Gynaecology Flashcards
1
Q
What is delayed puberty in girls and boys?
A
8-14 or 9-15
4 years with thelarche in girls.
2
Q
What is primary amenorrhea puberty in girls defined as?
A
Not staring by 13 with no other evidence or by 15 years of age with other signs of development such as breast development
3
Q
What is the cause of primary amenorrhea?
A
Structural
Hypogonadotropic hypogonadism
Hypergonadotropic hypogonadism
AIS
CAH
Kallmans
Exercise
Not known constitutional
4
Q
What are some causes of hyponadotropic hypogonadism?
A
Hypopitutarism
Radiotherapy or surgery
Kalman syndrome
Congenital diseases like CF
Constituitional delay -
Hypothyroidism
Hypoprolactinemia
5
Q
What is constituitional delay in puberty?
A
Delay without physical pathology
6
Q
What are some causes of hypergonadotropic hypogonadism?
A
Torsion, cancer, infection like mumps
Congenital absence
Androgen insensitivity syndrome
Congenital adrenal hyperplasia
Turner’s
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absence uterus
FGM
7
Q
What is CAH?
A
21 hydroxylase enzyme deficiency = less cortisol and aldosterone. Genetic condition that is autosomal recessive.
Severe cases neonate is unwell with electrolyte imbalances and hypogylcaemia
8
Q
What are the structural causes of primary ammenorhea?
A
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absence uterus
FGM
9
Q
What testing should be done in delayed puberty?
A
Past medical history
Height, weight, stages of development
No evidence of changes aged 13
Some evidence but no progression after 2 years
Bloods:
FBC + FERRITIN
Urea and electrolyres
anti-TTG for coeliac
Hormonal blood tests:
Thyroid function tests
IGF-1
Prolactin
Testosterone
Genetic testing
Imaging of wrist
Pelvic US
MRI scan for pituitary
10
Q
What can be used to help with withdrawal bleeding in women with PCOS?
A
14 day medroxyprogesterone
11
Q
What are the causes of secondary ammenorhea?
A
Pregnancy
Menopause or POI
PCOS
Uterine - Asherman
Thyroid pathology
Hyperprolactinemia
Extremes of weight
Sheehan’s syndrome
12
Q
How is secondary amenorhea tested?
A
Presenting complaint and family history
bHCG
FSH
LH:FSH ratio
Prolactin
TFTs
Testosterone
US
13
Q
What is PMS?
A
Physical, social and psychological impacts of period.
Fluctuating of oestrogen and progesterone
Presentation include low mood, anxiety, mood swings, bloating, breast pain, cognitive differences and reduced libido
PMDD
Symptom diary required
14
Q
What is the treatment for PMS?
A
General lifestyle changes, exercises, reducing sleep,eat more carbohydrates
CBT, SSRI and COCP
Yasmin
Danazol and tamoxifen for breast pain
Spirnolactone
15
Q
What is HMB?
A
> 80ml and >7 days
16
Q
What causes HMB?
A
PALM COEIN
17
Q
What exams and investigations are done for HMB?
A
History
Pelvic and bimanual exam + speculum
FBC and haematinics
Thyroid
Anticoagulation
TVUSS
Hysteroscopy
Swabs
18
Q
How is HMB managed?
A
Non hormonal: Transexamic acid with bleeding
Mefenamic acid with pain and bleeding
Hormonal: Mirena coil
COCP
Progesterone pills
19
Q
What is balloon thermal ablation?
A
Hot water to burn the inner lining of uterus
20
Q
What are fibroids?
A
Oestrogen dependent leiomyomas
Genetic link - fumarate hydratase
Often assymptomatic
Prolonged bleeding
Dyspareunia, subfertility, fullness
Nulliparous women
Obese
African
Submucosal
Intramural
Pedunculated
Subserosal
Heavy menstrual bleeding
Constipation
Urinary outflow obstruction
Torsion
<1% leiomyosarcoma
21
Q
What are fibroids treatment?
