Week 6 Flashcards
What is female genital cutting/mutilation (FGC/M)?
- Female Genital Mutilation/Cutting is the deliberate cutting or altering of the female genital area for no medical reason. It has many names, including cutting, female circumcision and ritual female surgery. It is harmful to women’s health and is not necessary.
- Female genital mutilation (FGM) involves any procedure resulting in the partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical purposes. It is illegal to carry out FGM in the UK and it is internationally recognised as a human rights violation.
Where is FGC/M practiced?
- Epidemiology?
Epidemiology
It is estimated that 125 million women and girls globally have undergone FGM. It is a common occurrence in many African countries. Somalia, Guinea and Dijbouti have the highest prevalence with rates over 90%. Data demonstrates that it is also practiced in other countries, such as Iraq, Yemen, and Indonesia.
Why is FGC/M practiced?
- 4 Reasons?
- What is it not?
FGM is practiced for a number of complex social, cultural and religious reasons, based on the mistaken belief that it will somehow provide benefit to the girl. For example, to preserve virginity, to uphold family honour or as a rite of passage. FGM is mainly performed on girls below the age of 15. Usually, it is carried out by traditional practitioners with no formal training. Worrying recent trends have shown that it is becoming increasingly common for FGM to be performed by medical professionals.
Classification of FGM: 4 Types?
- Type 1 – The partial or total removal of the clitoris. This sometimes may involve the partial or total removal of the clitoral hood.
- Type 2 – The partial or total removal of the clitoris and the labia minora. This sometimes may also occur with removal of the labia majora.
- Type 3 – The making of a covering seal in order to narrow the vaginal opening. Also referred to as infibulation. This is done by cutting and altering the placement of the labia minora or majora, sometimes involving stitching. This may also be performed with the removal of the clitoris.
- Type 4 – This involves any and all other harmful procedures to the female genitalia for non-medical needs. This includes piercing, cutting, burning, scraping and pricking.
What are the Possible Health Consequences of FGC/M?
- 6 Short term?
- 8 Long term?
Short-term complications may include:
1. Bleeding
2. Urinary retention
3. Genital swelling
4. Severe pain
5. Infection
6. Poor wound healing
Long-term complications may include:
1. Scarring
2. Dyspareunia
3. Urinary tract problems – eg infections, dysuria, urinary stricture or fistulae
4. Impaired sexual function
5. Dysmenorrhea
6. Chronic infections – eg increased of risk Herpes Simplex type 2 and Bacterial vaginosis infections
7. Psychological problems – eg PTSD, anxiety and depression
8. Increased risk of obstetric complications – including prolonged and difficult labour, postpartum haemorrhage, needing neonatal resuscitation and stillbirth
What are the Laws around FGC/M in Western Australia?
- Mandatory reporting?
What is my responsibility as a doctor to those at risk of FGC/M?
**
How can you identify/ screen patients at risk of FGC/M?
Identifying FGM
- It is important for all healthcare professionals to be aware of FGM and be able to recognise risk factors. This can help to identify cases, provide necessary medical care and potentially prevent future cases of FGM.
- All patients should be screened for FGM at the time of booking their pregnancy, regardless of their country of origin, or ethnic background. Women with FGM have an increased risk of obstetric complications and so this will need to be managed appropriately. Additionally, obstetric consultations are an important opportunity for education, risk assessment and prevention of FGM to the unborn child and other female relatives.
Management of FGC/M?
A culturally sensitive approach to working with women and families from communities affected by fgm/c:
- Be clear about your role, scope, authority and responsibility.
- Make appropriate referrals by knowing what services are available in your area and what they can do.
- Be clear with women about what is happening and ensure that they are informed at every stage.
- Use skilled female interpreters where possible.
- Consult with FARREP workers and the target community.
- Use a welcoming manner and friendly body language.
- Maintain a non-judgemental and respectful approach.
You have just performed a routine bimanual pelvic examination in a healthy 22 year old woman and have found a mobile ovarian cyst about 7 cm in diameter. What would you do and why?
- Algorithm to approach of adenexal mass.
Follow approach to an adenexal mass protocol.
- Hx, Exam, Risk factors
- Tumour markers
- Imaging - US
- Risk of Malignancy index/ROMA etc
- Between 5 and 10 cm, review and repeat ultrasound pelvis after 10 weeks, if stable and asymptomatic – no further follow-up is required.
