Gynae Flashcards
What is needed following a medical termination of pregnancy?
Multiple level pregnancy test in 2 weeks
Management of vaginal thrush?
Oral fluconazole
Enlarged boggy uterus?
Adenomyosis
What is a C/I to injectable progesterone contraceptives?
Current breast cancer
Management of pregnant women who are<6 weeks gestation with painless bleeding?
Expectant management - repeat test in 7 days
Imaging of choice for adenomyosis?
Transvaginal US
How long should women wait before starting regular hormonal contraception after taking ulipristal?
5 days
Management of 2 missed pills in week 3?
Take an active pill and omit the pill-free interval
What is acceptable with nearly all anti epileptic drugs?
Breastfeeding
Risks of HRT?
- Increased risk of breast cancer
- Increased risk of endometrial cancer(if no progresterone)
- Increased risk of VTE
Unopposed oestrogen increases the risk of?
Endometrial cancer
If one pill missed, what is the next steps?
Take the next pill ASAP then continue as normal
If 2 pills are missed in week 2, what is the next steps?
No emergency contraception needed if previous 7 days have been taken correctly
What is the drug of choice for reversing respiratory depression caused by mag sulphate?
Calcium Gluconate
When should anti-D prophylaxis be given to women who are having an abortion?
If rhesus negative and after 10 weeks gestation
Management of switching from IUD to COCP
No additional contraception needed if removed on day 1-5
If later, barrier contraception needed for 7 days
When should oestrogen containing contraceptives be discontinued before surgery requiring immobilisation?
4 weeks before
COCP protects against which cancers?
Ovarian and endometrial
Presence of heartbeat on US of ectopic suggests what?
Surgical management needed
When do women require contraception post partum?
After 21 days
First line for menorrhagia?
Mirena IUS
2nd line= tranexamic acid or NSAIDs; if want hormonal then COCP or cyclical oral progestogen
Risk factors for premature ovarian failure?
positive family history, exposure to chemotherapy/radiation and autoimmune disease.
Which contraceptives are not affected by enzyme inducing drugs?
- Copper IUD
- Injection
- Mirena
When is anti-D given?
28 and 34 weeks
What are the normal blood test results for PCOS?
- Raised LH:FSH ratio
- Normal/Raised testosterone
- SHBG is normal/low
Most common ovarian cancer type?
Epithelial cell tumour
Most common type of fibroid?
Intramural fibroid
Vulval itching with white atrophic patches of skin?
Lichen sclerosis
What can be precipitated by antibiotic exposure?
Fungal infection
Current breast cancer is a C/I to what?
All hormonal contraceptives
Management of all postmenopausal women with atypical endometrial hyperplasia
Hysterectomy with bilateral salpingo-oophorectomy
Itching and vaginal burning with latex condoms?
Irritant contact dermatitis
blue and bulging membrane with a mass protruding from behind
Imperforate hymen
Failure of the corpus luteum to regress can lead to what?
Corpus luteal cyst
Why is a urine dip done when patients have hyperemesis gravidarum?
Assess for ketones as these would suggest ketosis/starvation
What vitamin can be given to patients with hyperemesis?
Thiamine to prevent Wernickes
What are causes of recurrent spontaneous miscarriages?
- Antiphospholipid
- Infection
- Uterine/Cervical abnormalities
What is CIN and how do you differ between CIN1/2/3?
CIN - premalignant condition where abnormally diving cells have now invaded below the basement membrane
1 - 1/3 of epithelium 2 - 2/3 of epithelium, 3 - 3/3 of epithelium
What are types of cervical cancer?
Squamous cell and adenocarcinoma
What is the investigation of choice to look for local and distant spread of invasive cervical carcinoma?
CT
What is an ectropion?
growth of endocervical columnar epithelium outside of the external os
Side effects of GnRH agonists?
Menopausal symptoms
Loss of bone mineral density
What causes ovarian torsion?
Small cyst ruptures on a free pedicle, restricting its blood supply causing potential ovarian necrosis
How do dermoid cysts arise?
Derived from primitive germ cells which can differentiate into any body tissue
What are signs of endometriosis on examination?
- Fixed, retroverted uterus
- Tender uterus
- Enlarged ovaries
- Uterosacral ligament nodules
- Visible lesions
Primary vs secondary infertility
Primary - couple have never been able to conceive
Secondary - couple have achieved conception in the past
Management of infertility in PCOS?
- Metformin
- Clomiphene
- Gonadotrophins
What is the classic PCOS triad?
- Hyperandrogenism
- Ovulatory dysfunction
- Polycystic ovaries
What bloods would you measure for ovulatory function?
- Day 21 progesterone
- FSH/LH
- Oestradiol
What are C/I to IUD insertion?
- STI/PID
- Ovarian/Endometrial/Cervical cancer
Why can women sometimes feel faint and become bradycardic during IUD insertion?
Cervical shock leads to vasovagal which causes reflex bradycardia
Where does endometrial cancer metastasize?
- Inguinal lymph nodes
- Lung
- Bone
- Liver
- Peritoneum
What are non contraceptive ways to manage menorrhagia?
- Tranexamic acid
- Aspirin
- Indomethacin
- Mefenamic acid
What are common places for endometrial tissue to grow?
- Ovaries
- Pouch of Douglas
- Uterosacral ligaments
What markers should be done in suspected ovarian cancer?
- CA125
- AFP
- BHCG
What are risk factors for uterovaginal prolapse?
- Multiparity
- Raised intrabdominal pressure
- Menopause
- Hysterectomy
What can be done to prevent prolapse?
- Pelvic floor excercises
- Support the vaginal vault during hysterectomy
What is management of prolapse?
- Pessaries
- Physio
- Surgical repair
What can cause oligohydramnios?
- PROM, renal agenesis, foetal abnormalities, IUGR
What complications can occur with oligohydramnios?
- Resp difficulties
- Skull deformities
- IUGR
- Pulmonary hypoplasia
- Cord compression
- Shoulder dystocia
- Foetal hypoxia
What is the management of oligohydramnios?
- Encourage maternal hydration
- Oligoinfusion
When should serum progesterone levels be taken to check ovulation?
7 days before next expected period
Missed pill rules
- If 1 missed (any time in cycle): take it and continue as normal
- If 2 or more missed: take it and use condoms for 7 days
- If 2 or more missed in week 1 and she has had sex this week or previous pill-free interval: + emergency contraception
- If 2 or more missed in week 3: start next pack as soon as she finishes current pack
Management of stage 1 cervical cancer to maintain fertility?
Cone biopsy
Which should be measured when thinking about premature ovarian insufficiency?
FSH - will be raised
What is the first line management for prolapse?
- If asymptomatic: nothing
- Conservative: weight loss and pelvic floor excercises
- Pessary
- Surgery: colporrhaphy
Which hormone surges just before ovulation?
LH
What is a fibroid?
Benign smooth muscle tumour originating from the myometrium
Most common tumour in young women?
Germ cell tumour
Lichen sclerosus needs what to be treated?
Potent topical steroid
Woman recently stopped breastfeeding with lump?
Galactocele
PCOS increases the risk of what?
Endometrial and ovarian cancer
What should be given to induce a withdrawal bleed when thinking about cancer in someone with PCOS?
Oral cyclical progestogen
When should a follow up smear after LLETZ be done?
6 months
Premenstrual syndrome management
COCP
SSRI
Before sterilisation, how long must women have been on effective contraception for?
1 month
Atrophic vaginitis often occurs in who?
post-menopausal women
How does atrophic vaginitis present?
vaginal dryness, dyspareunia and occasional spotting
exam= pale and dry
Mx of atrophic vaginitis?
vaginal lubricants and moisturisers
if don’t help then topical oestrogen creams
What is cervical ca screening?
HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Who is screened for cervical ca?
25-49yrs= every 3yrs
50-64yrs= every 5yrs
Scotland= 25-64yrs every 5yrs
Cervical screening if pt is pregnant?
delayed until 3m post-partum unless missed screening or previous abnormal smears
What women may opt out of cervical ca screening?
women who have never been sexually active so have very low risk
Best time to take a cervical smear?
around mid-cycle
Umbilical cord prolapse?
when umbilical cord descends ahead of the presenting part of the fetus
1/500 deliveries
What if umbilical cord prolapse is left untreated?
can lead to compression of cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death
RFs for cord prolapse?
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations eg. breech, transverse lie
50% of cord prolapses occur when?
at artificial rupture of the membranes
When is cord prolapse typically diagnosed?
when fetal heart rate becomes abnormal and the cord is palpable vaginally or if the cord is visible beyond the level of the introitus
Mx of umbilical cord prolapse?
obstetric emergency
- presenting part of fetus may be pushed back into uterus to avoid compression
- if cord is past level of introitus then minimal handling and it should be kept warm and moist to avoid vasopasm
- ask pt to go ‘on all fours’ until immediate c-section (left lateral position is alternative)
- tocolytics can be used to reduce uterine contractions
- retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
- c-section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
What is the introitus?
opening that leads to the vaginal canal
Umbilical cord prolapse= what if the cord is past the entrance to the vagina (introitus)?
minimal handling and it should be kept warm and moist to avoid vasospasm
Umbilical cord prolapse= ask pt to do what whilst awaiting c-section?
go on all fours
Umbilical cord prolapse= what can be used to reduce uterine contractions?
tocolytics
Umbilical cord prolapse= what may be helpful to gently elevate the presenting part?
retrofilling the bladder with 500-700ml saline
Umbilical cord prolapse: if treated early then…?
fetal mortality is low
incidence has been reduced due to increase in c-sections used in breech presentations
Ectopic pregnancy?
implantation of a fertilised ovum outside the uterus
Typical history for ectopic pregnancy?
female with history of 6-8w amenorrhoea who presents with lower abdo pain and later develops vaginal bleeding
Lower abdo pain in ectopic pregnancy?
due to tubal spasm
typically 1st symptom
pain is usually constant and may be unilateral
Vaginal bleeding in ectopic pregnancy?
less than normal period
may be dark brown
Amenorrhoea in ectopic pregnancy?
typically 6-8w from start of last period
if longer eg. 10w this suggests another cause eg. inevitable abortion
Other than abdo pain what other type of pain may be present in ectopic pregnancy?
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
CP of ectopic pregnancy?
- lower abdo pain
- vaginal bleeding
- amenorrhoea 6-8w
- shoulder tip pain +/- pain on defecation/urination
- dizziness, fainting or syncope
- symptoms of pregnancy eg. breast tenderness
Ectopic pregnancy= examination findings?
- abdo tenderness
- cervical excitation (aka cervical motion tenderness)
- adnexal mass= DO NOT EXAMINE for adnexal mass due to increase risk of rupture of pregnancy BUT pelvic exam to check for cervical excitation is recommended
Pregnancy of unknown location, a serum b-hCG level of what points towards diagnosis of ectopic pregnancy?
> 1500
Ix for ectopic pregnany?
- stable= Ix and Mx in early preg assessment unit
- unstable= refer to A&E
Ix= pregnancy test positive;
GOLD= transvaginal USS
3 ways to manage ectopic pregnancy?
1) expectant Mx
2) medical Mx
3) surgical Mx
Expectant Mx for ectopic pregnancy criteria?
- <35mm
- unruptured
- asymptomatic
- no fetal heartbeat
- hCG <1000
- compatible if another intrauterine pregnancy
Medical Mx for ectopic pregnancy criteria?
- <35mm
- unruptured
- no signif pain
- no fetal heartbeat
- HCG <1500
- not suitable if intrauterine pregnancy
Surgical Mx for ectopic pregnancy criteria?
- > 35mm
- can be ruptured
- pain
- visible heartbeat
- HCG >5000
- compatible with another intrauterine pregnancy
Expectant Mx for ectopic pregnancy involves what?
monitor closely over 48hrs and if B-hCG levels rise again or pt develops symptoms the intervention needed
Medical Mx for ectopic pregnancy?
methotrexate but only if pt is willing to attend follow up
Surgical Mx for ectopic pregnancy?
Salpingectomy or salpingotomy
Salpingectomy or salpingotomy for ectopic pregnancy?
- Salpingectomy 1st line if not other RFs for infertility
- Salpingotomy if RFs for infertile eg. contralateral tube damage
- 1 in 5 who have salpingotomy also need further Tx eg. methotrexate and/or salpingectomy
Pathophysiology for ectopic pregnancy?
97% are tubal, with most in ampulla
more dangerous if in isthmus
3% in ovary, cervix or peritoneum
trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
Natural history of ectopic pregnancy?
Natural history - most common are absorption and tubal abortion:
- tubal abortion
- tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
- tubal rupture
fertilised ovum implanting and maturing outside the uterine cavity.
ectopic pregnancy
Where do most ectopic pregnancies (97%) impant?
fallopian tube
others= ovary, abdomen, cervix, caesarean section scar, interstitial part of the fallopian tube, or the cornua of a unicornuate or bicornuate uterus.
RFs for ectopic pregnancy?
tubal damage, maternal age over 35 years, and smoking. However, there are no identifiable risk factors in about a third of cases.
Cx of ectopic pregnancy?
Tubal rupture (which may lead to maternal death, if treatment is delayed).
Recurrent ectopic pregnancy.
Adverse effects of treatment.
Grief, anxiety, or depression.
Signs and symptoms of ectopic pregnancy?
Common symptoms include abdominal or pelvic pain, amenorrhoea or missed period, and vaginal bleeding. Less common symptoms include gastrointestinal symptoms, dizziness, shoulder tip pain, and urinary symptoms.
Common signs include pelvic, adnexal, and abdominal tenderness. Less common signs include cervical motion tenderness, pallor, abdominal distension, shock, and hypotension.
If women presents with symptoms of ectopic pregnancy then…
Pregnancy should be confirmed (if not already done).
The woman should be examined for signs of an ectopic pregnancy.
Immediate hospital admission for ectopic preg when?
if there are signs of haemodynamic instability or significant concerns about the degree of pain or bleeding.
Ectopic pregnancy: Immediate referral to an early pregnancy assessment service or out-of-hours gynaecology service should be arranged for women…..
with a positive pregnancy test, and the following on examination:
- Abdominal pain and tenderness.
- Pelvic tenderness.
- Cervical motion tenderness.
Ectopic pregnancy: Referral to an early pregnancy assessment service (with urgency depending on clinical judgement) should be arranged for women if they have….
bleeding or have other symptoms and signs of early pregnancy complications if they also have any of the following:
- Pain.
- A pregnancy of 6 weeks’ gestation or more.
- A pregnancy of uncertain gestation.
When should expectant Mx be used for women in ectopic pregnany?
less than 6 weeks’ gestation who are bleeding but not in pain, and who have no risk factors, such as a previous ectopic pregnancy. Advise these women:
- To return if bleeding continues or pain develops.
- To repeat a urine pregnancy test after 7 to 10 days and to return if it is positive.
- That a negative pregnancy test means that the pregnancy has miscarried.
Diagnostic tool of choice for ectopic pregnancy?
transvaginal ultrasound
Secondary care Tx options for ectopic pregnancy?
expectant management (watchful waiting), medical management (commonly with methotrexate), or surgery.
After Tx for ectopic pregnancy, what should be done?
woman should be followed up in primary care and offered appropriate support, information, and advice.
Endometriosis?
condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of reproductive age have a degree of endometriosis.
Clinical features for endometriosis?
