GYNAE 2: IMB, PCB, Pruritus Vulvae, STIs, Urinary Sx Flashcards
What are some causes of IMB?
- contraceptives
- cervical cancer (abnormal vaginal bleeding, pelvic pain, dyspareunia)
- endometrial cancer (pelvic pain, weight loss, PMB)
- PID/STIs (lower abdo pain, dysuria, abnormal vaginal discharge)
- atrophic vaginitis
How is IMB investigated?
Speculum
Bimanual examination
STI screen
Bloods
Pregnancy test
Cervical screening
Pelvic USS
What are the different types of contraceptives?
Barrier - condoms
Oral - COCP, POP
Injectable - medroxyprogesterone acetate
Implantable - etonogestrel
Intrauterine - IUD, IUS
Patch
What is the mode of action of the COCP and when is it indicated?
MOA = inhibits ovulation
BENEFITS/INDICATIONS =
- acne
- heavy or painful periods
- PMS
- endometriosis
- PCOS
- reduced ovarian/endometrial cancer risk
What are risks/contraindications of the COCP and what are its side effects?
RISKS/CONTRAINDICATIONS =
- missed pill
- VTE
- breast/cervical cancer
- stroke/IHD
SEs = headache, nausea, breast tenderness
What advice should be given when starting the COCP?
- take additional contraception if not started within first 5 days of cycle
- take at same time everyday
- can tricycle or pill-free break
- less efficacy when vomiting within 2hrs, medication induces diarrhoea/vomiting, liver enzyme inducing drugs
What advice should be given in the case of a missed COCP pill?
1 pill missed = take last pill even if 2 in one day, continue as normal
2 or more pills missed:
- take last pill even if 2 pills taken in 1 day
- use barrier protection/abstain until pills are taken 7d in a row
- WEEK 1 = emergency contraception if UPSI in pill-free interval or week 1
- WEEK 2 = if pills are taken 7 days in a row no need for emergency contraception
- WEEK 3 = finish pills in current pack, start new pack next day (no pill-free interval)
What are UKMEC 4 contraindications to the COCP?
- > 35yo and >15 cigarettes/day
- migraine w/aura
- hx thromboembolic disease/thrombogenic mutation
- PMHx of stroke/IHD
- breastfeeding <6w post-partum
- uncontrolled HTN
- current breast cancer
- major surgery + prolonged immobilisation
- +ve antiphospholipid antibodies e.g. in SLE
What are UKMEC 3 contraindications to the COCP?
- > 35yo and <15 cigarettes/day
- BMI >35
- FHx thromboembolic disease in first degree relatives
- controlled HTN
- immobility e.g. wheelchair use
- carrier of gene mutations assoc. w/breast cancer e.g. BRCA1/2
- current gallbladder disease
What do the UKMEC levels mean?
1 = no contraindication
2 = advantages > disadvantages
3 = disadvantages > advantages
4 = unacceptable health risk
What is the mode of action, side effects and benefits/indications of the POP?
MOA = thickens cervical mucus
SEs = irregular bleeding
Benefits/indications =
- painful/heavy periods
- endometriosis
- can take immediately after birth/breastfeeding
- oestrogen is contraindicated
What are the types of POP?
Traditional = Micronor, Noriday, Nogeston, Femulen
Desorgestrel pill = Cerazette
Drospirenone pill
What advice should be given when starting the POP?
TRADITIONAL/DESOGESTREL:
- if started day 1-5 protected immediately, otherwise take extra contraception for 2 days
DROSPIRENONE PILL:
- only protected if taken on day 1, otherwise take extra contraception for 7 days
What advice should be given for a missed POP?
TRADITIONAL POP:
- less than 3 hours late, no action required
- more than 3 hours late = take missed pill ASAP, continue w/rest of pack, extra precaution for 38hrs
DESORGESTREL PILL:
- less than 12 hours late, no action required
- more than 12 hours late, see above
How should the combined contraceptive patch (Evra) be used?
