Men + Women Health Flashcards
what ref flags in LUTS require referral
- recurrent UTIs/haematuria
- retention
- stress incontinence (coughing)
BPH medication options
just enlarged = alpha blocker (alfuzosin, tamsulosin, doxazosin)
- hypotension, rhinitis. r.v in 1month then 6months
enlarged with raised PSA = 5alpha reductase finasteride
- takes 3months to work
- council on tetrogenic, impotence, reduced lidio, gynaecomastia
When offer PSA + DRE
is it a good test - sens vs spec
LUTS, ED, haematuria
low sens but high spec
- higher in age, infection etc
- low in statins, thiazides, aspirin, 5apls reductase
Sensitivity refers to a test’s ability to designate an individual with disease as positive. A low sensitive test means that there are lots false negative results
The specificity of a test is its ability to designate an individual who does not have a disease as negative - v unlikely if it’s negative
how is prostate ca staged
TNM staging, PSA, glenosone score (micrscopic appereance)
when is hormones + orchidectomy considered
as neo=adjuctant to RxT or advanced mets
is LHRH agonist (gosrelin) + bilateral orchidectomy
- can get menopause symptoms, ostemoalacia!
what is the gold standard 1st Ix after PSA raised
multiparameteric MRI before biopsy
antibiotics choice for prostasis
- some risk of them
Quinolones = ciprofloaxin or olfaxacin for 14
- tendon rupture, aortic aneursm, seizures
Ix for ED
Lipids, HbA1c, Testetone (LHFSH), PRL, PSA, TFT
Type of drug sildenafil is
- some s/e and avoidence
PDE5 inhibitor
- hypotentsion, flushing, nasuesa, dizzy
NOT with nitrates
what are some secondary causes of testetone def
Microprolactinoma, endogenous Cushing’s syndrome, functional/late-onset hypogonadism.
GnRH, LH/FSH, Testosterone all low
Drug causes of testosterone deficiency include:
Oral glucocorticoids and anabolic steroids.
Opioids (including methadone) and marijuana.
Antipsychotics, antiretrovirals and some anticonvulsants.
Androgen deprivation therapy.
Radiotherapy and chemotherapy.
Painful phimosis tx
Hydrocortisone/betametasone 4 weeks with gentle traction
What is Balanitis Xeretiea Obliterons
Thickened white foreskin, scarred and non-retractable
Need circu
When does hypospadias surgery usually occur
1 - 2 years
Undescended testes at 6 week check
- plan
Re-check at 3months, if still there refer to urology
When would it be appropriate to check FSH
What can cause false low
<45year + menopausal (x2 positive tests + > 30year - early), <40 = premature
>50 + want or stop contraception
>55 years you are not fertile
Depop
Would need to stop COCP + HRT 6 weeks before
What are the UKMEC 3 for COCP (7)
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
UKMEC 4 for COCP (8)
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history 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)
What cancers does the COCP reduce risk and increase risk of
Reduced = endo, colorectal, ovarian
Increase = breast + cervical (which normalises after stopping)
Rules if not starting contraception on day 1 of cycle
- COCP
- POP
- Implant/depot
- IUS
- Copper
Fine first 5 days, then need protection for 7 days
Fine first 5 days, then need protection for 2 days
Fine first 5 days, then need protection for 7 days
Fine first 7 days, then need protection for 7 days
Nothing needed for copper
Rules for starting COCP after emergency contraception
Start immediate after levorgesterol, use extra for 7 days, preg test at 3 weeks
Wait 5 days after ullipristal, then use extra for 7 and preg test at 3 weeks
What might you do if you get on going breakthrough bleeding
Rule out STI, check cervix
Consider US
If okay - try increase oestrogen preparation, then change prog and finally increase prog
What is Co-cyprindiol license for
Acne symptoms
But higher VTE risk, switch after 3 months of acne control
Drugs that reduce efficacy of COCP (enzyme inducing)
Rifamycins, antiviral like ritonavir
St. John’s wort
Phenyotin, carbamazepine, topirmate, modafinl
What happens if develops migraines on pill
Goes from 2 to 3 (without
UKMEC for POP stage 3 + 4
UKMEC 3 (relative contraindication)
A new diagnosis while on the POP of: IHD, CVA or migraine with aura.
Active gestational trophoblastic neoplasia (abnormal hCG).
History of breast cancer >5y ago.
Active viral hepatitis.
Severe cirrhosis.
Liver tumours.
UKMEC 4 (absolute contraindication)
Current breast cancer.
UKMEC 2 for POP
UKMEC 2 (benefits usually outweigh risks)
HISTORY of:
Current or past VTE.
Ectopic pregnancy.
Migraine with aura.
IHD or CVA.