Explain 4 Complications of Ovarian Cysts?
Complications
1. Ovarian torsion
2. Ruptured ovarian cyst
3. Hemorrhage
A patient presents to you for a second opinion. She had one day of pelvic pain recently. The pain settled quickly but she has had a pelvic ultrasound done which reports a 1.8 cm cyst on the right ovary. What should be done?
- Prepubertal: If cyst of any size or type, request non-acute gynaecology assessment.
- Premenopausal: For simple cysts measuring less than 5 cm and the patient is asymptomatic, no follow-up is required. If symptomatic, review and request US pelvis in 10 weeks.
- Post-menopausal: If the cyst is simple, less than 3 cm, the patient is asymptomatic, and has no family history of breast or ovarian cancer, no Ca125 measurement or follow-up is required.
A 30 year old recently married woman presents with dyspareunia and also complains of increasing dysmenorrhoea. On examination, she has a retroverted fixed uterus, tender nodules in the Pouch of Douglas and a fixed cystic mass palpable in the right fornix. What is the most likely diagnosis?
= Endometriosis
Endometriosis
- What is it?
- Epidemiology: Age of Onset, Incidence, Ethnicity?
- Aetiology?
- 5 Risk Factors?
Endometriosis is a common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue outside the uterus.
- Age of onset: 20–40 years
- Incidence: 2–10% of all women
- Ethnicity: In the US, endometriosis is more common in white and Asian women than in black and Hispanic women.
Endometriosis
- Pathophysiology?
- Clinical features?
The clinical presentation, including dyspareunia (pain during sexual intercourse), dysmenorrhea (painful menstruation), retroverted fixed uterus, tender nodules in the Pouch of Douglas (an area between the uterus and the rectum), and a fixed cystic mass palpable in the right fornix, strongly suggests endometriosis.
Endometriosis
- Diagnostics?
- Role of Ultrasound?
- Role of Laparoscopy?
Endometriosis - Pathology
- Macroscopic?
- Microscopic?
Microscopic findings in Endometriosis
- Normal endometrial glands
- Normal endometrial stroma
- Preponderance of hemosiderin laden macrophages due to cyclic hemorrhages into endometriomas
Endometriosis - Pathology
- Treatment?
Why does ovarian carcinoma have such a poor prognosis - 5 Reasons?
What are the principles of management? (7)
What 9 issues need to be discussed with a woman requesting tubal ligation? What assessment does she need?
Assessment - Before performing the procedure, healthcare providers should conduct a thorough assessment, which may include:
1. A medical history to ensure there are no contraindications to surgery.
2. A discussion about the woman’s reasons for choosing sterilization and any concerns she might have.
3. A review of her reproductive history, including the number of children she has and her age.
4. A discussion about any potential future life changes, such as relationship status or health changes, that could influence her decision.
5. A review of her understanding of the procedure and its permanence.
What are 7 secretions that are present normally in the vagina?
The vagina is a self-cleaning and self-regulating organ that maintains its health through a delicate balance of various secretions. These secretions are produced by the vaginal epithelial cells and the surrounding glands. Normal vaginal secretions help maintain a healthy pH, provide lubrication, and offer protection against infections. The composition and amount of these secretions can vary based on factors such as the menstrual cycle, age, hormonal changes, and overall health.
How would you manage a 25 year old healthy woman who complains of an offensive vaginal discharge? (6 points)
- 3 Causes?
Causes
1. Non-sexually transmitted infections (STIs): Group B streptococcal vaginitis, Candida albicans, bacterial vaginosis (BV). While BV is not considered an STI, it is associated with sexual activity.
2. Non-infectious causes: hormonal contraception, physiological, cervical ectropion and cervical polyps, malignancy, foreign body (e.g. retained tampon), dermatitis, fistulae, allergic reaction, erosive lichen planus, desquamative inflammatory vaginitis, atrophic vaginitis in lactating and postmenopausal people, and in trans men and non-binary people using gender affirming testosterone replacement.
3. STIs: Chlamydia trachomatis, Mycoplasma genitalium (M. Genitalium), Neisseria gonorrhoea, Trichomonas vaginalis, Herpes Simplex Virus (HSV).
What is the discharge for each of the following STIs like:
- Physiological?
- Bacterial vaginosis?
- Candidiasis?
