Gynaecology Flashcards
Define atrophic vaginitis
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.
Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause.
It occurs in women entering the menopause.
Describe the presentation of atrophic vaginitis
Atrophic vaginitis presents in postmenopausal women with symptoms of:
- Itching
- Dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding due to localised inflammation
Consider atrophic vaginitis in older women presenting with recurrent UTI, stress incontinence or pelvic organ prolapse.
Describe what can be seen in the examination of atrophic vaginitis
Examination of the labia and vagina will demonstrate:
Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair
Describe the management of atrophic vaginitis
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen can make a big difference in symptoms. Options include:
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. Women should be reviewed annnually.
Define bacterial vaginosis
BV refers to overgrowth of anaerobic bacteria in the vagina. It is caused by a loss of the lactobacilli bacteria in the vagina. BV can increase the risk of women developing STIs.
Describe the aetiology of bacterial vaginosis
Lactobacilli are part of healthy vaginal bacterial flora. These produce lactic acid which keeps the vaginal pH under 4.5.
The acidic environment keeps other bacteria from overgrowing but in BV, since there is less lactobacilli, the pH rises. Te more alkaline environment enables anaerobic bacteria to multiple.
Give examples of anaerobic bacteria associated with bacterial vaginosis
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
Describe the risk factors of bacterial vaginosis
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
Describe the presentation of bacterial vaginosis
- FISHY-SMELLING
- watery grey or white vaginal discharge
half of the women with BV are asymptomatic
itching, irritation and pain are not typically associated with BV so think other causes
Describe the investigations of bacterial vaginosis
- speculum examination to confirm typical discharge and swab
- vaginal pH testing using swab and pH paper (normal = 3.5-4.5)
- charcoal swab for microscopy which shows CLUE CELLS!
What are clue cells?
epithelial cells from the cervix that have bacteria stuck inside them, usually gardnerella vaginalis.
Describe the management of bacterial vaginosis
Metronidazole orally or by vaginal gel. Clindamycin is an alternative but less optimal.
Assess the risk of additional pelvic infections with swabs for chlamydia and gonorrhoea
What should you advice to someone when prescribing metronidazole?
Avoid alcohol as it can have disulfiram-like-reaction with nausea and vomitting, flushing and sometimes severe symptoms of shock and angioedema
What are the complications of bacterial vaginosis?
Can increase the risk of catching STIs
In pregnant women:
- miscarriage
- preterm delivery
- premature rupture of membranes
- chorioamnionitis
- low birth weight
- postpartum endometritis
Define vaginal candidiasis
commonly referred to as “thrush” is a vaginal infection with a yeast from the candida family, most commonly candida albicans.
What are the risk factors for vaginal candidiasis?
Diabetes Mellitus
Drugs: antibiotics, steroids
High oestrogen: Pregnancy
Immunosuppression: HIV
Describe the presentation of vaginal candidiasis
- COTTAGE CHEESE , non offensive discharge
- thick white discharge
- vulval and vaginal itching, irritation and discomfort
- dyspareunia
- dysuria
Describe the investigations of vaginal candidasis
often treatment is started based on presentation.
Vaginal pH using swab and pH paper to differnetiate between BV and trichomonas (pH >4.5) and candidiasis (pH <4.5)
Charcoal swab with microscopy can confirm diagnosis
Describe the management based on NICE guidelines of vaginal candidiasis
Initial uncomplicated cases, any of the following:
- single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
- A single dose f clotrimazole pessary (500mg) at night
- 3 doses of clotrimazole pessaries (200mg) over 3 nights
- single dose of fluconazole (150mg)
What is the OTC medication for vaginal candidiasis?
Canesten Duo: it contains a single fluconazole tablet and clotrimazole cream to use externally.
What do you need to warn women about in regards to antifungal creams and pessaries?
They can damage latex condoms and prevent spermicides from working so alternative contraception is required for at least 5 days after use.
What is the management for recurrent vaginal candidiasis?
Recurrent = 4 or more in 1 year.
Induction: oral fluconazole every 3 days for 3 doses
Maintenance: oral fluconazole weekly for 6 months.
What is tested first in the cervical smear?
hrHPV first and if that is positive then cytology is performed
Management of negative hrHPV test
return to normal recall, unless:
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
Management of positive hrHPV test
samples are examined cytologically:
if the cytology is abnormal → colposcopy this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
Cervical screening timeframe
Between ages of 24.5 to 49, offered every 3 years
Between ages of 50 and 64, offered every 5 years
What is chlamydia?
A gram negative bacteria. It is an intracellular organism.
Most common STI in the UK.