Side effects of
- oestrogen
- progresterone
Breast tenderness, nausea, headaches
Mood swings, dry vagina, acne
Pill check rules
3months, then 6 monthly, then annual
Smoking rules on COCP
Ukmec 3 if stopped within 1 year + >35
Ukmec 2 if less 35 and smokes what ever
First line for emergency contraception
- timings
- CI
Copper IUD
- within 5d (120hr) or 5 days after ovulation (D19)
- active STI
Drug option of emergency conception
Ullipristal acetate - x1 a cycle, 5 days after UPSI (pre ovulation)
- need to delay regular conception for 5 days
Levonorgestrel - within 3 days (72hrs)
- avoid if BMI >26. Double dose if on enzyme drugs
Age POP can be continued to
55
Stopping contraception after the menopause
Non-Hornmonal = 2yr no period <50 + 1yr >50
COCP or inject prog = till 50
Implant, POP or IUS = till 50
- if stopped, continued till 55
- if not check FSH. >30 = stop after 1yr, <30 = rpt in 1 yr
- stop 55 definitely
What are the majority abortions done under 1967 act
C: the pregnancy is ≤24w and continuance would involve risk, greater than if the pregnancy were terminated, of injury to the mental/physical health of the woman.
Age (with symptoms) and diagnosis of menopause can be made
> 45
When would you check FSH x2
Concerned about early (<45) or premature (<40) menopause
> 50 + want to stop POP
1 st line for vasomotor symptoms in menpause
HRT - reduced OP for 5 years
Oestrogen if no uterus or minrena
Menopausal options if needs contraception
Mirena + oestrogen
Sequenstral and POP
When would you consider testosterone supplement in menopausal
(After androgen is progesteron
Low sexual desire
Vag atrophy can give topical oestrogen
Risk of HRT
Smal risk of Breast, endo and ovaria Ca
- duration and dose dependent, reduced after stopping
Small CVD + VTE
- patches after
Premature ovarain failure HRT advice
Till 50/52 - no cancer risk
Better for bone and CVD health
Absolute CI to HRT
Breast, endo and ovarian cancer
Liver disease
Confirmed VT diseased
Undiagnosised vaginal bleeding
Previous arterial clots (MI, stroke)
What is an example of a more androgenic testerone
Alternative to this
Norethesisone
Micronised prog (MPA)
When would continuous HRT be advised
No periods for 2yr if <50 or 1yr >50
Alernatives to HRT for vasomotor symptoms
OP
Venlaflaxine, SSRI
Clonidine - stop if no better after 6 weeks
Gabapentin
OP -bisophospahtes, ca/vit d
Complimentary HRT therapies what can be effective
Isoflavones (red clover), black cohosh, don quai, primrose oil, sage leaf
Tests for secondary or oligomenorrhoea
Commonest hypothalamic amenorrhea (low LH+oestodial), PCOS, premature ovarian failure
2x FSH taken 6 weeks a part (>30 = Premature menopause)
LH
Oestridaol (fertility!)
Testosterone (high) + SHBG (low) in PCOS LH also raised more the FSH
Symptoms relating to PRL, TSH
Glucose tolerance if BMI >30
What is cause of gynaecomastia
- not mid to late puberty where it is useless oestrogen levels, resolved 1 - 2 years once testosterone levels increase
Tests
anti-androgens, TCAs, metrondidazole, spironolactone, CCB, cimetidie
cirrhosis, puberty, overweight
Testerone (hypogonadism) + oesterodiol
Rare testicular cancer => hCG
conditions associated with low serum tesoterone
Primary (hypergonadotropic) TD - testicular failure - raised LH/FSH (Klinefelter syndrome, undescended testes, mumps orchitis, cancer treatment)
Secondary (hypogonadotropic) TD - commoner- hypothalamus-pituitary dysfunction - Low LH/FSH (age>50y, prolactinoma, obesity/metabolic syndrome, late-onset hypogonadism)
Combined Primary and Secondary TD- variable LH/FSH (glucocorticoids, alcoholism, sickle cell disease, haemochromatosis, thalassaemia)
Impaired action/suppression of testosterone
Side-effects of glucocorticoids, opioids, anticonvulsants, antipsychotics, antiretrovirals, chemotherapy
Diagnosis of test def requires what
Who do yo consider screening
Requires BOTH characteristic symptoms and signs of TD AND reduced serum total testosterone (TT) or free testosterone (FT).
All men presenting with ED, loss of spontaneous erections or low sexual desire
All men with type 2 diabetes mellitus, BMI >30 kg/m2 or waist circumference >102 cm (40.2 inches)
All men on long-term opiate, antipsychotic or anticonvulsant medication
Tx options for stress incontience
lifestyle + bladder diary
pelvic floor (8 contrace TDS) for 3 months
biofeedback
Duloxetine
consider if mixed = anticholeirgeic
red flags for urology referral
>45
>60
x2
whats no urgent
visible haematuria without or post UTI
(even if on anticoag or warfarin)
non-visble haematuria + WCC/dysuria
non-urgent if >60 + persisent UTI
>40 + NVH
efgr <30
haematuri wih raised BP or afer URTI
tx for urge incontience/OAB
bladder retraining
Oxybutynin/Tolteridone/Tropsium
- trail for 4 weeks, not in elderlt frail, dry/cins s/es
what can mirabgeron be used for
3rd line OAB - caution can raise BP
