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GP FELLOWSHIP RNZGP > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Three types of emergency contraception (dose and time course)

A
  1. Levonorgestrel (LNG) 1.5mg taken within 96 hours
  2. Ulipristal acetate 30mg taken within 120 hours
  3. Copper IUD inserted within 120hours

Note: follow up with pregnancy test 3 weeks later

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2
Q

Pre- MHT Considerations (and tests)

A

-Consider other causes: Thyroid, diabetes, depression, iron deficiency
- Smoking
- Iron deficiency (ferritin)
- Bleeding abnormalities
- CST
- Mammogram
- screen for vte risk
- cvd risk

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3
Q

Melasma management options

A
  1. Hydroquinone 2% topically twice daily for 2-4 months
  2. Cease hormonal contraception
  3. Topical Tretinoin 0.025% daily
  4. Sun safety (spf 50+)

NOTE: NO LASER

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4
Q

Categories of MHT

A
  • Cyclical Combined
  • Continuous combined
  • Estrogen only
  • Vaginal topical preparations
  • Non hormonal (SSRIs, gabapentin)
  • Tibolone
  • conjugated estrogens & bazedoxifene
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5
Q

Intravaginal hormonal replacement (be specific)

A
  1. “Ovestin cream”
    Estriol 1mg/g one applicatorful nocte for 2-3 weeks then once or twice weekly ongoing
    OR
  2. “Vagifem” pessary
    Estradiol 10 microg nocte for 2 weeks then twice weekly
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6
Q

Cyclical Combined MHT

A
  • 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

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7
Q

MHT
Oestrogen example (transdermal and oral )

Progesterone example

A

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

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8
Q

Breast cancer risk in MHT

A

Fewer than one case in 1000 per year used.
Oestrogen only = less risk

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9
Q

Cardiovascular risk in MHT

A

NO increased risk (without background CVD ), actually less (in started before 60 then 48% less CVD found.

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10
Q

VTE risk with MHT

A

ORAL MHT
Not increased with transdermal!!!!

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11
Q

Management of PCOS

A
  • Metformin 500mg IR or MR up to 1500mg daily (if BMI >25)
  • COCP (lowest dose estrogen preparation)
  • 5% weight loss
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12
Q

Investigations for PCOS

A

FAI
fasting glucose
Pelvic US (although not needed if 2 other criteria met) (>20)
Sex hormone binding globulin
LH
FSH

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13
Q

Risk factors for ectopic pregnancy

A
  • Previous ectopic
  • PID
  • Previous tubal surgery
  • IUD
  • IVF
  • COCP
  • Smoking
  • Previous pelvic surgery
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14
Q

Indications for CST (Asymptomatic)

A

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

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15
Q

Nipple thrush

A

Update

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16
Q

Dose of folic acid and iodine for pregnancy

A

Folic acid: 500mcg

Iodine: 150mcg

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17
Q

Nipple and breast pain Ddx

A
  • Mastitis
  • Nipple thrush
  • Nipple trauma
  • Blocked duct
  • Nipple contact dermatitis
  • Nipple eczema
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18
Q

2 NON- hormonal (but pharmacological) MHT options for hot flushes

A

Escitalopram 5mg (up to 20mg)
Or any SSRI
or
Pregabalin 75mg BD

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19
Q

Non pharmacological hot flush management strategies

A

CBT
Hypnosis for 5 weeks
Weight loss in overweight people
Mindfulness

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20
Q

Contraindications to systemic MHT

A

> 60
VTE
TIA/CVA/AMI
uncontrolled HTN
endometrial ca
breast ca
SLE
Porphyria
high risk breast Ca- REFER first for opinion

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21
Q

Secondary amenorrhea investigations

A
  • Prolactin
  • FSH
  • LH
  • Serum/urine bHCG
  • TSH
  • Progesterone
  • Oestrogen
  • (consider SHBG, FAI, testosterone)
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22
Q

Complications to consider in PCOS

A
  • Diabetes
  • CVD
  • Depression, disordered eating
  • Subfertility
  • Metabolic associated fatty liver disease
  • Sleep apnoea
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23
Q

PCOS: management of irregular cycles

A
  • 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

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24
Q

PID empirical therapy

A

Ceftriazxone 500mg in 2mL 1% lidocaine IM

PLUS
Metronidazole 400mg BD 14d

PLUS
Doxycycline 100mg BD 14d

***if pregnant /non adherent then azithromycin

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25
Q

IUD in PID to remove or not to remove

A

NOT
unless…

1) Severe
or
2) No improvement in 48-72 hours

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26
Q

Non-hormonal MHT options for vasomotor menopausal symptoms

A

SNRIs***
- Desvenlafaxine 50mg daily

SSRI
- Escitalopram 5mg daily

Gabapentinoids ***
- gabapentin 100mg nocte increasing to TDS

Clonidine 25mcg daily

***good for sleep issues

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27
Q

Bio-identical hormones- issues with these

A
  • 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)
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28
Q

