OBGYN Flashcards
1 in 20 women have heavy menstrual bleeding. Define Heavy Menstrual Bleeding
Excessive menstrual bleeding affecting the patient’s QoL.
What quantity of bleeding constitutes heavy menstrual bleeding
> 80ml/month
A 28 year old patient, G1P0 presents with excessive PV bleeding. Give your differentials.
Physiological bleeding
Presence of IUD (especially copper)
Congenital uterine abnormality (e.g. bicornuate uterus)
Hormone producing tumours
+PALM COEIN
Polyp
Adenomyosis
Leiomyoma
Malignancy/Hyperplasia
Coagulopathy
Ovulatory dysfunction
Endometrial cancer/endometriosis
Infection/Iatrogenic (anticoagulant)
Not known/Idiopathic = Dysfunctional Uterine Bleeding
Define Dysfunctional Uterine Bleeding
Abnormal bleeding in the absence of detectable/recognizable organic pathology
What are the only 2 investigations that should be done routinely in the case of Heavy Menstrual Bleeding?
What are the other tests you should do, giving the condition to perform them
FBC for anaemia (technically and coagulation with platelets)
+ B-HCG to rule out pregnancy
Ferritin only if evidence of anaemia from FBC
Coagulation profile/checking for coagulation disorders only if heavy menstrual bleeding since periods started or if personal/family history suggesting coag disorder
Female hormone profile only if symptoms of menopause
TFTs only if symptoms and signs of hypo/hyperthyroidism (other than the heavy menstrual bleeding ofcourse)
What are the management options for heavy menstrual bleeding in primary care
What about secondary care
Hormonal Therapy => Contraception but possibility for future planning in the future
!!!! Iron supplements (if anaemic) AND
First Line: LNG-IUS
Second Line: COCP
Third Line: Systematic Pregestogen
Fourth Line: Depot Progestogen
Notice no GnRH in primary care
Hormonal therapy should be given outside of the period
Non-hormonal => Future planning
First Line: NSAIDS
Second Line: Anti-fibrinolytic Agents - Tranexamic Acid
Non-hormonal therapy should be prescribed during the period
Secondary care:
GnRH analogues prior to surgery
Surgical:
First Line: Endometrial Ablation
Second Line: Myomectomy (acceptable for future planning)
Third Line: Uterine Artery Embolisation
Fourth Line: Hysterectomy
What NSAIDs are used in the treatment of Heavy Menstrual Bleeding?
Iburpofen or Mefenamic acid
Give the generic name for a Systemic Progestogen
Norethisterone
Give the generic name for a depot progesterone
Medroxyprogesterone.
LNG-IUS is the first like treatment of HMB
What type of drug is it releasing?
What should be explained to the patient when starting?
LNG is indicated as the first-line treatment of HMB only in 3 circumstances. What are they?
Progestogen
Anticipate changes to bleeding pattern (irregular bleeding) that can last up to 6 months. Wait 6 months to assess effects of tx
- No identified pathology, or
- Fibroids <3cm diameter that are not distorting the uterine cavity, or
- Adenomyosis
A patient presents to you with very heavy bleeding. a lot… How would you manage?
1) Resuscitate as necessary— admit if shocked
2) Reduce/ stop bleeding with progestogen, e.g. norethisterone 5mg tds or Medroxyprogesterone 10mg tds for 10d. Effective in 24– 48h. A lighter bleed follows on stopping. An alternative is tranexamic acid 1– 1.5g tds for 4d
3) Correct anaemia and refer for specialist gynaecology assessment
What is the average age of menopause?
51 (median is 52)
What is the effect of smoking on menopause
Average menopause in smokers is 2 years before (49) that of non-smokers (51)
What is the follow up after starting any treatment of menopause
3 months and then annually
Without laboratory tests,
What is the diagnosis of perimenopause?
What is the diagnosis of menopause?
