromocriptine or cabergoline
If ovulation or pregnancy does not occur following second-line treatments then IVF is the next step.

Question 17

Assisted conception methods for male sub fertility

Answer 17

1) intrauterine insemination (IUI)- if there is mild to moderate sperm dysfunction.
2) If more severe oligospermia is present then IVF is used; if this is very severe then intracytoplasmic sperm injection (ICSI) is used as part of an IVF cycle.
3) If there is azoospermia, sperm can be extracted direct from the testis (surgical sperm retrival (SSR) and then used from ICSI-IVF.
4) Or donor sperm may be used, after appropriate counselling; this is called donor insemination (DI).
5) Frozen-thawed sperm is injected into the uterus during a natural menstrual or mildly stimulated cycle at the time of ovulation. Children born from current sperm, oocyte of embryo donations in the UK can contact the donor from the age of 18, contributing to a critical national shortage of gamete and embryo donors.

Question 18

Investigations into dyspareunia

Answer 18

Superficial
- High vaginal swab
- Cervical swab
Deep
- Ultrasound scan (or MRI)
- Laparoscopy

Question 19

Management of superficical dyspareunia

Answer 19

1) If painful ulceration= Other herpes simplex. Swab, contact tracing, acyclovir
2) If discolouration- Vulvar intraepithelial neoplasia (VIN), Biopsy, then treat
3) If vaginal discharge- Trichomoniasis, candidiasis. Take swabs, treat
4) If thin red epithelium- Atrophic vaginitis. Topical oestrogen/hormone replacement therapy (HRT)
5) If mass- Vaginal cyst, Bartholin’s abscess, Surgery
6) If normal- Psychological/vaginismus, Gradual dilation; psychotherapy
7) If recent surgery/birth- Perineal trauma. Unless obvious abnormality, wait 6 months before surgery (e.g. Fenton’s repair)

Question 20

Signs and symptoms of imperforate hymen

Answer 20

• Cyclical pain
• Primary amenorrhoea
• Bluish bulging membrane and visible introitus

Question 21

Investigations of imperforate hymen

Answer 21

• A thorough history and examination
• Abdominal and TVS and invaluable, but not appropriate if not sexually active
• MRI is the gold standard, especially if complex surgery is planned
• Examination under anaesthesia +/- vaginoscopy, cystoscopy and hysterectomy may be required
• Karyotyping to exclude 46XY female (androgen insensitivity syndrome) if uterus and upper vagina are absent
• Renal tract ultrasound +/- IV urography should always be undertaken because of high incidence of related renal tract abnormalities

Question 22

Candidiasis in pregnancy

Answer 22

• It is very common in pregnancy with no apparent adverse effects
• Topical imidazoles are not systemically absorbed and are therefore safe at all gestations
• In general only symptomatic women should be treated as lots of women are chronic carriers

Question 23

Stages of cervical cancer

Answer 23

• CIN I (mild dysplasia): atypical cells are found only in the lower third of the epithelium
• CIN II (moderate dysplasia): atypical cells are found in the lower two-thirds of the epithelium
• CIN III (severe dysplasia): atypical cells occupy the full thickness of the epithelium. This is carcinoma in situ; the cells are similar in appearance to those in malignant lesions, but there is not invasion. Malignancy ensure if these abnormal cells invade through the basement membrane

Question 24

Complications of mastitis

Answer 24

Can develop into a breast abscess, this generally requires incision and drainage

Question 25

Treatment of mastitis for non-lactating women

Answer 25

Prescribe co-amoxiclav, if penicillin allergic prescribe erythromycin or clarithromycin and metronidazole

Question 26

Categories of mastitis

Answer 26

• Lactational: occurs during breastfeeding, the most common organism is Staphylococcus aureus. Happens due to milk stasis because of reduced breastfeeding
• Non-lactational: occurs in non-lactating women of any age. The infection is usually mixed, the commonest organisms are staph aureus, enterococci, and anaerobic bacteria.
• Granulomatous: a rare breast infection which occurs in women with diabetes mellites, autoimmune diseases and sarcoidosis.

Question 27

Risk factors and symptoms of mastitis

Answer 27

• Changes in feeding regime
• Introduction of bottle feeding
• Poor attachment of the infant to the breast
• Maternal stress and fatigue
• Inverted nipple, nipple piercing, skin conditions like eczema, diabetes, immunosuppression

Symptoms: erythema of the breast, swelling of the breast, painful breast, fever and general malaise

Question 28

Menopause symptoms

Answer 28

• Change in menstruating: change in length of menstrual cycle, dysfunctional uterine bleeding may occur
• Vasomotor symptoms- hot flushes, night sweating
• Urogenital: vaginal dryness and atrophy, urinary frequency
• Psychological: anxiety and depression, short term memory impairment
• Longer term: osteoporosis, increased risk of ischaemic heart disease

Question 29

Menopause

Answer 29

Average age is 51, when ovarian function stops. The permanent cessation of menstruation, due to a loss in follicular activity. Clinically diagnosed and is usually made in primary care, when the women has not had a period in 12 months.