- Chlamydia and M. genitalium?
- Gonorrhoea?
- Trichomoniasis?
Which tests are needed to screen for different STIs?
Perform cervical screening if overdue. Human papillomavirus (HPV) testing only is indicated for vaginal discharge, a co-test (HPV + cytology) should be ordered for abnormal bleeding, or suspicious findings on examination of the cervix.
How does Herpes simplex infection of the lower female genital tract present? How would you confirm the diagnosis?
- Genital HSV is highly stigmatised and poorly understood in the community.
- Other human herpes viruses can cause genital ulceration (herpes zoster virus [HZV]; Epstein-Barr virus [EBV]).
- Initial episodes may be severe, and treatment should never be delayed while waiting for a test result.
- Most HSV is asymptomatic or mild enough that diagnosis is never sought.
- f symptoms do appear, it can be days or years after HSV was first acquired.
- More than 50% of primary genital infections are caused by HSV 1 in young people.
- Recurrences are more common in the first year with HSV 2.
- Severe and frequent recurrences may be treated with continuous suppressive or episodic antivirals.
Outline the management for Genital Herpes Simplex Virus.
Other immediate management:
1. Written information and support.
2. Regular analgesia
3. Topical lignocaine to reduce pain from erosions, fissures and ulcers
4. Urinating in a bath or shower relieves superficial dysuria.
5. Neuropathic bladder requires urgent catheterisation and referral.
6. Avoid intimate contact with partners until symptoms have resolved.
7. Routine sexual health screening
8. Use of barriers i.e., waterproof dressings.
9. HSV is not a notifiable disease.
10. Contact tracing is not recommended, but patients may need support if they wish to disclose to current or future sexual partners.
How would you clinically differentiate between trichomonal and candida vaginitis?
Discharge Characteristics: Trichomonal vaginitis is often associated with a frothy, yellow-green, or greyish vaginal discharge that has a strong, unpleasant odour. Candida vaginitis typically presents with a thick, white, “cottage cheese-like” discharge. It might not have a strong odour.
Itching and Irritation: Some itching and irritation may be present in trichomonal vaginitis, but they are generally less severe compared to candida infections. Severe itching and burning sensations in the vaginal and vulvar areas are common symptoms of candida vaginitis.
How would you treat trichomonal and candida vaginitis?
Treatment advice for Candida
- Intravaginal and oral azoles have similar efficacy – topical therapy provides quicker symptom relief but women generally prefer oral therapy.
- Vulvar treatment alone is inadequate due to a vaginal reservoir – both sites should be treated.
- The addition of hydrocortisone 1% cream may provide symptomatic relief.
- No evidence that specific diets or use of probiotics influence recurrence.
- Reconsider diagnosis if no response to therapy.
- Oral azoles cannot be used in pregnancy.
- No hepatic monitoring is required for fluconazole use at the above doses.
Other immediate management
- Avoid local irritants e.g., soap, bath oil, body wash, bubble bath, spermicide, vaginal lubricant and vaginal hygiene products.
- Latex barrier contraception e.g., condoms can be damaged by antifungal vaginal creams or oil-based products.
- Post-coital penile hypersensitivity to vaginal Candida colonisation is possible and responds to partner treatment Hydrocortisone 1% cream may provide symptomatic relief. Partners do not usually require treatment.
What factors or disorders predispose to chronic or recurrent candida vulvo - vaginitis? What would be your approach to management in such a case?
Factors Predisposing to Recurrent Candida Vulvovaginitis:
1. Immunosuppression: Conditions that weaken the immune system, such as HIV/AIDS, diabetes, and certain autoimmune disorders, can increase the risk of recurrent candida infections.
2. Antibiotic Use: Frequent or prolonged use of antibiotics can disrupt the balance of vaginal flora, allowing candida to overgrow.
3. Hormonal Changes: Fluctuations in hormone levels, such as those occurring during pregnancy, menstruation, or the use of oral contraceptives, can impact vaginal pH and make the environment more conducive to candida growth.
4. Underlying Medical Conditions: Conditions like uncontrolled diabetes, hormonal imbalances (e.g., polycystic ovary syndrome), and thyroid disorders can contribute to recurrent candida infections.
5. Sexual Activity: Although candida is not considered a sexually transmitted infection, sexual activity can introduce new organisms and disrupt the vaginal environment.