50% men and 75% women are asymptomatic
Describe the national chlamydia screening programme
National chamydia screening programme (NCSP) aims to screen every sexually active person under 25 years of age annually or when they change partners.
If they test positive, they have to re-test in 3 months.
What tests should be done when a patient attends a GUM clinic for STI screening?
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
What are the types of swabs used in sexual health and what do they look for?
Charcoal swab: allow for microscopy, culture and sensitivities. Can confirm: BV, Candidiasis, Gonorrhoea, Trichomonas vaginalis and other bacteria such as Group B strep.
Nucleic acid amplification test (NAAT) swabs: checck directly for DNA or RNA of the organism. Can confirm chlamydia and gonorrhoea.
Describe the presentation of chlamydia
Women: discharge, pelvic pain, abnormal vaginal bleeding, dyspareunia and dysuria.
Men: discharge, dysuria, epididymo-orchitis and reactive arthritis.
What are the examination finds in chlamydia?
Pelvic or abdominal tenderness Cervical motion tenderness Inflamed cervix (cervicitis) Purulent discharge
Describe the diagnosis of chlamydia including time frame
NAAT used:
Women first line: vulvovaginal swab
Men first line: first catch urine
testing should be carried out 2 weeks after possible exposure
Describe the management for chlamydia
first-line: doxycycline 100mg twice a day for 7 days
If contraindicated e.g. pregnancy then:
azithromycin 1g stat then 500mg once a day for 2 days
Contacts of confirmed chlamydia cases should be treated before investigation results
What are the complications of chlamydia?
pelvic inflammatory disease increased incidence of ectopic pregnancies infertility reactive arthritis conjunctivitis lymphogranuloma venerum
Describe lymphogranuloma venerum
LGV is a complication of chlamydia. Most commonly occurs in MSM.
Stage 1 is a painless ulcer
Stage 2 is lymphadenitis
Stage 3 is proctitis and anal inflammation.
Treatment is doxycyline 100mg twice daily for 21 days
What are the different methods of contraception?
Natural family planning Barrier methods Combined contraceptive pills Progesterone only pills Coils Progesterone injection Progesterone implant Surgery (
Describe the UKMEC
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
What are some key risk factors and contraindications in contraception?
Breast cancer: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)
Wilson’s disease: avoid the copper coil
What are the UKMEC absolute contraindications for the combined contraceptive pill?
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 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 and antiphospholipid syndrome
Which form of contraception is safe and which is not while breast feeding?
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Describe the efficacy and mechanism of action of the combined contraceptive pill
Combination of oestrogen and progesterone. 99% effective (91% with typical use). Licensed for use upto 50 years of age.
MOA:
PREVENTS OVULATION
oestrogen and progesterone have a negtative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH, LH and FSH. PREVENTS OVULATION.
What is the protocol for a missed pill in relation to the COC?
Less than 72 hours: Take the pill as soon as you remember even if it means taking 2 on the same day.
After 72 hours: additional contraception is needed until they take the pill 7 days in a row.
Describe the efficacy and contraindications of the progesterone only pill
99% effective (91% with typical use).
Only UKMEC 4 absolute contraindication is active breast cancer.
What are the different types of POP?
- Traditional progesterone only (cannot be taken more than 3 hours late)
- Desogestrel-only pill (cannot be taken more than 12 hours late)
Describe the mechanism of action of the traditional POP
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Describe the MOA of the desogestrel only pill
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
Describe the efficacy and use of the progesterone only injection
99% effective (94% with typical use)
Every 12 to 13 weeks injection.
Can take upto 12 months for fertility to return.
What are the contraindications for progesterone only injection?
UKMEC 4: active breast cancer UKMEC 3: ischaemic heart disease and stroke unexplained vaginal bleeding severe liver cirrhosis liver cancer
Can cause osteoporosis in older women.
Describe the MOA of the progesterone only injection
inhibits ovulation by inhibiting FSH secretion by the pituitary gland, preventing the development of the follicles in the ovaries.
What are the side effects fo the progesterone only injection?
changes to the bleeding schedule (1/3s)
Other SE:
- WEIGHT GAIN
- OSTEOPOROSIS
- acne
- reduced libido
- mood changes
- headaches
- flushes
- hair loss
How does the progesterone only injection cause osteoporosis?
Oestrogen helps maintain bone mineral density in women and is mainly produced by the follicles in the ovaries. Suppressing the development of follicles reduces the amount of oestrogen produced leading to decreased bone mineral density.
Describe the efficacy, contraindication and use of the progesterone implant
99% effective. Needs to be replaced every 3 years.
only UKMEC 4: active breast cancer
MOA of the progesterone implant
inhibits ovulation
thicken cervical mucus
altering the endometrium and making it less accepting of implantation
