Vaginal Bleeding + Vaginitis

Question 1

Non-Ob DDx of vaginal bleed

Answer 1

Trauma
Cervical polyp or cancer
Vaginitis
Hemorrhagic cyst
Perineal lesion
Vulvar varicosities

Question 2

Ob DDx of vag bleed

Answer 2

Physiologic
Abnormal pregnancy (ectopic, molar)
Abortion

Question 3

Types of spontaneous abortion

Answer 3

Spontaneous: pregnancy loss >20w
Inevitable (cervix dilated, no products expelled)
Incomplete (some expelled, retained products)
Complete (products expelled)
Missed (fetal demise but no uterine activity)
Recurrent (>3)
Septic (complicated by uterine infection)

Question 4

RF for spontaneous abortion

Answer 4

advanced age, thrombophilia, autoimmune disease (antiphospholipid antibody syndrome), infection (BV, HSV, GC, CT, HIV, CMV), IUD

Question 5

Ix for ?abortion

Answer 5

Ix: bHCG (66% rise in 48hrs = viable), group and screen, US

Question 6

Management of spontaneous abortion

Answer 6

Expectant
Medical: misoprostol 800mcg vaginally then repeated 24hrs later if no bleeding
RhoGAM if Rh negative (<12w = 120mcg, >12w 300mcg)
Surgical: vacuum aspiration

Question 7

Counselling with miscarriage

Answer 7

Acknowledge + dispel guilt
Acknowledge + legitimise grief
Assess grief
Counsel how to tell others
Include partner
Provide comfort + support
Reassure about future
Warn about anniversary phenomenon

Question 8

Pre-abortion counselling

Answer 8

Pregnancy options: abortion, term pregnancy, adoption
Abortion methods
Risks: bleeding, cramping, GI sx, HA, may need SA
Supports, confirm decision is voluntary
Emotional needs
Contraception

Question 9

Process for medical abortion

Answer 9

If >49d pregnant, Rh neg = give RhoGAM 24hr prior to MA
Mifepristone 200mg PO then 24hrs later misoprostol 800mcg
FU day 14

Question 10

What is the Apt test?

Answer 10

positive = fetal blood, negative = maternal blood

Question 11

Sx lichen sclerosus

Answer 11

Sx:
Pruritis
Dyspareunia
Dysuiria
PV bleeding
White, polygonal papules that turn to plaques, shiny porcelain appearance, can obliterate labia minora

Question 12

Dx + rx of lichen sclerosus

Answer 12

Dx: biopsy
Management:
Asymptomatic = nothing
Symptomatic = topical steroids (clobetasol)

Question 13

What demographic is most at risk + what types of cancer cause vulvar cancer?

Answer 13

Women >65
Squamous + melanoma

Question 14

Sx, dx + rx of vulvar cancer

Answer 14

Long term pruritus, lumps or masses
Dx: biopsy
Management: surgery, RT

Question 15

Sx + rx of thrush (acute + recurrent)

Answer 15

Vulvovaginal: asymptomatic, itchy, dysuria, dyspareunia, white DC
Acute: clotrimazole 500mg PV x 1 dose + fluconazole 150mg PO
Recurrent: fluconazole 150mg PO Q3D x 3 doses then q1week for 6 months

Question 16

Management of vaginal atrophy

Answer 16

Quit smoking
Regular sex
Moisturiser + lubricants
Systemic estrogen or local
Premarin 0.625mg QHS x2w then q3d x6mo
Estring in upper vagina x3mo
Vagifem 1 tab PV q3d

Question 17

Causes of abnormal uterine bleeding

Answer 17

endometrial polyp, endometriosis, endometrial hyperplasia, uterine sarcoma, endometrial cancer, bleeding disorder

Question 18

What tests to do in abnormal uterine bleeding?

Answer 18

Endometrial biopsy, pap, colposcopy

Question 19

RF of HRT

Answer 19

VTE, stroke, breast cancer after 5 yrs, CAD, endometrial cancer

Question 20

Recurrent culture negative UTI?

Answer 20

Interstitial cystitis

Question 21

Non hormonal pain relief for endometriosis

Answer 21

NSAIDs, aromatase inhibitors, GnRH antagonists

Question 22

CI to GnRH antagonists

Answer 22

postmenopausal, under 18