- chronic pelvic pain
- secondary dysmenorrhoea= pain typically starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynae= urinary symptoms eg. dysuria, urgency, haematuria; dyschezia (painful bowel movements)
- pelvic exam= reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Endometriosis= findings on pelvic exam?
reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Dyschezia?
painful bowel movements
Ix for endometriosis?
- no role for Ix in primary care eg. USS= if symptoms signif then refer pt for definitive diagnosis
- GOLD= laparoscopy
GOLD standard Ix for endometriosis?
laparoscopy
Mx of endometriosis depends on what?
clinical features
Is there correlation between laparoscopic findings and severity of symptoms in endometriosis?
no there is poor correlation
Mx for endometriosis?
NSAIDs +/or paracetamol 1st line for symptomatic relief
if analgesia doesn’t help= COCP or progestogens eg. e.g. medroxyprogesterone acetate should be tried
doesn’t help/fertility priority= refer to secondary care eg. GnRH analogues or surgery
Secondary care Mx options for endometriosis if analgesia/hormonal Tx doesn’t improve symptoms or if fertility is a priority?
- GnRH analogues
drug therapy doesn’t seem to have impact on fertility
- Surgery= laparoscopic excision or ablation of endometriosis + adhesiolysis to try and improve chance of conception; ovarian cystectomy (for endometriomas) also recommended
Role of GnRH analogues in endometriosis if analgesia/hormonal Tx ineffective?
induces a ‘pseudomenopause’ due to low oestrogen levels
growth of endometrium-like tissue outside the uterus.
endometriosis
Endometriosis= Endometriotic deposits are most commonly distributed where?
pelvis; on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas. Extra-pelvic deposits, such as in the bowel and pleural cavity, are rare
Endometriosis is associated with what?
menstruation. The hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation
Cause of endometriosis?
The exact cause of endometriosis is unknown. It is thought that endometriosis develops as a result of a combination of several factors, including retrograde menstruation, personal genetics, metaplasia, and environmental factors.
Summary of endometriosis?
can be a chronic disease affecting women throughout their reproductive lives (and sometimes beyond). For most women, symptoms can be controlled with hormonal treatment, however, some women may have complex needs and require long-term support.
When to suspect endometriosis?
in women (including young women aged 17 years and younger) presenting with one or more of the following symptoms or signs:
- Chronic pelvic pain (defined as a minimum of 6 months of cyclical or continuous pain).
- Period-related pain (dysmenorrhoea) affecting daily activities and quality of life.
- Deep pain during or after sexual intercourse.
- Period-related or cyclical gastrointestinal symptoms, in particular painful bowel movements.
- Period-related or cyclical urinary symptoms, particularly blood in the urine or pain passing urine.
- Infertility in association with one or more of the above.
What to do if suspect endometriosis?
thorough history and examination should be undertaken to:
- Identify RFs (such as early menarche, nulliparity, or family history of endometriosis).
- Exclude differential diagnoses (such as other gynaecological conditions, irritable bowel syndrome, or pelvic inflammatory disease).
- Identify complications (such as fertility problems or depression).
Ix if suspect endometriosis?
if suspected then transvaginal ultrasound scan should be arranged to exclude other pathology, identify endometriomas and deep endometriosis, and to guide referral and management.
The possibility of endometriosis should not be excluded if the abdominal or pelvic examination or ultrasound is normal. If clinical suspicion remains or symptoms persist, referral for further assessment and investigation should be considered.
Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis.
Diagnosis of endometriosis can only be made definitively by what?
laparoscopic visualisation of the pelvis
Summarise Mx for suspected/confirmed endometriosis?
Review to manage endometriosis-related pain with simple analgesics and/or hormonal treatment, as appropriate.
Assessing the woman’s individual information and support needs, taking into account her circumstances, symptoms, priorities, desire for fertility, aspects of daily living, and her physical, psychosexual, and emotional needs.
Assessing for, and managing, complications of endometriosis, such as fertility problems or depression.
Endometriosis: when to refer to secondary care?
Where the diagnosis is unclear.
For women with severe, persistent, or recurrent symptoms.
For women with pelvic signs of endometriosis.
If the initial management is not effective, not tolerated, or contraindicated (for consideration of other management options, including diagnostic laparoscopy).
When to review pt with endometriosis?
after 3–6 months, or earlier if symptoms are troublesome.
If initial hormonal treatment for endometriosis is ineffective, not tolerated, or contraindicated, refer the woman to a gynaecology service, specialist endometriosis service, or paediatric and adolescent gynaecology service
For women with confirmed endometriosis, particularly women who choose not to have surgery, ensure that they are followed up in secondary care if they have:
Deep endometriosis involving the bowel, bladder or ureter or
One or more endometrioma that is larger than 3 cm.
What happens to BP in normal pregnancy?
BP normally falls in 1st trimester (esp diastolic), and continues to fall until 20-24w
after this time the BP usually increases to pre-pregnancy levels by term
Women who are at high risk of developing pre-eclampsia should take what?
aspirin 75mg od from 12 weeks until the birth of the baby
Hypertension in pregnancy in usually defined as what?
- systolic > 140 mmHg or diastolic > 90 mmHg
or
- an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing a pregnant pt is hypertensive what should be done?
categorise into either pre-existing HTN; pregnancy induced HTN (PIH aka gestational HTN) or pre-eclampsia
3 categories of HTN in pregnant pt?
1) pre-existing HTN
2) pregnancy induced HTN
(PIH) aka gestational HTN
3) pre-eclampsia
Pre-existing hypertension in pregnancy?
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women
Pre-existing hypertension in pregnancy Mx?
If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review
If pt has pre-existing HTN in pregnancy, what meds should be stopped?
ACE inhibitor or ARB for pre-existing should be stopped and start alternative eg. labetalol or nifedipine
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)?
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension) Mx?
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
Pre-eclampsia?
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)?
pre-eclampsia
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Pre-existing hypertension
Mx of HTN in pregnancy?
1st line= oral labetalol
2nd= nifedipine eg. is asthmatic or methyldopa
Definition of hypertension in pregnancy?
diastolic blood pressure of 90–109 mmHg and/or systolic blood pressure of 140–159 mmHg.
Definition of severe hypertension in pregnancy?
diastolic blood pressure of 110 mmHg or greater and/or systolic blood pressure of 160 mmHg or greater.
Definition of chronic HTN in pregnancy?
Hypertension that is present at, or prior to the booking visit, or before 20 weeks’ gestation — blood pressure tends to fall during the first and second trimesters and a woman with high blood pressure before week 20 of pregnancy can therefore be assumed to have pre-existing hypertension.
Definition of gestational HTN?
New hypertension presenting after 20 weeks’ gestation without significant proteinuria.
Definition of pre-eclampsia?
New hypertension presenting after 20 weeks’ gestation with significant proteinuria. Pre-eclampsia is a multi-system disorder which can affect the placenta, kidney, liver, brain, and other organs of the mother.
HELLP syndrome?
(Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome) is a severe form of pre-eclampsia.
Severe form of pre-eclampsia?
HELLP syndrome
HELLP syndrome stands for what?
Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome
Eclampsia?
occurrence of one or more seizures in a woman with pre-eclampsia.
What is defined as significant proteinuria in pregnancy?
a urinary protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol. Proteinuria of at least [1+] on dipstick testing should prompt one of these additional tests.
Pregnant Women at high risk of pre-eclampsia should take?
aspirin 75—150 mg daily from 12 weeks’ gestation until the birth of the baby.
What should be taken at presentation and at each antenatal visit to check for HTN in pregnancy?
Blood pressure should be taken and a dipstick urine test done for proteinuria
An explanation of the symptoms of pre-eclampsia should be given and the woman advised to seek immediate medical review if she develops any of the following (including during the first four weeks postpartum):
Severe headaches (increasing frequency unrelieved by regular analgesics).
Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
Persistent new epigastric pain or pain in the right upper quadrant.
Vomiting.
Breathlessness.
Sudden swelling of the face, hands, or feet.
Women with suspected pre-eclampsia require…
urgent secondary care assessment
What is essential in HTN in pregnancy?
postpartum monitoring and follow up
Official definition of pre-eclampsia?
new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
1) Proteinuria, or
2) Other maternal organ dysfunction:
- Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more).
- Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain).
- Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata.
- Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis.
- Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.
women are considered to be at high risk of pre-eclampsia if they have?
One of the following high risk factors:
- A history of hypertensive disease during a previous pregnancy.
- CKD
- Autoimmune disease, such as SLE or antiphospholipid syndrome.
- DMT1/2
- Chronic HTN
Two or more of the following moderate risk factors:
- First pregnancy.
- Aged 40 years or older.
- Pregnancy interval of more than 10 years.
- BMI of 35 kg/m2 or greater at the first visit.
- Family history of pre-eclampsia.
Multiple pregnancy.
For women assessed to be at high risk of pre-eclampsia?
1) Refer for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
2) Ensure that aspirin 75—150 mg daily is prescribed from 12 weeks’ gestation until birth. This is usually arranged in secondary care, but should be initiated in primary care if the woman will not be seen by a specialist until after 12 weeks.
Seek specialist advice before prescribing aspirin to girls younger than 16 years of age, and in those with thrombophilia or uncontrolled blood pressure. There is no evidence that use of low-dose aspirin in pregnancy is associated with an increased risk of congenital abnormalities or other fetal complications.
3) Offer advice about healthy lifestyle (including rest, work, exercise, and weight
For all pregnant women, dipstick the urine for protein and measure blood pressure at each antenatal visit.
If dipstick screening is positive [1+ or more], use…
albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
- If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria.
- If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold.
- Do not use first morning urine void to quantify proteinuria in pregnant women.
Arrange emergency secondary care assessment for any woman in whom pre-eclampsia is suspected. Advise women with severe hypertension (blood pressure of 160/110 mmHg or more) then
they will be offered hospital admission for ongoing monitoring of their condition and of their baby’s wellbeing.
Women with less severe hypertension may be offered admission depending upon whether there are clinical concerns for the wellbeing of the woman or baby or if they are considered to be at high risk of adverse events. If there are no such concerns, the woman will be offered ongoing specialist management on an outpatient basis.
Pre-existing HTN in pregnancy: women with chronic hypertension are at high risk of what?
pre-eclampsia and should be referred for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
Pre-existing HTN in pregnancy: advice?
Healthy lifestyle (including work, rest, exercise, healthy diet, and weight) as recommended for all pregnant women.
Restriction of dietary salt.
Pre-existing HTN in pregnancy: stop what drugs?
ACE inhibitor, ARB. thiazide or thiazide-like diuretic
Be aware that pregnant women previously diagnosed with chronic hypertension may exhibit blood pressure within the normal range due to the physiological drop in blood pressure that occurs in early pregnancy. Continued antihypertensive treatment is not necessary if:
Sustained systolic blood pressure is less than 110 mmHg, or
Sustained diastolic blood pressure is less than 70 mmHg, or
The woman has symptomatic hypotension.
If a woman with chronic hypertension is not already taking antihypentensive treatment, while she is waiting to see a specialist, offer drug treatment if there is:
Sustained systolic blood pressure of 140 mmHg or higher, or
Sustained diastolic blood pressure of 90 mmHg or higher.
Target blood pressure following antihypertensive treatment in pregnancy is
135/85 mmHg.
How should I manage a woman with new hypertension after 20 weeks’ gestation?
Arrange secondary care assessment by a healthcare professional trained in the management of hypertensive disorders of pregnancy for all women with new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy.
Be aware of the signs and symptoms of, and risk factors for pre-eclampsia.
Advise women with new onset severe hypertension (blood pressure of 160/110 mmHg or more) that they are likely to be admitted to hospital for ongoing monitoring of their condition and of their baby’s wellbeing.
Women with less severe hypertension may not be routinely admitted and will instead be offered additional maternal and fetal monitoring on an outpatient basis.
Women with existing HTN in preg need to take what?
aspirin from 12w
If the woman is over 20 weeks’ gestation and has new proteinuria on dipstick testing but no hypertension:
this can be a symptom of impending pre-eclampsia —if there are other symptoms of pre-eclampsia, arrange same-day obstetric assessment.
If there are no other symptoms of pre-eclampsia, consider possible urinary tract infection (UTI):
- If there is [1+] protein on dipstick testing and either the woman has symptoms of a UTI, or the dipstick test is positive for nitrite or for both leucocyte esterase and blood, make a working diagnosis of UTI.
- Send a midstream specimen of urine (MSU) for culture and sensitivity
Proteinuria in pregnancy after 20w gestation: If there is [2+] protein or more on dipstick testing…
arrange urgent secondary care assessment, even if there is evidence of a possible UTI.
Proteinuria in pregnancy after 20w gestation: For women exhibiting [1+] protein on dipstick testing and no other symptoms of pre-eclampsia?
follow-up and reassess in 1 week:
Advise the woman to seek immediate medical attention if she develops symptoms of pre-eclampsia in the intervening period.
Dipstick the urine and measure the blood pressure. Use albumin:creatinine ratio or protein:creatinine ratio to quantify persistent ([1+] on dipstick) proteinuria.
Seek specialist obstetric advice if proteinuria is significant (protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol), or if there are any other concerns or uncertainty.
All women with pre-eclampsia who are discharged to primary care with abnormal blood results should have what?
repeat blood tests to measure platelet count, transaminases, and serum creatinine as clinically indicated, until results return to normal
Follow up= Women with pre-eclampsia who did not take antihypertensive treatment:
Should have their blood pressure measured at least once between days 3–5 after birth. If blood pressure is abnormal, it should then be measured on alternate days until it normalizes.
Target blood pressure is lower than 140/90 mmHg.
Antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
Follow up= Women with pre-eclampsia who took antihypertensive treatment:
Should continue receiving antihypertensive treatment.
Should have their blood pressure measured every 1–2 days for up to 2 weeks after transfer to community, care until treatment is no longer required and there is no hypertension.
If blood pressure falls below 140/90 mmHg — a reduction in treatment can be considered.
If blood pressure falls below 130/80 mmHg — treatment can be reduced.
HTN in pregnancy: If antihypertensive treatment is required in the postnatal period:
Be aware that methyldopa taken during pregnancy should ideally be stopped within 2 days of birth as it may increase the risk of depression.
For women who are not breastfeeding or planning to breastfeed, hypertension should be managed as for a member of the general population.
HTN in pregnancy: what it pt wants to breastfeed?
start enalapril post-partum or If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this sucessfully)
if not controlled then nifedipine (or amlodipine) + enalapril
ineffective then + atenolol or labetalol
What HTN drugs should be avoided in women who are breastfeeding?
diuretics and ARB
As antihypertensives can pass (in small quantities) into breastmilk, women who are breastfeeding should be advised to monitor their babies for symptoms of hypotension, such as
drowsiness, lethargy, pallor, cold peripheries, or poor feeding
HTN in pregnancy= A postnatal review 6–8 weeks after birth should be carried out in primary care or by a specialist:
All women who have had pre-eclampsia should undergo medical review of their hypertension.
A urinary reagent-strip test should be carried out. Women with [1+] proteinuria should be offered a further review in primary care or by a specialist three months after delivery to assess kidney function.
How should I follow up a woman with chronic hypertension postpartum?
Measure blood pressure (this will usually be done by the community midwife after hospital discharge):
- Daily for the first 2 days postnatally.
- At least once between days 3–5 postnatally.
- As clinically indicated if the woman’s antihypertensive treatment is changed postnatally.
Continue antihypertensive treatment if required:
Aim to keep blood pressure lower than 140/90 mmHg.
Review antihypertensive treatment 2 weeks postnatally.
Ensure that women with chronic hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.
