Women’s Health Flashcards
Mastitis (lactating women): Mx
5
- Simple analgesia
- Continue breastfeeding if possible, express if needed
- May require Abx - 1st line flucloxacillin
- May send milk culture
- Admit if unwell, sepsis, etc
Mastitis (non-lactating): Mx
3
- More likely to be infective cause cf lactating women, therefore ALL given Abx - first line co-amoxiclav 10-14 days
- Simple analgesia
- Admit if unwell, sepsis, etc
Nipple discharge - when to act
Blood discharge - all need to be referred
Consider further Ix if:
- Unilateral
- Only one duct involved
- Thin consistency
- Happens spontaneously (ie. Without pressure)
Familial breast cancer - when to refer for full risk assessment (genetic clinic, breast clinic)
(6)
- 1º F breast cancer <40
- 1º M breast cancer any age
- 1º relative with bilateral breast cancer (first one <50)
- Two 1º (or one 1º & one 2º) with breast cancer
- One relative w breast cancer and one w ovarian cancer
- Three relatives with breast cancer
Copper coil
—> toxic to sperm/ovum
Can be inserted and removed any time
Can be used as emergency contraception
Change very 5-10 years
IUS - levonorgestrel
Names 4; MOA; Insertion; Removal
4 licensed for use in UK:
- Mirena (5 years)
- Kyleena (5 years)
- Levosert (5 years)
- Jaydess (3 years)
MAO: Prevents implantation of fertilised ovum
Insertion:
- On day 1-7 of cycle - no extra protection
- Any other day (= off-label) - extra protection for 7 days
Can be removed at any point, no delay in return to fertility
LARC injections
3 licensed in UK:
- Depo-provera —> 12 weekly, long-term (medroxyprogesterone acetate 150mg)
- Saya-press —> 13 weekly, long term (medroxyprogesterone acetate 104mg)
- Noristerat —> 8 weekly, only licensed for 2 doses (norethisterone enantate)
OK up to 14 weeks since last dose (Noristerat up to 10 weeks)
No known interactions with liver-enzyme inducing drugs
Review every 2 years
Can take up to a year to return to normal fertility (periods can take several months to return to normal)
Antenatal advice - food
Avoid…
- Listeria (soft mould ripened cheese, e.g. Brie, unpasteurised milk, pate)
- Salmonella (raw shellfish, uncooked/undercooked cured meat)
- Liver and liver products (high vitamin A)
- High levels of methylmercury (e.g. swordfish, shark, marlin)
- Toxoplasmosis (so throughly cook meat, thoroughly wash fruit and veg)
Antenatal advice - general lifestyle
Vitamin D:
10mcg every day throughout pregnancy
Smoking:
Increases risk of miscarriage, prematurity, ectopic, low birth weight.
Consider NRT (different to usual forms)
Alcohol:
Avoid as no safe limit identified.
—> fetal alcohol spectrum disorder (structural birth defects, learning and behavioural problems)
Nausea & vomiting in pregnancy
Usually resolves buy around 16/40
Ketonuria suggests hyperemesis
Mx:
Mild…ginger, P6 wrist acupressure
1st line… oral promethazine/cyclizine —> reassess at 24 hours
If continues… oral prochlorperazine/metoclopramide/ondansetron —> reassess at 24 hours
If continues then specialist advice
Dyspepsia/heartburn in pregnancy
Lifestyle modification
1st line: antacids / alginates
2nd line: acid-suppressants - omeprazole…. (ranitidine alternative but not licensed in pregnancy)
Constipation
Increase fluid/fibre
Laxatives only if dietary measures fail —> bulk-forming laxatives 1st line, (then lactulose/macrogol)
Antiepileptics in pregnancy
3
- W COCP —> need increased dose of oestrogen (at least 50 mcg) otherwise increased risk of pregnancy due to reduced efficacy OR change contraceptive method, eg. IUD/IUS
- Increase teratogenicity risk (e.g. sodium valproate so may require alternatives)
- Higher folic acid dose needed (5mg) to reduce risk of NTD
Obstetric cholestasis
- exact cause unknown
- Typically from 28/40 onwards
- Intense itching, worse at night. May focus on palms and soles but can be anywhere
- If suspected —> same day maternity review for bloods —> high bile acids +/- abnormal LFTs
- Mx…
1. Emollients
2. Antihistamines
3. Ursodeoxycholic acid
4. Monitoring bloods
Polymorphic eruption of pregnancy
- Most common in 3rd trimester
- Presentation varies, e.g. erythematous rash, urticaria plaques or papules leading to intense itching. Often starts on abdomen
- Lasts 4-6 weeks usually, settles soon after delivery
- Mx…
1. Emollients
2. Topical steroids
3. Antihistamines
Nabothian cyst
Mucus retention cyst on cervix
Harmless and may need cryotherapy if discharge occurring
Cervical polyps
Benign neoplasms.
Usually asymptomatic but may bleed, e.g. on intercourse.
Can be removed and sent for histology if concerns.
Cervicitis
Causes include chlamydia, gonorrhoea, herpes.
May mask underlying cancer.
Cervical ectropion
= erosion/abrasion
Normal columnar epithelium occurs beyond os
Common in teenagers, pregnancy, on COCP
Can lead to discharge, bleeding
Often does not need treatment, but can remove, e.g. diathermy/cryotherapy
Cervical incompetence
Painless dilation of cervix which can lead to miscarriage/premature labour —> may need prophylactic stitch
Cervical screening
Look for two things - HPV and cells
If HPV negative —> routine recall
If HPV +ve….
