gynae Flashcards
1
Q
TOP
A
- A termination can be carried out before 24 weeks. I will refer you to a termination service which will carry out the procedure. The decision to have a termination is yours alone and impartial information and support is available from the counselling service and Reproductive Choices UK. You may also want to speak to family, but you do not have to. If you don’t want to tell anyone, your details will be kept confidential.
- The service will perform an ultrasound to work out how many weeks pregnant you are. They will talk to you about your decision and what happens next.
- Where possible, you will be given a choice between medical and surgical termination. With medical, you take 2 medications 24-48 hours apart. With surgical, you have a procedure to remove the pregnancy and go home afterwards. Afterwards, you should take things easy for a few days and expect vaginal bleeding and minor cramping for up to 2 weeks.
- Termination is safe and most women don’t experience any problems but there is a small risk of complications such as infection of the womb, excessive bleeding, damage of the womb or cervix or some of the pregnancy remaining in the womb. You might need surgery if these occur.
- A termination doesn’t affect your chance of getting pregnant in future. You should use contraception if you do not wish to get pregnant. Have you given it much thought?
- Safety net: you should take a pregnancy test 3 weeks after the termination which should be negative. If it’s not, wait another week and repeat the test. If it’s still positive, come back and see us. Go to A&E if you develop a fever or severe tummy pain or if you continue bleeding after 2 weeks or if you don’t start bleeding after 24hr.
2
Q
miscarriage
A
- The symptoms you’ve been experiencing are signs of a miscarriage. Do you know what this is?
- A miscarriage is the loss of a pregnancy before 24w and happens in 1 in 6 pregnancies. We don’t know why miscarriages happen and they’re not caused by the mother- it could not have been prevented. For most women, it’s a one-off event and they go on to have a successful pregnancy in future.
- I’d like to do an ultrasound to confirm whether the pregnancy is in the uterus or not.
- There are 3 options for management of the end of a pregnancy. You can wait 2 weeks and the pregnancy will naturally pass- during this time you will experience bleeding and some light tummy cramping. With medical, you take a tablet to speed up the passing of the pregnancy. With surgical, you have a procedure to remove the pregnancy and go home afterwards.
- You can try for another baby as soon as your symptoms have settled and you’re emotionally and physically ready. Most women are able to have a healthy pregnancy after a miscarriage.
- Safety net: you should take a pregnancy test 3 weeks after the termination which should be negative. If it’s not, wait another week and repeat the test. If it’s still positive, come back and see us. Come back if you develop a fever or severe tummy pain or if you continue bleeding after 2 weeks.
3
Q
ectopic pregnancy
A
- The symptoms you’ve been experiencing are signs of an ectopic pregnancy. Do you know what this is?
- An ectopic pregnancy is when the fertilised egg implants outside of the womb, usually the tubes connecting the ovaries to the womb. It’s an emergency as it’s a risk to your health if the pregnancy continues. It’s not possible to save the pregnancy so it has to be removed using medicine or an operation.
- There are 3 options for management of an ectopic. You can be carefully monitored, or you can have an injection to assist the passage of the pregnancy. Afterwards, you should take things easy for a few days and expect vaginal bleeding and minor cramping for up to 2 weeks. You can also choose to have keyhole surgery to remove it with the affected tube if you don’t want to wait. The options depend on your US results. All carry a small risk of infection and excessive bleeding.
- An ectopic pregnancy does not affect your likelihood of a successful pregnancy in future. However, some treatments may reduce your chance of natural conception so I will have a senior colleague discuss this with you if you are concerned.
- 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. Let your GP know as soon as you are pregnant to get early scans.
- An ectopic pregnancy can be difficult to cope with; you and your partner might benefit from counselling or support from the Ectopic Pregnancy Trust.
- Safety net: call 999 if you experience, sharp, intense tummy pain or feel very dizzy or faint.
4
Q
contraception
A
- There are 3 options for emergency contraception. There’s the copper IUD, levonorgestrel (‘the pill’) and ulipristal acetate.
- We’d recommend the IUD first as it has a longer window of action and provides ongoing contraception beyond the last UPSI. Discuss risks and benefits.
- Levonorgestrel: risks and benefits.
- Ulipristal acetate: risks and benefits.
- After taking the emergency contraception, you should take a pregnancy test if your next period is more than 5 days late.
- We’d recommend a form of long-acting contraception to prevent pregnancy in future. There are intrauterine devices/systems, injections, patches, implants and pills. We can talk about the benefits and side-effects of each: do you have a preference?
- You should also use condoms to protect against STIs.
- We’d recommend an STI screen now and then another in 12 weeks as some infections don’t show up on tests immediately.
5
Q
heavy menstrual bleeding
A
- Heavy periods happen in around half of women with menstrual bleeding and may or may not have an underlying cause.
- Before we discuss the options, could I ask if you are planning to begin trying for a baby soon?
- No identified pathology: we would recommend trialling a type of hormonal contraception called LNG-IUS with is a progestogen hormone that regulates periods and can make them lighter. They last 3-5 years and can be removed at any time if you want to conceive without a delay in return to fertility. The other option is using normal painkillers like ibuprofen or a medication called tranexamic acid that reduces bleeding. Both of these are non-hormonal methods.