A
Transexamic
Mirena coil
Mefenamic acid
Cyclical progesterons
Hysterectomy
Endometrial ablation - balloon ablation with high temp fluid
Myomectomy - laproscopic or open
Uterine artery embolisation - surgical for larger, uses interventional radiologist, particles injected with oxygen which causes to shrink
GnRH agonists needed to reduce before surgery
I HAEM GUNS
22
Q
What is red degeneration?
A
Red degeneration - necrosis and ischaemia - more than 5cm in pregnancy 2nd and 3rd enlarge. Bleeding and temperature in pregnancy
Supportive management
23
Q
What is endometriosis?
A
Ectopic endometrial tissue
Chocolate cysts
No genetic link found, but thought to be about flow
Acts like tissue in endometrium
Deep pelvic pain, cyclical abdominal pain, cyclical bleeding, dyschezia, dyspareunia, subfertility
Leads to adhesions
Kinking of fallopian tubes
24
Q
What investigations are done for endometriosis?
A
TVUSS may not find much
Gynaecology referral
Gold standard is diagnostic laparoscopy
25
What are the staging system for endometriosis
American Society for Reproductive Medicine - ASRM
Stage 1 small superficial
Stage 2- more deeper implants
Stage 3 - small chocolate cysts
Stage 4- large chocolate cysts
26
What are the different medications for endometriosis?
1. Definitive diagnosis
2. Education required
2. COCP, medroxyprogesterone, mirena coil, GnRH agonist
3. Surgical adehsiolysis, hysterectomy
27
How can early menopause be induced?
Goserelin Zoladex
28
What are treatments for adenomyosis?
Mefenamic acid + transexamic acid
COCP,
Implant, depot
GnRH analogues
Surgery - ablation
My Calling Is General Surgery
29
What is menopause?
Retrospective diagnosis
12 months after the last menstrual period
Perimenopause is the time before menopause and women might get vasomotor symptoms
Menopause before 44 years is premature menopause
FSH and LH high, oestrogen and progesterone is high
30
What are perimenopausal symptoms?
Irregular periods
Vaginal dryness and atrophy
Low libido
Prolapse
Incontinence
Cardiovascular disease
Stroke
31
What is the diagnosis for menopause?
2015 guideline FSH blood test under 40 years or women 40-45 with perimenopause symptoms
32
What are side effects of depot injection?
Weight gain
Osteoporosis
33
What other therapies are there for menopause?
Non-hormonal clonidine, SSRI and venfelexaline, gabapentin,
CBT, lifestyle advice
Moisturiers
Oestrogen replacement
34
What is seen in premature ovarian insufficiency?
Defined as menopause before 40 years
Early onset of symptoms
Hypergonadotropic hypogonadism
Elevated FSH more than 2 diagnosis separated by 4 weeks.
35
What can cause POI?
Autoimmune
Iatrogenic
Genetic
Infections -mumps, TB, CMV
36
What is the treatment for POI?
HRT - helps with osteoporosis and stroke
COCP
Under 50 not seen as risk factor for breast cancer
Use transfermal if high risk of DVT
37
What are non hormonal treatments for menopause?
Lifestyle - reduce stress, caffiene and do exercise
CBT
ClonIdine is for hot flushes, dry mouth, fatigue, headaches and dizziness. Be mindful of withdrawal
SSRI - flouxetine
Venfelexaine
Gabapentin
38
What are the different benefits and disadvantages of HRT?
Benefits improved vasomotor, mood and joint, quality of life, reduce osteoporosis and heart disease
Risk of cancers and VTE
39
What needs to be considered when starting HRT?
Local or systemic
Uterus or no uterus
Period or no period
40
How many withdrawal bleeds are needed in women with PCIS?
At least 3 to 4 a year, as if no ovulation then progesterone may not get released.
41
What are the ways of delivering progesterones?
Tablets
c19 progesterens
C20 progesterens = medroxyprogesterone
Patches
Evorel sequi
Evorel conti
IUD
42
What is Tibolone?
Androgens receptors, progesterone and oestrogen
43
What are the side effects of oestrogen and progesterone?
