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MBBS VI: O&G > OGCO-E29 Guidelines for patients management in general gynaecology clinics > Flashcards

OGCO-E29 Guidelines for patients management in general gynaecology clinics Flashcards

1
Q

What is the history taking for menstrual irregularity?

A
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2
Q

When is examination indicated for menstrual irregularity?

A

OGCO-E18 Protocal for initial management of patients on tamoxifen

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3
Q

What is done for exam of menstrual irregularity?

A
  • BMI
  • Pallor
  • Abd mass
  • Cervical lesion, local cause
  • Uterus: size, irregularity, mobility
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4
Q

What are the ix done for menstrual irregularity?

A
  • pregnancy test if indicated
  • Take cervical smear when: due for cervical screening, cervix looks suspicious but no obvious lesion
  • Indicatiosn for endometrial biopsy: presence of RF for endometrial pathology (e.g. obesity, PCOS, on tamoxifen, failed treatment, needs endometrial sampling). If age >40 and persistent IMB or irregular bleeding. If age <45 and regular heavy period can consider trial of hormoanl therapy without endometrial sampling)
  • CBP if suspect anemia
  • Iron status: fasted morning iron profile: beware of conditions like acute inflammatory disease, chronic illness, pregnancy and patients on combined pills may affect results
  • Hb pattern

Indications for hysteroscopy +/-endometrial biopsy
* Suspect endometrial polyp/submucosal fibroid
* Irregular bleeding while on hormonal therapy for more than 3 months
* Endometrial aspirate failed/result inconclusive

Indication for USG examination: if structural abnormality suspected or examination inclusive or difficult

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5
Q

What are the parameters included in iron deficiency anemia?
Which is affected earliest and latest?

A
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6
Q

What is treatment of menstrual irregularity?
What is the follow up interval?

A
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7
Q

What is the mx algorithm for menstrual irregularity?

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8
Q

What is the history taking for post menopausal bleeding?

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9
Q

What is the Ix for postmenopausal bleeding?

A
  • Cervical smear (if without regular screening)
  • Endometrial aspiration for all patients
  • Transvaginal USG for endometrial thickness(may skip if taking tamoxifen)
  • Hysteroscopy if taking tamoxifen, endometrial thickness >4mm or recurrence or refractory
  • symptoms despite given treatment for atrophic change
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10
Q

What is the Tx for atrophic vaginitis/endometritis?

A

local oestrogen cream Premarin cream 0.5 g qd for 2 weeks and 3 times weekly thereafter for 6 months

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11
Q

When to consider secondary dysmenorrhea?

A
  • occur in first 6 months after menarche
  • begin more than 2 years after menarche
  • late onset after a history without previous dysmenorrhea
  • pain during non-menstrual phases of the menstrual cycle
  • associated with other symptoms e.g. menorrhagia, intermenstrual bleeding pelvic abnormality on physical examination
  • little or no response to therapy with NSAID, OC pills or both
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12
Q

What is the Mx for dysmenorrhea?

A
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13
Q

When is follow up for dysmenorrhea?

A

4 months after the initiation/change of treatment

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14
Q

What is the history taking for abd pain?

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15
Q

What is the PE for abd pain?

A
  • Abdominal examination and pelvic examination – focal tenderness or trigger points, mass, distortion, tethering or prolapse
  • ?pain at ovarian point – junction of the upper and middle thirds of a line drawn between the umbilicus and the anterior superior iliac spine(typical of pelvic congestion syndrome)
  • Sacroiliac joint or pubic symphysis tenderness is suggestive of musculoskeletal origin of pain
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16
Q

What are the Ix done for abd pain?

A
  • msu to exclude urinary tract infection
  • If suggestive of pelvic congestion syndrome – consider MRI for pelvic varices If no other symptom
  • endocervical swabs for gonococcus, chlamydia pelvic ultrasonogram for pelvic pathology
  • If all investigations negative and other causes of pain excluded but pain persisted for 6 months - consider laparoscopy (if therapeutic trial of hormonal therapy failed after 6 months) and/or MRI
  • If all investigations and laparoscopy negative consider referral to clinical psychologist/ other specialist as appropriate
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17
Q

What is the Mx algorithm for abd pain?