How can you distinguish between bacterial vaginosis, trichomoniasis, candidiasis?
How would you manage a 6 year old girl with a bloody, irritating vaginal discharge?
Vulvovaginitis is the general term which refers to many types of vaginal/vulva inflammation or infection. In prepubertal girls usually 2-8 years, non-specific vulvovaginitis is responsible for 25-75% of vulvovaginitis.
What are the differentials for a 6 year old girl with a bloody, irritating vaginal discharge?
Differential diagnosis - If persistent, offensive or bloody discharge, consider the following:
1. Threadworm - if pruritus (vulval and/or perianal) is prominent especially at night.
2. Foreign body - if chronic vaginal discharge, intermittent bleeding, offensive odour. Toilet paper commonest foreign body. Refer to paediatric gynaecologist as required.
3. Specific organisms if discharge is profuse/offensive take an introital swab.
What are 6 differential diagnoses for a 75 year old woman with an itchy vulva associated with white patches on the vulva? How would you manage her?
Lichen sclerosus is a chronic inflammatory disease of unknown cause that is characterized by white, atrophic plaques with intense pruritus affecting the skin, nails, hair, and/or mucous membranes. It most commonly affects the anogenital area and often occurs in postmenopausal women. Although the condition is benign, it is associated with an increased risk of squamous cell carcinoma. Lichen sclerosus is diagnosed clinically and should be confirmed via punch biopsy in adults, which can concurrently screen for squamous cell carcinoma. Treatment primarily consists of superpotent topical steroids but may also include surgical excision in steroid-refractory disease.
Treatment of Lichen Sclerosis
- First-line: superpotent topical steroids (clobetasol, sometimes betamethasone)
- Second-line: topical calcineurin inhibitors (e.g., tacrolimus)
- If necessary, surgical excision
How would you manage a 35 year old G2P2 woman who has developed heavy regular periods? Her pelvic findings, including endometrial biopsy, are normal. There is evidence that she is ovulating normally. What are the side-effects of any treatments? Does everyone with this problem need an endometrial biopsy?
- Differentials?
How would you manage a 35 year old G2P2 woman who has developed heavy regular periods? Her pelvic findings, including endometrial biopsy, are normal. There is evidence that she is ovulating normally. What are the side-effects of any treatments? Does everyone with this problem need an endometrial biopsy?
- Which investigations should be performed for this woman?
- Indications for endometrial biopsy?
Investigations of Heavy Menstrual Bleeding
Clinical examination should include a routine CST. A full blood examination should be performed if anaemia is suspected or a serum ferritin to detect iron deficiency. As a coagulopathy such as Von Willebrand disease is a possible cause in the adolescent woman,
a coagulation screen or platelet function tests should be performed when appropriate. Other tests such as thyroid function tests, renal investigations or autoantibodies such as lupus coagulant should be performed if organic disease is suspected. A transvaginal
ultrasound (except in the adolescent woman) will aid in excluding pelvic causes of heavy bleeding. Hysteroscopy with dilation and curettage or endometrial biopsy, or laparoscopy if there is associated pain, will be
diagnostic but not curative for HMB.
How would you manage a 35 year old G2P2 woman who has developed heavy regular periods? Her pelvic findings, including endometrial biopsy, are normal. There is evidence that she is ovulating normally. What are the side-effects of any treatments? Does everyone with this problem need an endometrial biopsy?
- What non-surgical treatments are available for HMB?
- What surgical treatments are available for HMB?
Medical Management:
1. NSAIDs: NSAIDs like ibuprofen can help reduce menstrual bleeding and pain.
2. Hormonal Birth Control: Options like combination oral contraceptives, hormonal IUDs, or the contraceptive implant can help regulate and lighten periods.
3. Tranexamic Acid: This medication helps reduce bleeding by promoting clot formation.
4. Progestin Therapy: Progestin-only methods, like birth control pills, injections, or hormonal IUDs, can help regulate and reduce bleeding.
Surgical Management: If medical treatment isn’t effective or appropriate, surgical options may be considered, including:
1. Endometrial Ablation: This procedure removes or destroys the lining of the uterus to reduce menstrual bleeding.
2. Hysterectomy: In severe cases, when other treatments fail or aren’t appropriate, a hysterectomy (removal of the uterus) may be considered.
Outline the medical treatments available for heavy menstrual bleeding.
