Women's Health

Question 1

What is atrophic vaginitis?

Answer 1

Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.

Question 2

Who does atrophic vaginitis commonly occur to?

Answer 2

It occurs in women entering the menopause.

Question 3

Describe the pathophysiology of atrophic vaginitis?

Answer 3

Inc. oestrogen = epithelial lining of vagina and urinary tracts = thicker, more elastic and producing secretions.

Therefore in menopause = oestrogen low = mucosa becoming thinner, less elastic and more dry = tissue more prone to inflammation + vaginal pH change = inc. infections.

Question 4

Sx of atrophic vaginitis?

Answer 4

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
Vaginal burning

In old ladies: Recurrent UTI’s, stress incontinence, pelvic organ prolapse

Question 5

What would examination of the labia and vagina demonstrate in someone with atrophic vaginitis?

Answer 5

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

Question 6

Management of atrophic vaginitis?

Answer 6

Vaginal lubricants can help dryness. E.g. Sylk, Replens and YES.

Topical oestrogen. E.g. Estriol cream

Question 7

What is bacteria vaginosis?

Answer 7

An overgrowth of bacteria in the vagina, specifically anaerobic bacteria.

Question 8

Describe pathophysiology of bacterial vaginosis

Answer 8

Lactobacilli (healthy vaginal bacterial flora) = produces lactic acid = keeps vaginal pH low (<4.5) = prevent other bacteria from overgrowing.

Low lactobacilli = high pH = alkaline = enables anaerobic bacteria to multiply

Question 9

What anaerobic bacteria’s are associated with bacterial vaginosis?

Answer 9

Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species

Question 10

RF for developing bacterial vaginosis

Answer 10

Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil

Question 11

Sx of bacterial vaginosis

Answer 11

Fishy-smelling watery grey or white vaginal discharge.
No other sx

Question 12

Ix for bacterial vaginosis

Answer 12

Vaginal pH (a swab and pH paper) pH >4.5
Vaginal swab - microscopy (clue cells)

Question 13

Tx for bacterial vaginosis

Answer 13

1st line - Metronidazole (oral or vaginal gel)
2nd line - Clindamycin

When giving metronidazole advise patients to avoid alcohol for the duration of treatment.

Question 14

What should patients avoid when taking metronidazole for bacterial vaginosis?

Answer 14

Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Question 15

Complications of bacterial vaginosis?

Answer 15

Increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.

Can also cause miscarriage and preterm delivery.

Question 16

What is candidiasis (thrush)?

Answer 16

Vaginal infection with a yeast of the Candida family.

Question 17

What kind of fungus causes candidiasis?

Answer 17

Candida Albicans

Question 18

What are the RF for candidiasis? (4)

Answer 18

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)

Poorly controlled diabetes

Immunosuppression (e.g. using corticosteroids)

Broad-spectrum antibiotics

Question 19

Sx of candidiasis?

Answer 19

Thick, white discharge - no smell
Vulval and vaginal itching + irritation.

If severe:
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria

Question 20

Ix for candidiasis?

Answer 20

Vaginal pH - to differentiate between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
Charcoal swab with microscopy

Question 21

Tx for candidiasis?

Answer 21

If mild:
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator

If systemic or more severe:
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)

Question 22

What should women be warned about when using antifungal creams and pessaries?

Answer 22

It can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.

Question 23

What is a breast abscess? What are the 2 types?

Answer 23

A collection of pus within an area of the breast, usually caused by a bacterial infection.
May be:
Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)

Question 24

What is mastitis? How does it happen?

Answer 24

Inflammation of breast tissue.
Bacteria enter nipple → back-track into ducts → cause infx + infl.

Note: Breast abscess may or may not be associated with mastitis.

Question 25

What are the RF for development of breast abscess/mastitis?

Answer 25

Smoking ** Damage to nipples (i.e. nipple eczema, piercings) Breast disease (i.e. cancer)

Question 26

What are the common causative bacteria for breast abscess/mastitis? (2)

Answer 26

Staphylococcus aureus (the most common) Streptococcal species Enterococcal species Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Question 27

Sx of mastitis with infection?

Answer 27

Nipple changes Purulent nipple discharge (pus from the nipple) Localised pain Tenderness Warmth Erythema (redness) Hardening of the skin or breast tissue Swelling

Question 28

What are the key features of a breast abscess?

Answer 28

A swollen, fluctuant (able to move fluid around within lump), tender lump within the breast.

Question 29

Tx of lactational mastitis?