…W normal cells —> repeat HPV in 1 year, and again in another 1 year —> if still HPV +ve then refer for colposcopy
…W abnormal cells —> colposcopy
Amenorrhoea
= absence or cessation of periods
Primary = periods dont start by expected menarche…
- may require Ix, e.g. Pelvic USS, hormone levels like TFT, prolactin, LH, FSH, testosterone
- refer for complete Ix and Mx if no 2º sexual characteristics and no periods by age 13
OR if normal 2º sexual characteristics but no periods by age 15
Secondary = periods stop at later point in life for at least 3 months (can happen due to many causes —> may need referral depending on suspected cause like gynae or endo
Stopping short term menstrual bleeding
—> norethisterone 5mg tds for 10 days
Tranexamic acid
= antifibrinolytic drug
Indications:
- Menorrhagia
- Epistaxis, hereditary angioedema, fibrinolysis
CI:
- fibrinolytic conditions following DIC, Hx of convulsions, severe renal impairment, history of thromboembolic disease
Cautions:
- irregular menstrual bleeding, haematuria, using OCP, using warfarin/anticoagulants
SE:
- GI - N, V, diarrhoea
- Allergic dermatitis
- Visual disturbances
- Thromboembolic events
- Convulsions
Dose:
(In menorrhagia) = 1g tds for up to 4 days
Can be increased to 4g per day if required
Endometriosis Mx
1st line - 3 month trial of paracetamol or NSAID
2nd line - hormonal treatment options, e.g. COCP or progestogen options
Fibroids:
Ix 2 and Mx 3
Ix:
- Usually Dx by USS
- Check FBC
Mx:
- Pharmacological…
- Symptomatic —> e.g IUS, tranexamic acid, NSAIDs, COCP, POP
- Reduce fibroid size —> e.g. GnRH agonists, ulipristal - Procedures…E.g. uterine artery embolisation, endometrial ablation
- Surgery… e.g. myomectomy (laparoscopic, abdominal, hysteroscopic), hysterectomy
Ovarian tumours
Types 2; RFs 6; Sx; Refer 2
Types:
- Benign (e.g. serous cystadenoma, fibroma, benign cystic teratoma)
- Malignant (often present late, e.g. epithelial tumours [most common], germ cell tumours)
RFs:
- > 50 yo
- Breast Ca FHx
- Endometriosis
- HRT
- Smoking
- Overweight
Sx:
Presentation varies - vague abdo pain, early satiety, weight loss, bloating, urine frequency, abdomino-pelvic mass, abnormal bleeding
Refer URGENTLY:
- W Ascites
- W pelvic/abdo mass (not fibroids)
Ovarian cancer: when to Ix in community
Especially if >50 and frequent Sx:
Bloating, feeling full/loss of appetite, pelvic or abdo pain, increased urinary urgency/frequency
Consider Ix if…
- Unexplained weight loss
- Fatigue
- Change in bowel habit
If age >50 and symptoms of IBS then consider Ca-125
Endometrial cancer
Refer 2ww if… Age >55 and PMB
Consider 2ww if… age under 55 and PMB
Consider direct access USS if age >55 and…
- Unexplained vaginal discharge with either of first time presentation / thrombocytosis / haematuria
- Visible haematuria with either low Hb / thrombocytosis / raised blood glucose
Gynae cancers 2ww
Cervix, vulval, vaginal
Consider 2ww if…
Cervix: consistent with cancer
Vulva: unexplained vulval lump, ulceration, bleeding
Vagina: palpable mass in or at entrance of vagina
PID
=; Lead to; Sx 4; Mx 3
= inflammation of female upper genital tract (including ovaries, uterus and Fallopian tubes)
- is a complication of STI, e.g. chlamydia/gonorrhoea
Can —> infertility, ectopic pregnancy, abscess formation, chronic pelvic pain
Sx can include:
- Discharge
- Deep dyspareunia
- Abdominal pain
- Fever
Mx:
- GUM clinic referral including contact tracing
- Analgesia, e.g. ibuprofen
- Oral or IV Abx (e.g. cef/met/doxy/oflox) - may need admission
Menopause: when to consider FSH test
(Provided not on hormonal treatment)…
- Over 45 with atypical symptoms
- 40-45 with menopausal symptoms change in cycle
- under 40 and premature menopause suspected
HRT contraindications
7
- Breast/oestrogen sensitive cancer
- VTE
- Angina
- MI
- Undiagnosed vaginal bleeding
- Endometrial hyperplasia
- Pregnancy
Contraceptive/menopause/fertility advice
Woman <50 is fertile for 2 years after LMP.
>50 is fertile for 1 year.
In general, can stop contraception at age 55.
Incontinence Mx
ALL:
Lifestyle - caffeine, fluids, weight loss
STRESS:
- Pelvic floor exercises (ideally for 3 months - 8 contractions 3x per day)
THEN - Refer for surgery (e.g. mid-urethral tape, colposuspension) OR duloxetine if surgery does not work/not wanted/inappropriate
URGE:
- Bladder training (at least 6 weeks)
THEN - Anticholinergic (oxybutynin, tolterodine, darifenacin) 1st line - takes 4 weeks to work
THEN - Refer if no benefit (e.g. for Botox injection, cystoplasty, etc)