How should I follow up a woman with gestational hypertension postpartum?
Most women with gestational hypertension will be followed up by the maternity unit after delivery until their blood pressure has returned to normal, or will be referred to a specialist if blood pressure remains elevated.
How should I follow up a woman with gestational hypertension postpartum= what should be done?
The woman’s blood pressure should be measured:
- Daily for the first 2 days postnatally.
- At least once between days 3–5 postnatally.
- As clinically indicated if the woman’s antihypertensive treatment is changed postnatally.
If continued antihypertensive treatment is required:
Target blood pressure is lower than 140/90 mmHg.
Gestational HTN follow up?
For women with gestational hypertension who did not take antihypertensive treatment and have given birth, antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
Women who remain on antihypertensive treatment postnatally should be offered a medical review in primary care, or with their specialist 2 weeks after transfer to community care.
Ensure that women with gestational hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.
Consider the possibility of imminent pre-eclampsia or eclampsia in a woman up to 4 weeks postpartum (even if she has not had previous hypertension or pre-eclampsia) if she develops any of the following:
Severe headaches (increasing frequency unrelieved by regular analgesics).
Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
Persistent new epigastric pain or pain in the right upper quadrant.
Vomiting.
Hypertension.
Proteinuria.
Breathlessness due to pulmonary oedema.
Sudden swelling of the face, hands, or feet.
Consider the possibility of eclampsia in any woman who has…
a seizure within 4 weeks of delivery.
Pre-eclampsia?
emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications.
Pre-eclampsia classic triad?
new-onset hypertension
proteinuria
oedema
Current definition of pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Potential consequences of pre-eclampsia?
eclampsia
fetal complications
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
Cx of pre-eclampsia= eclamsia?
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
Cx of pre-eclampsia= fetal Cx?
intrauterine growth retardation
prematurity
Features of severe pre-eclampsia?
hypertension: typically > 160/110 mmHg and proteinuria
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
High RFs for pre-eclampsia?
Moderate risk factors
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
Moderate RFs for pre-eclampsia?
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
Reducing the risk of hypertensive disorders in pregnancy?
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth:
≥ 1 high risk factors
≥ 2 moderate factors
Initial assessment for pre-eclampsia?
arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
Further Mx for pre-eclampsia?
oral labetalol 1st line
Nifedipine (e.g. if asthmatic) and methyldopa may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Average age of menopause?
51yrs
Menopause= climacteric?
the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail
Menopause= recommended to use effective contraception until when?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Definition of menopause?
permanent cessation of menstruation
when women has not had a period for 12m
Cause of menopause?
loss of follicular activity
Diagnosis of menopause?
clinical: not had period for 12m
Symptoms of menopause typically last for how long?
7yrs but may resolve quicker or last longer
duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.
Summarise menopause Mx into categories?
- Lifestyle modifications
- Hormone replacement therapy (HRT)
- Non-hormone replacement therapy
Menopause= Mx with lifestyle?
Hot flushes= regular exercise, weight loss, reduce stress
Sleep disturbance= avoid late evening exercise and good sleep hygiene
Mood= sleep, regular exercise and relaxation
Cognitive symptoms= regular exercise and sleep hygiene
Contraindications for HRT?
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
HRT= If the woman has a uterus then it is important not to give what?
unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.
HRT= If the woman does not have a uterus then what can be given?
oestrogen alone can be given either orally or in a transdermal patch.
HRT: Women should be advised that the symptoms of menopause typically last for how long?
2-5yrs
Risks of HRT?
VTE= a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke= slightly increased risk with oral oestrogen HRT.
Coronary heart disease= combined HRT may be associated with a slight increase in risk.
Breast cancer= there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer= increased risk with all HRT.
Mx of menopause without HRT= vasomotor symptoms?
fluoxetine, citalopram or venlafaxine
Mx of menopause without HRT= vaginal dryness?
vaginal lubricant or moisturiser
Mx of menopause without HRT= Psychological symptoms?
self-help groups, cognitive behaviour therapy or antidepressants
Mx of menopause without HRT=
Urogenital symptoms?
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
Menopause= For vasomotor symptoms, how long of HRT may be required with regular attempts made to discontinue treatment?
2-5yrs
Menopause= how long may vaginal oestrogen be used?
may need long term
Stopping HRT?
When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
When should women be referred to secondary care for menopause?
if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.
Obesity in pregnancy definition?
BMI >30 at 1st antenatal visit
Obesity in pregnancy: maternal risks?
miscarriage
venous thromboembolism
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
postpartum haemorrhage
wound infections
higher c-section rate
Obesity in pregnancy: fetal risks?
congenital anomaly
prematurity
macrosomia
stillbirth
increased risk of developing obesity and metabolic disorders in childhood
neonatal death
Obesity in pregnancy: Explain to women with a BMI of 30 or more at the booking appointment what?
how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy
Folic acid dose if pregnant women is obese (BMI >30)?
5mg not 400mcg
Mx for obesity in pregnancy?
- 5mg folic acid
- screen for gestational diabetes with OGTT at 24-28w
- if BMI >=35 then give birth in consultant led obstetric unit
- if BMI >=40 then antenatal consultation with obstetric anaesthetist and a plan made
Placenta praevia?
placenta lying wholly or partly in the lower uterine segment
what % will have low-lying placenta when scanned at 16-20 weeks gestation?
5%
but incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix
Placenta praevia= associated factors?
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
Clinical features of placenta praevia?
shock in proportion to visible loss
NO PAIN
uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large
Diagnosis of placenta praevia?
digital vaginal examination should NOT be performed before an ultrasound as it may provoke a severe haemorrhage
often picked up on the routine 20 week abdominal USS
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
Grading of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
Placenta praevia= If low-lying placenta at the 20-week scan?
rescan at 32 weeks
no need to limit activity or intercourse unless they bleed
if still present at 32 weeks and grade I/II then scan every 2 weeks
Placenta praevia= when determines the method of delivery?
final ultrasound at 36-37 weeks to determine the method of delivery
Method of delivery for placenta praevia?
elective caesarean section for grades III/IV between 37-38 weeks
if grade I then a trial of vaginal delivery may be offered
if a woman with known placenta praevia goes into labour prior to the elective caesarean section what should be done?
an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
Placenta praevia with bleeding?
admit
ABC approach to stabilise the woman
if not able to stabilise → emergency caesarean section
if in labour or term reached → emergency caesarean section
Placenta praevia prognosis?
death is now extremely rare
major cause of death in women with placenta praevia is now PPH
Placental abruption?
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
occurs in approximately 1/200 pregnancies
Placental abruption cause?
not known but associated factors:
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
Placental abruption clinical features?
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
Placental abruption Mx= Fetus alive and < 36 weeks?
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Placental abruption Mx= Fetus alive and > 36 weeks?
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Placental abruption Mx= fetus dead?
induce vaginal delivery
Cx of placental abruption?
Maternal:
- shock
- DIC
- renal failure
- PPH
Fetal:
- IUGR
- hypoxia
- death
Placental abruption prognosis?
associated with high perinatal mortality rate
responsible for 15% of perinatal deaths
Postpartum haemorrhage (PPH) is defined as?
blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
Primary PPH?
occurs within 24 hours. It affects around 5-7% of deliveries.
The causes of PPH (postpartum haemorrhage)?
4 Ts:
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Risk factors for primary PPH include?
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
Mx of PPH?
life-threatening emergency - senior members of staff should be involved immediately
ABC approach=
- two peripheral cannulae, 14 gauge
- lie the woman flat
- bloods including group and save
- commence warmed crystalloid infusion
mechanical=
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output
medical=
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
surgical= if medical options fail to control the bleeding then surgical options will need to be urgently considered
PPH Mx= ABC approach?
two peripheral cannulae, 14 gauge
lie the woman flat
bloods including group and save
commence warmed crystalloid infusion
PPH Mx= mechanical?
palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
catheterisation to prevent bladder distension and monitor urine output
PPH Mx= medical?
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
there is also interest in the role tranexamic acid may play in PPH
PPH Mx= Surgical options?
intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
PPH Mx= what medical Mx is first line? What can not be used in asthma? What can not be used in HTN?
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
Secondary PPH?
occurs between 24 hours - 12 weeks.
Secondary PPH typically due to what?
It is typically due to retained placental tissue or endometritis.
DM in pregnancy?
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes.
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes
Most common medical disorder complicating pregnancy?
HTN
then gestational diabetes
RFs for gestational diabetes?
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Test of choice to screen for gestational diabetes?
oral glucose tolerance test (OGTT)
When is the oral glucose tolerance test (OGTT) done to screen for gestational diabetes?
pt with previous gestational diabetes= OGTT asap after booking and at 24-28w if 1st test is normal
any other RFs= OFTT at 24-28w
What is also recommended as an alternative of OGTTs to test for gestational diabetes?
early self-monitoring of blood glucose
Diagnostic thresholds for gestational diabetes?
either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Mx of gestational diabetes= newly diagnosed women should be seen where?
in a joint diabetes and antenatal clinic within a week
Mx of gestational diabetes?
- diabetes and antenatal clinic within 1w
- self-monitoring of blood glucose
- advice about diet (foods with low glycaemic index) and exercise
- fasting glucose <7 at diagnosis= trial diet and exercise
- if not met within 1-2w then start metformin
- still not met= + short acting insulin
- fasting glucose >=7 at diagnosis= start insulin
- glucose 6-6.9 and evidence of Cx eg. macrosomia or hydramnios= insulin
- glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Mx of gestational diabetes= fasting glucose <7 at diagnosis?
- trial diet and exercise
- if not met within 1-2w then start metformin
- still not met= + short acting insulin
Mx of gestational diabetes= fasting glucose >=7 at diagnosis?
start insulin
Mx of gestational diabetes= glucose 6-6.9 and evidence of Cx eg. macrosomia or hydramnios?
insulin
Mx of gestational diabetes= glibenclamide should only be offered for women who?
cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Gestational diabetes= Mx of pre-existing diabetes?
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)?
Time Target
Fasting= 5.3 mmol/l
1 hour after meals= 7.8 mmol/l
or
2 hour after meals= 6.4 mmol/l
Gestation limit for abortion?
24w
When may women get termination of pregnancy after 24w?
in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman.
How is termination of pregnancy approved/who can perform?
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
When should anti-D prophylaxis be given in termination of pregnancy?
to women who is rhesus D negative and are having an abortion after 10+0 weeks gestation
Where is medical termination of pregnancy done?
can be done at home depending on gestation
How long does medical termination of pregnancy occur?
hrs to days to complete
can be unpredictable
Medical Mx for termination of pregnancy?
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
After medical Mx for termination of pregnancy, what must be done?
pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test
Surgical options for termination of pregnancy?
use of transcervical procedures to end a pregnancy, including manual
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
Termination of pregnancy= women are offered a choice between medical or surgical abortion up to and including what age of gestation?
23+6w
Choice between medical and surgical termination of pregnancy?
after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate
before 10 weeks medical abortions are usually done at home
1967 Abortion Act?
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
2 methods of abortion?
medical and surgical
Medical abortion summary?
the use of medications (mifepristone followed by misoprostol) to end a pregnancy.
Surgical abortion summary?
the use of transcervical procedures (manual vacuum aspiration, electric vacuum aspiration, or dilatation and evacuation) to end a pregnancy.
In England, Scotland, and Wales, a pregnancy can be lawfully terminated by a registered medical practitioner in an NHS hospital or premises approved for this purpose if two medical practitioners are of the opinion, formed in good faith, that either:
The pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant person or any existing children of their family.
The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant person.
Continuing the pregnancy would involve risk to the life of the pregnant person, greater than if the pregnancy were terminated.
There is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Are abortions free on NHS?
yes
How to access abortion services?
people can self-refer directly to an abortion care provider or be referred by a GP, sexual health clinic, or specialist clinic (such as Brook service)
Fibroids?
benign smooth muscle tumours of the uterus.
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Who are uterine fibroids more common in?
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Features of uterine fibroids?
may be asymptomatic
menorrhagia= may result in iron-deficiency anaemia
bulk-related symptoms=
lower abdominal pain (cramping pains, often during menstruation); bloating; urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
Subfertility
Menorrhagia
lower abdo pain, often during menstruation
bloating
urinary frequency
fibroids
Diagnosis of uterine fibroids?
transvaginal USS
Mx of asymptomatic fibroids?
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids?
- IUS= useful if the woman also requires contraception; cannot be used if there is distortion of the uterine cavity
- NSAIDs e.g. mefenamic acid
- tranexamic acid
- combined oral contraceptive pill
- oral progestogen
- injectable progestogen
Treatment to shrink/remove fibroids= medical?
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term - why?
treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Treatment to shrink/remove fibroids= surgical?
myomectomy: this may be performed abdominally, laparoscopically or
hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
Treatment to shrink/remove fibroids- options?
- medical
- surgical= myomectomy
- uterine artery embolization= if there are symptomatic fibroids and a woman wishes to avoid surgery
Prognosis of uterine fibroids?
generally regress after menopause
Cx of uterine fibroids?
subfertility and iron-deficiency anaemia
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
What are uterine fibroids?
(leiomyomas) are benign tumours which are caused by proliferation of a mixture of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium.
Fibroids size?
They can be single, multiple, of variable size, and may develop anywhere within the myometrium (subserosal, intramural, or submucosal).
Who do fibroids typically develop in?
women of reproductive age and regress after the menopause.
Uterine fibroids are commonly….
asymptomatic and may be found incidentally on pelvic examination or ultrasound scan.
RFs for fibroids?
increasing age (until the menopause); early menarche; older age at first pregnancy; comorbidities such as obesity and hypertension; black and Asian ethnicity; family history
Cx of fibroids?
iron deficiency anaemia from heavy menstrual bleeding; bladder and bowel compressive symptoms (especially with large fibroids); subfertility or infertility; obstetric complications; tortion (of a pedunculated fibroid)
Fibroids= Typical clinical features on history-taking include?
Heavy menstrual bleeding and/or dysmenorrhoea.
Pelvic pain, pressure, or discomfort; dyspareunia.
Abdominal discomfort or bloating; back pain.
Urinary symptoms, such as frequency, urgency, urinary incontinence, or retention; urinary tract infections (UTIs).
Bowel symptoms, such as bloating, constipation, and/or painful defecation.
Subfertility or infertility (particularly if there are submucosal fibroids).
Fibroids= typical clinical features on examination?
A firm, enlarged, and irregularly shaped non-tender uterus on pelvic examination.
A central irregular abdominal mass (if a large fibroid).
Assessment of a women with suspected or confirmed fibroid(s) includes?
Asking about symptoms including severity, duration, and impact on daily functioning and quality of life; previous fertility issues and hopes for future fertility; risk factors; and any previous treatments.
Performing an abdominal and bimanual pelvic examination to assess for pelvic tenderness and any mass(es).
Arranging a routine pelvic ultrasound scan to determine the number, size, and location of fibroid(s).
Checking a FBC to assess for iron deficiency anaemia if there is a history of heavy menstrual bleeding and/or symptoms of anaemia.
Fibroids: arrange an urgent referral to an appropriate specialist using a two-week cancer pathway when?
if there are any clinical or radiological features suggesting a gynaecological or other malignancy
Fibroids: arrange a referral to an appropriate specialist when?
if she has an uncertain diagnosis; severe or refractory symptoms; confirmed fibroids measuring 3 cm or more in diameter or suspected submucosal fibroids; suspected fertility or obstetric issues; rapid or unexpected growth of fibroids after the menopause.