Lasts 4 weeks
First 3 weeks = wear patch every day, change weekly
Last week = withdrawal bleed
What advice should be given if there is a delay in changing patch?
End of week 1 or 2:
- <48hrs = change immediately, no further precautions
- >48hrs = change immediately, use barrier contraception for 7d (UPSI in last 5d or SI in patch-free interval, emergency contraception)
Week 3: remove patch, start new patch on usual cycle start day for next cycle, no additional contraception
Delayed patch application at end of patch-free week: additional contraception for 7d
Summarise the injectable contraceptive?
MOA: inhibits ovulation, thickens cervical mucus
Instructions = IM injection every 12 weeks
PROS = missed pill
CONS = delayed return to fertility up to 1yr
SEs = irregular bleeding, weight gain, osteoporosis
CIs = current/past breast ca
Summarise the implantable contraceptive?
MOA = inhibits ovulation, thickens cervical mucus
Instructions = subdermally in proximal non-dominant arm
PROs = most effective, lasts 3yrs, doesn’t contain oestrogen, insertion after TOP
CONs = professional insertion, need additional contraceptive for first 7d
SEs = irregular/heavy bleeding, headache, nausea
CIs = anti-epileptics, rifampicin, current breast Ca (UKMEC4), IHD/stroke, vaginal bleeding unexplained, past breast Ca, severe liver cirrhosis, liver Ca (UKMEC3)
Summarise the IUD?
MOA = decreased sperm motility and survival
Instructions = can rely on use immediately
PROs = 5-10yr use
CONs = uterine perforation, increased risk of ectopics, infection, expulsion
SEs = heavier, longer, more painful periods
Summarise the IUS?
MOA = prevents endometrial proliferations, cervical mucus thickening
Instructions = can rely on use after 7d
PROs = effective for 5yrs, can use as part of HRT for 4yrs
CONs = uterine perforation, increased risk of ectopics, infection, expulsion
SEs = frequent uterine bleeding and spotting
What are the different options for emergency contraception?
IUD
Levonorgestrel
Ulipristal (EllaOne)
IUD - emergency contraception advice
- most effective so offered to all women
- only insert within 5d of UPSI or within 5d of likely ovulation date
- inhibits fertilisation OR implantation
- can be kept in-situ for long term contraception
Levonorgestrel - emergency contraception advice?
- stops ovulation and inhibits implantation
- must take within 72hrs of UPSI
- single dose 1.5mg or double if BMI >26 or weight >70
- vomiting occurs in 3hrs = repeat dose
- can take hormonal contraception immediately
Ulipristal - emergency contraception advice?
- 30mg oral dose
- must take within 5d of UPSI
- restart hormonal contraceptive 5d later
- avoid in severe asthma
- avoid breastfeeding for 1w
What questions should you ask when seeing a person seeking emergency contraception?
- how many days since UPSI?
- do you normally take hormonal contraception?
- do you breastfeed?
- what is your weight/BMI?
- PMHx of asthma?
Counselling = return to GP if vomiting
Outline contraceptive options for postpartum?
COCP:
- contraindicated before 6w if breastfeeding
- avoid in first 3w due to increased VTE risk
- UKMEC2 if breastfeeding for 6w to 6mths - use additional contraception for first 7d
POP:
- can start any time post partum
- after day 21 use additional contraception for first 2d
IUD/IUS:
- can be inserted within 48hrs of birth OR after 4w
Lactational amenorrhoea:
- fully breastfeeding + amenorrhoea + <6mths post partum
What is endometrial hyperplasia?
Abnormal proliferation of endometrium - assoc. w/HPV 16, 18 and 33
Types inc. simple, complex, simple atypical and simple complex
Features inc. abnormal vaginal bleeding e.g. IMB
How is endometrial hyperplasia without atypia managed?
- PO or local IUS for 6mths
- continuous progestogens for women who decline IUS
- hysterectomy
- bilateral salpingo-oophorectomy added for postmenopausal women
How is endometrial hyperplasia with atypia managed?