A
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18
Q

What is the history taking and PE for uterine leiomyoma?

A
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19
Q

What Ix done for uterine leiomyoma?

A
  • Complete blood picture
  • Ultrasonogram as baseline
  • Consider endometrial biopsy for heavy menstrual bleeding if >45 year old or with risk factors
  • Subsequent ultrasound only if there is rapid increase in size or difficulty in assessing uterine size
  • Diagnostic hysteroscopy to assess resectibiity if submucosal and <5cm
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20
Q

What is the different Tx options for uterine leiomyomas?

A
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21
Q

When to follw up uterine leiomyoma?
When to discharge from clinic?

A

Follow up in 6 months if stable

Refer to integrated clinic when heavy periods controlled by medical therapy or if uterine size >16 weeks and asymptomatic; while awaiting appointment at integrated clinic, patients should be followed up routinely.
Close case if asymptomatic and uterine size static (<16 weeks)

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22
Q

What is the history taking for adnexal mass in premenopausal women?

A

Bloating/fullness/pressure in the abdomen Urinary urgency ± frequency
Abdominal pain or low back pain Dysmenorrhoea
Appetite change
Family history of ovarian or breast cancer

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23
Q

What is the Ix for adnexal mass in premenopausal women?

A
  • USG – preferably transvaginal
  • CA125 – not needed as a routine; save serum before operation
  • LDH, AFP, HCG – in women under 40 with complex ovarian mass
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24
Q

What is the treatment of adnexal mass in premenopausal women?

A
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25
Q

What is Mx algorithm for adnexal mass in premenopausal women?

A
26
Q

What is Ix for ovarian cyst in postmenopausal women?

A
  • Serum CA-125
  • USG pelvis (TVS) to look for bilateral lesions, multiloculations, solid area, metastasis, ascites
27
Q

What is treatment for ovarian cyst in postmenopausal women?

A
28
Q

What is Mx algorithm for ovarian cysts in postmenopausal women?

A
29
Q

What is the history taking and PE for genital prolapse?

A
30
Q

What are the indications for Ix in genital prolapse?

A
  • Post-menopausal bleeding while on ring pessary– to investigate as post-menopausal bleeding Vaginal discharge – for microbiological investigations as appropriate
  • Urinary symptoms - needs to rule out UTI; if complain of retention of urine, check residual urine
31
Q

What is the follow up interval for genital prolapse?
What is Mx?

A
32
Q

What is the Mx algorithm for pelvic organ prolapse?

A
33
Q

What is the PE and Ix done for pruritis vulvae?

A
34
Q

What is the general advise for pruritis vulvae?

A
35
Q

What is Mx for lichen sclerosis?

A
36
Q

What is Mx for lichen planus?

A
37
Q

What is Mx for lichen simplex chronicus/squamous hyperplasia/chronic vulval dermatitis?

A
38
Q

What is Mx for atrophic vaginitis?

A

Vaginal conjugated oestrogens cream 0.5 g daily for 2 weeks then on alternate days for 24
weeks
Review after 6 months

39
Q

What is Mx for pruritis vuvlae with no pathology?

A
40
Q

What is the Mx algorithm for pruritis vulvae?

A
41
Q

What is the Mx algorithm for biopsy proven lichen sclerosus or lichen planus or pruritis vulvae?

A
42
Q

What is history taking for vaginal discharge?

A
  • Details of discharge (what has changed, onset, duration, cyclicity, odour, colour, consistency, exacerbating factors)
  • Associated symptoms (itch, superficial dyspareunia, dysuria, vulval or vaginal pain, abnormal bleeding)
  • Sexual history (risk for STD) and contraceptive use
  • Medical conditions and concurrent medications/previous treatment
  • History of douching
  • Consider non-infective causes (foreign body, cervical ectopy, genital tract malignancy)
  • Patient’s concern
43
Q

What is the PE and Ix for vaginal discharge?