Asymptomatic fibroids Mx?
Reassurance that no treatment is routinely needed
Ix for fibroids?
clinical
routine pelvic ultrasound scan (transabdominal and transvaginal, if needed) to determine the number, size, and location of fibroid(s), particularly if there are any of the following:
- The uterus is palpable abdominally.
- History or examination suggests a pelvic mass.
- Examination is inconclusive or difficult, for example, if a woman is obese.
Differential diagnosis for fibroids?
Malignant= ovarian ca; endometrial ca; GI malignancy
Benign= endometrial polyp or hyperplasia; adenomyosis or endometriosis; urinary retention; pregnancy; ectopic pregnancy
Chickenpox in pregnancy= risk to who?
both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Chickenpox in pregnancy= risks to the mother?
5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)?
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Features of fetal varicella syndrome?
skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Chickenpox in pregnancy= risks to fetus?
- fetal varicella syndrome
- shingles in infancy= 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Severe neonatal varicella?
chickenpox= if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= any doubt about the mother previously having chickenpox?
maternal blood should be urgently checked for varicella antibodies
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= 1st line PEP for pregnant women at any stage of pregnancy?
oral aciclovir (or valaciclovir) given at day 7 to day 14 after exposure, not immediately
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= when should oral aciclovir be given for PEP?
at day 7 to day 14 after exposure, not immediately
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= why give oral aciclovir for PEP at day 7 to day 14 after exposure, not immediately?
in a study the incidence and severity of varicella infection was significantly higher in those given aciclovir immediately (10/13 (77%) who received aciclovir immediately developed clinical varicella compared with 3/14 (21%) who started aciclovir at day 7)’
Mx of chickenpox in pregnancy= when should oral aciclovir be given if she presents with chickenpox (not exposure)?
if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
If pregnant women develops chickenpox in pregnancy, what should be sought?
specialist advice
there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of…
aciclovir in pregnancy
Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) if a pregnant woman has suspected chickenpox and any of:
Respiratory symptoms.
Neurological symptoms.
Haemorrhagic rash or bleeding.
Severe disease (for example dense rash with or without numerous mucosal lesions).
Significant immunosuppression (including recent use of systemic corticosteroids).
Chickenpox in pregnancy= Consider/discuss the need for admission with a specialist if other risk factors for severe illness and complications are present such as:
Pregnancy approaching term.
Previous obstetric complications or risk factors.
Smoking.
Chronic lung disease.
Social risk factors.
Close monitoring in the community is not possible.
Chickenpox in pregnancy- after giving oral aciclovir, what else needs to be done?
Close monitoring is needed — review daily, or earlier if her condition deteriorates and have a low threshold for considering admission. Where close monitoring in the community is not possible, admission should be considered.
If there is deterioration, fever persists, or cropping of the rash continues after 6 days, refer for urgent hospital assessment.
If a high temperature develops (particularly after initial improvement) with redness and pain surrounding the chickenpox lesions, consider bacterial superinfection and manage accordingly.
Chickenpox in pregnancy= most infectious period?
from 24 hours before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5 days after the onset of the rash)
During this time, advise a pregnant woman with chickenpox to avoid contact with:
- People who are immunocompromised (for example those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
- Other pregnant women.
- Infants aged 4 weeks or less.
Chickenpox in pregnancy= what can be given to alleviate the itch?
Topical calamine lotion.
Chlorphenamine is NOT recommended for the management of the itch of chickenpox in pregnancy.
Chickenpox in pregnancy= what can be used for fever or pain?
paracetamol NOT NSAIDs
If the woman has no history of chickenpox or shingles (or is uncertain) and has a history of significant contact, establish the stage of gestation and seek urgent specialist advice. Test for what?
varicella-zoster immunoglobulin G (IgG) antibodies
Chickenpox in pregnancy= results of varicella-zoster immunoglobulin G (IgG) antibodies if immunity unknown?
If the test shows varicella-zoster immunoglobulin G antibodies (evidence of immunity from past infection or immunization), the woman can be reassured that she is immune.
If the woman’s antibody status is negative, urgently discuss with a specialist the need for prophylaxis (antiviral treatment)
Pregnancy is a RF for developing what?
VTE
A woman with a previous VTE history is automatically considered high risk and requires what in pregnancy?
low molecular weight heparin throughout the antenatal period and also input from experts.
A pregnant woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for what?
antenatal prophylactic low molecular weight heparin.
VTE in pregnancy: The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy
VTE in pregnancy= what if pt has 4 or more RFs for VTE?
immediate treatment with low molecular weight heparin continued until six weeks postnatal
VTE in pregnancy= what if pt has 3 or more RFs for VTE?
low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
VTE in pregnancy: If diagnosis of DVT is made shortly before delivery what should be done?
continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Tx for VTE prophylaxis in pregnancy?
LMWH
Tx for VTE in pregnancy?
LMWH
Example of LMWH?
alteparin sodium, enoxaparin
What should NOT be used for VTE Tx or prophylaxis in pregnancy?
DOAC and warfarin should be AVOIDED
What should not be performed in the investigation of acute VTE in pregnancy?
D-dimer
Causes of abdominal pain in early pregnancy?
- ectopic pregnancy
- miscarriage
Causes of abdominal pain in late pregnancy?
- labour
- placental abruption
- Symphysis pubis dysfunction
- Pre-eclampsia/HELLP syndrome
- uterine rupture
Causes of abdominal pain at any stage in pregnancy?
- appendicitis
- UTI
Most important cause of abdo pain to exclude in early pregnancy?
ectopic pregnancy
What % of pregnancies are ectopic?
0.5%
RFs for ectopic pregnancy?
(anything slowing the ovum’s passage to the uterus):
- damage to tubes (salpingitis, surgery)
- previous ectopic
- IVF (3% of pregnancies are ectopic)
Types of miscarriage?
threatened
missed (delayed)
inevitable
incomplete
Threatened miscarriage?
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
cervical os is closed
complicates up to 25% of all pregnancies
Missed (delayed miscarriage)?
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable miscarriage?
cervical os is open
heavy bleeding with clots and pain
Incomplete miscarriage?
not all products of conception have been expelled
Labour pain?
Regular tightening of the abdomen which may be painful in the later stages
Symphysis pubis dysfunction?
Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
Pre-eclampsia/HELLP syndrome as cause of abdo pain?
Associated with hypertension, proteinuria. Patients with HELLP also have haemolysis, elevated liver enzymes and a low platelet count.
The pain is typically epigastric or in the RUQ
Uterine rupture- cause of abdo pain?
Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree
Appendicitis in pregnancy?
Occurs in 1:1,000-2:1,000 pregnancies, making it the most common non-obstetric surgical emergency
Higher morbidity and mortality in pregnancy
Location of pain changes depending on gestation, moving up from the RLQ in the first trimester to the umbilicus in the second and the RUQ in the third
UTI in pregnancy?
1 in 25 women develop in UTI in pregnancy
Associated with an increased risk of pre-term delivery and IUGR
Ix for gynae causes of abdo pain?
all female patients should also undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.
When diagnostic doubt persists a laparoscopy provides a reliable method of assessing suspected tubulo-ovarian pathology.
Differential diagnosis for abdo pain in females (gynae)?
- Mittelschmerz
- Endometriosis
- Ovarian torsion
- Ectopic gestation
- PID
Mittelschmerz summary?
Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
Full blood count- usually normal
Ultrasound- may show small quantity of free fluid
Tx= Conservative
Endometriosis summary?
25% asymptomatic, in a further 25% associated with other pelvic organ pathology.
Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina.
Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
Intra-abdominal bleeding may produce localised peritoneal inflammation.
Recurrent episodes are common.
Ultrasound- may show free fluid
Laparoscopy will usually show lesions
Usually managed medically, complex disease will often require surgery and some patients will even require formal colonic and rectal resections if these areas are involved
Ovarian torsion summary?
Usually sudden onset of deep seated colicky abdominal pain.
Associated with vomiting and distress.
Vaginal examination may reveal adnexial tenderness.
Ultrasound may show free fluid
Laparoscopy is usually both diagnostic and therapeutic
Mx= Laparoscopy
Ectopic pregnancy summary?
Symptoms of pregnancy without evidence of intra uterine gestation.
Present as an emergency with evidence of rupture or impending rupture.
Open tubular ruptures may have sudden onset of abdominal pain and circulatory collapse, in other the symptoms may be more prolonged and less marked.
Small amount of vaginal discharge is common.
There is usually adnexial tenderness.
Ultrasound showing no intra uterine pregnancy and beta HCG that is elevated
May show intra abdominal free fluid
Mx= Laparoscopy or laparotomy is haemodynamically unstable. A salphingectomy is usually performed.
PID summary?
Bilateral lower abdominal pain associated with vaginal discharge.
Dysuria may also be present.
Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort.
Fever >38o
Full blood count- Leucocytosis
Pregnancy test negative (Although infection and pregnancy may co-exist)
Amylase - usually normal or slightly raised
High vaginal and urethral swabs
Usually medical management
Abdo swelling= Young female
Amenorrhoea
pregnancy
Abdo swelling= History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds
Intestinal obstruction
Abdo swelling= History of alcohol excess, cardiac failure
ascities
Abdo swelling= History of prostate problems
Dullness to percussion around suprapubic area
urinary retention
Abdo pain= Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating
ovarian ca
Cervical ca screening= negative hrHPV?
return to normal recall, unless:
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
- the untreated CIN1 pathway
- follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- follow-up for borderline changes in endocervical cells
Cervical ca screening= positive hrHPV?
cytology
Cervical ca screening= cytology abnormal?
colposcopy
Cervical ca screening= colposcopy?
includes the following results:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
Cervical ca screening: if the cytology is normal (i.e. hrHPV +ve but cytologically normal)?
the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
Cervical ca screening: if sample is ‘inadequate’?
repeat the sample in 3 months
if two consecutive inadequate samples then → colposcopy
Cervical ca screening: The follow-up of patients who’ve previously had CIN?
individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
Cervical ca screening= treatment of CIN?
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia.
LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
Alternative techniques include cryotherapy.
Abx for UTI in pregnancy?
First choice is nitrofurantion 100 mg modified-release twice daily for 7 days (avoid in third trimester).
Second choice is either cefalexin 500 mg twice a day for 7 days or amoxicillin 500 mg 3 times a day for 7 days.
Primary amenorrhoea?
failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
Secondary amenorrhoea?
cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Causes of primary amenorrhoea?
- gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
Girl with amenorrhoea who has anorexia?
functional hypothalamic amenorrhoea
Most common cause of primary amenorrhoea?
gonadal dysgenesis (e.g. Turner’s syndrome)
Causes of secondary amenorrhoea (after excluding pregnancy)?
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis (hypothyroidism may also cause amenorrhoea)
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
Secondary amenorrhoea in women who does XS exercise or very stressed?
hypothalamic amenorrhoea
Ix for amenorrhoea?
exclude pregnancy with urinary or serum bHCG
FBC, U&E, coeliac screen, TFTs
gonadotrophins=
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure); raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels= raised levels may be seen in PCOS
oestradiol
Amenorrhoea with raised androgen levels?
?PCOS
Amenorrhoea with low levels of gonadotrophins?
hypothalamic cause
Amenorrhoea with raised levels of gonadotrophins?
ovarian problem (e.g. Premature ovarian failure)
or
gonadal dysgenesis (e.g. Turner’s syndrome)
Mx of primary amenorrhoea?
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
Mx of secondary amenorrhoea?
exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause
Summarise primary amenorrhoea?
failure to establish menstruation by the expected age, variably considered to be 15 or 16 years of age in girls with normal secondary sexual characteristics (such as breast development), or 13 or 14 years of age in girls with no secondary sexual characteristics.
Causes of amenorrhoea?
physiological states; outflow tract obstruction; genetic and congenital conditions; disorders of the ovaries, hypothalamus, or pituitary gland; and disorders of other endocrine glands
Most common causes of primary amenorrhoea?
anatomical abnormalities due to genetic or congenital conditions, functional hypothalamic amenorrhoea (related to eating disorders, stress, weight loss, and excessive exercise) and polycystic ovary syndrome (PCOS)
Most common causes of secondary amenorrhoea/
polycystic ovary syndrome, functional hypothalamic amenorrhoea, premature ovarian insufficiency, and hyperprolactinaemia
Amenorrhoea: The following preliminary investigations may be considered in primary care to aid diagnosis and/or guide referral:
Ultrasound.
Serum prolactin.
Thyroid-stimulating hormone.
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Oestradiol.
Total testosterone (if there are features of androgen excess).
Referral to a gynaecologist should be arranged for women with secondary amenorrhoea and any of the following:
Elevated FSH and LH levels (and younger than 40 years of age).
Recent history of uterine or cervical surgery, or severe pelvic infection.
Infertility.
Suspected PCOS where the diagnosis is unclear or where there are complications that cannot be managed in primary care.
Referral to an endocrinologist should be arranged for women with secondary amenorrhoea and any of the following:
Hyperprolactinaemia.
Low FSH and LH.
An increased testosterone level not explained by PCOS.
Features of Cushing’s syndrome or late-onset congenital adrenal hyperplasia.
Women with secondary amenorrhoea due to PCOS, hypothyroidism, menopause, or pregnancy should be managed in
primary care if appropriate
Amenorrhoea caused by weight loss, excessive exercise, stress, or chronic illness may be managed in primary care after what?
endocrinologist has assessed and excluded other hypothalamic or pituitary causes (such as a tumour). However, if an eating disorder is suspected, a prompt referral should be made to an age-appropriate community eating disorders service.
When to suspect primary amenorrhoea?
Girls who have not established menstruation by the age of 13 years and have no secondary sexual characteristics (such as breast development).
Girls who have not established menstruation by the age of 15 years and have normal secondary sexual characteristics.
Girls who have not established menstruation within 3 years of the start of breast development (thelarche), or within 5 years if breast budding occurred before the age of 10.
Amenorrhoea= pelvic USS showing uterus present?
normal secondary sexual characteristics= outflow obstruction (for example, imperforate hymen or transverse vaginal septum) and polycystic ovary syndrome (PCOS).
no secondary sexual characteristics= Turner’s syndrome (46XO; ‘streak’ ovaries only) and gonadal agenesis (46XX or 46XY).
Amenorrhoea= pelvic USS shows Absent or abnormal uterus?
could be caused by androgen insensitivity syndrome.
Amenorrhoea= Prolactin levels greater than … mIU/L usually warrant further investigation by an endocrinologist
1000
Amenorrhoea= causes of prolactin levels >1000?
usually magnetic resonance imaging [MRI] of the pituitary fossa is required
pituitary adenoma, empty sella syndrome, hypothyroidism, and drugs (including antipsychotics [particularly risperidone], antidepressants [particularly selective serotonin reuptake inhibitors], and antiemetics [such as metoclopramide or domperidone]).
Amenorrhoea= raised prolactin- The most common causes of mild hyperprolactinaemia in primary care are?
stress and medications (such as antipsychotics).
Amenorrhoea= other causes of raised prolactin?
Pregnancy and breastfeeding.
Needle phobia or traumatic venesection (can double or occasionally quadruple basal prolactin concentrations).
Vigorous exercise within 30 minutes of the blood sample being taken.
PCOS (in 10–20% of people; rarely above 1000 mIU/L).
Renal impairment (occasionally associated with mild hyperprolactinaemia; typically less than 2000 mIU/L).
Hypothyroidism (uncommon, often still within the reference range and only rarely above 1200 mIU/L).
