Women's Health Flashcards
Three types of emergency contraception (dose and time course)
- Levonorgestrel (LNG) 1.5mg taken within 96 hours
- Ulipristal acetate 30mg taken within 120 hours
- Copper IUD inserted within 120hours
Note: follow up with pregnancy test 3 weeks later
Pre- MHT Considerations (and tests)
-Consider other causes: Thyroid, diabetes, depression, iron deficiency
- Smoking
- Iron deficiency (ferritin)
- Bleeding abnormalities
- CST
- Mammogram
- screen for vte risk
- cvd risk
Melasma management options
- Hydroquinone 2% topically twice daily for 2-4 months
- Cease hormonal contraception
- Topical Tretinoin 0.025% daily
- Sun safety (spf 50+)
NOTE: NO LASER
Categories of MHT
- Cyclical Combined
- Continuous combined
- Estrogen only
- Vaginal topical preparations
- Non hormonal (SSRIs, gabapentin)
- Tibolone
- conjugated estrogens & bazedoxifene
Intravaginal hormonal replacement (be specific)
- “Ovestin cream”
Estriol 1mg/g one applicatorful nocte for 2-3 weeks then once or twice weekly ongoing
OR - “Vagifem” pessary
Estradiol 10 microg nocte for 2 weeks then twice weekly
Cyclical Combined MHT
- IUD (Mirena) with transdermal or oral oestrogen
- Transdermal oestrogen and cyclical oral progesterone
- Oral continuous oestrogen with cyclical progesterone (combined formulation or separate)
BRAND: “Estrogel pro”: 0.75mg per pump transdermal oestrogen gel PLUS 200mg micronised progesterone for 12 days of each cycle
NOTE: low dose= 1 pump, med = 2 pumps
MHT
Oestrogen example (transdermal and oral )
Progesterone example
Oral oestrogen eg:
“progynova” Oestradiol valerate
Low dose= 0.5mg
Med dose= 1mg
High =2mg
Transdermal oestrogen eg:
“Estrogel” 0.75mg (1 pumps) oestradiol daily
NOTE: medium =2pumps, high 3 pumps
Progesterone eg:
“prometrium” progesterone (micronised) 200 mg, nocte for the same 12 to 14 days
Breast cancer risk in MHT
Fewer than one case in 1000 per year used.
Oestrogen only = less risk
Cardiovascular risk in MHT
NO increased risk (without background CVD ), actually less (in started before 60 then 48% less CVD found.
VTE risk with MHT
ORAL MHT
Not increased with transdermal!!!!
Management of PCOS
- Metformin 500mg IR or MR up to 1500mg daily (if BMI >25)
- COCP (lowest dose estrogen preparation)
- 5% weight loss
Investigations for PCOS
FAI
fasting glucose
Pelvic US (although not needed if 2 other criteria met) (>20)
Sex hormone binding globulin
LH
FSH
Risk factors for ectopic pregnancy
- Previous ectopic
- PID
- Previous tubal surgery
- IUD
- IVF
- COCP
- Smoking
- Previous pelvic surgery
Indications for CST (Symptomatic)
- Abnormal vaginal bleeding (post coital, inter-menstrual or post menopausal)
- Abnormal persistent vaginal discharge (esp if blood stained or offensive)
If due:
- Deep Dyspareunia
- Vaginal discharge
Indications for CST (Asymptomatic)
Risk Populations:
- Immunocompromised (if oncogenic HPV NOT detected then every 3 yrs)
- early sexual debut (<14 and no vaccine prior to debut) between age 20-24
DES exposure in utero: annual co test and colposcopy
note: daughters of DES - normal screening
Nipple thrush
Update
Dose of folic acid and iodine for pregnancy
Folic acid: 500mcg
Iodine: 150mcg
Nipple and breast pain Ddx
- Mastitis
- Nipple thrush
- Nipple trauma
- Blocked duct
- Nipple contact dermatitis
- Nipple eczema
2 NON- hormonal (but pharmacological) MHT options for hot flushes
Escitalopram 5mg (up to 20mg)
Or any SSRI
or