Nausea and bloating, leg cramps, breast tenderness
Fluid retention, acne, greasy skin, irritability
44
What is the Rotterdam criteria?
2 of 3 of:
Polycystic ovaries - 10cm3 volume or string of beads
Anovulation
Hyperandrogenism
45
What are some COMPLICATIONS of PCOS?
Insulin resistance
Acanthosis nigricans
Cardiovascular disease
Endometrial hyperplasia
OSA
Depression and anxiety
Sexual problems
Hirsutism
46
What is the link between PCOS and SHBG?
High levels of oestrogen reduces sex hormone binding globulin SHBG
47
How is PCOS diagnosed
Fullhistory:
Blood tests:
Testosterone
sbhg
Lh + fsh
prolactin
tsh
Imaging:
TVUSS - string of pearls 12 or more or 10mm3
OGTT
48
How is PCOS managed?
Monitoring:
Cardiovascular QRISK
Cancer risk - endometrial
Sleep apnoea
Anxiety
Insulin resistance
Weight loss
Ovarian drilling
Medroxyprogesterones/ metformin
Eflornithine, dianette (tablet risk of DVT), finasteride, co-cyrindiol
N
Sprinolactone
Letrozolerine
Adapalene
Monitoring
Psychological support
TVUS for endometrial hyperplasia - IUS, COCP, cyclical progesterens
49
What are ovarian cysts?
Pre-menopause are often benign
Most are assymptomatic
Non-specific pelvic pain
Torsion and rupture is a risk
Functional, Intraepithelial, Germ cell, Endometrioma, Stromal
Functional cysts = follicle, corpus luteum cysts
Dermoid cysts / teratomas = torsion
Sex cord traumas = granulosa cell
Check benign or malignant
Weight loss, pain and lymphadenopathy
<5cm do not require further investigation.
Family history like bRCA1 and 2
Test CA125, AFP and BHCG
RMI if older
50
What is RMI?
Menopause
US
CA125
51
What do the different sizes of cyst diameter suggest?
<5cm frequent monitoring, resolve
>5cm routine monitoring
>7cm may require MRI
52
What is Meigs syndrome?
Ovarian fibromas
Pleural effusion
Ascites
53
What is ovarian torsion?
Ovarian mass larger than 5cm
Sudden onset, severe, unilatral pain
Nausea and vomiting
Twist and untwist
Localised tenderness
TVUSS
Whirpool sign
54
What is seen in cervical ectropion
Columnar cells are more vulnerable to trauma
These are seen in the transformation zone
Many are assymptomatic
increased discharged, PCB or dyspareunia
Endocervix seen near ectocervix
55
What are the 3 P's of cervical ectropion?
Pills
Pregnancy
Puberty
56
How are cervical ectropion managed?
Assymptomatic = no treatment needed
Symptomatic = cauterisation
57
What are the type of vaginal prolapse?
Cystocele
Urethrocele
Rectocele - faecal loading - constipation
Enterocele
POP-Q
Dragging or heavy symptoms, bowel symptoms, sexual dysfunction
Worse on bearing down
Use a simm's speculum is a U shaped, anterior wall for rectocole and posterir wall for cystocele
58
How are prolapses managed?
Conservative - physio, weight loss, lifestyle, oestrogen cream
Vaginal pessary - ring shaped, shelf and gel horn, donut,
Surgery
59
How is incontinence investigated?
Medical history
Urinary focus
Pelvic tone, atrophic vaginitis,
Pelvic exam - modified Cambridge system
Bladder diary
Urine dipstick testing
Post void residual testing
Urodynamic testing - X ray
60
How is stress incontinence managed?
Stress incontinence:
- Avoiding caffiene
- Supervised Pelvic floor - 8 contraction 3 times daily
- Dulouxetine
- Surgery like colposuspension, autologous fascial sling procedures, intramural urethral bulking
Urge:
Bladder retraining
Oxybutynin, mirabegron and toletirodine (mirabegron better in eldelry but avoid in hypertensive patients - hypertensive crisis risk - TIA and stroke
Botox injection,
augmentation cystoplasty,
percutaneous sacral nerve stimulation,
a urinary diversion.