Amenorrhoea= peristent moderate elevations in prolactin?
?pituitary adenomas.
Amenorrhoea= causes if FSH and LH normal?
?outflow obstruction
(although they can be normal in other common causes such as functional hypothalamic amenorrhoea and PCOS).
Amenorrhoea= FSH and LH with absent secondary sexual characteristics are absent?
karyotyping in secondary care may be necessary.
- Short stature and high FSH and LH levels suggest Turner’s syndrome.
- Short stature and low FSH and LH levels suggest an intracranial lesion, for example, hydrocephalus.
- Normal height and high FSH and LH levels suggest ovarian failure (normal karyotype) or 46XY (abnormal karyotype).
- Normal height and low FSH and LH levels suggest constitutional delay, weight loss, anorexia nervosa, or excessive exercise.
Amenorrhoea= high total testosterone?
(refer to local laboratory reference range) warrant investigation to exclude androgen insensitivity (46XY genotype, female phenotype), late-onset congenital adrenal hyperplasia, Cushing’s syndrome, or an androgen-secreting tumour.
Amenorrhoea= moderately high total testosterone?
may be seen in PCOS.
Secondary amenorrhoea= low oestradiol
normal/low FSH
normal/low LH
high prolactin
normal testosterone
hyperprolactinaemia
Secondary amenorrhoea= normal/high/low oestradiol
normal FSH
normal/slightly increased LH
normal/slightly increased prolactin
Normal/moderately increased testosterone
Free androgen index increased
PCOS
Secondary amenorrhoea= low oestradiol
high FSH
high LH
normal prolactin
normal/low testosterone
premature ovarian insufficiency
Secondary amenorrhoea= low oestradiol
normal/low FSH
normal/low LH
normal/low prolactin
normal/low testosterone
Functional hypothalamic (for example weight loss, excessive exercise, or stress)
PCOS defined on USS as?
presence of 20 or more follicles in at least one ovary
Secondary amenorrhoea= high testosterone?
High levels of total testosterone (refer to local laboratory reference ranges) warrant investigation to exclude other causes, such as Cushing’s syndrome, late-onset congenital adrenal hyperplasia, or an androgen-secreting tumour.
A moderately increased testosterone level or free androgen index may be seen in PCOS.
Secondary amenorrhoea= high FSH and LH?
suggest premature ovarian insufficiency (POI) in women younger than 40 years of age. Diagnosis of POI is confirmed by oligo/amenorrhoea for at least 4 months and elevated FSH (>25 IU/l) on two occasions at least 4 weeks apart.
Secondary amenorrhoea= normal or low FSH and LH?
suggest hypothalamic causes (weight loss, excessive exercise, stress, or rarely, a hypothalamic or pituitary tumour).
Secondary amenorrhoea= normal FSH and normal/moderatley increased LH?
PCOS
Secondary amenorrhoea= examine for?
BMI
Cushing’s syndrome (striae, buffalo hump, significant central obesity, easy bruising, hypertension, and proximal muscle weakness).
Thyroid disease.
Excess androgens (hirsutism and acne) or virilization (hirsutism, acne, deep voice, temporal balding, increase in muscle bulk, breast atrophy, and clitoromegaly).
Adrenal insufficiency (orthostatic hypotension, pigment changes, and decreased axillary or pubic hair).
Decreased endogenous oestrogen (reddened or thin vaginal mucosa).
If appropriate, examine for galactorrhoea (suggesting raised prolactin levels).
Assess visual fields (if a pituitary tumour is suspected).
2 types of barrier methods?
condoms (male and female)
diaphragms & cervical caps
Efficacy definition in terms of contraception?
percentage of women experiencing an unintended pregnancy within the first
year of use
Efficacy of male condoms?
perfect use - 98%, typical use - 80%
Efficacy of female condoms?
95%, typical use - 80%
Efficacy of diaphragms and cervical caps?
if used with spermicide then 92-96%
What should not be used with latex condoms?
oil based lubricants
What condoms should be used in pts allergic to latex?
polyurethane condoms
Advantages of combined oral contraceptive pill?
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill?
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen
Does the COCP cause weight gain?
not found to but some users do report to
How does the COCP vary?
by amount of oestrogen and progestogen and by presentation eg. everyday pill/phasic presentation, patches etc
COCP for first time users?
consider using a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone (e.g. Microgynon 30 - ethinylestradiol 30 mcg with levonorgestrel 150 mcg)
2 new COCPs developed in recent years?
work slightly differently compared to traditional pills - Qlaira and Yaz.
New COCP: Qlaira?
combination of estradiol valerate (as opposed to the usual ethinylestradiol) and dienogest. It has a quadraphasic dosage regimen which is designed to give optimal cycle control. Users take a pill everyday of a 28 day cycle, with 26 of the pills containing estradiol +/- dienogest and 2 of the pills being inactive. During the cycle the dose of estradiol is gradually reduced and that of dienogest is increased
New COCP: Qlaira= levels of estradiol and dieongest depending on day of cycle?
day 1-2= 3mg E and no D
3-7= 2mg E and 2mg D
8-24= 2mg E and 3mg D
25-26= 1mg E and no D
27-18= no E or D
New COCP: Qlaira= aim?
give women a more ‘natural’ cycle with more constant oestrogen levels. The efficacy is similar to that of other COCPs with a Pearl Index of 0.4 failures per 100 women-years in subjects aged 18-35 years
New COCP: Qlaira= disadvantages?
cost: currently £8.39 per month, which is considerably more than some standard COCPs which can cost < 70p per month
limited safety data to date. For the time being the FSRH
suggest using standard COCP UKMEC critera
there are different missed pill rules
New COCP: Qlaira= missed pill rules?
If a pill is taken 12 hours late it is classed as ‘missed’ (compared to 24 hours for standard COCPs).
If a woman has missed more than 2 pills
emergency contraception may be needed
New COCP: Qlaira= missed pill rules depending on day?
Day 1-17= Take missed pill immediately and the next tablet at the usual time (even if means taking two on same day). Continue with the tablet taking in the normal way
Abstain or use an additional contraceptive method for 9 days
18-24= Discard the rest of the packet. Start taking the Day 1 pill from a new packet immediately and continue
taking these pills at the correct time. Abstain or use an additional contraceptive method for 9 days
25-26= Take the missed tablet immediately and the next tablet at the usual time
(even if it means taking two tablets on the same day). Additional contraception is not necessary.
27-28= Discard the forgotten table and continue tablet taking in the normal way.
Additional contraception is not necessary.
New COCP: Yaz?
product combining 20mcg ethinylestradiol with 3mg drospirenone is soon to be launched in the UK. In the US and Europe it is branded as Yaz and has an interesting 24/4 regime, as opposed to the normal 21/7 cycle. The idea is that a shorter pill-free interval is both better for patients with troublesome premenstrual symptoms and is also more effective at preventing ovulation. Studies have shown Yaz causes less pre-menstrual syndrome and blood loss reduced by 50-60%.
There are many conditions which may affect choice of contraceptive; reference will be made to what?
UKMEC recommendations on contraceptions made by the Faculty of Sexual and Reproductive Health (FSRH)
How many types of UKMEC are there?
1 (no risk), 2, 3 and 4
UKMEC 2?
advantages generally outweigh the disadvantages
UKMEC 3?
disadvantages generally outweigh the advantages
UKMEC 4?
represents an unacceptable health risk
COCP= smoking and COCP use can increase risk of what?
CVD disease
UKMEC 2 for COCP and smoking?
age <35yrs + smoke
UKMEC 3 for COCP and smoking?
age > 35 years and smoking < 15 cigarettes/day
UKMEC 4 for COCP and smoking?
age > 35 years and smoking > 15 cigarettes/day
UKMEC if pt is smoking and wants progesterone pill?
no increased CVD risk with progesterone only so UKMEC 1 regardless of age/smoking
UKMEC for COCP and obesity?
UKMEC 2: BMI 30-34 kg/m²
UKMEC 3: BMI >= 35 kg/m²
All other methods of contraception have a UKMEC of 1.
COCP and UKMEC for migraine?
COCP contraindicated (i.e. UKMEC 4) in patients with a history of migraine with aura.
For patients who have migraines without aura the recommendation by the FSRH is that the COCP is UKMEC 3 for continued prescribing and UKMEC 2 for initiation.
Progestogen only methods such as the progestogen-only pill (POP), implant and injection are UKMEC 2 and are hence better choices.
Factors to consider for contraception and epilepsy?
the effect of the contraceptive on the effectiveness of the anti-epileptic medication
the effect of the anti-epileptic on the effectiveness of the contraceptive
the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
Contraceptive advise for pt with epilepsy?
consistent use of condoms + other form of contraception
Contraception & epilepsy= for women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine?
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
Contraception & epilepsy= for women taking lamotrigine?
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
Contraception & epilepsy= if a COCP is chosen then it should contain what?
minimum of 30 µg of ethinylestradiol.
What is UKMEC?
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale.
UKMEC 1?
condition for which there is no restriction for the use of the contraceptive method
Examples of UKMEC 3 conditions?
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Examples of UKMEC 4 conditions?
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
UKMEC and DM?
diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
UKMEC and breastfeeding?
breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled in a number of areas such as?
- potential harms and benefits
- advice on taking the pill
- discussion on situations where efficacy may be reduced
- discussion on STIs
- concurrent Abx use
Couselling/advice before starting COCP: Potential harms and benefits?
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
How to take the COCP?
Should be taken at same time every day.
‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break.
Do you need additional contraception when u start the COCP?
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
COCP= is intercourse during the pill-free period safe?
only if the next pack is started on time
When may efficacy be reduced when taking the COCP?
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
Do Abx affect the COCP?
no
only enzyme inducing Abx eg. rifampicin
COCP= what if 1 pill is missed at any time in the cycle?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
COCP= what if 2 or more pills are missed?
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
COCP= what if 2 or more pills are missed in week 1 (days 1-7)?
emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
COCP= what if 2 or more pills are missed in week 2 (days 8-14)?
after seven consecutive days of taking the COC there is no need for emergency contraception
(theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off)
COCP= what if 2 or more pills are missed in week 3 (days 15-21)?
she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
theoretically women would be protected if they took the COC in a pattern of…
7 days on, 7 days off
COCP mode of action?
main: stops ovulation
also: thickens cervical mucus (reducing chance of semen entering uterus) and thins endometrial lining (reducing chance of implantation)
Are any contraceptives contraindicated by age alone?
no
All methods are UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years).
Combined oral contraceptive pill (COCP) in women >40yrs?
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
Depo-Provera in women >40yrs?
women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
Stopping contraception= Non-hormonal (e.g. IUD, condoms, natural family planning) in women <50?
stop after 2yrs of amenorrhoea
Stopping contraception= Non-hormonal (e.g. IUD, condoms, natural family planning) in women >=50?
stop after 1yr of amenorrhoea
Stopping contraception= COCP in women <50?
can be continued to 50yrs
Stopping contraception= COCP in women >=50?
switch to non-hormonal or progestogen only method
Stopping contraception= Depo-Provera in women <50?
can be continued to 50yrs
Stopping contraception= Depo-Provera in women >=50?
Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice (to do with HRT)
Stopping contraception= implant, POP, IUS in women <50?
can be continued beyond 50yrs
Stopping contraception= implant, POP, IUS in women >=50?
continue
if amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
HRT and contraception?
HRT cannot be relied upon for contraception so a separate method of contraception is needed.
POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium).
In contrast the IUS is licensed to provide the progestogen component of HRT.
Methods of contraception?
barrier methods
daily methods
long-acting methods of reversible contraception (LARCs)
Barrier methods of contraception?
condoms
Daily methods of contraception?
COCP and progesterone only pill (POP)
Long-acting methods of reversible contraception (LARCs)?
implantable contraceptives
injectable contraceptives
intrauterine system (IUS): progesterone releasing coil
intrauterine device (IUD): copper coil
Condoms= method of action?
Physical barrier
Relatively low success rate, particularly when used by young people
Help protects against STIs
COCP= method of action?
Inhibits ovulation
Increases risk of venous thromboembolism
Increases risk of breast and cervical cancer
Progestogen-only pill (excluding desogestrel)= method of action?
Thickens cervical mucus
Irregular bleeding a common side-effect
Injectable contraceptive (medroxyprogesterone acetate)= method of action?
Primary: Inhibits ovulation
Also: thickens cervical mucus
Lasts 12 weeks
Implantable contraceptive (etonogestrel)= method of action?
Primary: Inhibits ovulation
Also: thickens cervical mucus
Irregular bleeding a common side-effect
Last 3 years
Intrauterine contraceptive device= method of action?
Decreases sperm motility and survival
Intrauterine system (levonorgestrel) (IUS)= method of action?
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
Irregular bleeding a common side-effect
desogestrel (type of progestogen-only pill)= method of action?
primary: inhibits ovulation
(as well as thickens cervical mucus)
Emergency contraception= levonorgestrel mode of action?
inhibits ovulation
Emergency contraception= Ulipristal mode of action?
inhibits ovulation
Emergency contraception= intrauterine contraceptive device (IUD)?
Primary: Toxic to sperm and ovum
Also: Inhibits implantation
Obesity increases the risk of what when on COCP?
VTE
UKMEC for COCP and obesity?
UKMEC 2: BMI 30-34 kg/m²
UKMEC 3: BMI >= 35 kg/m²
Combined contraceptive patch may be less effective in pts over what weight?
90kg
What methods of contraceptive have a UKMEC of 1 if pt is obese?
all except COCP (and patch less effective if >90%)
Contraception for pts who have had a gastric sleeve/bypass/duodenal switch?
cannot have oral contraception ever again due to lack of efficacy, including emergency contraception.
What does quick starting contraception mean?
starting contraception at any time other than the start of the menstrual cycle.
All methods of contraception can be quick started at any time in the menstrual cycle if it is reasonably certain that there is no risk the woman could be
pregnant
If any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
no intercourse since the start of the last menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
correct and reliable contraception use
within 5 days onset of a normal menstrual period
< 21 days post-partum (non-breastfeeding)
fully breastfeeding, amenorrheic, <6 months post-partum
within the first 5 days after an abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease
not had intercourse for >21 days and urine pregnancy test is negative
The combined oral contraceptive pill, progestogen-only pill, and progestogen-only injectable/implant are safe without extra precautions if started on
days 1-5 of the menstrual cycle and days 1-7 for the levonorgestrel intrauterine system.
When starting hormonal methods, additional contraceptive precautions (condoms or abstinence) may be required depending on the day of the menstrual cycle (see table below). For example, when starting the combined oral contraceptive (COC) from day…
6 onwards then an additional 7 days of extra precautions are required.
Days of additional contraception needed when starting COCP?
7
Days of additional contraception needed when starting POP?
2
Days of additional contraception needed when starting progestogen only injectable and implant?
7
Days of additional contraception needed when starting IUS?
7
Days of additional contraception needed when starting IUD?
0
Days of additional contraception needed when starting COCP on day 6+ of menstrual cycle?
7
Days of additional contraception needed when starting POP on day 6+ of menstrual cycle?
2
Days of additional contraception needed when starting injection or implant on day 6+ of menstrual cycle?
7
Days of additional contraception needed when starting IUS on day 8+ of menstrual cycle?
7
Days of additional contraception needed when starting IUD on any day of menstrual cycle?
0
Quick starting contraception aka
emergency contraception
Name 3 types of emergency contraception?
Levonorgestrel
Ulipristal acetate
Copper IUD
Levonorgestrel for emergency contraception?