Pregabalin 75mg BD
Non pharmacological hot flush management strategies
CBT
Hypnosis for 5 weeks
Weight loss in overweight people
Mindfulness
Contraindications to systemic MHT
> 60
VTE
TIA/CVA/AMI
uncontrolled HTN
endometrial ca
breast ca
SLE
Porphyria
high risk breast Ca- REFER first for opinion
Secondary amenorrhea investigations
- Prolactin
- FSH
- LH
- Serum/urine bHCG
- TSH
- Progesterone
- Oestrogen
- (consider SHBG, FAI, testosterone)
Complications to consider in PCOS
- Diabetes
- CVD
- Depression, disordered eating
- Subfertility
- Metabolic associated fatty liver disease
- Sleep apnoea
PCOS: management of irregular cycles
- COCP (eg Levlen,femmetab- ethinylestradiol/levonorgestrel 30/150mg)
- Mirena 52mg IUD
- Micronised progesterone 200mg for 12 days /month (SHORT TERM)
**note: metformin & spironolactone does not aid in menstrual cycle regulation
PID empirical therapy
Ceftriazxone 500mg in 2mL 1% lidocaine IM
PLUS
Metronidazole 400mg BD 14d
PLUS
Doxycycline 100mg BD 14d
***if pregnant /non adherent then azithromycin
IUD in PID to remove or not to remove
NOT
unless…
1) Severe
or
2) No improvement in 48-72 hours
Non-hormonal MHT options for vasomotor menopausal symptoms
SNRIs***
- Desvenlafaxine 50mg daily
SSRI
- Escitalopram 5mg daily
Gabapentinoids ***
- gabapentin 100mg nocte increasing to TDS
Clonidine 25mcg daily
***good for sleep issues
Bio-identical hormones- issues with these
- Expensive
- Not regulated by TGA
- Variable concentrations therefore variable effect
- Progesterone dose might not be sufficient to protect from endometrial hyperplasia
- Expensive (testing and actual medication)
Dose of folate for pregnancy
(note obesity)
0.5mg
5mg if BMI >30
Dose of iodine
150ug per day
Target TSH levels in pregnancy (by trimester)
1: 0.1 - 2.5
2: 0.2 - 3
3: 0.3 - 3
Obesity in pregnancy extra things to consider
- Higher folate dose 5mg
- Check vitamin D levels
History Questions for sub-fertility to identify cause
- PCOS symptoms: hirsutism, acne, irregular periods
- Deep dyspareunia or severe dysmenorrhoea (Endometriosis)
- Galactorrhoea or visual changes (prolactinoma)
- Weight gain or cold intolerance (hypothyroidism)
- Recent depo-provera (delayed ovulation)
- Hot flushes (premature menopause)
- STI /discharge (PID)
Preliminary fertility investigations
- Day 2-4 FSH, LH and oestradiol
- AMH
- TSH
- TV US
- Semen analysis
- Day 21 progesterone
Post bariatric surgery pregnancy considerations
- NO OGTT
- Need multivitamin
- If BMI>30 then High dose folate
PCOS frequency of OGTT in pregnancy (hint: three)
- Preconception
- <20 weeks
- All women 28-30 weeks
Antenatal first consult examination
- BMI
- BP
- Gum & dental health
- Thyroid examination
- Breast exam
- CST
- Cardiovascular exam for murmurs
Gestational diabetes post partum check:
75g 2hour OGTT 6-12 weeks post partum
Differential diagnoses of vaginal irritation/pain/itch
- Lichen sclerosus
- Lichen planus
- Psoriasis
- Vulvovaginal candidiasis
- Atopic dermatitis
- Allergic contact dermatitis
- Atrophic vaginitis
- HSV - if acute
- bacterial vaginosis (mild itch)
Thrush pharmacology
Fluconazole 150mg PO stat
Clotrimazole 1% 6 nights
Causes for post coital or intramenstrual bleeding
- Cervical polyp
- Cervical ectropion
- Cervicitis (secondary to chlamydia/gonorrhoea)
- Cervical ca
- Endometrial ca
- Endometrial hyperplasia
- Von Willebrand
- Uterine fibroid
- Pregnancy/threatened miscarriage