Laparoscopic total hysterectomy
Bilateral salpingo-oophorectomy should be added for post menopausal women
What are risk factors for endometrial cancer?
EXCESS OESTROGEN:
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen e.g. HRT
- metabolic syndrome e.g. obesity, diabetes, PCOS
- tamoxifen
- HNPCC
How is endometrial cancer investigated?
Suspected cancer pathway if >55yo w/PMB
TVUSS
Hysteroscopy w/endometrial biopsy
How is endometrial cancer managed?
LOCALISED = total abdominal hysterectomy w/BSO
HIGH RISK = post op radiotherapy
What are some causes of PCB?
- cervical cancer
- cervical ectropion
- atrophic vaginitis
- PID
- polyps
What is a cervical ectropion?
Larger area of columnar epithelium present on ectocervix caused by elevated oestrogen levels
Transformation zone = area between native and unaffected columnar epithelium of the endocervical canal and native squamous epithelium
Squamo-columnar junction = abrupt change from columnar cells to squamous cells (hence SCC most common type of cervical cancer)
Location depends on age, hormonal status, birth trauma, contraceptives, pregnancy
How is a cervical ectropion investigated and managed?
Ix = speculum
Mx = no treatment, but if symptomatic can cauterise w/silver nitrate or cold coagulation
What is CIN? What are the stages?
CIN = abnormal changes of cells that line the cervix with mild/moderate dyskaryosis
CIN 1 = 1/3 depth of surface of cervix
CIN 2 = 2/3 depth of surface of cervix
CIN 3 = whole thickness of surface of cervix
How is CIN managed?
If CIN 2/3 = LLETZ, cone biopsy
If CIN 1 = watch and wait, screen again in 12 months
What is cervical cancer, what are the 2 types?
Highest incidence in people aged 25-29yo
SCC = 80%
Adenocarcinoma = 20%
What are risk factors for cervical cancer?
- HPV 16&18
- smoking
- HIV
- early first intercourse
- many sexual partners
- high parity
- lower SES
- COCP
How is cervical cancer investigated?
Screening programme = HPV first system
- 25-49 = 3yrly screening
- 50-64 = 5yrly screening
Delayed until 3mths post partum
Can opt out if never sexually active
How does cervical cancer screening progress based on HPV results?
-ve HPV = return to normal recall
+ve HPV = check cytology
normal = repeat in 12 months
abnormal = colposcopy, then mx
inadequate sample = repeat in 3 months
NOTE: HPV strains inc. 16, 18, 33
How is cervical cancer managed?
Stage IA1 = microinvasive disease
- loop electrosurgical excision and conization
- simple hysterectomy if no wish for fertility
Stage IA2 - IB2 = early stage disease
- radical hysterectomy and bilateral salpingectomy and/or bilateral oophorectomy w/bilateral pelvic lymphadenectomy
- may consider adjuvant chemo/radio if high risk
Stage IB3 - IVA (locally advanced disease)
- external beam radiotherapy, intracavity brachytherapy, concomitant chemotherapy
- surgency not recommended
Stage IVB (spread to distant organs)
- systemic chemotherapy
Recurrent/metastatic disease = salvage surgery or chemo/radiotherapy
Outline chlamydia investigations, screening and management?
Most prevalent STI in UK, incubation period 7-12d
Sx = asymptomatic in most, may have discharge, bleeding, dysuria
Ix = NAATs using urine, vulvovaginal swab or cervical swab, 2w post exposure
Screening open to everyone 15-24
Mx = 7d doxycycline (if pregnant: azithromycin, erythromycin, amoxicillin), partner notification w/offer of treatment
What are some complications of chlamydia?
PID, endometritis, ectopic, infertility, reactive arthritis, perihepatitis
Summarise gonorrhoea?
Organism = gram-negative diplococcus, Neisseria gonorrhoea
Sx = cervicitis (abnormal discharge)
Complications = dissemination, damage to urethral structures, salpingitis
Dissemination - most common cause of septic arthritis, initially tenosynovitis, migratory polyarthritis, dermatitis. Later = septic arthritis, endocarditis, perihepatitis
Mx = IM ciprofloxacin 1g, 2nd line = oral cefixime 400mg + oral azithromycin
Summarise trichomonas vaginalis?