61
What is atrophic vaginitis and how is it managed?
Thin skin, pale mucosa, reduced folds, erythema, dryness and sparse hair.
Vaginal lubricants, silk
Topical oestrogens
Pessaries
Oestradiol ring
62
What are Bartholin's cysts and how is it treated?
Ducts of the cysts become blocked and can cause an abscess to form. Good hygiene, warm compresses
Antibiotic for abscess.
Take swabs
Word catehter + marsupialisation
63
What is lichen sclerosus and how is it treated?
Older woman with itching and skin changes
Koebner's phenomenon
Clobetasol or dermovate
64
Where is FGM highest in the world?
Somalia, Ethiopia, ErItreia
65
How is FGM managed?
<18 = police, safeguarding lead, psychological support, paediatrics
66
What do female reproductive organs develop from?
Mullerian duct
67
What is a bicornuate uterus?
Horn shaped uterus
68
What is imperforate hymen?
Menses sealed in vagina and causes pelvic pain and cramping
69
What are vaginal septae?
Congenital abnormality
70
What is vaginal agenesis?
No vagina
Requires dilator
or surgery
71
What groups of women should have yearly screening for cervical cancer?
HIV
Immunocompromised
CIN
72
What does colposcopy involve?
Stains with acetic acid makes normal cells stain white - aceto white.
Schiller's Iodine test stains healthy cells a brown colour
Punch biopsy might be taken
73
What is a cone biopsy?
For testing malignancy --> GA used --> pain, bleeding infection, pre-term labour
74
What is the FIGO staging
Stage 1 - cervix
Stage 2 - upper 2/3rds of vagina or and uterus
Stage 3 - lower 1/3 of vagina
Stage 4 - bladder, rectum or beyond
75
What are treatments for cervical cancer?
CIN 2. 3 - LLETZ or cone biopsy
Stage 2 - Hysterectomy
Stage 3 - chemo and radiotherapy
Stage 4 - palliative care
Pelvic exenteration
Anti-VEGF - avastin
76
When is the HPV vaccine given?
12 and 13 for boys and girls/ Gardasil --> needs to be given before, 8,11, 16 and 18
77
What causes cervical cancer?
HPV, smoking, immunosuppression are the main risk factors. It is unlike endometrial cancer caused by squamous cell carcinoma
78
What is endometrial cancer?
Mostly adenocarcinoma
Obesity, diabetes are risk factors, early menarche, late menopause, unopposed oestrogen, tamoxifen use, HNPCC
Smoking is protective
Endometrial hyperplasia is a pre-malignant change, <5% become endometrial cancer, may require progestorens. Typical and atypical hyperplasias
79
What are progestegens?
Progestogens, also sometimes written progestagens or gestagens,[1] are a class of natural or synthetic steroid hormones that bind to and activate the progesterone receptors (PR).
80
Compare and contrast cervical and endometrial cancer.
Cervical is squamous, endometrial is adenocarcinoma
Smoking is a RF for cervical and protective in endometrial
COCP risk factor for cervical, vs unopposed in endometrial
81
What is the 2 week wait for endometrial cancer?
2 week wait:
PMB
TVUSS over 5mm
Visible haematuria
Raised platelets
82
What investigations are needed for PMB?
TVUSS, normal is <4mm
Pipelle
Hysteroscopy
83
What are the FIGO stages for endometrial cancer?
1 - confined to uterus - total hysterectomy and oophorectomy
2 - cervix
3 - ovaries, fallopian tube and vagina - radial pelvic hysterectomy
4 - bladder, rectum or beyond pelvis
84
What is ovarian cancer?
Epithelial cell tumours are most common type.
Serous tumours
85
Which cancer is associated with torsion?
Dermoid tumour
86
What is Krukenberg?
Metastasis from a different primary
87
What do Krukenberg have?
Signet rings as from bowel OR stomach
88
What are risk factors for ovarian cancer?