UPSI within 72hrs (3d) and copper IUD unsuitable or declied
Levonorgestrel for emergency contraception= when can POP or progestogen only implant be started after?
immediately
Ulipristal acetate for emergency contraception?
UPSI within 120hrs (5d) and copper IUD unsuitable or declined
Ulipristal acetate for emergency contraception= when can take progestogen contraception after taking?
5 days
Copper IUD for emergency contraception?
Unprotected sex within the last 5 days / within 5 days of the earliest estimated date of ovulation
Copper IUD for emergency contraception= when fitted it is…
immediately effective for ongoing contraception
1st line for emergency contraception?
copper IUD
How long after UPSI should a pregnancy test be taken (took emergency contraception)?
21d
What does transgender mean?
someone whose gender identity is not congruent with the sex they were assigned at birth
Transgender women?
someone who was assigned the sex of male but identifies as a woman
Transgender man?
assigned the sex of female but identifies as a man
Nonbinary?
describes any gender identity which does not fit the male and female binary.
Transgender and non-binary people= condoms?
Condoms and dental dams are recommended to all individuals at risk of sexually transmitted infections. Condoms may be considered as a contraceptive choice, but efficacy in prevention of pregnancy may be considered sub-optimal, with a failure rate quoted as 18% with typical use (2% failure rate with perfect use).
Transgender and non-binary people= cervical screening?
for all sexually active individuals with uterus
Transgender and non-binary people= HPV vaccines?
all sexually active individuals
Transgender and non-binary people= individuals engaging in anal sex and rimming should be advised the risk of what?
hep A and B and offered vaccinations
Transgender and non-binary people= individuals at risk of HIV transmission should be advised of what?
availability of pre-exposure prophlyaxis (PrEP) and post-exposure prophylaxis (PEP) as required
What type of contraception would be permanent and not affect hormonal therapy if pt if transgender/non-binary?
may already have hysterectomy or bilateral orchiectomy
if not then fallopian tube occlusion or vasectomy
regular contraception in patients assigned female at birth and with a uterus?
Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects.
Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy.
Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.
Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.
In patients assigned female at birth where there is a risk of pregnancy following unprotected vaginal intercourse and the patient would like to avoid an unplanned pregnancy, what emergency contraception?
Either of the available oral emergency contraceptive options may be considered as it is believed that neither oral formulation interacts with testosterone therapy. In addition, the non-hormonal intrauterine device may be considered, however, this may have unacceptable side effects in some patients.
In patients assigned male at birth, contraception?
oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients assigned male at birth engaging in vaginal sex wishing to avoid the risk of pregnancy.
Age of consent in UK?
16
children under the age of 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger…
child protection measures
When may contraceptive advice be offered to pt under 16yrs?
if doctor feels they are ‘competent’
assessed using the Fraser guidelines
The Fraser Guidelines state that all the following requirements should be fulfilled:
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
young people should be advised to have STI tests when?
2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)
Choices of contraception for young people?
long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication
however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice
the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people
Mode of action of levonorgestrel?
acts both to stop ovulation and inhibit implantation
Dose of levonorgestrel for emergency contraception?
1.5mg (a progesterone)
When should the dose of levonorgestrel be doubled (to 3mg)?
if BMI >26 or weight over 70kg
or if taking enzyme-inducing drugs (although a copper IUD as emergency contraception is preferable in this situation)
When may you need to take another dose of levonorgestrel for emergency contraception?
if vomit within 3hrs of taking
Can you take more than one dose of levonorgestrel more than once in a menstrual cycle if indicated?
yes
when can hormonal contraception be started after using levornogestrel (Levonelle) for emergency contraception?
immediately
Mode of action of ulipristal for emergency contraception?
inhibition of ovulation
Brand name of levorgestrel for emergency contraception?
EllaOne
Dose of ulipristal for emergency contraception?
30mg oral
When can pt start/restart contraception after taking ulipristal for emergency contraception?
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
Who is ulipristal indicated in?
pts with severe asthma
Can ulipristal be used more than once in same cycle?
yes
Can pts breastfeed after taking ulipristal or levonorgestrel for emergency contraception?
ulipristal= delay for 1w after taking
levonorgestrel= no restrictions
Most effective form of emergency contraception?
copper IUD
What if criteria for copper IUD for emergency contraception not met?
if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered
in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
When can copper IUD be fitted for emergency contraception?
within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
Copper IUD mode of action for emergency contraception?
inhibit fertilisation or implantation
What may be given as well as copper IUD for emergency contraception?
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
How effective is emergency contraception?
copper IUD= 99%
levnorgestrel= 84%
How long can copper IUD be left in situ once fitted for emergency contraception?
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
Implanon was the original non-biodegradable subdermal contraceptive implant which has been replaced by…
Nexplanon
Nexplanon is the same as Implanon (implantable contraceptives). The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Mode of action of implantable contraceptives eg. Nexplanon?
Both versions slowly releases the progestogen hormone etonogestrel.
The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.
Where is the implantable contraceptive eg. Nexplanon fitted?
They are typically inserted in the proximal non-dominant arm, just overlying the tricep.
Most effective form of contraception?
Implantable contraceptive (Nexplanon)
highly effective: failure rate 0.07/100 women-years
How long does Implantable contraceptive (Nexplanon)
last?
3yrs
Can Implantable contraceptive (Nexplanon)
be used if PMH of VTE, migraine ect?
yes as doesnt contin oestrogen
When can Implantable contraceptive (Nexplanon)
be inserted following termination of pregnancy?
immediately
Implantable contraceptive (Nexplanon) disadvantages?
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
Implantable contraceptive (Nexplanon) adverse effects?
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
‘progestogen effects’: headache, nausea, breast pain
‘progestogen effects’
headache, nausea, breast pain
Implantable contraceptive (Nexplanon) interactions?
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Implantable contraceptive (Nexplanon) contraindications?
UKMEC 3: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
UKMEC 4: current breast cancer
Main injectable contraceptive?
Depo Provera
Depo Provera (injectable contraceptive) contains what?
medroxyprogesterone acetate 150mg
Depo Provera (injectable contraceptive) is given how?
IM injection every 12w
can be given up to 14w after last dose without need for extra precautions (BNF says do preg test if given after 12w and 5d)
Noristerat?
another form of injectable contraceptive given every 8w but rarely used
Mode of action of Depo Provera (injectable contraceptive)?
main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Disadvantages of Depo Provera (injectable contraceptive)?
injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
What contraception has a delay of fertility after stopping for up to 12m?
Depo Provera (injectable contraceptive)
Adverse effects of Depo Provera (injectable contraceptive)?
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
What contraceptive can cause weight gain?
Depo Provera (injectable contraceptive)?
Contraindications for Depo Provera (injectable contraceptive)?
current breast ca (UKMEC 4) and past breast ca is UKMEC 3
Intrauterine contraceptive devices includes?
copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirenaµ)
2 uses of IUS?
contraception and in Mx of menorrhagia
How effective are the IUD and IUS?
99%
What contains hormones (levonorgestrel)- IUD or IUS?
IUS
Mode of action of IUD?
prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
Mode of action of IUS?
levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
How long is IUD effective?
majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years
How effective is IUS?
the most common IUS (i.e. Mirenaµ - levonorgestrel 20 mcg/24 hrs) is effective for 5 years
if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years
When can IUD be relied upon for contraception?
immediately following insertion
How until long can the IUS be relied upon for contraception?
7d after insertion
Cx of IUD and IUS?
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
New IUS system?
The Jaydessµ IUS is licensed for 3 years. It has a smaller frame, narrower inserter tube and less levonorgestrel (LNG) than the Mirenaµ coil (13.5 mg compared to 52 mg). This results in lower serum levels of LNG.
The Kyleenaµ IUS has 19.5mg LNG and is also smaller than the Mirenaµ but is licensed for 5 years. It also results in lower serum levels of LNG. The rate of amenorrhoea is less with Kyleenaµ compared to Mirenaµ.
UKMEC 3 for IUD or IUS? (risks outweigh benefits)
between 48 hours and 4 weeks postpartum (increased risk of perforation)
initiation of method in women with ovarian cancer
UKMEC 4 for IUD and IUS? (unacceptable risk)
pregnancy
current pelvic infection, puerperal sepsis, immediate post-septic abortion
unexplained vaginal bleeding which is suspicious
uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
What UKMEC is current VTE (on anticoag) for IUD and IUS?
UKMEC 1 (used to be 3)
screening for sexually transmitted infections (STI) before insertion of an intrauterine contraceptive device?
Chlamydia trachomatis in women at risk of STIs
Neisseria gonorrhoeae in women at risk of STIs, in areas where it is prevalent
any STIs in women who request it
For women at increased risk of STIs what should be given before inserting an intrauterine contraceptive device if testing has not yet been completed
prophylactic antibiotics
After giving birth, when do women need contraception?
after day 21
When can women start POP after giving birth (breastfeeding and non-breastfeeding)?
any time
additonal contracpetion for 2d after starting if after day 21
Can women on POP breastfeed?
small amount of progestogen enters breast milk but this is not harmful to the infant
When is COCP absolutely contraindicated after giving birth (UKMEC 4)?
if breastfeeding or <6w post-partum
COCP if breastfeeding 6w-6m postpartum?
UKMEC 2
Why should COCP not be used in first 21d post partum?
increased risk of VTE
Can COCP be used when breastfeeding?
can reduce breast milk production
When can COCP be used after giving birth?
after 6w
When can IUD or IUS be inserted after giving birth?
within 48 hours of childbirth or after 4 weeks
Lactational amenorrhoea method (LAM) for contraception?
98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of…
preterm birth, low birth weight and small for gestational age babies.
Contraindications to breastfeeding?
drugs
galactosaemia
viral infections
What drugs can be given to mothers who are breastfeeding?
antibiotics: penicillins,
cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics (AVOID CLOZAPINE)
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
what antipsychotic should be avoided in breastfeeding?
clozapine
What drugs should be avoided in breastfeeding?
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
clozapine
Techniques to suppress lactation?
stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline is the medication of choice if required
What drug can be used to suppress lactation if not wanting to breastfeed?
cabergoline
HRT purpose?
involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side effects of HRT?
nausea
breast tenderness
fluid retention and weight gain
Potential Cx of HRT?
increased risk of…
- breast ca
- endometrial ca
- VTE
- stroke
- ischaemic heart disease if taken more than 10yrs after menopause
What hormone eg. in HRT increases risk of breast ca?
progesterone
The risk of breast cancer begins to decline when HRT is…
stopped and by 5 years it reaches the same level as in women who have never taken HRT
Oestrogen by itself should not be given as HRT to…
women with uterus
How to longer the risk of endometrial ca with HRT?
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
he additional risk is eliminated if a progestogen is given continuously
What in HRT increases risk of VTE?
addition of a progestogen
What form of HRT does not increase risk of HRT?
transdermal
oral increases VTE risk
NICE state women requesting HRT who are at high risk for VTE should be…
referred to haematology before starting any treatment (even transdermal)
Up to 50% of women who are going through the menopause use what?
complementary or alternative medicines to try and alleviate their symptoms
Menopause complementary or alternative medicines= Black Cohosh?
Herbal medicine from a North American plant Actaea racemosa
The Medicines and Healthcare products Regulatory Agency (MHRA) has given a preparation of Black Cohosh called Menoherb a Traditional Herbal Registration for the relief of menopausal symptoms
The most important adverse effect to inform women about is the risk of liver toxicity
The results of randomised controlled trials have been mixed
Menopause complementary or alternative medicines= Black Cohosh adverse effect?
risk of liver toxicity
Menopause complementary or alternative medicines= Evening primrose oil?
may potentiate seizures
Menopause complementary or alternative medicines= Ginseng?
may cause sleep problems and nausea
Menopause complementary or alternative medicines= Red clover?
Contains a type of phytoestrogens
Theoretical risk of endometrial hyperplasia and stimulating hormone-sensitive cancers
Menopause complementary or alternative medicines= Dong Quai?
Type of Chinese medicine
May cause photosensitivity and interfere with warfarin metabolism
HRT= uterus + LMP <1yr ago?
Elleste-duet (pill) or
Evorel Sequi (patch)
(estradiol + northisterone)
HRT= uterus and LMP >1yr ago?
Elleste-duet Conti (pill) or
Evorel Conti
(estradiol + northisterone)
HRT= no uterus (regardless of LMP)?
Elleste-Solo (pill) or
Evorel Solo (patch)
(estradiol)
When are symptoms of menopause seen?
in the climacteric perioid
What causes the symptoms of menopause?
reduced levels of female hormones, principally oestrogen
Menopause= change in periods?
change in length of menstrual cycles
dysfunctional uterine bleeding may occur
Menopause= types of symptoms?
change in periods
vasomotor symptoms (80%)
urogenital changes (35%)
psychological
longer term Cx
Menopause= vasomotor symptoms?
affects around 80% of women. Usually occur daily and may continue for up to 5 years
hot flushes
night sweats
Menopause= urogenital changes?
vaginal dryness and atrophy
urinary frequency
Menopause= psychological?
anxiety and depression may be seen - around 10% of women
short-term memory impairment
Menopause= longer term Cx?
osteoporosis
increased risk of ischaemic heart disease
Ix for menopause if = women aged over 45 years with atypical symptoms; aged between 40–45 years with symptoms; and younger than 40 years with suspected POI (premature ovarian sufficiency)?
FSH
Management of women requesting hormone replacement therapy (HRT) should include:
Enabling an informed choice of preparation, based on age, symptoms, and co-morbidities, including discussion of risks, benefits, adverse effects, and contraindications.
Prescribing the lowest dose for the shortest possible duration.
Offering an oestrogen plus progestogen preparation for women with a uterus, or oestrogen-only preparation for women without a uterus.
Offering low-dose vaginal oestrogen first-line for urogenital symptoms.
Arranging regular review to assess the efficacy and tolerability of treatment(s), adjusting the dose or preparation if needed, and advice on stopping HRT.
Menopause= Management of women where HRT is not tolerated or contraindicated should include?
Offering antidepressants, clonidine, gabapentin, and/or cognitive behavioural therapy (CBT) for vasomotor symptoms, depending on her wishes and local service provision.
Offering self-help resources and CBT for mood disorders and problems with sleep.
Vaginal moisturizers and/or lubricants for urogenital symptoms.
Arranging regular review to assess the efficacy and tolerability of treatment(s).
Menopause= Referral to a specialist should be offered if there?
Are ongoing symptoms despite treatment.
Are persistent, troublesome adverse effects.
Is uncertainty about the most suitable treatment option.
Is uncertainty about the diagnosis or management of POI.
Is a need for psychological treatment for people who have experienced an early menopause.
Initial change to the menstrual pattern in menopause?
the menstrual cycle length may shorten to 2–3 weeks or lengthen to many months. The amount of menstrual blood loss may change, and commonly increases slightly.
Hot flushes/night sweats (vasomotor symptoms) in menopause?
A sudden feeling of heat in the upper body (face, neck, and chest) that spreads upwards and downwards. In some cases, this becomes generalized, typically lasting 2–4 minutes, and can be associated with excessive sweating, palpitations, or anxiety.
They can be embarrassing and distressing, and triggers may include spicy food and alcohol.