Organism = flagellated protozoan parasite
Sx = frothy, yellow-green discharge, vulvovaginitis, strawberry cervix, pH >4.5
Ix = microscopy of wet mount - motile trophozoites
Mx = oral metronidazole 5-7d
What is PID?
PID = infection of female pelvic organs and surrounding peritoneum. Ascending infection from endocervix.
Most common cause = chlamydia trachomatis
Sx = dysmenorrhoea, fever, deep dyspareunia, dysuria, abnormal discharge, cervical excitation, violin string appearance, RUQ pain
How is PID investigated and managed?
Pregnancy test, high vaginal swab, screen for chlamydia and gonorrhoea
Mx = IM ceftriaxone 1g, PO doxycycline 100mg BD, PO metronidazole 400mg BD for 14d + consider removing IUD/IUS
What are some complications of PID?
Fitz-Hugh Curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy
Summarise bacterial vaginosis?
BV = overgrowth of anaerobic organisms e.g. Gardnerella vaginalis
Sx = fishy offensive discharge, asx in 50%, vaginal pH >4.5
Dx = Amsel’s criteria 3/4
- grayish, white discharge coating vaginal walls
- vaginal pH >4.5
- +ve whiff test
- clue cells on wet prep
Mx = asx no mx, sx = oral metronidazole for 5-7d
What are causes of pruritus vulvae?
Atrophic vaginitis
Lichen sclerosus
Outline atrophic vaginitis?
- thinning and drying of vaginal walls
Sx = vaginal dryness, dyspareunia, occasional spotting
Ix = speculum, pale and dry vaginal wall
Mx = vaginal lubricants and moisturisers, topical oestrogen cream
(if menopausal/post menopause w/other sx consider HRT clinic referral)
Summarise lichen sclerosus?
Inflammatory condition leading to atrophy of epidermis and white plaque formation.
Sx = white patches, itching, dyspareunia, dysuria
Ix = speculum + external genitalia exam
Mx = topical steroids and emollients, f/u due to increased risk of vulval cancer
- 1st line = topical clobetasol propionate
- 2nd line = topical tacrolimus (only initiated in specialist clinics)
What are causes of urinary incontinence?
Overactive bladder/urge incontinence = bladder oversensitivity from infection or neurologic disorders
Stress incontinence = relaxed pelvic floor, increased abdo pressure
Mixed incontinence
Overflow incontinence = urethral blockage, bladder unable to empty properly
Summarise urge incontinence?
Detrusor overactivity
Sx = urge to urinate followed by uncontrollable leakage
Ix = bladder diaries for 3d, vaginal exam, urine dip and culture, urodynamic studies
Mx = bladder retraining for min. 6w, bladder stabilising drugs e.g. antimuscarinics (oxybutynin, tolterodine, darifenacin), beta-3-agonist (mirabegron) if frail and elderly
Summarise stress incontinence?
Leakage of urine with increased intra-abdominal pressure
RFs = childbirth, hysterectomy, FHx, advancing age, high BMI
Ix = bladder diaries for 3d, vaginal exam, urine dip and culture, urodynamic studies
Mx = pelvic floor muscle training (8 contraction 3x/day for 3 months), duloxetine, surgical procedures
What are the different types of urogenital prolapse?
Cystocele
Uterine prolapse
Rectocele
Enterocele
Summarise urogenital prolapse?
Descent of a pelvic organ, leading to protrusion on the vaginal walls
RFs = increased age, multiparity, vaginal deliveries, obesity
Sx = pressure, heaviness, bearing down, urinary sx
Ix = bimanual/speculum, bladder diaries for 3d, urine dip and culture, urodynamic studies
Mx = asx no mx, conservative - weight loss, pelvic floor muscle exercise, ring pessary, surgery (cystocele = anterior colporrhaphy; vaginal vault prolapse = sacrocolpopexy)
