Gynae management Flashcards
Termination of pregnancy
Management
Less than 14w:
Medical:
• Up to 9w: mifepristone 200mg PO then misoprostol 800mcg PV, buccal, sublingual 24-48hrs later.
• From 64d to 13+6: mifepristone 200mg PO then misoprostol 800mcg PV, buccal, sublingual 24-48hrs later. Then 400mcg every 3hrs until abortion. Or misoprostol 800mg PV, buccal, sublingual then 400mcg every 3hrs until abortion. Offer anti-D IgG 250IU for medical TOP after 10+0.
Surgical:
• Vacuum aspiration and inspection. 200mg doxycycline or 500mg azithromycin 2hrs before. Consider anti-D IgG for surgical TOP up to 10+0.
Over 14w (new guidelines say after 12w this should be done in clinic): Medical: • This should be done as an inpatient. Mifepristone 200mg PO then misoprostol 800mcg PV 12-48hrs later. Then misoprostol 400mcg PO or PV every 3hrs until abortion. 24hrs later, mifepristone can be repeated 3hrs after the misoprostol, then misoprostol can be commenced again 12hrs later. Or misoprostol 800mcg PV then 400mcg every 3hrs until abortion. Offer anti-D IgG 250IU for surgical TOP after 10+0.
Surgical:
• Vacuum aspiration and inspection. 200mg doxycycline or 500mg azithromycin 2hrs before.
• Dilation and evacuation with dilators 12-24hrs earlier or mifepristone 200mg 12–24hrs before or misoprostol 400mcg PV 3hrs or sublingually 2hrs before.
• Offer anti-D IgG 250IU.
After 23+6, intracardiac KCl should be used to induce feticide.
Miscarriage (NICE)
Management
Expectant: suitable for confirmed pregnancy with no abdominal pain or RFs.
• Expect 2w of bleeding, advise to use sanitary pads and analgesia. Advise pregnancy test in 3w and, if positive, 4w. Offer repeat TVUSS if bleeding persists beyond 14d or doesn’t start.
Medical:
• Missed: 800mcg misoprostol.
• Incomplete: 600mcg misoprostol.
• Offer analgesia and anti-emetics as required.
• Advise pregnancy test in 3w and, if positive, 4w.
Surgical: for RPOC or ongoing symptoms post-14 days of expectant or medical management.
• Vacuum aspiration: LA.
• Dilation and curettage (after 14w): GA.
• Advise pregnancy test in 3w and, if positive, 4w.
• Antibiotic prophylaxis 100mg doxycycline BD 3d.
• Anti-D IgG 250IU (50mcg) IM to all non-sensitised RhD-negative women within 72hrs.
Ectopic pregnancy
Management
Expectant: offered to women who are stable and pain free, tubal ectopic<35mm with no visible heartbeat on TVUSS, serum hCG<1000IU, return for follow up. Repeat hCG on d2,4,7and then weekly until negative (<20IU)
Medical: no significant pain, unruptured ectopic with adnexal mass<35mm with no visible heartbeat, serum hCG<1500IU, empty uterus, return for follow up. Repeat hCG on d4 and 7 then 1 per week until negative.
• IM methotrexate 1mg/kg
Surgical: significant pain, ectopic>35mm, fetal heartbeat visible, serum hCG >5000 IU, no intrauterine pregnancy. Offer salpingectomy and take pregnancy test after 3w. If they have RFs for subfertility, salpingotomy should be offered with serum hCG at 7d then weekly until negative.
• Anti-D IgG 250IU (50mcg) IM to all non-sensitised RhD-negative women within 72hrs.
Emergency contraception
Management
Cu-IUD: inserted up to 120hrs after UPSI or ovulation (whichever is latest) and provides ongoing contraception.
• Offer testing for chlamydia before insertion. If results are unavailable at the time of insertion and the woman is at high risk of an STI, consider prophylactic azithromycin.
• Risks: pelvic infection in the first 20d, uterine perforation in 2 per 1000, pain, expulsion in 1 in 20 especially in the first 3m, heavy and prolonged bleeding in the first 6m.