Define Early menopause
Define Premature menopause
Clinical for both
For a healthy female aged >45,
Perimenopause = vasomotor symptoms and infrequent periods
Menopause = If not period for 12+ months AND not using hormonal contraception.
Early: <45 yo
Premature: <40 yo
How would you diagnose menopause in a patient who has had a hysterectomy?
Based on symptoms of menopause alone
When should FSH be tested (in general)?
Days 2-5 of the cycle
With laboratory testing, how would you diagnose menopause?
What is the indication for this test to be done?
If the age of the woman is <45 (=> early) and having menopausal symptoms, check FSH.
If FSH >30IU/L on 2 occasions, >1 month apart => suggests that the patient is post-menopausal
A patient aged 40 presents with changes to her menstrual pattern and with some symptoms similar to that of menopause. What other causes may lead to this?
Physical illness: Chronic diseases such as DM, CKD, thyroid disease, and anemia (think hypo hypo amenorrhoea)
Social or psychiatric problems
Medications: Calcium medications cause flushing
How does the period pattern change as you approach menopause?
At the age of 40, the cycle typically shortens about 7-10 days before lengthening to about 2-3 months before finally stopping at menopause
Late menstruation >54yo should be investigated especially because of
Risk of malignancy (endometrial)
What are the 5 main groups of complications of Menopause?
1) Vasomotor instability
2) Urogenital symptoms
3) Osteoporosis
4) Heart disease
5) Psychiatric
What are the vasomotor instability symptoms of menopause?
In primary care, how would you manage this?
Hot flushes (palpitations, sweating, nausea, lightheadedness, anxiety), may occur at night (fatigue, depression, lethargy)
tx
1) Lifestyle changes
2) HRT
3) Non-hormonal treatments including SSRIs and SNRIs (sertraline, gabapentin, clonidine)
Note: do not prescribe fluoxetine or paroxetine if woman is on tamoxifen (for breast cancer prevention and treatment)
What are the urogenital symptoms of menopause?
In primary care, how would you manage the uro and genital part separately?
Vulval and vaginal dryness (estrogen in charge of secretions) => Dyspareunia and increased risk of bacterial vaginosis
tx
1) Vaginal lubricants/moisturizers
2) Topical oestrogen
+ Loss of libido
Urethral + Bladder tissue atrophy => readuced elasticity => Increased frequency, dysuria (pain on urination), Nocturia = Incontinence
+ Recurrent UTIs!!
tx:
Recurrent UTIs and urge incontinence is reduced with the use of topical vaginal oestrogen but not stress incontinence
A patient presents to your clinic complaining of loss of libido and wants medication to fix it. She is already on HRT. What will you give her?
It responds well to testosterone along with HRT however it is unlicensed (applied to abdomen and upper thigh)
Is it safe to prescribe oestrogen cream in a patient already on HRT?
Is it safe to prescribe topical oestrogen cream to a patient with a history of breast cancer/previously had breast cancer?
Yes it is safe if on HRT
It is thought to be safe but check with supervising specialist if current/recent breast cancer
A post-menopausal has developed osteoporosis with bone pain as of her last DEXA scan showing -2.5 (T score). In primary care, how would you manage this?
Imp: Do no prescribe HRT unless premature menopause (<40)
1) Lifestyle advise:
a) Nutrition: Maintain BMI >19 + Vit. D + Calcium supplements
b) Physiotherapy + Weight bearing exercises
c) Smoking and alcohol cessation
2) Medical management:
a) Bisphosphonates (Alendronate/Ibandronate) weekly
b) Denosumab (monoclonal antibody)
c) Raloxifine (not indicated here because needs past hx of fragility fracture - SERM)
d) Teriparatide (daily injection for maximum duration of 18 months)
A patient is diagnosed with premature menopause at the age of 39. She suffers from bone pain and on her DEXA scan her T score was -1.6.