DES- exposed women screening guidelines
- Yearly co-test and colposcopy
DES- exposed women screening guidelines
- Yearly co-test and colposcopy
Lichen sclerosus pharmacotherapy
Betamethasone Dipropionate 0.05% OV (SUPER POTENT) BD until itch ceased and then once daily until skin normalises
Risk factors for endometrial cancer
- Chronic anovulation
- Unopposed oestrogen exposure
- PCOS
- Tamoxifen
- Nullip
- Obesity
- Strong family history eg lynch syndrome
Causes of recurrent miscarriage
- Antiphospholipid syndrome
- Hypothyroidism
- Diabetes
- Uterine leiomyoma
- Septate uterus
- Idiopathic recurrent pregnancy loss
- Chromosomal anomaly
Bacterial Vaginosis pharmacological management
Metronidazole 400mg BD 7 days (with food)
Medications that induce Cytochrome p450 & reduce contraceptive efficacy:
Antiepileptics:
- Carbamazepine
- Phenytoin
- Topiramate
Antiretrovirals
Antibiotics
- Rifampicin
St John’s wort
** note: levetiracetam and sodium valproate are FINE
Nipple & breast thrush treatment
Fluconazole 150mg every 2nd day for 3 doses
Then
Nystatin tablet 2x 500,000 unit tables TDS
AND
Miconazole gel to nipples QID
PLUS
Miconazole gel for BABY QID for 1 week
Then daily for 1 week
Nipple & breast thrush treatment
Fluconazole 150mg every 2nd day for 3 doses
Then
Nystatin tablet 2x 500,000 units TDS
AND
Miconazole gel to nipples QID
PLUS
Miconazole gel for BABY QID for 1 week
Then daily for 1 week
Post Ullipristal time before using hormonal contraception
5 days
Missed more than 1 pill in the first 7 days of a pack OR start a new pack more than 24 hours late
AND intercourse in last 7 days or during hormonal break:
Advice?
Consider Emergency contraception
PLUS condoms for 7 days
Sexual assault STI testing time frame
- Baseline
- 2 weeks
- 6 weeks
- 12weeks
Sexual assault time frame for forensic investigation
Within 72
Sometimes up to 10 days
Hep B prophylaxis post assault (time frame and options)
- Immunoglobulins within 72 hours (but up to 14 days) IF ASSAILANT positive
- Course of vaccination if non immune within 14 days
Pre-eclampsia Symptoms
- Headache
- Persistent visual symptoms (photopsia, scotomata, blindness)
- Swelling of extremities
- RUQ pain
- Oligouria
Pre-eclampsia initial investigations
- Urine dipstick for proteinuria
- Urine protein: creat ratio
- FBC (platelets)
- EUC
- LFT (inc LDH) transaminitis, raised bilirubin
- Fetal HR
- CTG
- USS fetal growth and well being
Simple anechoic ovarian cyst <5cm follow up
No follow up
When to use Ca 125?
POST menopausal to calculate RMI
Endometrial thickness cute off
4mm
Initial investigations for overactive bladder
- UA
- Bladder diary 3 days
- US and PVR
Single episode post coital bleeding - What to do ?
1) Co test
2) Then if cervix NAD then reassure
Unexplained intermenstrual bleeding investigations?
- Cotest and refer
Lamotrigine effect on contraception
Reduced efficacy of the COCP and ring
Carbamazepine:
1) Effect on contraception?
2) What options are ok?
REDUCED
use
- Depo-provera
- Mirena
- Copper IUD
Asymptomatic bacteriuira first step
Repeat with second culture
Asymptomatic bacteriuira approach
1) Repeat sample
2) Treat
3) Confirm clearance
Antibiotic choice for Acute Cystitis in Pregnancy
1) Nitrofurantoin 100mg 6 hourly 5 days
Second line: cephalexin
NOTE: Trimethoprim fine for trimester 2 & 3
Non severe (no fever) endometritis antibiotics
(bonus: hypersensitivity option)
Augmentin DF 7 days
Allergy?