Answer 29

Conservatively: continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia. If infection or sx persist after 12-24hrs post conservative mx: Abx (flucloxacillin, if penicillin allergy - clarithromycin)

Question 30

Tx of non-lactational mastitis?

Answer 30

Analgesia Broad spectrum abx: Co-amoxiclav Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)

Question 31

What's the average age for menopause and how long would a women have no periods for to be diagnosed with menopause?

Answer 31

Around 50+ yrs No periods for 12 months

Question 32

A lack of what causes menopause? Describe changes in hormone in menopause.

Answer 32

Lack of ovarian follicular function Changes in hormone: Oestrogen and progesterone levels are low LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

Question 33

What are perimenopausal sx

Answer 33

Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido

Question 34

What can a lack of oestrogen increase the risk of?

Answer 34

Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Question 35

What is pelvic inflammatory disease?

Answer 35

Inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix.

Question 36

What are the causes of PID?

Answer 36

MC - sexually transmitted pelvic infections: 1. Neisseria gonorrhoeae 2. Chlamydia trachomatis 3. Mycoplasma genitalium

Question 37

RF for PID

Answer 37

Same as STIs: No barrier Multiple sexual partners Existing STIs

Question 38

Sx of PID

Answer 38

Pelvic or lower abdominal pain Abnormal vaginal discharge - purulent Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria Inflamed + tender cervix

Question 39

Ix for PID

Answer 39

Tests to find STI causative organisms: 1. NAAT swabs for gonorrhoea and chlamydia 2. HIV test 3. Syphilis test 4. High vaginal swab - bacterial vaginosis, candidiasis and trichomoniasis Pregnancy test - rule out ectopic pregnancy (Ddx)

Question 40

Tx for PID

Answer 40

Intramuscular ceftriaxone (cover gonorrhoea) Doxycycline (cover chlamydia + Mycoplasma genitalium) Metronidazole (cover anaerobes i.e. Gardnerella vaginalis)

Question 41

Describe each of the following types of oral contraceptive pill instruction: 1. Monophasic 2. Tricyclic regimen 3. Everyday pills

Answer 41

1. 21 days of administration, followed by 7 days off 2. 9 weeks of taking a pill every day (63 pills total) followed by 4, or 7 days off 3. One pill to be taken each day. The packets include 21 active pills and 7 inactive pills

Question 42

What are some rules for starting the OC pill in terms of if the patient is: 1. Starting the pill 1st day of her period (upto 5 days) 2. Starting at any other time in her cycle 3. New mother

Answer 42

1. She will be protected from pregnancy immediately 2. Will need to use condoms for 7 days 3. Can begin to take the pill 21 days after giving birth, providing they are not breastfeeding.

Question 43

Side effects of progesterone only pill?

Answer 43

Depression Breast tenderness, enlargement Headache Changes to mood and libido Nausea and vomiting Irregular menstrual bleeding, spotting, amenorrhoea Ovarian cysts

Question 44

What is a levonelle tablet and what time period should it be taken within?

Answer 44

Progesterone only tablet that should be taken within 72 hours (3 days) of unprotected sexual intercourse

Question 45

What are the side effects of levonelle and also when should a single'double dose be given?

Answer 45

Side effects include headache, nausea and dysmenorrhoea Levonelle may be less effective in women weighing >70 kg or with a BMI >26 kg/m2. An unlicensed "double dose" may be used in these circumstances If vomiting occurs within 3 hours of taking Levonelle, a repeat dose should be given

Question 46

Can women with a history of breast cancer use hormonal contraception?

Answer 46

Women with a history of breast cancer require the use of a copper intrauterine device for contraception due to hormonal treatments being contraindicated.

Question 47

When are women advised to stop taking contraception in the postmenopausal period?

Answer 47

Stop contraception after one year of amenorrhoea if over 50 years old or two years if under 50.

Question 48

Which cancers does the OCP decrease and increase the chances of having?

Answer 48

Reduces risk of ovarian and endometrial cancer, increases risk of breast and cervical cancer

Question 49

What is a EllaOne tablet and what time period should it be taken within?

Answer 49

It's a progesterone receptor modulator that works by inhibiting or delaying ovulation. It is licensed for use within 120 hours (5 days) of unprotected sexual intercourse

Question 50

What are some CI for taking EllaOne (emergency contraceptive) and what are some of the SE?

Answer 50

CI - severe asthma controlled with oral steroids, severe liver impairment, avoid breastfeeding for 1 week after raking meds. Common side effects include headache, nausea and dysmenorrhoea.