The patient is osteopenic and with early menopause, runs the risk of developing osteoporosis. HRT is only recommended in the prevention of osteoporosis in premature menopause. The only other time is if it is prescribed for reasons outside of menopause
A 54 year old patient presents with a fragility fracture in T12 on MRI. You decide to perform a DEXA scan which reveals her score to be <2.5. You ask the patient if shes been on bisphosphonates before and she tells you her previous doctor told her she cant take it. What does the patient likely have (2)?
What drug is she likely on now?
Give 1 contraindication and 1 disease that this drug increases the risk for.
Bisphosphonates are contraindicated in oesophageal disease or CKD (renaly excreted)
She is likely on the second-like drug Tamoxifen (not brought up in the oxford handbook). It is contraindicated in pregnancy and severely increases the risk of endometrial cancer
A 57 year old woman presents with new onset low mood and is asking for help with it. How do you manage the psychological complication of low mood as a result of menopause?
Most important: Do not prescribe SSRI or SNRI unless clinical depression (go study that later)
1) HRT (if not on already)
2) Regular sustained aerobic exercise (swimming, running) (a/w reduced psychological symptoms and insomnia)
3) CBT
Is HRT also considered a contraceptive
Not unless it contains levonorgestrel IUS as the progesterone component
Are women on contraception advised to continue using contraception after menopause?
Only women who are on non-hormonal contraception (barrier or copper IUD) should be advised to continue using until 1 year since their last LMP if >50 and 2 years after their last LMP if <50
Give 5 contraindications to HRT
Hx of/current breast or endometrial cancer
Unknown/irregular vaginal bleed
Active Liver disease
Porphyria Cutanea Tarda (mcq shit)
VTE/Stroke/TIA (not in oxford)
Pregnancy (not in oxford)
Explain your management approach to a 52 patient presenting with amenorrhoea for the past 14 months.
If the patient does not wish for hormonal therapy, Natural Phytoestrogens (diet) will help.
In terms of hormonal replacement therapy, this depends on whether the patient has a uterus or not. If there is no uterus, Oestrogen-only therapy would be used.
If the patient does have a uterus then the next thing to look at is whether they are pre- or post-menopausal. If the patient is pre-menopausal, then we would have a Sequential approach whereby the patient will have continuous oestrogen + Cyclical progesterone to ensure monthly withdrawal bleed. If the patient is Post-menopausal, then a Continuous approach is used whereby both oestrogen and progesterone are continuous.
A women, with a uterus, wants HRT. She does not want anything inserted into her vagina or uterus. She is post-menopausal. What type of HRT should she be given?
What is the best medication for HRT according to the oxford handbook?
She should be given continuous oestrogen and progesterone therapy.
Tibolone is the best. It contains oestrogen and progesterone as well as weak andronergic action. It is used as a continuous HRT.
In menopause what days are most important for the woman to receive progesterone to prevent endometrial hyperplasia?
Last 12-14 days of her cycle (remember the last portion of the menstrual cycle is constant which is why ovulation always occurs 14 days before menstruation and progesterone levels are taken 7 days before.
HRT should eventually be stopped due to risks of ongoing therapy.
If no complications occur, when should HRT be stopped?
How should HRT be stopped
After about 5 years of starting
HRT should be stopped gradually
A patient for HRT is due for an elective major surgery. How long before then should it be stopped?
When can they commence HRT again?
What would you do in the case of an emergency surgery?
Stop HRT 4-6 weeks before surgery and may resume only after full mobilization
LMWH prophylaxis and compression hosiery (If ABPI >0.8) is needed
What are the risks of HRT?
1) VTE risk (incl. stroke) with oral not transdermal HRT Note: Tibolone increases stroke risk by x2.2 after first year
2) Breast cancer: oestrogen alone has no increased risk but togeher (including tibolone does) Risk returns to baseline <5 years after stopping
3) Endometrial cancer (if oestrogen-only) but shouldnt happen if protocol followed
4) Ovarian cancer: Slight increased risk but returns to baseline on stopping
Note: No increased CVD risk (oestrogen actually reduces), No increased T2DM risk as well