Outline the surgical treatments available for heavy menstrual bleeding.
What does a D&C involve - how would you explain it to a patient and how do the histological findings affect her management? What is hysteroscopy?
Dilation and curettage
A gynecological procedure in which the cervix is dilated and tissue is removed from the uterus using a curette. May be performed for therapeutic purposes (e.g., spontaneous or induced abortions at < 13 weeks’ gestation, molar pregnancies, removal of uterine masses) or diagnostic purposes (e.g., obtaining uterine tissue samples for histological examination).
What are the complications of uterine fibromyoma (fibroids)? What problems may uterine fibromyoma (fibroids) cause in pregnancy?
- Infertility
- Iron deficiency anemia (due to heavy menstrual bleeding)
- Fibroid torsion - A pedunculated subserosal fibroid may twist and become necrotic, which presents with acute pelvic pain.
- Thromboembolism - Large leiomyomas may compress the vena cava.
- Very rare: malignant transformation to uterine leiomyosarcoma
A 45 year old woman presents with a 5 year history of gradually worsening menorrhagia. She had a tubal sterilisation at the age of 38. On examination she has an enlarged uterus (size about 8 week pregnancy). What is your differential diagnosis and management?
Differential Diagnosis:
1. Uterine Fibroids (leiomyomas): These benign growths in the muscular wall of the uterus can cause menorrhagia and an enlarged uterus.
2. Adenomyosis: This condition involves the abnormal growth of endometrial tissue into the uterine muscle, leading to heavy and painful periods, as well as an enlarged uterus.
3. Endometrial Hyperplasia: A condition characterized by excessive growth of the uterine lining, which can cause heavy bleeding. It can sometimes progress to endometrial cancer.
4. Endometrial Polyps: Small growths in the uterine lining can cause heavy bleeding.
5. Uterine Cancer/Endometrial Carcinoma: Although less common, uterine cancer can cause abnormal bleeding and an enlarged uterus.
Gestational trophoblastic disease
- What is it?
- What is a hydatidiform mole? 2 types?
Gestational trophoblastic disease includes both benign and malignant proliferations of placental cells. At the benign end of the spectrum, there’s hydatidiform mole, also called molar pregnancy; while at the malignant end, there’s gestational trophoblastic neoplasia, which includes choriocarcinoma and trophoblastic tumors.
Gestational trophoblastic disease
- What is Gestational trophoblastic neoplasia (GTN)? 4 types?
5 Types of Hysterectomy/Terminology?
‘Total’ means with the cervix and ‘sub-total’ means without the cervix.
You are consulted by a 19 year old single woman with abnormal menstruation. She has always had prolonged episodes (up to 10 days) of heavy painless menstrual bleeding with intervals of up to 6 weeks. What is the most likely diagnosis? What is its hormonal and pathological basis? How should you manage the condition?
Anovulatory dysfunctional bleeding, also known as anovulatory bleeding or abnormal uterine bleeding (AUB), refers to irregular or abnormal bleeding from the uterus that occurs due to anovulation, which is the absence of ovulation in a menstrual cycle. Ovulation is the process where an egg is released from the ovaries, and it plays a key role in regulating the menstrual cycle. During a normal menstrual cycle, the uterine lining (endometrium) builds up in preparation for a potential pregnancy. If ovulation occurs and the egg is not fertilized, hormonal changes lead to the shedding of the uterine lining, resulting in a menstrual period. However, when ovulation doesn’t occur, hormonal imbalances can disrupt the typical menstrual cycle, leading to various types of abnormal bleeding patterns.
Questions to aid in the diagnosis of abnormal uterine bleeding in adolescents?
- Menstrual history?
- Sexual/reproductive history?
- Past medical history?
- Review of systems?
- Family history?
- Social history?
Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer. Causes include polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics.
Physical examination of the adolescent with abnormal uterine bleeding?
- Vitals?
- Growth parameters?
- Eyes?
- Lymph nodes?
- Skin and hair?
- Neck?
- Thorax/breasts?
- Abdomen?
- Tanner staging?
- External genitalia?
- Pelvic examination?
A woman who is 8 weeks pregnant has presented with painless bleeding. Ultrasound shows features of a hydatidiform mole. Outline the immediate and longer term management.
