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