• Advise that if her next period is late, she should take a pregnancy test.
• Advise that if she wants the IUD removed, she should attend in the first few days after the onset of menstruation or abstain for 7d before removal.
• Offer a follow-up appointment after her next period.
Levonorgestrel 1.5mg: taken within 72hrs of UPSI or contraceptive failure (3mg on EIDs).
• Avoid in people taking ciclosporin, griseofulvin or tizanidine.
• Advise that if she vomits up to 3hrs after taking the pill, she should take a second dose.
• LNG can be used more than once in a cycle if clinically indicated.
• Advise that if her next period is late, she should take a pregnancy test.
• Risks: nausea, diarrhoea, breast tenderness, ectopic pregnancy, spotting (this is not her period and this time is not safe for UPSI), does not provide ongoing contraception.
Ulipristal acetate 30mg: taken within 120hrs of UPSI or contraceptive failure.
• Avoid in people taking drugs that increase gastric pH, griseofulvin or EIDs.
• Ulipristal should not be used more than once in a cycle.
• Advise that if she vomits up to 3hrs after taking the pill, she should take a second dose.
• Advise that if her next period is late, she should take a pregnancy test.
• Risks: nausea, diarrhoea, breast tenderness, ectopic pregnancy, spotting (this is not her period and this time is not safe for UPSI), does not provide ongoing contraception.
- Offer a LARC and advise women to use condoms against STIs. They should allow 7d before they are protected against pregnancy.
- Perform a risk assessment for STIs and offer tests where appropriate.
Heavy menstrual bleeding
Management
Women with no identified pathology, fibroids <3cm, adenomyosis
1. LNG-IUS
2. If declined, consider non-hormonal (tranexamic acid, NSAIDs) or hormonal (COCP, cyclical POP).
3. If unsuccessful, consider referral for investigations, alternative pharmacotherapies and surgical options
4. For women with submucosal fibroids, consider hysteroscopic removal.
Women with fibroids >3cm
- Consider referral for additional investigations
- Offer tranexamic acid and/or NSAIDs. Consider hormonal treatments (LNG-IUS, COCP, cyclical POP), uterine artery embolization and surgical options (myomectomy, hysterectomy). MRI should be considered before embolization or myomectomy. GnRH analogues should be given before hysterectomy and myomectomy.
- Consider endometrial ablation.
- Discuss route and method of hysterectomy and removal of the cervix and ovaries.
Subfertility
Management
Preconception counselling
• Advise couples that vaginal intercourse every 2-3d optimises the chance of conception.
• Women should drink no more than 2 units of alcohol per week. Excessive intake for men is detrimental to semen quality.
• Women who smoke should be referred to a smoking cessation programme.
• Women and men with a BMI>30 should be advised to lose weight. Women with a BMI<19 should be advised to gain weight.
• Inquire as to OTC and recreational drug use in case of fertility interference.
• Advise women TTC to take 0.4g folate OD up to 12w.
Male factor infertility
Medical: offer gonadotrophin drugs to men with hypogonadotropic hypogonadism.
Surgical: offer surgical correction of epididymal blockage for obstructive azoospermia as an alternative to surgical sperm recovery and IVF. Offer treatment for ejaculatory failure.
Ovulation disorders Group 1 (hypothalamic pituitary failure eg anorexia): advise women to gain weight if necessary. Offer pulsatile GnRH or gonadotrophins with LH.
Group 2 (hypothalamic-pituitary-ovarian dysfunction eg PCOS): advise women to lose weight if necessary.
- Offer clomiphene citrate and/or metformin. Offer US monitoring during the first treatment of clomiphene. Do not continue treatment for over 6m.
- For those resistant to clomiphene, consider laparoscopic ovarian drilling or gonadotrophins. Women with PCOS treated with gonadotrophins should not be offered GnRH agonist concomitantly due to risk of ovarian hyperstimulation.
- Women with hyperprolactinaemia should be offered dopamine agonists.
- Ovarian US monitoring of follicular size and number should be performed to reduce the risk of multiple pregnancy and ovarian hyperstimulation.