A

PE: abd exam, pelvic exam (speculum and bimanual): tenderness, discharge, lesion

Ix:
* HVS for T/M, culture for bacteria (no need to culture for fungi unless not responsive to treatment)
* Consider STD screening for high risk women

44
Q

What is the follow up interval for vaginal discharge?

A
  • Start treatment if discharge typical; no need to follow up
  • If discharge atypical, see after 2 months(or earliest appointment available if no appointment available at 2 months) to check culture results and symptoms; general advice(p. 20);
  • call back for treatment if culture positive in symptomatic patient If persistent but HVS negative – screen for gonococcus and chlamydia
  • If Trichomoniasis found – need to screen for other STDs
  • If recurrent candidiasis – discuss with specialist
45
Q

What is specific treatment for vaginal discharge?

A
46
Q

When is follow up after post suction evacuation/STOP/2nd trimester TOP?
What is the history taking?

A

1st follow up 6 weeks after management of miscarriage, earlier if complication anticipated.

History
* Review OT record
* Review histology (POG)
* Return of normal menses (flow, dysmenorrhoea)
* Abnormal symptoms (spotting, abdominal pain)
* Contraception – adherence, side effects, correct method of using the contraceptive

47
Q

What is the Mx algorithm for post SE/STOP/2nd trimester TOP?

A
48
Q

What is the Ix for post laparoscopic adnexal surgery?
What is treatment?

A

Ix
* Endometrial cysts: pelvic scan every year for 5 years
* Other benign cysts: nil

Treatment
* Endometriotic cysts: symptom relief (analgesics/ COC pills/depot medroxyprogesterone acetate). Secondary prevention: the role of COC pills
* Others: nil

49
Q

What is the follow up post lap adnexal surgery for endometrioticy cysts and other cysts?

A
50
Q

What is Mx algorithm for post lap adnexal surgery?

A
51
Q

What is the Ix and Tx post myomectomy?

A
52
Q

When is follow up for post hysterectomy/LAVH?
What is the history taking?

A
53
Q

Who undergoes vault smear after hysterectomy?

A
54
Q

What is the history taking and PE for post vaginal hysterectomy and pelvic floor repair?

A
55
Q

What are the actions for cervical smear unsatisfactory for evaluation?

A
  • repeat smear, within 4 months
  • colposcopy after 2 consecutive unsatisfactory
    smears
56
Q

What are the actions for cervical smear negative, but obscured by inflammatory exudates?

A
  • treat if specific infection found(screen for infection including chlamydia and gonococcus)
  • repeat smear after treatment
  • colposcopy after 2 consecutive smears obscured by
    inflammatory exudates
57
Q

What are the actions for cervical smear negative, but absent transformation zone/endocervical component?

A

No further action

58
Q

What are the actions for cervical smear negative, but endometrial cells present?

A
  • age <40: should not be reported
  • age >40: in phase with LMP or not; perform
    endometrial aspiration in the presence of abnormal uterine bleeding
59
Q

What are the actions for cervical smear negative, with intracellular (eosinophilic) inclusions or metaplastic cells with cytoplasmic granules and vacuolation?

A

-screen for infection including chlamydia (strong odor and yellowish) and gonococcus (green, yellowish/whitish discharge)

60
Q

What are the actions for cervical smear candida?

A

No need treatment if asymptomatic

61
Q

What are the actions for cervical smear trichomonasis?

A
  • treat with metronidazole (see treatment of vaginitis) - perform full STD screening
  • refer social hygiene clinic
62
Q

What are the actions for cervical smear actinomyces in patietns with IUCD in situ?

A

asymptomatic: no further action - symptoms of pelvic pain:
remove IUCD >5 days from last coitus
send IUCD for culture
antibiotic (penicillin) for at least 8 weeks and
consult microbiologist
consider other cause of pain including STD alternative contraception should be advised

MBBS VI: O&G (109 decks)

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