- Fibroids >3cm: I’d like to refer you to Gynaecology for additional investigations. In the meantime, you can use normal painkillers like ibuprofen, or a medication called tranexamic acid that reduces bleeding. Both of these are non-hormonal methods. We can also think about hormonal treatments like the pill or surgical options if you’d like.
- We’ll check your iron levels, and you might need supplements if you’re anaemic.
6
Q
Subfertility
A
- What you’ve described sounds like it might be 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 or IUI depending on the cause of the problem and what’s available from your local CCG. There is no guarantee that treatment will be effective. It might also carry risks of multiple pregnancy or an ectopic, where the fertilised egg implants outside of the womb.
- In the meantime, we’d advise regular unprotected vaginal sex every 2-3 days and for you and your partner to ideally stop drinking alcohol and smoking. We have services to help with this. It’s also important to avoid putting pressure on yourselves to conceive as this can make it harder to do so.
- Resources and support can be found at RESOLVE, an association for people experiencing subfertility.
7
Q
Urinary incontinence
A
- Urinary incontinence is when you unintentionally pass urine. There are several different types, and you might have a mix of types. It affects millions of people. Though it isn’t dangerous, it can have a serious impact on a person’s life and daily activities.
- The first step is to keep a diary about how much fluid you drink and how often you have to urinate. You should also cut down on caffeine and alcohol and use incontinence products in case you leak. Losing weight can also help.
- Stress incontinence: this is usually caused by increasing age and pregnancy and vaginal birth as these things weaken the pelvic floor. We’d recommend 3 months of pelvic floor exercise which a physiotherapist will teach you to do. You should do 8 of these 3x a day for 3 months. If that doesn’t help, we can consider a medication called duloxetine. Surgeries may also help but these carry risks- we can discuss this when I next catch-up with you in a few weeks.
- Overactive bladder incontinence: this is due to overactivity of the muscles controlling the bladder. We’d recommend 6 weeks of bladder training where you learn ways to wait longer between needing to urinate and passing urine. If that doesn’t help, we can consider medications or surgery, but these carry side effects and risks- we can discuss this when I next catch-up with you in a few weeks.
- If you develop burning or stinging when you urinate or the urine smells bad, come back to the GP as this might be a urine infection and it needs antibiotics.
- Pelvic organ prolapse: this occurs when one of the pelvic organs slip down and bulge into the vagina. I’d like you to avoid heavy lifting and constipation, as these can worsen prolapse. We’d recommend supervised pelvic floor muscle training for 4 months. If there are signs of the muscle around the vagina shrinking, we can offer vaginal oestrogen which is a hormone that can help. Surgery is a last resort, but we can discuss this when I next catch-up with you in a few weeks.
8
Q
Menopause
A
- The symptoms you’ve been experiencing sound like the menopause. Do you know what this is?
- Menopause is a natural part of ageing that occurs between 45 and 55 and can involve the symptoms you’ve told me about (recall symptoms). These symptoms begin before your period and can last around 4 years after your last period.
- Vasomotor symptoms: you can use hormone replacement therapy to reduce the symptoms you’ve described. This is a combination of oestrogen and progesterone that mimics your body’s normal hormones. There is a slightly increased risk of blood clots and breast cancer, but it protects you against osteoporosis. You might get unscheduled bleeding in the first 3 months with this- let me know if this happens.
- Psychological symptoms: we’d recommend CBT to discuss your thoughts with a therapist. HRT may also help.
- Altered sexual function: HRT can help. If it doesn’t, we can consider testosterone which is the hormone that is responsible for libido.
- Urogenital atrophy: you can use vaginal oestrogen or systemic HRT for this.
- I’d like to catch-up in 3 weeks to discuss your symptoms.
9
Q
Endometriosis
A
- The symptoms you’ve been experiencing sound like endometriosis. Do you know what this is?
- Endometriosis is a condition where the tissue lining the womb starts to grow in other places, such as the ovaries and fallopian tubes. It affects 10% of women across all ages and we don’t know why it happens.
- Endometriosis is a long-term condition that can impact life, but there are treatments which can help:
- Pain: there are 2 types of medication we can use to control the pain. You can try non-hormonal methods like paracetamol and NSAIDs. You can also try hormonal methods like the COCP - this regulates your cycle and reduces bleeding and pain. We’ll explain in more detail how exactly to take the pill, but it’s important to know that it might cause side effects like headache, nausea and breast tenderness for a few months. It also slightly increases the risk of blood clots and breast cancer. If medication doesn’t work, we can discuss referring you to Gynaecology for more tests.
- Fertility: do you plan on having more children? Endometriosis can make it harder to get pregnant. Surgery can improve the chance but there is no guarantee. It can also sometimes cause further problems.
- Psychological: receiving a diagnosis of a long-term condition can be difficult, physically and emotional. You’ll receive ongoing support from us but can also contact Endometriosis UK for detailed advice and support.
