Gyneacology Flashcards
What is hormone replacement therapy?
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side-effects:nausea
•breast tenderness
•fluid retention and weight gain
What is the risk associated with HRT?
- increased risk of venous thromboembolism: increased by the addition of a progestogen
- increased risk of stroke
- increased risk of ischaemic heart disease if taken more than 10 years after menopause
- increased risk of breast cancer: increased by the addition of a progestogen
- increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously.
What is the relationship between HRT and the increased risk of breast cancer?
- in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
- the increased risk relates to duration of use
- breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations
- the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
What are the featuers of chlamydia trachomatis?
Chlamydia Trachomatis in a obligate intracellular pathogen. Its incubation period is 7-21 days. Most cases (70%) are asymptomatic. Women may present with cervicitis (bleeding, discharge), and dysuria. Men may present with urethral discharge, and dysuria.
What are the potential complications of chlamydia infection?
- Epidydimitis
- Pelvic Inflammatory Disease
- Endometritis
- Increased risk of ectopic pregnancy
- Infertility
- Reactive Arthritis
- Perihepatitis (Fitz-Hugh-Curtis Syndrome)
How do you test for chlamydial infections?
Samples taken from first pass urine, vulvovaginal swab, or cervical swab may be used. These samples are then tested using a Nuclear Acid Amplification Test (NAAT).
How do you manage a Chlamydial infection?
- 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 erythromycin or amoxicillin may be used. The SIGN guidelines suggest considering azithromycin ‘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 symptomatic infection all partners from the four weeks prior to the onset of symptoms should be contacted
- 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)
What is the mechanism of action for copper IUDs?
primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions). The IUD is effective immediately following insertion
What is the mechanism of action for Mireena IUS?
levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening. The IUS can be relied upon after 7 days.
What are the indications for HRT?
- vasomotor symptoms such as flushing, insomnia and headaches
- premature menopause: should be continued until the age of 50 years
- osteoporosis: but should only be used as second-line treatment
How do you treat menhorrhagia?
- FBC, and appropriate investigations based on Hx and Exam
- If not requiring contraception: Mefenamic acid or Tranexamic acid taken on the first day of period.
- If requiring contrception: Insertion of Mirena device, combined oral contraceptive pill, or long acting progesterone.
- Noethisterone can be used as a short term option to stop rapid bleeding.
After excluding pregnancy, what are the causes of secondary amennohoea?
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis
What are the initial tests that you would order in someone presenting with secondary amenorrhoea?
- exclude pregnancy with urinary or serum bHCG
- gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- prolactin
- androgen levels: raised levels may be seen in PCOS
- oestradiol
- thyroid function tests
What are the presenting symtpoms of endometrial cancer?
Endometrial cancer tends to occurs in older, post menopausal women (though it can occur in premenopausal women). It tends to be detected early and has a good prognosis. Patients present with post menopausal bleeding (or bleeding inbetween periods). Rarely there is discharge or pain.
What are the risk factors for endometrial cancer?
Unopposed oestrogen (HRT without progesterone) Obesity Diabetes Mellitus Early Menarche Late Menopause Nulliparity Tamoxifen PCOS
How do you investigate and treat endometrial cancer?
First line investigatin in a transvaginal ultrasound. A normal endometrial thickness is 4mm, continue by doing a hysteroscopy and endometrial biopsy.
Manage localised disease with a total abdominal hysterectomy and bilateral salpingoopherectomy. Patients with high-risk disease may have radiotherapy.
Progesterone therapy may sometimes be used for elderly frail women who would not be candidates for surgery.
What are the potential harms and benefits of taking the Combined Oral Contraceptive?
- the COC is > 99% effective if taken correctly
- small risk of blood clots
- very small risk of heart attacks and strokes
- increased risk of breast cancer and cervical cancer
What advice should be given upon taking the COC?
•if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
•should be taken at the same time everyday
•taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
•advice that intercourse during the pill-free period is only safe if the next pack is started on time
Efficacy may be reduced if: •if vomiting within 2 hours of taking COC pill
•if taking liver enzyme inducing drugs
