Gynaecology

Question 1

Missed pills

Answer 1

If miss pill <24hr (Ie <48 since last pill taken) still protected take when remember

If miss pill >24hr (ie >48hr since last pill) continue to take pill + 7/7 condoms/abstinence

If less than 7 pills left in pack, don’t take sugar pills continue with hormone pills + 7/7 condoms/abstinence

If missed pill in first 7 days of new pack after sugar tabs and have had sex in sugar pill phase or within 7 days after missed pills = emergency contraception + condoms/abstinence + recommence pill

Question 2

Emergency contraception

Answer 2

1. copper intrauterine contraceptive device (IUD): prevents fertilisation and implantation
   - can be inserted up to 5/7 post sex
   - need to exclude current pregnancy
2. oral emergency contraception: prevent or delay ovulation.
   - reduced effectiveness if BMI >30

a) ulipristal
- single dose taken as soon as possible and within 120 hours (5 days) of unprotected sexual intercourse.
- most effective (other than copper IUD)
- not recommended if taking steroids
- not recommended if taking medication affecting liver enzymes
- must wait 5 days before commencing/re-commencing hormonal contraception

2) levonorgestrel
- 1.5 mg orally, as a single dose taken as soon as possible and within 96 hours (4 days) of unprotected sexual intercourse

Levonorgestrel and ulipristal can cause nausea and vomiting; the dose should be repeated with an antiemetic if vomiting occurs within 3 hours of the dose.

A follow-up pregnancy test is recommended if the next menstrual period is more than 7 days late (occurs in 18.5% of users) or is lighter than usual

Question 3

Ovarian Mass

Answer 3

Must be evaluated using USS

CA125 not reliable in pre-menopausal women. Reliable in post-menopausal women

Use risk of malignancy index (RMI). If >200 -> Refer
- requires Ca125

Protective factors:

• parity
• breastfeeding
• COCP use

Risk factors:
FHx Breast/ovarian/uterine/colon ca.

PRE-menopausal:
If <5cm + simple -> Reassure
If 5-7cm -> Repeat USS 3/12. If Increasing -> Refer
If >7cm -> Refer

POST-menopausal:
Calculate RMI
RMI < 25 -> Surveilance with USS + Ca125 at 3/12
RMI >25 -> Refer