Group 3 (hyper-gonadotropic, hypoestrogenic anovulation eg hyperprolactinaemia): no treatment as of yet recommended by NICE.
Group 4 (ovarian failure)
Tubal and uterine abnormalities
- For proximal tubal obstruction, consider selective salpingography with tubal catheterisation or hysteroscopic tubal cannulation.
- Women with hydrosalpinges should be offered salpingectomy before IVF.
- Women with intrauterine adhesions should be offered adhesiolysis.
Unexplained infertility
• Do not offer clomiphene citrate.
• Advise women to try regular unprotected vaginal intercourse for 2y before IVF is considered. Then offer IVF:
• Consider pre-treatment with COCP in women not undergoing down-regulation protocols.
• Use downregulation to avoid premature LH surges in gonadotrophin-stimulated IVF cycles.
• Use ovarian stimulation with urinary or recombinant gonadotrophins. Monitor with US.
• Offer women hCG to trigger ovulation.
• Offer conscious sedation during oocyte retrieval. Sperm recovery before ICSI may be performed eg cryopreservation.
• Offer US-guided embryo transfer ensuring an endometrium of >5mm thickness with 20 mins bedrest. No more than 2 embryos should be transferred.
• Offer women progesterone luteal phase support
Other methods of assisted conception include donor insemination and oocyte donation. Fertility may be preserved using cryopreservation of semen, oocytes and embryos in patients with cancer. There is no lower age limit and the conventional eligibility criteria for infertility treatment do not apply.
Incontinence
Management
Stress incontinence
1. Consider advising fluid intake modification. Advise women with BMI>30 to lose weight.
2. Digital assessment to confirm pelvic floor contraction before offering a 3m trial of pelvic floor exercises. At least 8 contractions 3 times daily.
3. Offer duloxetine if conservative measures fail and surgery is not preferred.
4. If incontinence is mixed, discuss the benefit of medicine for urge incontinence before surgery.
5. Offer the choice of colposuspension or an autologous rectus fascial sling. These are preferred to retropubic mid-urethral sling as it is permanent.
6. Consider the use of intramural bulking agents in women unsuitable for surgery.
7. Follow up all women who have had a surgical procedure within 6m. Include a vaginal check for exposure or extrusion of the sling. Offer a GP review for women on medicine every 12m, or every 6m if >75y.
Overactive bladder incontinence
- Recommend a caffeine reduction.
- Offer bladder training for 6w. This should be combined with a medicine if unsuccessful.
- Offer oxybutynin 5mg TDS or tolterodine second line (avoid both in frail elderly women). Explain anticholinergic side effects. Effects are seen after 4w.
- Offer mirabegron (contraindicated in uncontrolled hypertension and cardiovascular disease).
- Intravaginal oestrogens may be used to treat overactive bladder in postmenopausal women with vaginal atrophy.
- Offer a review within 4w of starting a new medicine. Offer a GP review for women on medicine every 12m, or every 6m if >75y.
- For women with refractory incontinence, offer a urodynamic study to determine whether detrusor overactivity is causing their symptoms.
- Offer botulinum toxin A injection then percutaneous posterior tibial nerve or sacral nerve stimulation and augmentation cystoplasty. Urinary diversion should be considered as a last resort.
- Desmopressin may be used in women experiencing nocturia (caution in CF patients and those >65y with cardiovascular disease or hypertension).
- Bladder catheterisation should be considered for persistent urinary retention causing incontinence, symptomatic infection or renal dysfunction.
Pelvic organ prolapse
1. Assess the degree of prolapse using POP-Q. Assess pelvic floor muscle activity and vaginal atrophy. Rule out a pelvic mass. Repeat the examination standing or squatting if findings do not explain symptoms.
2. Advise women to lose weight if BMI>30, minimise heavy lifting and prevent/treat constipation.
3. Consider a supervised trial of pelvic floor muscle training for 16w for stage 1 or 2 prolapse.
4. Consider vaginal pessary alone or in conjunction with training in symptomatic women. Offer these women a pessary clinic appointment every 6m if they are at risk of complications due to physical or cognitive impairment.
