Miscellaneous Flashcards
Potential causes for raised CA125
Endometrial cancer
Bowel cancer
Any disseminated intra-abdominal cancer
Pancreatic Cancer
Benign ovarian neoplasms
Uterine leiomyomas
Hepatitis
Liver cancer
Liver cirrhosis
SLE
Pelvic inflammatory disease
Normal variation
Precautions to COCP use
Personal or 1st degree degree relative < 45yo with DVT
Recent breast lumps
Pregnancy status
Breastfeeding or post-partum status
Carrier of BRCA gene
Migraine with aura
Known thrombogenic mutations
Previous VTE
Advice regarding POP use
Only effective if taken at same time every day
Barrier prophylaxis should be used for at least 2 days if POP taken 3hours outside of time.
Vomiting or severe diarrhoea will reduce efficacy
Possibly will cause intermenstrual bleeding
Takes 3 days for method to start working
MEC
UK Medical Eligbility Criteria Categorisation
1 No restriction
2 Advantages outweigh theoretical or proven risk
3 Risks outweigh advantages
4 Unacceptable health risk if method is used.
MEC Criteria relating to COCP
Age < 35 - 2
Age >= 35, ex-smoker >= 1 year - 2
Age >= 35 + smoker < 15cigs/day - 3
Age >= 35 + smoker >= 15cigs/day - 4
BMI >= 30-34 - 2
BMI >=35 - 3
Breastfeeding < 6 weeks post-partum - 4
6 weeks to 6 months - 2
>= 6 months - 1
VTE
- Personal history - 4
- Family history < 45yo - 3
- Family history >=45 - 2
- Major surgery with prolonged immobilisation - 4
- Immobility unrelated to surgery - 3
Migraine with Aura - 4
Current breast cancer - 4
Past breast cancer - 3
BRCA mutation - 3
Alternatives to COCP safe according to MEC
Cu-IUD, Levenorgestrel IUD - Progestogen-only Implant, POP, Progestogen-only injectable.
Symptomatic pharmacological management of menorrhagia
Mirena IUD
Oral progestins - Medroxyprogesterone 10mg PO TDS on days 1-21 of 28 days cycle for up to 6 months, Norethisterone 5mg PO TDS Day 5-26 of cycle
Mefenamic acid 500mg PO TDS
Tranexamic acid 1.5g PO TDS for first 3-5 days of cycle.
Causes of menorrhagia
Pregnancy-related - Miscarriage, implantation bleed
Uterine pathology
- Adenomyosis, leiomyoma, malignancy, endometrial hyperplasia
Fumctional Pathology
- Coagulopathy (vWF), Ovulatory dysfunction (Hypothyroidism, PCOS), endometrial haemostasis
Iatrogenic
- IUD, Anticoagulation, Tamoxifen, Exogenous oestrogens
- Alternative medicines - Gingko, soya, ginseng
Approach to menorrhagia
Exclude pregnancy
Perform CST if due
Check FBC/Ferritin
Consider coag profile
Consider TSH.
US - Day 5-10 of menstrual cycle.
Symptomatic teatment.
- Attempting to conceive? Transexamic acid 1.5g PO TDS for first 3-5 days of cycle. NSAIDS can also be used until conception.
- No attempting to conceive? Contraception
Causes of oligomenorrhoea
PCOS
HPO axis changes - Anorexia, weight loss, excessive exercise, stress
Prolactinoma - ?Galactorrhoea
Hypothyropidism - Cold intolerance, weight gain, dry skin
Iatrogenic - Contraceptive use
Advice surrounding Depot Medroxyprogesterone use
Medroxyprogesterone 150mg deep IM every 12 weeks
Delay of 8 months in return to fertility
Can cause amenorrhoea, irregular beeding
Accelerated bone lose with long-term use.
Contraceptive effects last less than 14 weeks and needs to be given regularly.
May experience breast tenderness.
Antibiotic choice for acute cystitis in pregnant women
1 - Nitrofurantoin 100mg PO QID x 5 days
2 - Cefalexin 500mg pO BD x 5 days
2nd or 3rd trimester? Can consider trimethoprim.
Indications for 5mg folic acid in pregnancy
Previous NT defect in pregnancy
Diabetes Mellitus
5-MTHFR deficiency
BMI > 30
Risk of malabsorption.