Question 30

Menopause- use contraception

Answer 30

• 12 months after the last period in women >50
• 24 months after the last period in women <50

Question 31

HRT contraindications

Answer 31

• Current or past breast cancer
• Any oestrogen sensitive cancer
  Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia

Question 32

HRT- if they have a uterus

Answer 32

If the women has a uterus then its important not to give unopposed oestrogen as it increases the risk of endometrial cancer. Therefore oral or transdermal combined HRT is given (contains progesterone as well).

Question 33

Risks and side effects of HRT

Answer 33

• Venous thromboembolism, stroke, coronary heart disease, breast cancer, ovarian cancer
• Oestrogen: breast tenderness, leg cramps, bloating, nausea and headaches.
• Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression and pelvic pain.

Question 34

Management of the menopause with non-HRT

Answer 34

• Vasomotor symptoms: fluoxetine, citalopram or venlafaxine
• Vaginal dryness: vaginal lubricant or moisturiser
• Psychological help: self help groups, CBT, antideppresaants
• Urogenital symptoms: vaginal oestrogen even if they are taking HRT

Question 35

HRT: stopping medication

Answer 35

• Vasomotor symptoms: 2-5 years of HRT with regular attempts to stop
• Vaginal oestrogen: long term
• Important to gradually reduce HRT

Question 36

HRT is indicated for:

Answer 36

• the treatment of menopausal symptoms where the risk/benefit ratio is favourable
• women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic
• women under 60 years who are at risk of an osteoporotic fracture in whom non-oestrogen treatments are unsuitable

Question 37

Premenstrual syndrome

Answer 37

The emotional and physical symptoms that women experience in the luteal phase of the normal menstrual cycle. Doesn’t occur prior to puberty, pregnancy or after the menopause

Question 38

Premenstrual syndrome- symptoms:

Answer 38

• Emotional: anxiety, stress, fatigue, mood swings
• Physical: bloating, breast pain

Question 39

Pre-menstrual syndrome definition and symptoms

Answer 39

The emotional and physical symptoms that women experience in the luteal phase of the normal menstrual cycle. Doesn’t occur prior to puberty, pregnancy or after the menopause

Symptoms:
* Emotional: anxiety, stress, fatigue, mood swings
* Physical: bloating, breast pain

Question 40

Pre-menstrual syndrome: management

Answer 40

• Lifestyle: eat frequent, small, balanced meals rich in complex carbohydrates
• Moderate symptoms: new generation COCP i.e. Yasmin
• Severe symptoms: SSRI, can be taken continuously or just doing the luteal phase i.e. day 15-28 of the menstrual cycle

Question 41

Termination of pregnancy: Legality

Answer 41

• two registered medical practitioners must sign a legal document (in an emergency only one is needed)
• only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Question 42

The method used to terminate pregnancy depends upon gestation

Answer 42

• less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandin analogue (Misoprostol) to stimulate uterine contractions
• less than 13 weeks: surgical dilation and suction of uterine contents
• more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

Question 43

When can an abortion be done

Answer 43

When its before 24 weeks and involved greater risk to the physical or mental health of the women or existing children of the family

An abortion can be performed at any time during the pregnancy if:
* Continuing the pregnancy is likely to risk the life of the woman
* Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Question 44

Post abortion care

Answer 44

May experience vaginal bleeding and abdominal cramps up to 2 weeks after the procedure. A urine test is performed 3 weeks after the abortion to confirm its complete

Question 45

Stillbirth- causes, risk factors, definition

Answer 45

The birth of a dead fetus after 24 weeks gestation. It is due to intrauterine fetal death.

Causes: Unexplained (50%), Pre-eclampsia, Placental abruption, Vasa praevi, cord prolaspse, obstetric cholestasis

Factors that increase the risk of stillbirth: Fetal growth restriction, smoking, alcohol, increased maternal age, maternal obesity, twins, sleeping on the back

Question 46

Stillbirth- prevention

Answer 46

• Risk assessment for having a baby that is SGA or FGS, those at risk are closely monitored with serial growth scans. May need planned early delivery
• Women at risk of pre-eclampsia are given aspirin
  *Stop smoking, avoid alcohol, control diabetes and sleep on their side
• Three key symptoms: reduced fetal movement, abdominal pain, vaginal bleeding

Question 47

Stillbirth- Management

Answer 47

• Rhesus D negative women are given anti-D prophylaxis
• Vaginal delivery unless reasons for caessarian. Can either have induction of labour or expectant management
• Induction of labour: combination of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue)
• Dopamine agonists i.e. cabergoline can suppress lactation after stillbirth

Question 48

With parental consent, testing is carried out after stillbirth to determine the cause:

Answer 48

• Genetic testing of the fetus and placenta
• Postmortem examination of the fetus (including xrays)
• Testing for maternal and fetal infection
• Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Question 49

Pregnancy of unknown location (PUL)

Answer 49

When the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded.

Question 50

Determining causes of Pregnancy of unknown location- Method

Answer 50

Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location. The serum hGC level is repeated after 48 hours, to measure the change from baseline.

Question 51

Determining cause of PUL: results

Answer 51

1) A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
2) A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
3) A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.