If testing FSH to diagnose menopause, what should the women NOT be on?
hormonal contraception or HRT
If the FSH level is in the premenopausal range, the woman should…
continue contraception and the FSH level should be rechecked in 1 year.
single elevated serum FSH level (more than 30 IU/L) indicates a degree of ovarian insufficiency, but not necessarily sterility. The British Menopause Society (BMS) recommends checking for an….
elevated FSH level on two blood samples taken 4–6 weeks apart.
Do you routinely use FSH to diagnose menopause?
no, usually clinical
Mx for urogenital symptoms of menopause?
low dose vaginal oestrogen for as long as needed
Non HRT Mx for vasomotor symptoms in menopause?
clonidine (alpha-2 adrenergic receptor agonist) or SSRI
How to stop HRT?
gradually reduce over 3-6m or stop suddenly depending on preference
Increased risk of VTE/BMI >30 and considering HRT?
transdermal over oral
Risks of HRT?
- VTE (oral>transdermal)
- small increased risk stroke if oral and if higher oestrogen & longer duration but not if <60
- increased risk of breast ca with combined
Benefits of HRT?
- fragility fractures decreased
- may improve muscle mass and strength
Dysmenorrhoea?
excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea?
no underlying pelvic pathology
How common is primary dysmenorrhoea?
up to 50% of menstruating women and usually appears within 1-2 years of the menarche.
What is thought to be partially responsible for primary dysmenorrhoea?
Excessive endometrial prostaglandin production
Features of primary dysmenorrhoea?
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
Mx of primary dysmenorrhoea?
1st line= NSAIDs eg. mefenamic acid or ibuprofen work in up to 80%
2nd= COCP
How do NSAIDs work to Mx primary dysmenorrhoea?
inhibit prostaglandin production
Secondary dysmenorrhoea?
typically develops many years after the menarche and is the result of an underlying pathology
When does the pain develop in secondary dysmenorrhoea?
usually starts 3-4 days before the onset of the period
Causes of secondary dysmenorrhoea?
endometriosis
adenomyosis
pelvic inflammatory disease
copper IUD
fibroids
Mx for secondary dysmenorrhoea?
refer all patients with secondary dysmenorrhoea to gynaecology for investigation.
Pain in primary vs secondary dysmenorrhoea?
Primary= typically starts just before or within a few hours of the period starting
Secondary= usually starts 3-4 days before the onset of the period.
Summarise primary dysmenorrhoea?
occurs in the absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain.
Summarise secondary dysmenorrhoea?
caused by an underlying pelvic pathology (such as endometriosis, fibroids, or pelvic inflammatory disease [PID]) or by intrauterine device (IUD) insertion.
RFs for primary dysmenorrhoea (or more severe episodes) ?
earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea.
What must be done before diagnosing primary dysmenorrhoea?
exclude secondary causes
Type of pain in primary dysmenorrhoea?
usually starts 6–12 months after the menarche once cycles are regular.
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
The pain is usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynaecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain.
Pelvic examination is normal.
Type of pain in secondary dysmenorrhoea?
starts after several years of painless periods.
The pain is not consistently related to menstruation and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
Other gynaecological symptoms (such as dyspareunia) are often present.
Pelvic examination may be abnormal, but normal findings do not exclude secondary dysmenorrhoea.
Clinical features indicating a serious secondary cause of dysmenorrhoea?
Positive pregnancy test with vaginal bleeding.
Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids).
Abnormal cervix on examination.
Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge.
When to refer to gynae for primary dysmenorrhoea?
If symptoms are severe and have not responded to initial treatment within 3–6 months or if there is doubt about the diagnosis.
Menorrhagia?
heavy bleedings - what the women considers to be excessive
Ix for menorrhagia?
- FBC in all women
- Routine transvaginal USS if symptoms suggest structural or histological abnormality (eg. intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) or if abnormal pelvic exam findings
Mx of menorrhagia if pt does not require contraception?
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Mx of menorrhagia depends on what?
if pt requires contraception or not
Mx of menorrhagia if pt requires contraception?
- 1st line= IUS (mirena)
- COCP
- long-acting progestogens
What can be used short-term for menorrhagia to rapidly stop heavy menstrual bleeding?
norethisterone 5mg tds
Definition of menorrhagia?
excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life. It can occur alone or in combination with other symptoms.
In almost 50% of women with menorrhagia what is the cause?
no underlying cause found
Causes of menorrhagia?
unknown, uterine fibroid, uterine cancer, endometriosis, systemic disorders (such as coagulation disorders and hypothyroidism), and medications (such as anticoagulants).
Menorrhagia= For women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis?
An LNG-IUS should be offered.
If this is declined or unsuitable, other pharmacological treatments should be considered, such as tranexamic acid, a nonsteroidal anti-inflammatory drug (NSAID), or hormonal treatments (combined hormonal contraception or cyclical oral progestogens).
If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, referral to a specialist should be considered for further investigations and consideration of alternative treatment options.
Menorrhagia= For women with fibroids of 3 cm or more in diameter then do what?
specialist referral should be considered for additional investigations and consideration of treatment options.
If pharmacological treatment is needed while the woman is awaiting treatment or referral, tranexamic acid and/or an NSAID should be offered.
When to arrange referral for menorrhagia?
Physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids).
The woman has a pelvic mass associated with any other features of cancer (such as unexplained bleeding or weight loss).
There are complications, such as compressive symptoms from large fibroids (for example, dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms).
The woman has iron deficiency anaemia that has failed to respond to treatment and other causes have been excluded.
Mittelschmerz?
‘middle pain’ and refers to abdominal pain associated with ovulation. This mid-cyclical pain is experienced by 20% of women.
Theories that may explain Mittelschmerz?
That it occurs due to a leakage of follicular fluid containing prostaglandins at the time of ovulation, which causes the pain.
Another explanation is that the growth of the follicle stretches the surface of the ovary, causing pain.
Features of Mittelschmerz?
Sudden onset of pain in either iliac fossa which then manifests as a generalised pelvic pain.
Typically, the pain is not severe and varies in duration, lasting from minutes to hours.
It is self-limiting and resolves within 24 hours of onset.
Pain may switch side from month to month, depending on the site of ovulation
Ix for Mittelschmerz?
There is no specific test to confirm Mittelschmerz and it diagnosed clinically, after taking a full history and examination to exclude other conditions
No abnormal signs on abdominal or pelvic examination.
Mx of Mittelschmerz?
not harmful and can be controlled with simple analgesia
What does PCOS stand for?
polycystic ovary syndrome
PCOS?
complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age
Cause of PCOS?
not fully understood
Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Features of PCOS?
subfertility and infertility
menstrual disturbances: oligomenorrhoea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
Ix for PCOS?
- pelvic USS= multiple cysts on ovaries
- FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
- check for impaired glucose tolerance
Bloods to Ix PCOS?
FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) results for PCOS?
raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis
prolactin may be normal or mildly elevated
testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
SHBG is normal to low in women with PCOS
If testosterone markedly raised when Ix for PCOS then?
consider other causes
A formal diagnosis of PCOS should only be made when?
after performing Ix to exclude other conditions
Criteria to diagnose PCOS?
Rotterdam criteria
Rotterdam criteria to diagnose PCOS?
- infrequent or no ovulation (usually manifested as infrequent or no menstruation; oligomenorrhea)
- clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
- polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
PCOS= clinical and/or biochemical signs of hyperandrogenism?
hirsutism, acne, or elevated levels of total or free testosterone
PCOS= polycystic ovaries of USS is defined as what?
presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³
General Mx for PCOS?
- weight loss if relevant
- COCP may help regulate her cycle if require contraception
- hirsutism & acne= COCP or topical eflornithine if no response
- infertility Mx
Mx of hirsutism and acne in PCOS?
COCP= options incl third generation COCP which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of VTE
if doesn’t respond to COCP then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
PCOS= Mx of infertility?
- weight reduction in relevant
- specialist Mx= metformin, clomifene or combination; gonadotrophins may be used
MOA of clomifene for fertility Mx in PCOS?
work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
There is a potential risk of multiple pregnancies with anti-oestrogen therapies.
Definition of PCOS?
heterogeneous endocrine disorder that appears to emerge at puberty
PCOS is characterised as what?
hyperandrogenism (with clinical features such as acne and hirsutism), ovulation disorder (usually manifested as infrequent or no menstruation), and polycystic ovarian morphology on ultrasound.
hyperandrogenism (with clinical features such as acne and hirsutism), ovulation disorder (usually manifested as infrequent or no menstruation), and polycystic ovarian morphology on ultrasound
PCOS
Most common endocrine disorder affecting women of reproductive age?
PCOS
Cx of PCOS?
Infertility.
Cardiovascular disease (CVD).
Metabolic disorders, such as impaired glucose tolerance and type 2 diabetes.
Obstructive sleep apnoea.
Psychological disorders, such as anxiety and depression.
Pregnancy complications, such as pre-eclampsia and gestational diabetes.
Endometrial cancer.
Non-alcoholic fatty liver disease.
According to NCIE, Polycystic ovaries on ultrasound is defined as the presence of…
20 or more follicles in at least one ovary
To help diagnose PCOS…
Free androgen index should be calculated to assess the amount of physiologically active testosterone present.
Luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone levels should be measured to rule out other causes of oligomenorrhoea and amenorrhoea (such as premature ovarian failure, hypothyroidism, and hyperprolactinaemia).
Referral for an ultrasound scan is required in adult women (unless the diagnosis of PCOS is obvious on clinical and biochemical grounds). An ultrasound scan should not be used for the diagnosis of PCOS in adolescents due to the high incidence of multi-follicular ovaries in this life stage.
Polycystic ovaries on ultrasound is defined as the presence of 20 or more follicles in at least one ovary.
In adults, PCOS should be diagnosed if two of the following are present (provided other causes of menstrual disturbance and hyperandrogenism have been excluded):
- Clinical and/or biochemical signs of hyperandrogenism.
- Ovulatory dysfunction.
- Polycystic ovarian morphology on ultrasound.
When diagnosing PCOS in adolescents, what is recommended?
tighter criteria requiring both hyperandrogenism and irregular menstrual cycles is recommended due to the overlap with normal pubertal reproductive physiology.
Management of PCOS includes:
Managing the clinical features of PCOS.
Screening for cardiovascular risk factors and advising on healthy lifestyle measures to reduce CVD risk. Where appropriate, weight loss should be advised.
Assessing for (and managing) other possible complications of PCOS.
Providing sources of additional information and support.
Adolescents who have features of PCOS but do not meet the diagnostic criteria should be considered to be what?
at ‘increased risk’ of PCOS and reassessed at or before full reproductive maturity (8 years post-menarche). This includes those with PCOS features before combined oral contraceptive pill commencement, those with persisting features, and those with significant weight gain in adolescence.
Definition of irregular menstrual cycles?
Normal in the first year post-menarche as part of the pubertal transition.
More than 1 year to less than 3 years of irregular cycles (more than 45 days or less than 21 days) after the onset of menarche.
More than 3 years of irregular cycles (more than 35 days or less than 21 days, or less than 8 cycles every year) post menarche to perimenopause.
More than 1 year of irregular cycles (more than 90 days for any one cycle) post menarche.
Primary amenorrhea by age 15 years or more than 3 years of irregular cycles post thelarche (breast development).
When may metformin be considered for PCOS Mx?
if BMI 25 or more for weight loss
Adverse effects of metformin?
GI symptoms and reduced vit B12
Offer all women with polycystic ovary syndrome (PCOS) regular monitoring for…
weight change and excess weight. Monitoring could be at each visit or at a minimum of 6–12 monthly, with frequency, planned and agreed with the woman.
PCOS= For women who are overweight or obese, explain that weight loss may…
Reduce hyperinsulinism and hyperandrogenism.
Reduce the risk of type 2 diabetes and CVD.
Result in menstrual regularity.
Improve the chance of pregnancy (if it is desired).
Assess glycaemic status at baseline in all women with PCOS. Thereafter, assessment should be every 1–3 years, depending on the presence of other diabetes risk factors.
Perform a
2-hour post 75 g oral glucose tolerance test (OGTT), fasting plasma glucose, or HbA1c to assess glycaemic status.
PMS stands for?
premenstrual syndrome
Premenstrual syndrome?
emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
PMS only occurs when?
in the presence of ovulatory menstrual cycles - it doesn’t occur prior to puberty, during pregnancy or after the menopause.
PMS emotional symptoms?
anxiety
stress
fatigue
mood swings
PMS physical symptoms?
bloating
breast pain
Mx of mild premenstrual symptoms?
lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
Mx for moderate premenstrual syndrome?
new-generation combined oral contraceptive pill (COCP)
examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)
Mx for severe premenstrual syndrome?
selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)
Phases of menstrual cycle?
Menstrual phase= days 1-5
Follicular phase= 6-14d
Ovulatory phase= day 14
Luteal phase= 15-28d
Premenstrual syndrome (PMS) is a condition characterized by…
psychological, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation).
Psychological symptoms include depression, anxiety, irritability, loss of confidence, and mood swings.
Physical symptoms include bloating and breast pain.
Behavioural symptoms include reduced cognitive ability and aggression.
A diagnosis of PMS is supported by?
timing (rather than the types) of symptoms and the degree of impact on daily activity.
To differentiate PMS from physiological premenstrual symptoms (experienced by up to 90% of women), it must be demonstrated that symptoms cause
significant impairment to the woman during the luteal phase of the menstrual cycle.
Premenstrual dysphoric disorder (PMDD)?
a severe form of PMS defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as occurring when a woman suffers from at least five out of 11 distinct premenstrual symptoms, one of which must be related to mood, and which cause significant distress or impaired functioning.
To diagnose PMS, a detailed history should be taken, a physical examination should be performed as indicated by the woman’s age and routine gynaecological and medical recommendations, and the woman should be asked to….
record a daily symptom diary for two or three cycles.
PMS= once the women has recorded a daily symptom diary for 2 or 3 cycles; the diagnosis of PMS can be confirmed if…
The diary shows a prominence of symptoms during the luteal phase of the menstrual cycle, which resolve with the onset of menses or soon after, followed by a symptom-free week.
Symptoms are severe enough to affect daily functioning or interfere with the woman’s work, school, performance, or interpersonal relationships.
There is an absence of other conditions that could explain the symptoms, such as depression, hypothyroidism, anaemia, irritable bowel syndrome, and endometriosis.
Management of PMS should be tailored to the
severity, impact and type of symptoms, the woman’s treatment preferences and goals, and any plans to become pregnant.
All women with PMS should be offered…
lifestyle advice (including advice on diet, regular exercise, smoking cessation, alcohol restriction, regular sleep, stress reduction, and complementary treatments and/or dietary supplements), a non-steroidal anti-inflammatory drug (NSAID) for pain as required (if relevant and not contraindicated), and patient information on PMS.
Additional options to consider for the Mx of PMS?
A drospirenone-containing combined oral contraceptive pill, particularly where contraception is desired (off-label use if not required for contraception).
Cognitive behavioural therapy.
A selective serotonin reuptake inhibitor (SSRI) (off-label use), particularly where symptoms are severe or affective symptoms are predominant.
PMS= women should be reviewed after how long to assess effectiveness of Tx?
2 months
Diagnostic criteria for premenstrual dysphoric disorder (PMDD)?
woman must have a minimum of five of the eleven listed symptoms, with a minimum of one being related to mood, during most menstrual cycles over the last year. The symptoms must be present in the final week before menstruation and start to improve within a few days of its onset, and be minimal or absent in the week after.
Diagnostic criteria for premenstrual dysphoric disorder (PMDD)= specific symptoms?
At least one of the following symptoms must be present:
- Marked mood lability/mood swings.