- I’d like to catch up in 3 months to review your symptoms on the new medication. If, in the meantime, the pain gets worse, please make another appointment to see us.
10
Q
fibroids
A
- The symptoms you’ve been experiencing sound like fibroids. Do you know what this is?
- Fibroids are non-cancerous growths that develop in or around the womb. They’re made of muscle and fibrous tissue and vary in size and cause the symptoms you described. They’re been linked to the hormone oestrogen, so they usually develop during reproductive years.
- There are 2 avenues of treatment: do you plan on having any more children?
- Contraception: hormonal medication can help shrink fibroids. The LNG-IUS is a small medication that is placed in the womb and releases a progestogen hormone. It lasts 3-5 years. The COCP can also be used instead. Both can cause side effects such as headache, acne and breast tenderness. It also slightly increases the risk of blood clots and breast cancer.
- Conception: since you are trying to conceive, we should avoid contraceptive methods. We’d recommend tranexamic acid, to reduce bleeding, or mefenamic acid for pain relief.
- I’d like to catch up with you in 3 months to see if the medication is improving your symptoms. If they aren’t, there are some other medications we can consider, and I can refer you to Gynaecology for more testing and to discuss possible surgery. If, in the meantime, the pain gets worse, please make another appointment to see us.
11
Q
PCOS
A
- We think you might have a condition called PCOS. Do you know what this is?
- PCOS is a condition that affects how the ovaries works and can cause the symptoms you’ve described. The exact cause is unknown but something it runs in families. It’s also related to insulin, the hormone that controls sugar levels.
- There is no cure for PCOS, but the symptoms can be managed. There are 2 avenues for treatment: do you plan on having more children?
- Contraception: we’d recommend using hormonal medication such as the COCP to regulate periods and help with the high testosterone. It can cause side effects such as headache and breast tenderness. It also slightly increases the risk of blood clots and breast cancer. You can also try a special cream to reduce facial hair.
- Conception: since you are trying to conceive, we should avoid using hormonal contraception. We can try a medication called clomiphene that helps with ovulation to increase the chance of conception. If this isn’t effective, we can refer you to Gynaecology for a simple surgical procedure called laparoscopic ovarian drilling. With treatment, most women with PCOS can get pregnant.
- Glucose tolerance: as PCOS involves the hormone insulin, it can sometimes cause high blood sugar. This may mean you have to take a sugar lowering drug called metformin to reduce the risk of developing diabetes. We’d also recommend regular exercise, losing weight, and a diet high in protein and fruits/vegetables and low in fat. All of these things will also make it easier to conceive.
12
Q
BV
A
- It sounds like you may have an infection called BV. This is a common cause of unusual vaginal discharge, but it is not an STI. We don’t fully understand why it happens.
- It is treated with antibiotic tablets or gels or creams used for up to 7d. It’s important to treat as it can reduce your natural defences against STIs.
- It is common for BV to come back, usually within 3m. You’ll need longer treatments if it comes back several times.
- 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.
13
Q
Trichomoniasis
A
- It sounds like you may have an infection called TV. This is an STI caused by a tiny parasite and is a common cause of unusual discharge.
- It is treated with antibiotic tablets for up to 7d. It’s important to treat as it is unlikely to go away otherwise.
- You should inform any sexual partners from the past month to also see their GP for treatment.
- Avoid sex for the next 7d and if symptoms persist beyond then, make another appointment to see us.
- The best way to prevent TV and is to have safer sex. This is best done using a condom.
14
Q
Thrush
A
- It sounds like you may have an infection called vaginal thrush. This is a common cause of unusual vaginal discharge, but it is not an STI.
- It is treated with antifungal oral tablets, creams or vaginal tablets for up to 7d. It’s not dangerous but it can be very uncomfortable.
- You might need longer treatment if the thrush keeps coming back.
- Your partner does not need to be treated.
- Avoid sex for the next 7d and if symptoms persist beyond then, make another appointment to see us.
- To relieve symptoms, we’d recommend using water and emollient like E45 to wash the area, dry properly after washing and wear cotton underwear. Avoid perfumed soaps, vaginal washes or strong detergents in underwear.
- Avoid sex until your symptoms have resolved. If you do have sex during treatment, use a method of contraception in addition to condoms as they can be damaged by antifungal creams.
15
Q
Gonorrhoea
A
- It sounds like you may have an STI called gonorrhoea which is caused by bacteria. The bacteria are passed between people through sexual intercourse.
- It is treated with 1 dose of antibiotic tablet or injection. It’s important to treat because it can move up and infect the entrance to the womb. It can also infect the rectum, throat or eyes.
- You should inform any sexual partners from the past 3 months to also see their GP for treatment. We can do that confidentially for you if you want.
- After you have the treatment, you should wait 2 weeks come back to do a ‘test of cure’. You should abstain from sex until 1 week after this test (approx. 3w from now).
- Treatment doesn’t make you immune and you can catch gonorrhoea again.
- The best way to prevent STIs like gonorrhoea is to have safer sex. This is best done using a condom during vaginal, anal or oral sex.
