OGCO-E29 Guidelines for patients management in general gynaecology clinics Flashcards
What is the history taking for menstrual irregularity?
When is examination indicated for menstrual irregularity?
OGCO-E18 Protocal for initial management of patients on tamoxifen
What is done for exam of menstrual irregularity?
- BMI
- Pallor
- Abd mass
- Cervical lesion, local cause
- Uterus: size, irregularity, mobility
What are the ix done for menstrual irregularity?
- 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
What are the parameters included in iron deficiency anemia?
Which is affected earliest and latest?
What is treatment of menstrual irregularity?
What is the follow up interval?
What is the mx algorithm for menstrual irregularity?
What is the history taking for post menopausal bleeding?
What is the Ix for postmenopausal bleeding?
- 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
What is the Tx for atrophic vaginitis/endometritis?
local oestrogen cream Premarin cream 0.5 g qd for 2 weeks and 3 times weekly thereafter for 6 months
When to consider secondary dysmenorrhea?
- 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
What is the Mx for dysmenorrhea?
When is follow up for dysmenorrhea?
4 months after the initiation/change of treatment
What is the history taking for abd pain?
What is the PE for abd pain?
- 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
What are the Ix done for abd pain?
- 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
What is the Mx algorithm for abd pain?
What is the history taking and PE for uterine leiomyoma?
What Ix done for uterine leiomyoma?
- 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
What is the different Tx options for uterine leiomyomas?
When to follw up uterine leiomyoma?
When to discharge from clinic?
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)
What is the history taking for adnexal mass in premenopausal women?
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
What is the Ix for adnexal mass in premenopausal women?
- USG – preferably transvaginal
- CA125 – not needed as a routine; save serum before operation
- LDH, AFP, HCG – in women under 40 with complex ovarian mass
What is the treatment of adnexal mass in premenopausal women?
What is Mx algorithm for adnexal mass in premenopausal women?
What is Ix for ovarian cyst in postmenopausal women?
- Serum CA-125
- USG pelvis (TVS) to look for bilateral lesions, multiloculations, solid area, metastasis, ascites
What is treatment for ovarian cyst in postmenopausal women?
What is Mx algorithm for ovarian cysts in postmenopausal women?
What is the history taking and PE for genital prolapse?
What are the indications for Ix in genital prolapse?
- 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
What is the follow up interval for genital prolapse?
What is Mx?
What is the Mx algorithm for pelvic organ prolapse?
What is the PE and Ix done for pruritis vulvae?
What is the general advise for pruritis vulvae?
What is Mx for lichen sclerosis?
What is Mx for lichen planus?
What is Mx for lichen simplex chronicus/squamous hyperplasia/chronic vulval dermatitis?
What is Mx for atrophic vaginitis?
Vaginal conjugated oestrogens cream 0.5 g daily for 2 weeks then on alternate days for 24
weeks
Review after 6 months
What is Mx for pruritis vuvlae with no pathology?
What is the Mx algorithm for pruritis vulvae?
What is the Mx algorithm for biopsy proven lichen sclerosus or lichen planus or pruritis vulvae?
What is history taking for vaginal discharge?
- 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
What is the PE and Ix for vaginal discharge?
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
What is the follow up interval for vaginal discharge?
- 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
What is specific treatment for vaginal discharge?
When is follow up after post suction evacuation/STOP/2nd trimester TOP?
What is the history taking?
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
What is the Mx algorithm for post SE/STOP/2nd trimester TOP?
What is the Ix for post laparoscopic adnexal surgery?
What is treatment?
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
What is the follow up post lap adnexal surgery for endometrioticy cysts and other cysts?
What is Mx algorithm for post lap adnexal surgery?
What is the Ix and Tx post myomectomy?
When is follow up for post hysterectomy/LAVH?
What is the history taking?
Who undergoes vault smear after hysterectomy?
What is the history taking and PE for post vaginal hysterectomy and pelvic floor repair?
What are the actions for cervical smear unsatisfactory for evaluation?
- repeat smear, within 4 months
- colposcopy after 2 consecutive unsatisfactory
smears
What are the actions for cervical smear negative, but obscured by inflammatory exudates?
- 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
What are the actions for cervical smear negative, but absent transformation zone/endocervical component?
No further action
What are the actions for cervical smear negative, but endometrial cells present?
- age <40: should not be reported
- age >40: in phase with LMP or not; perform
endometrial aspiration in the presence of abnormal uterine bleeding
What are the actions for cervical smear negative, with intracellular (eosinophilic) inclusions or metaplastic cells with cytoplasmic granules and vacuolation?
-screen for infection including chlamydia (strong odor and yellowish) and gonococcus (green, yellowish/whitish discharge)
What are the actions for cervical smear candida?
No need treatment if asymptomatic
What are the actions for cervical smear trichomonasis?
- treat with metronidazole (see treatment of vaginitis) - perform full STD screening
- refer social hygiene clinic
What are the actions for cervical smear actinomyces in patietns with IUCD in situ?
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