- Marked depressed mood, feelings of hopelessness or self-deprecating thoughts.
- Marked irritability or anger or increased interpersonal conflicts.
- Marked anxiety or tension.
Additionally there must be further symptoms, reaching a total of five between the two lists:
- Reduced interest in usual activities.
- Difficulty concentrating.
- Lethargy, easily tired, or lack of energy.
- Marked changes in appetite.
- Sleep changes (hypersomnia or insomnia).
- A sense of feeling overwhelmed or out of control.
- Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain.
These symptoms must cause significant distress or interference with usual activities or relationships.
The symptoms do not represent an exacerbation of another mental health disorder, and cannot be attributable to a substance or another medical condition.
There should be confirmation by using a symptom diary for at least two cycles.
Urogenital prolapse?
descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women
Types of urogenital prolapse?
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
RFs for urogenital prolapse?
increasing age
multiparity, vaginal deliveries
obesity
spina bifida
Presentation of urogenital prolapse?
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency
Mx of urogenital prolapse?
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery
Surgical options for urogenital prolapse?
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
Common causes of vaginal discharge?
physiological
Candida
Trichomonas vaginalis
bacterial vaginosis
Less common causes of vaginal discharge?
Gonorrhoea
Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
ectropion
foreign body
cervical cancer
Atrophic vaginitis often occurs in women who are
post-menopausal
How does atrophic vaginitis present?
Vaginal dryness, dyspareunia and occasional spotting.
On examination, the vagina may appear pale and dry.
Tx for atrophic vaginitis?
vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
Vaginal itching is common. It is estimated that how many women will seek help at some point.
1 in 10
In contrast to pruritus ani, pruritus vulvae usually has what?
an underlying cause
pruritus ani?
skin condition characterized by the sensation of perianal itching or burning
Causes of pruritus vulvae?
irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis: seen in around a third of patients with psoriasis
Mx of pruritus vulvae?
women who suffer from this should be advised to take showers rather than taking baths
they should also be advised to clean the vulval area with an emollient such as Epaderm or Diprobase
clean only once a day as repeated cleaning can aggravate the symptoms
most of the underlying conditions will respond to topical steroids
combined steroid-antifungal may be tried if seborrhoeic dermatitis is suspected
Lichen sclerosus?
inflammatory condition that usually affects the genitalia and is more common in elderly females
Lichen sclerosus leads to what?
atrophy of the epidermis with white plaques forming
Features of lichen sclerosus?
white patches that may scar
itch is prominent
may result in pain during intercourse or urination
Lichen sclerosus diagnosis?
clinical grounds but a biopsy may be performed if atypical features are present
Lichen sclerosus Mx?
topical steroids and emollients
Why is lichen sclerosus followed up?
increased risk of vulval ca
Lichen sclerosus= skin biopsy is not necessary when a diagnosis can be made on clinical examination. Biopsy is required if?
if the woman fails to respond to treatment or there is clinical suspicion of VIN or cancer.
Lichen sclerosus= histological examination is advisable if there are atypical features or diagnostic uncertainty and is mandatory if there is any suspicion of neoplastic
change. Patients under routine follow-up will need a biopsy if?
(i) there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions;
(ii) the disease fails to respond to adequate treatment;
(iii) there is extragenital LS, with features suggesting an overlap with morphoea;
(iv) there are pigmented areas, in order to exclude an abnormal melanocytic proliferation;
and
(v) second-line therapy is to be used.
Vulval intraepithelial neoplasia (VIN)?
pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated.
The average age of an affected woman is around 50 years
RFs for vulval intraepithelial neoplasia (VIN)?
human papilloma virus 16 & 18
smoking
herpes simplex virus 2
lichen sclerosus
Features of vulval intraepithelial neoplasia (VIN)?
itching, burning
raised, well-defined skin lesions
Ix for vulval intraepithelial neoplasia (VIN)?
biopsy: punch biopsy or excisional biopsy for histological diagnosis
HPV Testing: PCR or in situ hybridisation for high-risk HPV DNA
Mx for vulval intraepithelial neoplasia (VIN)?
topical therapies:
- imiquimod= Immune response modifier
- 5-Fluorouracil: Topical chemotherapeutic agent
surgical Interventions:
- aimed at complete removal of dysplastic areas while preserving normal anatomy and function as much as possible.
- techniques include wide local excision, laser ablation, or more radical approaches like partial vulvectomy in cases of extensive disease.
Mx for vulval intraepithelial neoplasia (VIN)= topical therapies?
- imiquimod= Immune response modifier
- 5-Fluorouracil: Topical chemotherapeutic agent
Mx for vulval intraepithelial neoplasia (VIN)= surgical interventions?
aimed at complete removal of dysplastic areas while preserving normal anatomy and function as much as possible.
techniques include wide local excision, laser ablation, or more radical approaches like partial vulvectomy in cases of extensive disease.
Follow up and surveillance for for vulval intraepithelial neoplasia (VIN)?
regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.
Sterilisation?
considered a permanent method of contraception.
The operation to sterilize a man is called a vasectomy.
The operation to sterilize a woman is called tubal occlusion.
There are two different types of natural family planning methods?
Fertility awareness methods (FAM).
Lactational amenorrhoea methods (LAM).
natural family planning methods= FAM?
Fertility awareness methods (FAM).
Basal body (waking) temperature — a slight rise in temperature that persists for 3 days indicates that the fertile time has ended.
Cervical secretions — an increase in the volume of wet, slippery, and clear cervical secretions indicates that ovulation is approaching.
Changes in the cervix — the fertile window starts at the first sign of the cervix changing from being low and firm, and the cervical os closed, to the cervix being high and soft and the cervical os open.
Length of menstrual cycle — involves calculating the length of the menstrual cycle and using this to estimate the time of ovulation and the fertile days of the menstrual cycle.
natural family planning methods= LAM?
Lactational amenorrhoea methods
involves breastfeeding after childbirth to prevent pregnancy (breastfeeding delays the return of ovulation by disrupting gonadotrophin release). The following conditions must all be met before LAM can be used:
Complete amenorrhoea.
Fully or nearly fully breastfeeding (that is, the baby is getting 85% or more of its feeds as breast milk).
Less than 6 months postpartum.
If a woman is considering a natural family planning method of contraception?
An assessment should be done to confirm the suitability of the method. As part of the assessment, the World Health Organization Medical Eligibility Criteria for Contraceptive Use should be applied to assess her eligibility for use of the method.
Verbal and written information should be provided on how the method works, as well as the efficacy, advantages, and disadvantages of the methods. Women wishing to use fertility indicators for contraceptive purposes should receive support and instruction on the method from a trained practitioner.
Advice should be offered on other methods of contraception, such as long-acting reversible contraception (LARC), and their comparative efficacy.
In women for whom pregnancy poses a significant health risk, the reliance on fertility indicators for the prevention of pregnancy is not recommended. Contraceptive options should be discussed with the woman and, where necessary, specialists involved in the management of her condition.
Women taking drugs that are known to have a teratogenic effect should not rely solely on fertility indicators for the prevention of pregnancy.
Adenomyosis?
characterized by the presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years.
Adenomyosis features?
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
adenomyosis
Ix for adenomyosis?
transvaginal ultrasound as the first-line investigation
MRI is an alternative
Mx for adenomyosis?
symptomatic= tranexamic acid to manage menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy= considered the ‘definitive’ treatment
Definitive Mx for adenomyosis?
hysterectomy
Androgen insensitivity syndrome?
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.
Complete androgen insensitivity syndrome is the new term for
testicular feminisation syndrome
Features of androgen insensitivity syndrome?
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
androgen insensitivity syndrome
Diagnosis of androgen insensitivity syndrome?
buccal smear or chromosomal analysis to reveal 46XY genotype
after puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys
Mx of androgen insensitivity syndrome?
counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy
Genetically male but female phenotype?
androgen insensitivity syndrome
‘full’ surrogacy
party carrying the foetus is not genetically related to the implanted foetus
‘partial’ surrogacy
which the surrogate’s egg is fertilised via IVF and then re-implanted
Surrogacy= according to the law, who is the legal mother to the child?
the women giving birth
Female genital mutilation (FGM)?
refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
Female genital mutilation (FGM) Type 1?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Female genital mutilation (FGM) Type 2?
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Female genital mutilation (FGM) Type 3?
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Female genital mutilation (FGM) Type 4?
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
Ovarian torsion?
partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply.
Ovarian torsion= what’s it called when the fallopian tube is also involved?
adnexal torsion
RFs for ovarian tosion?
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
Features of ovarian torsion?
Usually the sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
Diagnosis of ovarian torsion?
Ultrasound may show free fluid or a whirlpool sign.
Laparoscopy is usually both diagnostic and therapeutic.
4 types of ovarian tumours?
surface derived tumours
germ cell tumours
sex cord-stromal tumours
metastasis
Ovarian tumours= surface derived tumours (65%) have greatest number of what?
malignant tumours
Ovarian tumours= surface derived tumours (65%)?
Serous cystadenoma
Serous cystadenocarcinoma
Mucinous cystadenoma
Mucinous cystadenocarcinoma
Brenner tumour
Ovarian tumours= surface derived tumours- Serous cystadenoma?
Benign
Most common benign ovarian tumour, often bilateral
Cyst lined by ciliated cells (similar to Fallopian tube)
Ovarian tumours= surface derived tumours- serous cystadenocarcinoma?
Malignant
Often bilateral
Psammoma bodies seen (collection of calcium)
Ovarian tumours= surface derived tumours- mucinous cystadenoma?
Benign
Cyst lined by mucous-secreting epithelium (similar to endocervix)
Ovarian tumours= surface derived tumours- mucinous cystadenocarcinoma?
Malignant
May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
Ovarian tumours= surface derived tumours- Brenner tumour?
Benign Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.
Ovarian tumours= germ cell tumours most common in who?
adolescent girls and are account for 15-20% of tumours. Similar cancer types to those seen in the testicle.
Ovarian tumours= germ cell tumours?
Teratoma
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
Ovarian tumours= germ cell tumours- teratoma?
Mature teratoma (dermoid cyst) - most common: benign
Immature teratoma: malignant
Account for 90% of germ cell tumours
Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
Ovarian tumours= germ cell tumours- dysgerminoma?
Malignant
Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH
Ovarian tumours= germ cell tumours- yolk sac tumour?
Malignant
Typically secrete AFP
Schiller-Duval bodies on histology are pathognomonic
Ovarian tumours= germ cell tumours- choriocarcinoma?
Malignant
Rare tumour that is part of the spectrum gestational trophoblastic disease
Typically have increased hCG levels
Often characterised by early haematogenous spread to the lungs
Ovarian tumours= sex cord-stromal tumours often produce what?
hormones
Represent around 3-5% of ovarian tumours.
Ovarian tumours= sex cord-stromal tumours?
Granulosa cell tumour
Sertoli-Leydig cell tumour
Fibroma
Ovarian tumours= sex cord-stromal tumours- Granulosa cell tumour?
Malignant
Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults.
Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
Ovarian tumours= sex cord-stromal tumours- Sertoli-Leydig cell tumour?
Benign
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome
Ovarian tumours= sex cord-stromal tumours- fibroma?
Benign
Associated with Meigs’ syndrome (ascites, pleural effusion)
Solid tumour consisting of bundles of spindle-shaped fibroblasts
Typically occur around the menopause, classically causing a pulling sensation in the pelvis
Ovarian tumours= what tumours are associated with Meigs’ syndrome (ascites, pleural effusion)?
Fibroma (sex cord-stromal tumours)
Ovarian tumours= metastatic tumours account for what % tumours?
5%
Ovarian tumours= metastatic tumours?
Krukenberg tumour
Ovarian tumours= metastatic tumours-Krukenberg tumour?
Malignant
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries. Early follicular phase?
early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.
Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries. Mid-follicular phase?
mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.
Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries. Luteal phase?
In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.
What leads to normal ovulation?
It is the unique balance of hormones and their feedback loops which leads to normal ovulation with each menstrual cycle, however with each class of ovulatory dysfunction, there is an alteration in this fine balance which may lead to irregular or complete anovulation.
3 main categories of anovulation?
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
Anovulation?
when the ovaries do not release an egg during a menstrual cycle
Goals of ovulation induction?
It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment
For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable
Forms of ovulation induction?
- exercise and weight loss
- letrozole
- Clomiphene citrate
- gonadotropin therapy
Forms of ovulation induction= exercise and weight loss?
Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss
Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered
Forms of ovulation induction= letrozole?
now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate
Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction
Side effects: fatigue (20%), dizziness (10%)
Forms of ovulation induction= clomiphene citrate?
While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead
Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)
Forms of ovulation induction= gonadotropin therapy?
This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism
For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial
This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome
Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly?
Ovarian hyperstimulation syndrome (OHSS)
What happens in Ovarian hyperstimulation syndrome (OHSS)?
ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications
Life threatening Cx of OHSS?
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
How common is OHSS?
rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction
OHSS Mx?
depends on severity
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic
paracentesis
Pregnancy termination to prevent further hormonal imbalances
Postcoital bleeding?
vaginal bleeding after sex
Causes of postcoital bleeding?
no identifiable pathology is found in around 50% of cases
cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill
cervicitis e.g. secondary to Chlamydia
cervical cancer
polyps
trauma
Ca suspected in post menstrual bleeding and post coital bleeding?
post menstrual= ?endometrial ca
post coital= ? cervical ca
Postmenopausal bleeding?
vaginal bleeding occurring after 12 months of amenorrhoea. Whilst the majority of women do not have an underlying malignancy it is important to exclude this in all women.
Causes of Postmenopausal bleeding?
vaginal atrophy= the most common cause of postmenopausal bleeding
the thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
HRT (hormone replacement therapy)=
periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
endometrial hyperplasia=
an abnormal thickening of the endometrium and a precursor for endometrial carcinoma
risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
endometrial cancer=
although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
cervical cancer=
it is important to obtain a full record of prior cervical screening programme attendance
ovarian cancer=
can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
vaginal cancer=
uncommon but can present with postmenopausal bleeding
other uncommon causes include=
trauma
vulval cancer
bleeding disorders
women over the age of 55 with postmenopausal bleeding should be investigated…..
within two weeks by ultrasound for endometrial cancer= transvaginal ultrasound:
- endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm
- however, it may miss some pathology and if clinical suspicion is high, further testing is required
women on HRT with postmenopausal bleeding still need to be investigated to rule out what?
endometrial ca
Ix for postmenopausal bleeding?
NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer
for those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice
women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer
Tx of postmenopausal bleeding?
Tx by cause
once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
- vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
- if a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
- in the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue
Premature ovarian insufficiency?
nset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
Causes of premature menopause?
idiopathic:
- the most common cause
- there may be a family history
bilateral oophorectomy:
- having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
radiotherapy
chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome= due to FSH receptor abnormalities
Premature ovarian insufficiency= Features are similar to those of the normal climacteric but the actual presenting problem may differ?
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
raised FSH, LH levels
e.g. FSH > 30 IU/L
elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart
low oestradiol
e.g. < 100 pmol/l
Bloods in premature ovarian insufficiency?
raised FSH, LH levels
e.g. FSH > 30 IU/L
elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart
low oestradiol
e.g. < 100 pmol/l
Bloods in premature ovarian insufficiency= elevated FSH levels should be demonstrated….
on 2 blood samples taken 4-6 weeks apart
Premature ovarian insufficiency= Mx?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes
