Gynae Flashcards
3 Key Contraception Counselling Points
- All the contraceptive methods, apart from condoms, do not protect again STI
- Whenever you have a new sexual partner to have a STI screen 3 weeks and 3 months after unprotected sex
- Always remember emergency contraception is available from A&E or GP or pharmacy
Contraception: Gillick Competence (5)
- Understand doctor’s advice
- Can’t be persuaded to inform their parents
- Likely to begin intercourse with or without contraception
- Unless they receive contraception their mental or physical health is likely tosuffer
- It’s in their best interest
Side effect of contraceptive injection
12 months return fertility
Osteoporosis
Weight gain
High Vaginal swab
BV, Candida, Trichomonas
Endocervical swab
Chlamydia, Gonorrhoea
Abortion counselling (3)
Accessibility = State that the service is free under the National Health Service.
Confidentiality =Reassure the patient that the procedure will remain confidential.
Appointments = Explain that she will be given two separate appointments. The first, to assess eligibility and choice of procedure; the second will be the procedure itself.
Also mention that the abortion should be completed within 3 weeks of the first contact she has made with the services
Urinary Gynae Questions
FUNDISH BBC DD
Frequency Urgency Nocturia Dysuria Incontinence Suprapubic pain Haematuria
Back/loin pain (pyelonephritis/neurological) Bowel symptoms (incontinence, constipation) Chronic cough (smoker/increase abdo pressure)
Dragging sensation/lump (prolapse)
Diet (coffee, alcohol)
Mx of termination of pregnancy under 14 weeks
• Up to 9w: mifepristone 200mg PO then misoprostol 800mcg PV, 24-48hrs later.
• 9 weeks to 13+6: mifepristone 200mg PO then misoprostol 800mcg PV, 24-48hrs later.
Then 400mcg every 3hrs until abortion.
Offer anti-D IgG 250IU for medical TOP after 10+0.
Surgery: Vacuum aspiration and inspection.
200mg doxycycline or 500mg azithromycin 2hrs before.
Consider anti-D IgG for surgical TOP up to 10+0
Termination of pregnancy >14 weeks
Inpatient
Mifepristone 200mg PO then misoprostol 800mcg PV 12-48hrs later. Then misoprostol 400mcg PO or PV every 3hrs until abortion
Surgery: Vacuum aspiration and inspection.
200mg doxycycline or 500mg azithromycin 2hrs before.
Dilation and evacuation with mifepristone 200mg 12–24hrs before.
Offer Anti-D
After 23+6 weeks, intracardiac KCL should be used to induce feticide
Counselling services for pregnancy termination
Impartial information and support is available from the counselling service and Reproductive Choices UK
Expectant Mx of miscarriage
Sanitary pads + analgesia
Pregnancy test in 3 weeks and again in 4 weeks
When is surgical Mx of miscarriage indicated?
Examples of Sx?
for RPOC or ongoing symptoms post-14 days of expectant or medical management.
Vacuum aspiration
Dilation and curettage (after 14 weeks)
(Antibiotic prophylaxis 100mg doxycycline BD 3d)
Mx of ectopic
Expectant
repeat bHCG at d2, d4, d7 then weekly until negative
IM Methotrexate 1mg/kg
repeat bHCG at d4 then d7, then weekly till negative
or
Salpingectomy
repeat bHCG at d7 then weekly until negative
Anti-D
Pregnancy after ectopic counselling
You should wait until you’ve had 2 periods after treatment before trying again for a baby when you and your partner feel physically and emotionally ready.
65% of women achieve a successful pregnancy 18 months after an ectopic
Menorrhagia with fibroid >3cm
Offer tranexamic acid and/or NSAIDs.
Consider hormonal treatments (LNG-IUS, COCP, cyclical POP), uterine artery embolization and surgical options (myomectomy, hysterectomy).
MRI should be considered before embolization or myomectomy.
GnRH analogues should be given before hysterectomy and myomectomy.
Consider endometrial ablation.
Infertility Ix
Semen analysis
FSH and LH if irregular cycls
21 day progesterone
Prolactin
Earlier referral to infertility clinic if >36 y/o
Subfertility counselling
Subfertility which is where couples have difficulty conceiving. This affects 1 in 7 couples. There are many possible causes and problems can affect either partner. In 25% of cases, it’s not possible to identify the cause.
I’d like to refer you to Gynaecology for some more tests and possible treatment. They will test both you and your partner for specific hormones and may perform minor procedures to look at your reproductive organs.