5. Consider vaginal oestrogen for women with signs of atrophy. Consider an oestrogen ring for women with physical or cognitive impairment.
6. Anterior prolapse: anterior repair without mesh.
Posterior prolapse: posterior repair without mesh.
Uterine prolapse: hysterectomy (+/- vaginal sacrospinous fixation), vaginal sacrospinous hysteropexy (for women who wish to conceive) or Manchester repair (for women who do not wish to conceive).
Vault prolapse: vaginal sacrospinous fixation (for women who do not wish to conceive) or sacrocolpopexy. Consider colpocleisis in women not intending to have penetrative vaginal sex.
7. Offer a review 6m after surgery. Check for mesh exposure.
Menopause
Management
- Vasomotor symptoms: offer oestrogen and progesterone or oestrogen alone (solely for women without a uterus). Explain that unscheduled PV bleeding is common within the first 3m of HRT but should be reported at the 3m review.
- Psychological symptoms: consider HRT. Consider CBT. There is no evidence for SSRIs or SNRIs in menopausal women with low mood without depression. Avoid these entirely in women with breast cancer taking tamoxifen.
- Altered sexual function: consider HRT. If this is ineffective, consider testosterone supplementation.
- Urogenital atrophy: offer vaginal oestrogen +/- systemic HRT. Do not offer routine monitoring of endometrial thickness during treatment.
- Review at 3m and annually thereafter.
Endometriosis
Management
- 3m trial of paracetamol +/- NSAID. Consider other forms of pain management.
- COCP or progestogen. Explain that this is symptomatic and has no permanent negative effect on fertility.
- Refer to gynaecology endometriosis service.
- Laparoscopic excision or ablation. Consider 3m GnRH agonists as an adjunct before surgery for endometriosis of bowel, bladder or ureter. Consider excision over ablation to maintain fertility.
- Consider hysterectomy and excise all visible endometriotic lesions.
- Prioritising fertility: offer excision/ablation with adhesiolysis for lesions involving bowel, bladder or ureter. Offer laparoscopic ovarian cystectomy to women with ovarian endometriomas.
Fibroids
Management
• Refer for complications such as dyspareunia, pelvic pain, constipation or urinary symptoms or if the fibroids are palpable abdominally or uterine length >12cm.
• For asymptomatic women, no treatment is required. For HMB, see above.
• Advise menopausal women with fibroids that HRT may modestly increase fibroids size. Prescribe HRT only after specialist advice and enquire about fibroid symptoms at each review.
For women seeking contraception
- LNG-IUS (may be expunged if cavity distorted).
- COCP (may increase size).
- POP/Depo-provera/Nexplanon.
- GnRH agonist 6m short course.
- Hysteroscopic myomectomy (submucosal fibroids only) or endometrial ablation.
- Hysterectomy. May offer 3m GnRH agonist prior.
- Uterine artery embolization.
For women seeking to conceive
- Tranexamic acid/mefenamic acid (depending on whether menorrhagia or dysmenorrhoea predominates). May be ineffective for submucosal fibroids.
- Ulipristal acetate (*suspended March 2020 pending a safety review regarding liver injury).
- Hysteroscopic myomectomy (submucosal fibroids only). May offer 3m GnRH agonist prior.
- Laparoscopic myomectomy (for refractory HMB) or surgical removal of fibroids.
Polycystic ovarian syndrome
Management
• Advise about weight loss, smoking cessation and the risk of impaired glucose tolerance.
• Refer for endometrial sampling if endometrial thickening >10mm is present.
For women seeking contraception
1. Prescribe COCP alone for hyperandrogenism and/or irregular menstrual cycles. The POP and LNG-IUS are alternatives.
• Regular TVUSS is required every 6m for women unwilling to take cyclical hormones or LNG-IUS.
2. Topical eflornithine BD may be used for facial hirsutism. Avoid in pregnant or breastfeeding women and people under 19.
3. Refer to specialist for advice regarding use of spironolactone and finasteride.
For women seeking to conceive
- Offer OGTT at preconception. If this is not possible, it should be offered before 20w.