A hydatidiform mole, also known as a molar pregnancy, is a rare condition where abnormal placental tissue grows in the uterus instead of a healthy fetus. Hydatidiform mole (HM) is one of a group of diseases that develop from abnormal proliferation of trophoblast and are classified as gestational trophoblastic disease (GTD). The two distinct types of HM, complete mole and partial mole, have different karyotypes, gross and microscopic histopathology, clinical presentations, and prognoses. Management is similar but with some differences. Treatment involves surgical removal of the molar pregnancy followed by surveillance of serial human chorionic gonadotropin (hCG) levels to confirm resolution of disease or to identify development of gestational trophoblastic neoplasia (GTN), which includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Although GTN is the invasive or metastatic form of GTD, it has an excellent cure rate with chemotherapy.
Treatment for Hydatidiform mole?
Hydatidiform mole: Treatment
1. Uterine dilation and evacuation (D&E) - Complete moles have a 20% risk of becoming invasive and a 2% risk of developing into choriocarcinoma. Therefore, complete evacuation of the uterine cavity is the mainstay of treatment.
2. Monitor β-HCG levels: until within reference range (usually 8–12 weeks)
3. Chemotherapy (usually methotrexate) if unresolved, as indicated by either of the following:
- β-HCG values do not decrease.
- Features of malignant GTN on histology or imaging
Your 20 year old patient has been using condoms for contraception. She comes to see you because the condom broke last night. How will you manage this? (Post-coital contraception) What are her options?
Emergency contraception (EC) refers to measures taken to prevent pregnancy within 5 days of unprotected intercourse or contraception failure (e.g., condom breakage, missed oral contraceptives).
Intrauterine devices for emergency contraception
- General principles?
- 2 Types?
- 3 Adverse effects?
Oral emergency contraception medication
- Pharmacodynamics?
- General principles?
- 3 Types?
- Adverse effects?
General Principles
- Most effective when taken within 3 days of unprotected intercourse (ulipristal acetate can be taken within 5 days).
- Does not disrupt embryo implantation or already established pregnancies.
- Significantly less effective in obese (BMI ≥ 30 kg/m2) or overweight (BMI 25–29.9 kg/m2) individuals.
A 16 year old schoolgirl is brought to you by her mother. The girl had her menarche at the age of 13. Her periods were pain free for 5 months but since then she has experienced severe colicky pelvic pain just before and on the first day of her period. What is the likely diagnosis and how would you approach the treatment of this patient?
Primary dysmenorrhea
- Definition: recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings that could account for those symptoms)
- Epidemiology: Prevalence up to 90% (most common gynecologic condition), Manifests during adolescence (typically within three years of menarche)
- Etiology: The etiology of primary dysmenorrhea is not completely understood. Associated with some risk factors (e.g., early menarche, nulliparity, smoking, obesity, positive family history)
- Pathophysiology: increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction/ischemia and stronger, sustained uterine contractions (to prevent blood loss).
Secondary dysmenorrhoea
- 5 Uterine causes?
- 4 Extrauterine causes?
- Definition?
- Epidemiology?
- Diagnostics? (5)
- 9 Clinical features?
Secondary dysmenorrhea
- Definition: recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition
- Epidemiology: May begin later in life than primary dysmenorrhea, Commonly affects female individuals ≥ 25 years of age.
- Diagnostics
1. CBC with differential (rules out infection)
2. Urinalysis (rules out UTIs)
3. β-hCG (rules out ectopic pregnancy),
4. Gonococcal/chlamydial swabs (rule out STDs and PID)
5. Pelvic ultrasound
9 Causes and 6 Clinical features of Secondary dysmenorrhea?
Secondary dysmenorrhea refers to menstrual pain that is caused by an underlying medical condition, unlike primary dysmenorrhea which occurs without any identifiable underlying cause. Secondary dysmenorrhea tends to develop later in life and often presents with more severe and persistent symptoms than primary dysmenorrhea.
6 Organic Conditions that May Cause Dyspareunia?
A 23 year old woman complains that intercourse is painful. What specific questions would you ask about her symptoms? Having excluded organic factors, how would you proceed with management? (6)
Pain Hx - SOCRATES
Management: If organic factors have been excluded and the pain is not due to a physical condition, the management of dyspareunia might involve addressing psychological, emotional, or relational factors that could contribute to the pain.
Why is Cardiac Disease in Pregnancy such a concern?
- Which cardiac diseases are associated with a high, medium and low risk of maternal mortality?