Age
BRCA 1 and 2
Ovulations
Obesity
Smoking
Clomifene
Late menopause
No pregnancies
89
What are 7 symptoms of ovarian cancer?
Non specific
Bloating
Early satiety
Appetite
Pelvic pain
Weight loss
Ascites
90
What are two week wait criteria?
Physical ascites and pelvic mass
CA125
Pelvic ultrasound
(RMI = menopause, US, CA125)
91
What are non specific causes of raised ca125?
eNDOMETRIOSIS
fIBRPOIDS
PELVIC INFECTION
92
What are stages of ovarian cancer?
1 - ovary
2 - pelvis
3 - abdomen
4 - distal metastasis
93
What is vulval cancer?
Squamous cell carcimomas
Advancing age, smoking, immunosuppression, HPV
Lichen sclerosus 5%
VIN is premalignant
Watch and wait,
wide local incision,
imiquimod,
laser ablation
Mostly incidental, lump, ulceration, bleeding and lymphadenopathy
2 week wait, biopsy, sentinel node biopsy, CT
FIGO staging
94
What does FIGO stand for?
International Federation of Gynecology and Obstetrics
95
What are the two types of swabs?
Charcoal
and NAAT
96
What treatments are given for PID
Metronidazole + doxocyline + cefrtriaxone
97
What are the treatments for HIV?
BHIVA suggest 2NRTI and proteas or integrase inhibitor
98
What test is done for Abacavir?
HLA-B5701 typing can be used for genetic risk stratification prior to initiation of Abacavir therapy 3. The FDA-approved drug label for abacavir recommends pre-therapy screening for the HLA-B5701 allele and the use of alternative therapy in subjects with this allele
99
How are mother's with a high viral load managed?
Zidovudine and caesarean is done if high risk
100
What is BHIVA?
British HIV association
101
Natural planning
Condoms
POP and COCP
Coils
Injections
Implant
102
How should you deliver information regarding a medication?
Prior knowledge
Ideas, concerns and expectations.
Mechanism of action
How to take
Benefits
Drawbacks
Risks
Contraindications
What to do if missed a dose?
Questions
103
How does the COCP work?
Progesterone** i**nhibits proliferation of the endometrium, reducing the chance of successful implantation
Progesterone **t**hickens the cervical mucus
Preventing **o**vulation (this is the primary mechanism of action)
Everyday formulations (e.g. Microgynon 30 ED) are monophasic pills, but the pack contains seven inactive pills, making it easier for women to keep track by simply taking the pills in order every day.
104
What are some advantages of the COCP?
The NICE Clinical Knowledge Summaries (2020) recommend using a pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin). These choices have a lower risk of venous thromboembolism.
Yasmin and other COCPs containing drospirenone are considered first-line for premenstrual syndrome. Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes. Continuous use of the pill, as opposed to cyclical use, may be more effective for premenstrual syndrome.
Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol) can be considered in the treatment of acne and hirsutism. Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism. The oestrogenic effects mean that co-cyprindiol has a 1.5 – 2 times greater risk of venous thromboembolism compared to the first-line combined pills (e.g. Microgynon). It is usually stopped three months after acne is controlled, due to the higher risk of VTE.
105
What are some examples of COCP combinations?
Microgynon contains ethinylestradiol and levonorgestrel
Loestrin contains ethinylestradiol and norethisterone
Cilest contains ethinylestradiol and norgestimate
Yasmin contains ethinylestradiol and drospirenone
Marvelon contains ethinylestradiol and desogestrel
106
Side effects of COCP
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
107
Benefits of COCP
Effective contraception
Rapid return of fertility after stopping
Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
Reduced risk of endometrial, ovarian and colon cancer
Reduced risk of benign ovarian cysts
108
Risks of COCP
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
109
UKMEC4 for COCP
When starting any form of contraception, it is essential to consider the contraindications for the individual. There are specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4):
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome
110
UKMEC3 for COCP
It is worth noting that a BMI above 35 is UKMEC 3 for the combined pill (risks generally outweigh the benefits).
