Gynaecology Flashcards
What is the standard frequency of cervical smears in the national screening programme
Screen age 24.5 - 64. Women should receive their first smear before they turn 25. 25-49 = every 3 years. 50-64 = every 5 years.
Women over 64 can be screened if a) they have had a recent abnormal cytology result or b) they have not had a smear since aged 50 and they wish for one
What is the protocol for cervical screening during pregnancy?
Routine cervical smears should be delayed until at least 12 weeks postpartum. However if the woman has had a previous abnormal smear then she should have colposcopy during pregnancy (late 1st or 2nd trimester) without delay. If the changes are only borderline then the colposcopy may be postponed until after delivery depending on clinical indication.
How does cervical screening work?
For routine smears, the lab first checks for high risk HPV - if this is negative then MOST get routine recall without cytology being performed. The exception is those who’s mother were exposed to DES (diethylstilbestrol) in their pregnancy (DES daughters) who even if high risk HPV is negative will require liquid-based cytology as maternal DES exposure increases the risk of clear cell adenocarcinoma (CCA).
If HPV is positive then the lab will do liquid-based cytology - which can be reported as inadequate, negative or abnormal.
If HPV positive and cytology is abnormal then they are referred for colposcopy.
What are the different abnormalities that cytology may detect in cervical screening?
Borderline Low grade dyskaryosis High grade dyskaryosis (moderate and severe) Invasive squamous cell carcinoma Glandular neoplasia
Which are the high risk strains of HPV that the cervical screening programme checks for?
16 and 18
What are relative contraindications for taking a cervical smear?
Pregnancy
< 12 weeks post-natal or post-miscarriage/TOP
Menstruating
Vaginal discharge / infection - treat the infection and then perform the smear
How should you manage inadequate cervical smear results?
If inadequate sample x1 repeat within 3 months (unless this is the smear that you are doing after 24 months of HPV positive in which case refer to colposcopy if inadequate).
If have x2 consecutive inadequate results = refer to colposcopy. If this is normal, then repeat smear in 12 months. If colposcopy is inadequate also, then repeat smear AND colposcopy in 12 months.
How should you manage a positive HPV result in routine screening?
Positive HPV + normal cytology = repeat HPV test in 12 months. If this also positive = repeat in another 12 months. If the third HPV test is positive = refer for colposcopy.
If HPV becomes negative at either 12 or 24 months then can return to routine recall so long as cytology is normal.
What advice do you give if a woman has missed x1 pill of her COCP?
To take the missed pill immediately (even if it means taking 2x pills in one day) and then resume normal pill taking with no further precautions necessary even if had intercourse in this time.
What advice do you give to a woman who has missed x2 or more pills of her COCP?
She should take the most recently missed pill immediately ( even if it means taking x2 pills in one day) and then resume normal pill taking. She should then abstain / use condoms until she has used pills continuously for 7 days in a row.
If the x2 or more missed pills occurred during week 1 and intercourse was had either in the pill-free week or during week 1 = consider emergency contraception
If occurred in week 2 = no need for emergency contraception
if occurred in week 3 = finish the current pack and straight away start the next pack MISSING THE PILL FREE INTERVAL
Which drugs are P450 inductors and thus risk reducing the efficacy of the COCP?
St Johns Wort Carbemazapine Phenytoin Rifampicin Chronic alcohol intake Smoking
What are category 1-4 of the UKMEC?
Cat 1 -> no restrictions on use
Cat 2 -> pros > cons
Cat 3 -> cons > pros -> should only be started by a specialist contraceptive provider
Cat 4 - absolutely contraindicated
What are absolute (category 4) contraindications for the COCP?
- <6 wks postpartum + BF (then cat 2 <6 months if BF)
- <3 wks postpartum + not BF AND other risk factors for VTE (if not BF and no other risk factors = cat 3.
3-6 wks = cat 3 if other risk factors or cat 2 if no other risks factors)
Note - after 6 wks in non-BF or after 6 months in BF COCP becomes cat 1 again
There is NO limit post-abortion (even in postabortion sepsis) - 35+ and smoking 15+ cigs/day
- BP 160+ systolic or 100+ diastolic
- Vascular disease
- Current or prev ischaemic heart disease
- Current or prev Stroke / TIA
- Current or prev VTE
- Major surgery with prolonged immobilisation
- Prothrombogenic disorder (Antiphospolipid syndrome, factor V leiden, protein c/s/antithrombin deficiencies, prothrombin mutation)
- complicated congenital or valvular heart disease
- cardiomyopathy with impaired cardiac function
- atrial fibrillation
- migraine with aura
- current breast cancer
- severe liver cirrhosis / hepatocellular adenoma or carcinoma
What are category 3 examples for the COCP?
ie should be avoided
< 3 weeks postpartum + not-BF
< 6 wks postpartum + not BF + other risk factors for VTE
35 years+ and smoking <15 cigs/day or only stopped smoking within the last year
BMI 35+
organ transplant with graft rejection
MULTIPLE cardiovascular risk factors (DM, ^ cholesterol, high BP)
Adequately controlled HTN or systolic 140-160 / diastolic 90-100
VTE in a 1st degree relative <45
Immobility eg wheelchair use
Migraine WITHOUT aura or a Hx of migraine with aura 5+ years ago
Undiagnosed breast mass / BRCA1/2 carrier / prev breast Ca
Diabetic nephropathy/neuropathy/retinopathy/vascular disease
Current gallbladder disease or prev COCP related cholestasis
Postpartum use of IUDs?
In the intial 48 hrs postpartum both Copper + Mirena coil are cat 1 whether SVC or c-section
48hrs - 4 weeks = cat 3
4 weeks + = cat 1 again
BOTH ARE CAT 4 IF POSTPARTUM OR POST-ABORTION SEPSIS
Any of the progesterone-only contraceptives are fine postpartum at any stage and in breast-feeding! (POP, depot, implant)