You may be offered medical treatment that helps with regular ovulation or surgical procedures to repair reproductive organs. You might also get assisted conception such as IVF
Incontinence Ix
Urine dipstick MSU (if UTI symptoms) Measure post-voidal residual volume by bladder scan Bladder diary POPQ rating scale
Stress incontinence Mx
Digital assessment to confirm pelvic floor contraction before offering 3 months pelvic floor exercises. At least 8 contractions TDS
Surgery or Duloxetine
Burch Colopsuspension
Urge incontinence Mx
Bladder training for 6 weeks
Oxybutynin TDS
Review within 4 weeks
(Mirabegron or Oestrogens)
Refractory - urodynamic study - surgery
Pelvic Organ Prolapse Mx
16 week PFMT if stage 1 or 2
Vaginal pessary in symptomatic women
Anterior prolapse: anterior repair without mesh.
Posterior prolapse: posterior repair without mesh.
Uterine prolapse: hysterectomy
Vault prolapse: Sacrocolpopexy
(review 6 months after surgery)
Menopause Mx options
HRT CBT SSRIs for vasomotor Sx Vaginal oestrogens Testosterone for sexual dysfunction
Review at 3 months and annually thereafter
Endometriosis Mx?
- 3m trial of paracetamol +/- NSAID.
- COCP or progestogen.
- Refer to gynaecology endometriosis service.
- Laparoscopic excision or ablation. Consider 3m GnRH agonists as an adjunct before surgery (Consider excision over ablation to maintain fertility.)
- Consider hysterectomy and excise all visible endometriotic lesions.
- Prioritising fertility: offer excision/ablation with adhesiolysis
Fibroids Mx
For women seeking contraception
- LNG-IUS (may be expunged if cavity distorted).
- COCP (may increase size).
- POP/Depo-provera/Nexplanon.
- GnRH agonist 6m short course.
- Hysteroscopic myomectomy (submucosal fibroids only) or endometrial ablation.
- Hysterectomy. May offer 3m GnRH agonist prior.
- Uterine artery embolization.
For women seeking to conceive
- Tranexamic acid/mefenamic acid
- Hysteroscopic Myomectomy
- Laporascopic Myomectomy
Review in 3 months
PCOS Ix
- Total testosterone, SHBG, androgen free index
- FSH, LH, prolactin, TSH
- TVUSS: polycystic ovaries are defined as the presence of ≥12 follicles in at least one ovary (2-9mm)
PCOS Mx
Seeking contraception:
COCP (or LNG-IUS)
Topical eflornithine for hirsutisim
Seeking to conceive:
Clomiphene
Offer OGTT - Metformin
Investigate other causes of subfertility
Resistant - laparoscopic ovarian drilling or GnRH agonist
BV Mx
• Avoid douching, antiseptics, bubble baths
Women who are not pregnant:
• Metronidazole 400mg PO BD 5-7d or a single dose of 2g.
If she prefers topical, give intravaginal metronidazole 0.75% OD 5d
Women who are pregnant
• Same as above but do not prescribe high dose 2g metronidazole.
BV counselling points
Not an STI
- To relieve symptoms, we’d recommend using water and plain soap to wash the genital area and taking showers instead of baths. Avoid perfumed soaps, vaginal washes or strong detergents in underwear.
- Your partner does not need to be treated (unless same-sex).
- Avoid sex for the next 7d and if symptoms persist beyond then, make another appointment to see us.
- The best way to prevent BV and is to have safer sex. This is best done using a condom
Trichomoniasis Mx
- Metronidazole PO 500mg BD 5-7d or metronidazole 2g single dose (unless pregnant or HIV+)
Repeat course if Sx persist
Inform any sexual partners from the past month see their GP
Avoid sex for the next 7d
Vulvovaginal candidiasis Ix
Not recommended if uncomplicated candidiasis is suspected.
- Test pH (exclude BV or TV)
- High vaginal swab (in severe or recurrent symptoms)
- Fungal speciation to non-albicans Candida (in treatment failure)
- MSU (UTI suspected)
- HbA1c test (exclude DM)
- STI screen
Vulvovaginal Candidiasis Mx
Topical Clotrimazole 1% TDS
Severe or recurrent: PO fluconazole, 2 or 3 doses taken 3 days apart
or Clotrimazole pessary
Avoid soaps, and sex (7d)
Tx of vulvovaginal candidiasis with diabetes, HIV or pregnant?