111
What needs to be considered when starting COCP?
Start on the first day of the cycle (first day of the menstrual period). This offers protection straight away. No additional contraception is required if the pill is started up to day 5 of the menstrual cycle.
Starting after day 5 of the menstrual cycle requires extra contraception (i.e. condoms) for the first 7 days of consistent pill use before they are protected from pregnancy.
When switching between COCPs, finish one pack, then immediately start the new pill pack without the pill-free period.
When switching from a traditional progesterone-only pill (POP), they can switch at any time but 7 days of extra contraception (i.e. condoms) is required. Ensure the woman is not already pregnant before switching (i.e. they have been using contraception reliably and consistently).
When switching from desogestrel, they can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel inhibits ovulation.
112
What are the two types of POP?
There are two types of POP to remember:
Traditional progestogen-only pill (e.g. Norgeston or Noriday)
Desogestrel-only pill (e.g. Cerazette)
The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.
The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.
113
What is the difference is function between traditional progesterone only pill and dosgestrel?
Traditional progestogen-only pills work mainly by:
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Desogestrel works mainly by:
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
114
When should the POP be started and should emergency contraception be used?
Starting the POP on day 1 to 5 of the menstrual cycle means the woman is protected immediately.
It can be started at other times of the cycle provided pregnancy can be excluded. Additional contraception is required for 48 hours. It takes 48 hours for the cervical mucus to thicken enough to prevent sperm entering the uterus.
115
What are the side effects of the POP?
Approximately:
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
Other side effects include:
Breast tenderness
Headaches
Acne
116
What are the RISKS of the POP?
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
Minimal increased risk of breast cancer, returning to normal ten years after stopping
117
What counts as a missed pill for POP?
More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
118
What is the success rate of female sterilisation?
Filshie clips 1 in 200
119
What needs to be considered with success rate of contraception?
Perfect use and normal use
120
When must 48 hours of contraception be added when changing to the POP?
If they have not had unprotected sex since day 3 of the hormone-free period, they can start the POP immediately but require additional contraception (e.g., condoms) for the first 48 hours of taking the POP.
121
When must 7 DAYS of barrier contraception be added when changing to the POP?
If they have had unprotected sex since day 3 of the hormone free period, they can start the POP immediately but require additional contraception for 7 days
122
When can the POP be started immediately?
They can start the POP immediately, without additional contraception, if they:
Have taken the COCP consistently for more than 7 days (they are in week 2 or 3 of the pill pack)
Are on days 1-2 of the hormone-free period following a full pack of the COCP
123
What counts as missed pills for POP?
More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
124
What is UKMEC4 for POP?
The only UKMEC 4 criteria for the POP is active breast cancer.
125
What is the progesterone injection
The main action of the depot injection is to inhibit ovulation.
Depot MedroxyProgesterone Acetate (DMPA)
It is given at 12 to 13 week intervals as an intramuscular or subcutaneous injection
99% with optimal use, 94% with typical use
Depo-Provera: given by intramuscular injection
Sayana Press: a subcutaneous injection device that can be self-injected by the patient
Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks.
126
What is UKMEC3 for the progesterone injection?
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
127
When can the depot be started?
Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.
Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective.
Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.
128
What are the side effects of the depot?
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss (alopecia)
Skin reactions at injection sites
129
What is the implant?
The progestogen-only implant is a small (4cm) flexible plastic rod that is placed in the upper arm, beneath the skin and above the subcutaneous fat. It slowly releases progestogen into the systemic circulation. It lasts for three years and then needs replacing.
The progestogen-only implant is more than 99% effective with perfect and typical use. Once in place, there is no room for user error. It needs to be replaced every three years to remain effective.
Nexplanon is the implant used in the UK. It contains 68mg of etonogestrel. It is licensed for use between the ages of 18 and 40 years.
130
When should the implant be injected?
Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection. Insertion after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms), similar to the injection.
130
What are the benefits of the implant?