Pregnancy is a stress for women with cardiac diseases because:
1. Cardiac output increases by 40% during pregnancy due to increase in stroke volume and heart rate
2. Cardiac output also increases soon after delivery because of tonic uterine contraction and relief from aorto-caval compression
3. These changes are not tolerated by a heart that is compromised by disease
4. Anaemia, infection, bleeding, hypertension, pre-eclampsia, GDM can further complicate cardiac disease in pregnancy
What is involved in the Pre pregnancy counselling for patients with cardiac disease? (7)
Intrapartum and Postpartum Management of women with cardiac disease? (11)
What are the risk factors for VTE in pregnancy? When does the risk go up/down?
Presentation (3)and Investigations (4) for VTE in pregnancy?
Management?
Presentation:
1. Leg pain discomfort, swelling, tenderness, pyrexia, erythema, raised WCC
2. Dyspnoea, Collapse, Chest pain,
3. Haemoptysis, Raised JVP, Focal signs in the chest
Investigations:
1. Thrombophilia screen- congenital and acquired
2. FBC, U and E, LFT, Coagulation screen
3. Imaging- Leg USS- Compression or Duplex
4. For PE- ECG, Chest X Ray, ABG, V/Q Scan, CT angiography/MRI
Why is Epilepsy a concern in pregnancy?
Main teratogenic risks of anticonvulsants?
Management?
5 Causes of Hypothyroidism in Pregnancy?
- Complications if left untreated?
- Management?
Causes of Hypothyroidism
1. Hashimoto’s thyroiditis
2. Atrophic thyroiditis
3. Congenital absence of thyroid
4. Thyroidectomy, radioiodine therapy, drugs ( Lithium, iodine)
5. Pituitary failure
Adenomyosis
- Definition?
- Epidemiology?
- Aetiology?
- 5 Clinical Features?
- Diagnostics?
- Treatment?
Adenomyosis
- Definition: benign disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
- Epidemiology: peak incidence at 35–50 years
- Aetiology: The exact etiology is unknown, though some risk factors have been identified: Endometriosis, Uterine fibroids, Parity
- Clinical features:
1. May be asymptomatic
2. Dysmenorrhea
3. Abnormal uterine bleeding
4. Chronic pelvic pain, aggravated during menses
5. Globular, uniformly enlarged uterus that is soft but tender on palpation
What is Chorioamnionitis?
- Aetiology?
- Risk factors? (3)
- Clinical features - 5 Maternal & 1 Fetal?
- Diagnosis?
Clinical features
Maternal
1. Fever (> 38 °C or > 100°F)
2. Tachycardia > 120/min
3. Uterine tenderness, pelvic pain
4. Malodorous and purulent amniotic fluid, vaginal discharge
5. Premature contractions, PROM
Fetal tachycardia > 160/min in cardiotocography
Chorioamnionitis
- Management?
- Complications - 8 Maternal? 6 Fetal?
What will you do for this girl?
Why is she getting these symptoms?
- Prostaglandins getting into gut = diarrhoea
- N&V - pain
- Syncope = retrograde blood getting into peritoneum causing irritation and vagal stimualtion
- Should take the mefanamic acid at the onset of her period (when prostaglandins released)
Management
- Education re : correct use of NSAIDs
- COCP to regulate periods & reduce prostaglandin production & skip periods & can time Mefenamic acid use
Outline the Medical Eligibility Criteria (MEC) for Contraception and give examples for each of the 4 categories?
- MEC Cat 1 – eg. 20yo F wanting COCP
- Cat 2 – eg. 20yo F wanting IUD
- Cat 3 – eg. BMI >35 & COCP – risk of thromboembolism
- Cat 4 – eg. COCP past VTE or migraine with aura (risk of stroke very high)
What are the main contraindications and MEC category of contraception types:
- Oestrogen plus progestogen?
- Progestogen only (Implanon, POP, Progestogen IUD)?
- Depot?
MEC categories?
For hormonal IUDs, add the same contraindications as implants (eg breast cancer, severe liver disease)
Effectiveness of Different Contraception Methods - Hormonal vs. Barrier methods?
Contraception - Implanon
- What is it?
- MOA?
- Positives & Negatives?
Implanon
* Flexible 4cm subdermal rod
* Contains desogestrel (a progestogen)
* Inserted under skin of inner upper arm
Progestogen containing IUDs
- Examples/Types?
