Gynaecology and Breast

Question 1

What are the methods of giving Combined hormonal contraception and how are they given?

Answer 1

Pill - Take one pill for 21 days and then 4 day break
Ring - Insert for 21 days
Patch - One patch one same day each week for 3 weeks

New ways of taking CHC:
- Shortened regime : (21 active pills, 1 ring or 3 patches) and then 4 day break
- Extended use/tricycling : (63 active pills, 9 patches followed by 4 day break)
- Flexible extended use : Take continuously until breakthrough bleeding occurs for 3-4 days then take 4 day break (not more than 1/month)
- COntinuous use - no break

Question 2

How does combined hormonal contraception work?

Answer 2

Main: Stops ovulation

But also: thickens cervical mucus (reducing chance of semen entering uterus) and thins endometrial lining (reducing chance of implantation)

Question 3

What is the UKMEC criteria?

Answer 3

The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk

Question 4

What are the pros of using combined hormonal contraception?

Answer 4

Periods - regular, lighter
**Ovarian cysts **- reduction in benign cysts and functional ovarian tumours
Acne/hirsutism (reduce in 3-6 months)
Cancer - Reduced endometrial and ovarian cancer
Endometriosis - Reduces symptoms
Fertility - returns quickly

FACE PO

Question 5

What are the cons of using combined hormonal contraception?

Answer 5

Can forget pills
No protection against STIs
Increased risk of VTE (DVT, IHD, stroke)
Increased risk of breast and cervical cancer

Question 6

What are UKMEC 4 conditions for Combined hormonal contraception?

Answer 6

**More than 35 years old and smoking more than 15 cigarettes/day
Migraine with aura
Hx of thromboembolic disease or thrombogenic mutation
Hx of stroke or ischaemic heart disease
Breast feeding < 6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
Positive antiphospholipid antibodies (e.g. in SLE)
Diabetes mellitus for >20 yrs, retinopathy. nephropathy or neuropathy **

Question 7

What are the side effects of combined hormonal contraception?

Answer 7

Breast tenderness
Breakthrough bleeding
Headaches
Bloating
Nausea
Cholasma (darker patches of skin on face, can also be seein pregnancy)
PV discharge

Question 8

When should the combined hormonal contraception be started in a cycle?

Answer 8

Idealy Day 1-5. If not then need additional contraception for 7 days.

Question 9

What to do with missed pills (COCP)

Answer 9

If 1 pill is missed (at any time in the cycle)
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

No additional contraceptive protection needed

If 2 or more pills missed
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day

The women should use condoms or abstain from sex until she has taken pills for 7 days in a row.

If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Question 10

What is cervical cancer and what causes it?

Answer 10

A HPV (Human Papilloma Virus) related malignancy.

Preventable by HPV vaccination and screening.

Question 11

What is the pathophysiology of cervical cancer?

Answer 11

The incubation from latent infection to presentation with cancer is typically 15 years.

HPV infection causes the release of oncoproteins E6 (which binds p53) and E7 (which interacts with retinoblastoma protein Rb), in conjunction with co-factors yet to be defined.

These drive uncontrolled cervical intra-epithelial neoplasia.

Question 12

Risk factors for cervical cancer?

Answer 12

Human papillomavirus (HPV), particularly serotypes **16,18 & 33 **is by far the most important factor in the development of cervical cancer.

Other risk factors include:
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill

Question 13

Symtpoms of cervical cancer?

Answer 13

May be detected during routine cervical cancer screening

Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding

Vaginal discharge - watery or red/brown, malodorous

Question 14

Screening for cervical cancer?

Answer 14

It’s offered to women and people with a cervix aged 25 to 64.

Under 25
- Up to 6 months before you turn 25

25 to 49
- Every 3 years

50 to 64
- Every 5 years

65 or older
- Only if a recent test was abnormal

The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.

Management of results

Negative hrHPV
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
- The untreated CIN1 pathway
- Follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- Follow-up for borderline changes in endocervical cells

Positive hrHPV
- 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

If the sample is ‘inadequate’
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy

The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve 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.

Question 15

Classification of cervical cancer (cytology) - CIN - what is it and the different types?

Answer 15

Cervical intraepithelial neoplasia (CIN) is a term that describes abnormal changes of the cells that line the cervix. CIN is not cancer. But if the abnormal cells are not treated, over time they may develop into cancer of the cervix (cervical cancer).

CIN 1
CIN 1 means one-third of the thickness of the cervical surface layer is affected by abnormal cells. This will often return to normal without any treatment at all. You will have further cervical smear tests or colposcopies to check the cells have improved. If these tests show the CIN 1 is not improving, you may be offered treatment.