Ectopic Pregnancy Risk factors
Risk factors
- Previous EP, Previous tubal surgery, IUD use, IVF treatment, Previous PID, previous STI, Smoking, previous abdominal surgery, In-utery DES exposure
COCP Missed pills plan
< 24 hours late (<48 hours since last pill)?
- Take 1 pill as soon as able to. Then take next pill at normal time.
> 24 hours late?
- Take 1 pill as soon as able to. Take the next 1 at usual time.
- Use barrier protection or abstain from sex for 7 days.
- May need to use emergency contraception.
- <7 hormone pills left in pack? Discard non-hormone pills and go straight to hormone pills of next pack.
Consideration of emergency contraceptive pill
Unprotected sex in previous 5 days
- Missed more than 1 pill in first 7 days of new pack of pills.
- Started a new pack more than 24 hours late.
- missed more than 1 pill.
Causes of secondary amenorrhoea
- Functional Amenorrhoea (Excessive exercise, weight loss, low BMI, severe chronic illness, psychological stress)
- PCOS
- Pregnancy
- Hypothyroidism
- Prolactinoma
- Premature ovarian insufficiency
- Medications (Antipsychotics, opiates, chemotherapy, hormonal contraception)
- Adrenal (Cushings, Congenital Adrenal Hyperplasia)
- Asherman syndrome
Testing
- Baseline - Prolactin, Testosterone, TSH, FSH +/- serum bHCG, LH, oestrogen, progesterone.
Vaginitis
Differential
- Vulvovaginal candidiasis
- Bacterial vaginosis
- HSV
- Irritant contact dermatitis
- Atrophic vaginitis
- Lichen Planus
- Psoriasis
- Vulvodynia (Chronic vulvar pain syndrome)
- STI
Treatment for Vaginal candidiasis
Pharmacological
- Fluconazole 150mg PO Stat (Use if not tolerating Topical therapy and is not pregnant.)
- Clotrimazole 1% cream intravaginally nocte x 6 nights
- Miconazole 2% cream intravaginally nocte x 7 nights
Non-pharmacological
- Wear cotton underwear
- Wash clothing in unperfumed laundry detergent
- Avoid wearing tight-fitting pants
- Avoid using soap or shampoo on the vulva.
- Wipe from front to back after going to toilet.
- Do not perform vaginal douching.
Genital Lichen Sclerosis
- Chronic inflammatory dermatosis
- White sclerotic patches that susequently coalesce, becoming shiny porcelain-white or ivory-white
Symptoms
- Asymptomatic
- Pruritus
- Pain, bleeding from fissuring or erosion.
- Dyspareunia
- Constipation and painful defecation if perianal skin is involved.
- Atrophy and distortion of anatomical structures including the clitoris, fusion of the labia majora and minora, stenosis of the introitus.
5% risk of vulvar SCC.
Associated auto-immune related illnesses
- Thyroid disease
- Vitiligo
- Alopecia Areata
- Pernicious anaemia
Treat with ultra-high potency corticosteroid
- Topical clobetasol 0.05% ointment OD
Risk factors for endometrial cancer
- History of chronic anovulation
- Exposure to unopposed oestrogen
- PCOS with chronic anovulation
- Exposure to tamoxifen
- Family history of Lynch Syndrome or endometrial cancer.
- Nulliparity
- Obesity
- Endometrial Thickness > 8mm
Approach to post-menopausal vaginal bleeding
- TVUS is initial screening tool
- Cervical Co-Test indicated
Advice regarding quick-start method to contraception with implanon and IUDs
- Explain possibility of missing an early pregnancy
- Urine bHCG performed prior to insertion of device
- If Ulipristal 30mg taken, must wait for 5 days following use to insert progesterone-based implants.
- Use of barrier protection for 7 days following insertion
- Repeat urine bHCG at 4 weeks after insertion
- Document actions taken in consult notes.
Causes of Primary Amenorrhoea
- Hypothalamic Amenorrhoea
- Hypopituitarism
- Constitutional delay in puberty
- PCOS
- Hypothyroidism
- Prolactinoma
- Turnery Syndrome
- Imperforate Hymen
- Vaginal Agenesis
- Congenital Adrenal hyperplasia.