Dose of folate for pregnancy
(note obesity)

A

0.5mg

5mg if BMI >30

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29
Q

Dose of iodine

A

150ug per day

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30
Q

Target TSH levels in pregnancy (by trimester)

A

1: 0.1 - 2.5
2: 0.2 - 3
3: 0.3 - 3

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31
Q

Obesity in pregnancy extra things to consider

A
  • Higher folate dose 5mg
  • Check vitamin D levels
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32
Q

History Questions for sub-fertility to identify cause

A
  • 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)
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33
Q

Preliminary fertility investigations

A
  • Day 2-4 FSH, LH and oestradiol
  • AMH
  • TSH
  • TV US
  • Semen analysis
  • Day 21 progesterone
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34
Q

Post bariatric surgery pregnancy considerations

A
  • NO OGTT
  • Need multivitamin
  • If BMI>30 then High dose folate
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35
Q

PCOS frequency of OGTT in pregnancy (hint: three)

A
  • Preconception
  • <20 weeks
  • All women 28-30 weeks
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36
Q

Antenatal first consult examination

A
  • BMI
  • BP
  • Gum & dental health
  • Thyroid examination
  • Breast exam
  • CST
  • Cardiovascular exam for murmurs
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37
Q

Gestational diabetes post partum check:

A

75g 2hour OGTT 6-12 weeks post partum

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38
Q

Differential diagnoses of vaginal irritation/pain/itch

A
  • Lichen sclerosus
  • Lichen planus
  • Psoriasis
  • Vulvovaginal candidiasis
  • Atopic dermatitis
  • Allergic contact dermatitis
  • Atrophic vaginitis
  • HSV - if acute
  • bacterial vaginosis (mild itch)
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39
Q

Thrush pharmacology

A

Fluconazole 150mg PO stat
Clotrimazole 1% 6 nights

40
Q

Causes for post coital or intramenstrual bleeding

A
  • Cervical polyp
  • Cervical ectropion
  • Cervicitis (secondary to chlamydia/gonorrhoea)
  • Cervical ca
  • Endometrial ca
  • Endometrial hyperplasia
  • Von Willebrand
  • Uterine fibroid
  • Pregnancy/threatened miscarriage
41
Q

DES- exposed women screening guidelines

A
  • Yearly co-test and colposcopy
42
Q

Lichen sclerosus pharmacotherapy

A

Betamethasone Dipropionate 0.05% OV (SUPER POTENT) BD until itch ceased and then once daily until skin normalises

43
Q

Risk factors for endometrial cancer

A
  • Chronic anovulation
  • Unopposed oestrogen exposure
  • PCOS
  • Tamoxifen
  • Nullip
  • Obesity
  • Strong family history eg lynch syndrome
44
Q

Causes of recurrent miscarriage

A
  • Antiphospholipid syndrome
  • Hypothyroidism
  • Diabetes
  • Uterine leiomyoma
  • Septate uterus
  • Idiopathic recurrent pregnancy loss
  • Chromosomal anomaly
45
Q

Bacterial Vaginosis pharmacological management

A

Metronidazole 400mg BD 7 days (with food)

46
Q

Medications that induce Cytochrome p450 & reduce contraceptive efficacy:

A

Antiepileptics:
- Carbamazepine
- Phenytoin
- Topiramate

Antiretrovirals

Antibiotics
- Rifampicin

St John’s wort

** note: levetiracetam and sodium valproate are FINE

47
Q

Nipple & breast thrush treatment

A

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

48
Q

Nipple & breast thrush treatment

A

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

49
Q

Post Ullipristal time before using hormonal contraception

A

5 days

50
Q

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?

A

Consider Emergency contraception

PLUS condoms for 7 days

51
Q

Sexual assault STI testing time frame

A
  • Baseline
  • 2 weeks
  • 6 weeks
  • 12weeks
52
Q

Sexual assault time frame for forensic investigation

A

Within 72
Sometimes up to 10 days

53
Q

Hep B prophylaxis post assault (time frame and options)

A
  • Immunoglobulins within 72 hours (but up to 14 days) IF ASSAILANT positive
  • Course of vaccination if non immune within 14 days
54
Q

Pre-eclampsia Symptoms

A
  • Headache
  • Persistent visual symptoms (photopsia, scotomata, blindness)
  • Swelling of extremities
  • RUQ pain
  • Oligouria
55
Q

Pre-eclampsia initial investigations

A
  • 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
56
Q

Simple anechoic ovarian cyst <5cm follow up

A

No follow up

57
Q

When to use Ca 125?

A

POST menopausal to calculate RMI

58
Q

Endometrial thickness cute off

A

4mm

59
Q

Initial investigations for overactive bladder

A
  • UA
  • Bladder diary 3 days
  • US and PVR
60
Q

Single episode post coital bleeding - What to do ?

A

1) Co test
2) Then if cervix NAD then reassure

61
Q

Unexplained intermenstrual bleeding investigations?