- MOA?
- Pros & Cons?
Progestogen IUDs
* Progestogen containing: – Mirena®
– Lasts 5 years (longer if only used for menstrual management)
– Initial frequent bleeding (3-6 months) followed by very little bleeding for most women
– Very low incidence “progestogen” side effects
Copper containing IUDs
- Examples?
- MOA?
- Pros & Cons?
Copper containing IUDs
– Copper T Standard – lasts 10 years
– Copper T Short – lasts 5 years – Load 375® - lasts 5 years
(formerly Multiload®)
* 40-50% chance of heavier or more painful periods
Pros & Cons of Sterilisation as a form of Contraception?
Depot injections
- MOA?
- Pros & Cons?
Combined pills & vaginal ring
- MOA?
- Positives & Negatives?
- Is skipping bleeds encouraged?
- “Skipping bleeds” is encouraged!!
– Take active tablets, skip inactive ones until a withdrawal bleed is desired - Regular withdrawal bleed once every 3 months, OR
- When any breakthrough bleeding occurs, have 4-7 inactive pills then continue active pills again
Progestogen only pills
- MOA?
- Positive & Negatives?
Positives & Negatives of Barrier forms of Contraception?
Positives & Negatives of Withdrawal (Pulling out) as a form of Contraception?
True or False:
- IUDs can only be used after a woman has had children.
- The combined contraceptive pill commonly causes weight gain.
- The contraceptive implant commonly causes weight gain.
- Depotinjectionscommonlycause weight gain.
True or False:
- It is advisable to take a break from the combined pill from time to time.
- Fertility can take a number of months to return after stopping the combined pill.
- Three standard combined pills can be used as emergency contraception.
- Antibiotics reduce the effectiveness of the combined pill.
What is the Law in WA regarding termination of pregnancy?
A female patient presents to your GP. From history & examination, she is pregnant with gestation is 6 weeks and requesting a TOP. What do you do next?
- What are her options?
- Discuss medical vs surgical options
- Discuss risks of termination and risks of continuing pregnancy
- Discuss contraception
- Offer STI screening
What are some possible complications of a termination of pregnancy?
Possible complications of termination
1. Infection – uncommon
2. Heavy bleeding – more likely with medical
3. Perforation – more likely with surgical; very uncommon
4. Incomplete expulsion – more likely with medical
Rare risks – mostly preventable
1. Rhesus isoimmunisation
2. Anaesthetic complications
3. Missed ectopic pregnancy
What clinical assessment and counselling is required of a 22 year old university student who has requested that she start the oral contraceptive pill?
- What is the combined contraceptive pill?
- What are the different types of pill available?
- How does the combined pill work?
- How effective is the combined pill?
- 7 Advantages of the COCP and 4 Disadvantages of the COCP?
How effective is the combined pill?
Patients understandably want to know how effective contraception is and this is often a major factor in their decision as to which type of contraception they want to use. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess! Explain to the patient that the effectiveness of the pill depends on compliance. However, if the pill is used correctly, it is 99% effective. “If you take the combined pill at the appropriate time each day and don’t miss pills, it is 99% effective at preventing pregnancy.”
COCP Counselling
- 3 Risks of the COCP?
- 8 Contrainfications of the COCP?
- When to start the pill?
- What to do if you miss a pill?
Risks of the combined pill
1. Venous thromboembolism - “There is a small increase in the risk of developing clots in your legs and lungs. There is also a small increase in the risk of having a heart attack or a stroke. If you have had any of these conditions in the past, then you should not use the pill. The risk of developing these conditions is increased if you smoke regularly, have a high BMI or if you are immobile for a long period of time.”
2. Breast cancer - “Research has shown that there is a small increased risk of breast cancer compared to people who are taking non-hormonal contraception. The risk reduces with time after stopping the pill.”
3. Cervical cancer - “Research has also shown that there is a small increased risk of developing cervical cancer with longer use of the combined oral contraceptive.”
COCP Counselling
- What happens if I’m sick or have diarrhoea?
- Which common medicines affect the efficacy of the pill?
- Is it harmful to miss a withdrawal bleed?
- What should the patient do if they want to try and become pregnant?
- What should the patient do if they want to stop taking the pill?
- Is it dangerous to take the pill for a long time?