Bactrim 160+800 BD 7 days PLUS Metronidazole 400mg 12 hourly 7 days
Severe endometritis IV therapy
Gentamicin 4-5mg/kg
PLUS
Metronidazole 500mg IV BD
Amoxicillin 2g 6 hourly
Definition of pre-eclampsia
– New BP >140mmHg or diastolic >90
(2 occasions at least 4 hours apart) after 20 weeks
AND
–Proteinuria
Urine Protein:Creat >0.3
OR urine dipstick >1+
OR
- Thrombocytopenia <100
- Doubling of serum creatinine
- LFTs: twice normal transaminase
- Persistent visual symptoms
Dose and timing of aspirin for high risk for pre-eclampsia
150mg daily from 12 weeks
Indications for aspirin during pregnancy (pre-eclampsia risk)
HIGH risk
- HTN in previous pregnancy
- Diabetes
- CKD
- HTN
IF 1 or more :
- First pregnancy
- >40
- Pregnancy interval >10yrs
- BMI >35
- Fam hx pre-eclampsia
- Multi-fetal pregnancy
Treatment of HTN in pregnancy
- Labetalol 100mg BD-TDS
or
Methyldopa 250mg TDS
Limitations of US in PCOS (HINT: age)
US unreliable in <8 yrs since menarche
Laboratory investigations for Hirsutism
- Total Serum Testosterone
- Free androgen index
- Serum 17- Hydoxyprogesterone (In follicular phase)
- LH, estradiol and progesterone (to confirm in follicular phase)
- TSH
Acute severe heavy menstrual bleeding treatment
Medroxyprogesterone 10mg 4-8 hourly until bleeding stops
OR
Norethisterone 5-10mg 4-8 hourly until bleeding stops
Non hormonal drug therapy for menorrhagia
Tranexamic acid 1-1.5g 6-8 hourly for first 3-5 days of cycle
Self collected Non 16/18 HPV what is next
Recall for clinician collected LBC
Heavy Menstrual Bleeding Acronym and causes
STRUCTURAL
Polyp
Adenomyosis
Leiomyoma
Malignancy
NON-STRUCTURAL
Coagulopathy
Ovulatory Dysfunction
Endometrial disorders
Iatrogenic
Not otherwise classified
Primary Amenorrhoea initial investigations?
LH
FSH
Oestradiol
Prolactin
TSH
Pelvic US
Cut off upper age for contraception
55
Common causes of post menopausal bleeding
- Endometrial Cancer
- Endometrial Hyperplasia
- Cervical polyp
- Cervical cancer
- Endometrial atrophy
Menopausal bleeding and tamoxifen…
Referral to gynaecologist for biopsy
Symptoms of ovarian cancer
Bloating
Early satiety
Urinary symptoms
Change in bowels
Pelvic pain
Dyspareunia
Contraindications for COCP
- Migraine with aura
- History of VTE
- Obesity >35 BMI
- Over 35 and smoker (even if quit within the year)
- Fam hx of VTE <45yrs
- Pregnant
- Within 6 weeks PP
- Within 6weeks PP and breastfeeding
- Un-investigated breast symptom
- Recent surgery or immobilisation
- BRCA gene
Progesterone only pill window
3 hours
Progesterone only starting (how many pills until effective)
3 days (or straight away if started on period)
Depot provera counselling
Uncertain delay of return of fertility 8months to 2 yrs
Irregular menstrual cycle
Accelerated bone loss with prolonged use
Contraceptive only lasts 14 weeks
Breast tenderness
UTI in pregnancy
Nitrofurantoin 100mg 6 hourly 5 days
APH differentials
- Placental abruption
- Placenta previa
- Vasa previa
- Early labour blood show
- Marginal placental bleed
- Cervical ectropion/polyp
Consequences of premature ovarian failure
- Infertility
- Increased risk of dementia
- Increased risk of CVD
- Osteoporosis
- Depression
Mastitis but allergic to penicillin
- Cephalexin (mild allergy)
- Clindamycin otherwise
BRCA2 variant when to have RRBSO
Early 40s
FSH checking for menopause: what are the rules
> 30 and again >30 on repeat in 6 weeks
Then wait 1 year
OR
over 55
Progesterone only pill counselling
- 3 hour window
- If missed pill then barrier contraception for next 48hrs (until 3 pills in a row)
- Irregular bleeding
- Vomiting or diarrhoea can affect efficacy
- It takes 3 days for the method to become effective if started at any time (quick start)
Category 3&4 (BAD) for COCP conditions
- Migraine with aura
- <6 weeks PP
- BMI >35
- > 35yrs smoker (3) even if stopped smoking (must be over 1 yr ago)
- If they develop migraine (even without aura) while on it then stop
- BRCA1/2
- Breast cancer
- Thrombotic mutation
- HYPERTENSION (even controlled)