A
  • Cotest and refer
62
Q

Lamotrigine effect on contraception

A

Reduced efficacy of the COCP and ring

63
Q

Carbamazepine:
1) Effect on contraception?
2) What options are ok?

A

REDUCED
use
- Depo-provera
- Mirena
- Copper IUD

64
Q

Asymptomatic bacteriuira first step

A

Repeat with second culture

65
Q

Asymptomatic bacteriuira approach

A

1) Repeat sample
2) Treat
3) Confirm clearance

66
Q

Antibiotic choice for Acute Cystitis in Pregnancy

A

1) Nitrofurantoin 100mg 6 hourly 5 days

Second line: cephalexin
NOTE: Trimethoprim fine for trimester 2 & 3

67
Q

Non severe (no fever) endometritis antibiotics

(bonus: hypersensitivity option)

A

Augmentin DF 7 days

Allergy?
Bactrim 160+800 BD 7 days PLUS Metronidazole 400mg 12 hourly 7 days

68
Q

Severe endometritis IV therapy

A

Gentamicin 4-5mg/kg
PLUS
Metronidazole 500mg IV BD
Amoxicillin 2g 6 hourly

69
Q

Definition of pre-eclampsia

A

– 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

70
Q

Dose and timing of aspirin for high risk for pre-eclampsia

A

150mg daily from 12 weeks

71
Q

Indications for aspirin during pregnancy (pre-eclampsia risk)

A

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

72
Q

Treatment of HTN in pregnancy

A
  • Labetalol 100mg BD-TDS
    or
    Methyldopa 250mg TDS
73
Q

Limitations of US in PCOS (HINT: age)

A

US unreliable in <8 yrs since menarche

74
Q

Laboratory investigations for Hirsutism

A
  • Total Serum Testosterone
  • Free androgen index
  • Serum 17- Hydoxyprogesterone (In follicular phase)
  • LH, estradiol and progesterone (to confirm in follicular phase)
  • TSH
75
Q

Acute severe heavy menstrual bleeding treatment

A

Medroxyprogesterone 10mg 4-8 hourly until bleeding stops

OR

Norethisterone 5-10mg 4-8 hourly until bleeding stops

76
Q

Non hormonal drug therapy for menorrhagia

A

Tranexamic acid 1-1.5g 6-8 hourly for first 3-5 days of cycle

77
Q

Self collected Non 16/18 HPV what is next

A

Recall for clinician collected LBC

78
Q

Heavy Menstrual Bleeding Acronym and causes

A

STRUCTURAL
Polyp
Adenomyosis
Leiomyoma
Malignancy

NON-STRUCTURAL
Coagulopathy
Ovulatory Dysfunction
Endometrial disorders
Iatrogenic
Not otherwise classified

79
Q

Primary Amenorrhoea initial investigations?

A

LH
FSH
Oestradiol
Prolactin
TSH

Pelvic US

80
Q

Cut off upper age for contraception

A

55

81
Q

Common causes of post menopausal bleeding

A
  • Endometrial Cancer
  • Endometrial Hyperplasia
  • Cervical polyp
  • Cervical cancer
  • Endometrial atrophy
82
Q

Menopausal bleeding and tamoxifen…

A

Referral to gynaecologist for biopsy

83
Q

Symptoms of ovarian cancer

A

Bloating
Early satiety
Urinary symptoms
Change in bowels
Pelvic pain
Dyspareunia

84
Q

Contraindications for COCP

A
  • 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
85
Q

Progesterone only pill window

A

3 hours

86
Q

Progesterone only starting (how many pills until effective)

A

3 days (or straight away if started on period)

87
Q

Depot provera counselling

A

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

88
Q

UTI in pregnancy

A

Nitrofurantoin 100mg 6 hourly 5 days

89
Q

APH differentials

A
  • Placental abruption
  • Placenta previa
  • Vasa previa
  • Early labour blood show
  • Marginal placental bleed
  • Cervical ectropion/polyp
90
Q

Consequences of premature ovarian failure

A
  • Infertility
  • Increased risk of dementia
  • Increased risk of CVD
  • Osteoporosis
  • Depression
91
Q

Mastitis but allergic to penicillin

A
  • Cephalexin (mild allergy)
  • Clindamycin otherwise
92
Q

BRCA2 variant when to have RRBSO

A

Early 40s

93
Q

FSH checking for menopause: what are the rules

A

> 30 and again >30 on repeat in 6 weeks
Then wait 1 year

OR
over 55

94
Q

Progesterone only pill counselling

A
  • 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)
95
Q

Category 3&4 (BAD) for COCP conditions

A
  • 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)
96
Q

DES- exposed women screening guidelines

A
  • Yearly co-test and colposcopy
97
Q

Indications for CST (Symptomatic)

A
  1. Abnormal vaginal bleeding (post coital, inter-menstrual or post menopausal)
  2. Abnormal persistent vaginal discharge (esp if blood stained or offensive)

If due:
- Deep Dyspareunia
- Vaginal discharge

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