Effective and reliable contraception
It can make periods lighter or stop all together
No need to remember to take pills (just remember to change the device every three years)
It does not cause weight gain (unlike the depo injection)
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
131
What are the drawbacks of the implant?
It requires a minor operation with a local anaesthetic to insert and remove the device
It can lead to worsening of acne
There is no protection against sexually transmitted infections
It can cause problematic bleeding
Implants can be bent or fractured
Implants can become impalpable or deeply implanted, leading to investigations and additional management
132
How does progesterone implant affect bleeding?
1/3 have infrequent bleeding
1/4 have frequent or prolonged bleeding
1/5 have no bleeding
The remainder have normal regular bleeds
133
What are the side effects of progestogens?
Headaches
Acne
Reduced sex drive
Tenderness
Irregular bleeding
134
What happens if the coil strings are not located?
When the coil threads cannot be seen or palpated, three things need to be excluded:
Expulsion
Pregnancy
Uterine perforation
Extra contraception (i.e. condoms) is required until the coil is located.
The first investigation is an ultrasound. An abdominal and pelvic xray can be used to look for a coil elsewhere in the abdomen or peritoneal cavity after a uterine perforation. Hysteroscopy or laparoscopic surgery may be required depending on the location of the coil.
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What is the IUD?
The copper coil (IUD) is a long-acting reversible contraception licensed for 5 – 10 years after insertion (depending on the device). It can also be used as emergency contraception, inserted up to 5 days after an episode of unprotected intercourse. It is notably contraindicated in Wilson’s disease.
Mechanism
Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation.
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What are the benefits of the IUD?
Reliable contraception
It can be inserted at any time in the menstrual cycle and is effective immediately
It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
It may reduce the risk of endometrial and cervical cancer
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What are the drawbacks of the IUD
A procedure is required to insert and remove the coil, with associated risks
It can cause heavy or intermenstrual bleeding (this often settles)
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Intrauterine devices can occasionally fall out (around 5%)
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What is the IUS?
he LNG-IUS works by releasing levonorgestrel (progestogen) into the local area:
Thickening cervical mucus
Altering the endometrium and making it less accepting of implantation
Inhibiting ovulation in a small number of women
The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.
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What are the benefits of IUS?
It can make periods lighter or stop altogether
It may improve dysmenorrhoea or pelvic pain related to endometriosis
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
The Mirena has additional uses (i.e. HRT and menorrhagia)
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What are the drawbacks of IUS?
A procedure is required to insert and remove the coil, with associated risks
It can cause spotting or irregular bleeding
Some women experience pelvic pain
It does not protect against sexually transmitted infections
Increased risk of ectopic pregnancies
Increased incidence of ovarian cysts
There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
Intrauterine devices can occasionally fall out (around 5%)
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What are the three options for emergency contraception?
Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
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What else should be addressed in an emergency contraception consultation?
For Real Stay Safe
Future contraception
Reassure about confidentiality
Sexually transmitted infections
Safeguarding, rape and abuse
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When is ullipristal avoided?
Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
Ulipristal should be avoided in patients with severe asthma
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What are the Gillick competencies?
They are mature and intelligent enough to understand the treatment
They can’t be persuaded to discuss it with their parents or let the health professional discuss it
They are likely to have intercourse regardless of treatment
Their physical or mental health is likely to suffer without treatment
Treatment is in their best interest
MPs Like My Bum
Maturity
Parents
Likely to continue
Mental health
Best interests
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When can emergency contraception be started following levonorgestrel and ullipristal acetate?
Levonorgestrel straight away and ullipristal wait 5 days
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When is the test of cure done?
6 months
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What is the threshold for endometrial cancer thickness?
>4mm
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How is endometrial hyperplasia managed?
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By what time should the placenta be delivered in the third stage of labour?
30 minutes with active management, 60 minutes with physiological
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What is the most common cause of death in pregnancy?
PE and venous thrombosis
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Give 5 causes of pruitis vulvae?
Lichen sclerosus
Lichen planus
Leukoplachia
Lichen simplex
Vulvovaginitis
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What are the benefits of HRT?
Bone, bowels, bed and blood.