- Consult a specialist regarding continuing metformin in pregnancy.
- Carry out an assessment to identify possible causes of infertility which may not be due to PCOS.
- Offer clomiphene citrate and/or metformin. Offer US monitoring during the first treatment of clomiphene. Do not continue treatment for over 6m.
- For those resistant to clomiphene, consider laparoscopic ovarian drilling or gonadotrophins. Women with PCOS treated with gonadotrophins should not be offered GnRH agonist concomitantly due to risk of ovarian hyperstimulation.
Bacterial vaginosis
Management
• Avoid douching, antiseptics, bubble baths
Women who are not pregnant
• Metronidazole 400mg PO BD 5-7d or a single dose of 2g. If she prefers topical, give intravaginal metronidazole 0.75% OD 5d or intravaginal clindamycin 2% OD 7d.
• If symptoms persist, check compliance and prescribe an alternative.
Women who are pregnant
• Same as above but do not prescribe high dose 2g metronidazole. Avoid oral clindamycin.
• Only consider treating partners if they are female.
Trichomoniasis
Management
Men and women (not pregnant or breastfeeding)
1. Metronidazole PO 500mg BD 5-7d or metronidazole 2g single dose.
2. If symptoms persist, repeat course.
Breastfeeding women and symptomatic pregnant women
1. Metronidazole PO 500mg BD 5-7d. Do not prescribe high single dose.
2. If symptoms persist, discuss with a GUM specialist and obstetrician before further treatment.
• Seek advice from a GUM specialist for asymptomatic pregnant women.
People with HIV
• Metronidazole PO 500mg BD 7d.
- Treat current partners simultaneously and any partners from the past 4w.
- Advise abstinence until 1w after treatment completion.
Vulvovaginal candidiasis
Management
• In all cases, if there are vulval symptoms, add topical clotrimazole 1% TDS.
• If symptoms persist, check compliance and prescribe an alternative except in pregnant women.
Uncomplicated
• Intravaginal clotrimazole (preferred) or PO fluconazole 150mg single dose. Prefer oral in women >60 and prescribe topical clotrimazole 1% TDS in girls 12-15. Pregnant women may have any preparation.
Severe
• Fluconazole 150mg PO 2 doses taken 3d apart or clotrimazole vaginal pessaries 500mg 3d apart. For breastfeeding women, prescribe 2 doses of clotrimazole 500mg vaginally.
Recurrent
- Induction course fluconazole 150mg PO 3 doses taken 3d apart or intravaginal clotrimazole 10-14d.
- Then give PRN prescription of fluconazole 150mg PO weekly or a maintenance 6m regimen of intravaginal clotrimazole 500mg weekly.
Women with diabetes, HIV or taking immunosuppressive drugs
• Extended course of intravaginal miconazole 2% 14d or intravaginal pessaries 100mg clotrimazole 12d or PO fluconazole 100mg 7d.
Pregnant women
- Intravaginal clotrimazole for 7d. Do not prescribe PO antifungal. Consider topical clotrimazole 1% TDS in girls 12-15.
- If symptoms persist, consider a second course of intravaginal clotrimazole.
• Only consider treating male partners with balanitis.
Gonorrhoea
Management
• Refer to GUM and perform above investigations.
• Encourage men to notify all partners from past 2w. Women and men with complicated gonorrhoea should notify all partners from past 3m. Notified partners should be tested and treated empirically.
• Advise abstinence until 1w after test of cure following treatment (another NAAT followed by culture if positive 2w after treatment).
• All failures of antibiotics must be reported to Public Health England.
• Admit people with disseminated gonorrhoea (fever, arthralgia, rash) and women with severe PID.
Uncomplicated anogenital gonorrhoea
• Ceftriaxone 1g IM single dose or spectinomycin 2g IM single dose plus azithromycin 2g PO. For needle phobia give cefixime 400mg PO single dose plus azithromycin 2g PO.
Complicated anogenital or pharyngeal gonorrhoea
• Ciprofloxacin 500mg PO single dose.
Pregnant or breastfeeding women
• Ceftriaxone 1g IM single dose.