Diabetes/HIV/immunosuppressed
• Extended course of intravaginal miconazole 2% 14d or intravaginal pessaries 100mg clotrimazole 12d or PO fluconazole 100mg 7d
Pregnant: 7d clotrimazole and cannot give PO fluconazole
Who to notify with gonorrhoea?
How long abstinence?
Encourage men to notify all partners from past 2w. Women and men with complicated gonorrhoea should notify all partners from past 3m. Notified partners should be tested and treated empirically
Advise abstinence until 1w after test of cure following treatment (NAAT)
Gonorrhoea Mx?
IM 1g Ceftriaxone single dose
For needle phobia give cefixime 400mg PO single dose plus azithromycin 2g PO (cannot if pregnant)
Test of cure in 2 weeks
Chlamydia Mx
7d BD 100mg Doxycylcine
or
PO 1d Azithromycin (if pregnant)
Encourage abstinence for 1w after treatment, notify partners (we can do that confidentially if you wanr), safe sex.
Mx of early and late latent syphilis?
Early syphilis (<2y) • Penicillin G IM 2.4million U or doxycycline PO 100mg BD 14d
Late latent syphilis
• Penicillin G IM 2.4million U once weekly for 3w or doxycycline PO 100mg BD 28d.
Abstain from sex for 2 weeks after treatment
PID Ix
- Bimanual exam
- Speculum exam
- Pregnancy test
- High vaginal swab (BV, VC)
- Endocervical swab
- STI screen for chlamydia + gonorrhoea
- Wet mount vaginal swear
- Offer test for HIV and syphilis
PID Mx
- Advise referral to GUM.
- Start empirical antibiotics (• Doxycycline PO 100mg BD 14d + metronidazole PO 400mg BD 14d + ceftriaxone IM 500mg single dose)
- If woman has IUD or IUS, discuss removal within 72hrs of starting antibiotics. Consider the need for emergency contraception.
- Partners from the last 6m should be referred to GUM and treated empirically with doxycycline PO 100mg BD 7d and treated appropriately if diagnosed as positive.
- Review within 72hrs and 2w after treatment.
(Double Ceftriaxone to 1g if high risk infection)
PID + RUQ pain
Fitz-Hugh-Curtis
Tx if test positive for Mycoplasma genitalium
Moxifloxacin PO 400mg OD 14d
HIV Mx
- ART
- Cardiovascular risk assessment (avoid statins and fibrates with ART)
- Annual cervical screening
- Ensure immunisations up to date (avoid live vaccines)
- Regular STI screening
HIV in pregnancy Mx
• Continue ART- tenofovir (NRTI) + lamivudine (NRTI) + efavirenz (NNRTI). Should be started by 20w at the latest.
- VL<50: planned vaginal delivery possible.
- VL 50-399: consider planned caesarean.
- VL>400: planned caesarean at 38w.
In women whose membranes spontaneously rupture:
• VL<50: immediate induction/augmentation of labour
• VL>50: immediate caesarean
• Intrapartum zidovudine infusion for women with VL>1000
Do not breastfeed, exclusively formula
Endometrial cancer Mx
TVUSS
Refer on 2w suspected cancer pathway for women
Diagnosis made on biopsy
“The most common treatment for womb cancer is removal of the womb- hysterectomy. This is likely to include removal of the ovaries and fallopian tubes too. This will mean that you will no longer be able to get pregnant.
If you would still like to have children, a hormone called progestogen might be used”
Cervical cancer Mx
Speculum
Refer on 2 week suspected cancer pathway
Diagnosis made on biopsy
Hysterectomy and bilateral salpingo oopherectomy
More advanced - chemotherapy and radiotherapy
Ovarian Cancer Ix
- Abdominal/pelvic exam
- Bimanual exam
- CA125>35 IU/ml
- TVUSS
Ovarian Cancer Mx
Hysterectomy and bilateral salpingo oopherectomy
More advanced - chemotherapy and radiotherapy
Vulval or vaginal cancer counselling?
- The main treatment is surgery to remove the cancerous tissue and any lymph nodes with cancerous cells. Radiotherapy or chemotherapy may be used.
- Overall, 7 in 10 women will survive at least 5 years. But even after treatment you will need regular follow-up appointments.
- Support is found in organisations like the Eve Appeal and Macmillan Cancer Support.
Placenta Praevia Mx
Do not have sex
Caesarian section at 37 weeks
Low-lying at 20 weeks, only 10% remain low, scan at 32 and 36 weeks
Admit if grade III/IV at 34 weeks
Grade I = vaginal
Anti-D