CIN 2
CIN 2 means two-thirds of the thickness of the cervical surface layer is affected by abnormal cells. There is a higher risk the abnormal cells will develop into cervical cancer. You may be offered treatment to stop this happening, or another colposcopy.

CIN 3
CIN 3 means the full thickness of the cervical surface layer is affected by abnormal cells. CIN 3 is also called carcinoma-in-situ. This sounds like cancer, but CIN 3 is not cervical cancer. Cancer develops when the deeper layers of the cervix are affected by abnormal cells. You will be offered treatment to stop this happening.

Question 16

What is a fibroid?

Answer 16

Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.

Question 17

Symptoms of a fibroid?

Answer 17

May be asymptomatic

Menorrhagia
Lower abdominal pain: cramping pains, often during menstruation
Bloating
Urinary symptoms, e.g. frequency, may occur with larger fibroids
Subfertility

Question 18

Investigations for a fibroid?

Answer 18

Pelvic/transvaginal USS
Can do bloods - may show iron deficinecy anaemia if heavy bleeding

Question 19

Management of a fibroid?

Answer 19

Management

Fertility desired:
- Medical management
- Levonorgestrel-releasing intrauterine system is recommended by CKS first-line
- Other options include tranexamic acid, combined oral contraceptive pill etc
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment. (Leuprorelin),

• Surgical management
  - Myomectomy

Fertility not desired:
Surgery is sometimes needed: myomectomy, hysteroscopic endometrial ablation, hysterectomy
uterine artery embolization

Question 20

When to refer for uterine fibroid?

Answer 20

Routine referral to a gynaecologist is not required, unless:

“Symptoms (for example, heavy menstrual bleeding) that have not improved despite initial treatments.
- Use of NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within 3 menstrual cycles.

Complications, such as compressive symptoms from large fibroids (for example dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms).

Fertility or obstetric problems associated with fibroids - for more information, see the CKS topic on Infertility.

A clinical or radiological suspicion of malignancy.

Fibroids which are palpable abdominally, or intracavity fibroids and/or whose uterine length is measured at ultrasound, or hysteroscopy, greater than 12 cm.”

Question 21

What is bacterial vaginosis?

Answer 21

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

Question 22

Clinical features of Bacterial Vaginosis and diagnosis?

Answer 22

Vaginal discharge: Thin, white discharge - ‘fishy smell’, Offensive
Asymptomatic in 50%

Diagnosis:
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
Thin, white homogenous discharge
**clue cells ** on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 23

Management of bacterial vaginosis?

Answer 23

Management

if the woman is asymptomatic, treatment is not usually required CKS
e.g. picked up on a swab done for different reasons
exceptions include if a woman is undergoing a termination of pregnancy

If symptomatic: oral metronidazole for 5-7 days CKS
70-80% initial cure rate
relapse rate > 50% within 3 months
a single oral dose of metronidazole 2g may be used if adherence may be an issue

If pregnant, BV results in an ** increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage**
it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy
if asymptomatic: discuss with the woman’s obstetrician if treatment is indicated
if symptomatic: either oral metronidazole for 5-7 days or topical treatment. The higher, stat dose of metronidazole mentioned above is not recommended

Question 24

What is trichomonas vaginalis?

Answer 24

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Question 25

Features of Trichomonas Vaginalis?

Answer 25

Features
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis

Question 26

Management of trichomonas vaginalis?

Answer 26

Management
oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Question 27

What is chlamydia and what causes it?

Answer 27

Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen (bacteria)

Question 28

Symptoms of chlamydia?

Answer 28

Features
Asymptomatic in around 70% of women and 50% of men

Women: Cervicitis (discharge, bleeding), dysuria
Men: urethral discharge, dysuria

Question 29

Risk factors for chlamydia?

Answer 29

Age under 25 years
Sexual activity with an infected partner
A new sex partner or multiple sex partners
A sex partner with other concurrent sex partners
History of a prior STI
Not using condoms.

Question 30

Investigations for chlamydia?

Answer 30

Nuclear acid amplification tests (NAATs) are now the investigation of choice

Urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

For women: the vulvovaginal swab is first-line
For men: the urine test is first-line
Chlamydia testing should be carried out two weeks after a possible exposure

Question 31

Management of chlamydia?

Answer 31

Management

**Doxycycline (7 day course) or azithromycin (single dose). **
- The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline

if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’

Patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM

For men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms

For women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)