Women's Health Flashcards
Acute cystitis in pregnancy (medication, follow up)
Medication:
● First line: nitrofurantoin 100mg PO 6 hourly for 5 days
● Trimethoprim can be used in 2nd or 3rd trimester
Follow up: repeat urine MCS in 1-2 weeks post-completion of treatment
Amenorrhoea (primary vs. secondary)
Definition
- Primary: never bled
- Secondary: has not had bleed for 3 months from previous
Approach
● Pregnancy test, serum LH/FSH, TSH, prolactin levels, pelvic US
**Refer to page 47-48 of GP study notes
Antenatal depression
● If mild to moderate depression develops during pregnancy, use psychotherapy as first-line
● Consider starting an antidepressant for moderate depression (e.g. sertraline)
● Avoid paroxetine or fluoxetine
Breast-feeding - low breast milk supply (signs, practical points)
Signs < 3 wet nappies per 24 hours Concentrated urine (crystals) Scant stools Weight loss > 10% < 20g weight gain per day Failure to regain birth weight by 2 weeks of age Breast fullness and heaviness post-feeds Persistent jaundice, sleepiness or lethargy
Practical points Skin to skin contact Frequent breastfeeding (3 hourly) Good attachment Switch feed Express post-feeds Compress or massage breast to promote let down Domperidone 10mg/TDS
Lactational mastitis (organism, contributing factors, approach)
Organism: Staph aureus
Contributing factors: poor infant positioning, milk stasis, nipple damage
Approach:
● No systemic symptoms - no antibiotics required
● Systemic symptoms - antibiotics required
○ Flucloxacillin 500mg QID for 5-10 days
○ Cephalexin 500mg QID for 5-10 days (if allergic to above)
● General
○ Encourage breastfeeding on affected breast
○ Express milk post-feeds
○ Warm compress pre-feeds, cold compress post-feeds
○ Gentle massaging of the affected area
● Imaging: consider ultrasound if symptoms do not improve in 24-48 hours ? abscess
Postpartum lactation suppression (indication, medication)
Indication: stillbirth/neonatal death, personal choice, medical conditions.
Medication: cabergoline 1mg PO single dose
● Should not be taken until 4 hours after anti-emetics
● Most effective if given in first 12 hours
Gestational diabetes (definition, prognosis, screening, diagnosis, management, education)
Definition: Glucose intolerance that begins or is first diagnosed during pregnancy.
Prognosis: 41% of women return to normal by 6-8 weeks postpartum.
Screening: First trimester, 24-28 weeks gestation (not previous history), repeat OGTT 6-12 weeks postpartum
Diagnosis:
● Fasting BSL >=5.5 or,
● Two-hour BSL >=8.0
Management: Lifestyle interventions, education and insulin. Follow up OGTT at 6-12 weeks postpartum. Fasting BSL
and HbA1c every 3 years thereafter. For annual OGTT for women contemplating pregnancy.
Education:
● Benefits of breastfeeding in reducing the risk of women developing T2DM in the future
● Associated with risk of baby developing obesity, heart disease and/or diabetes in the future
Menorrhagia - approach
Exclude pregnancy-related bleeding (ectopic), coagulation disorders or anovulatory cycles in acute severe cases.
Summary
- Exclude pregnancy, perform CST (if due), Hx and Ex, initial Ix (FBE, ferritin, coag profile, TSH)
- If Ix suggest gynae cause, perform US
- Treat underlying cause
** Refer to page 182 of GP Study Notes
Menorrhagia - investigations and indications for referral
Investigations
● CST (if due)
● Transvaginal ultrasound to assess endometrial thickness (day 5-10 of menstrual cycle)
● Specialist investigations: saline-infused sonography, hysteroscopy, endometrial biopsy
Indications for specialist referral General ● Has not resolved after 6 months Early referral ● Severe dysmenorrhoea ● Dysmenorrhoea that does not respond to medications after 3 months ● Patients that wish to conceive ● Fibroids > 3 cm ● Endometrial polyps ● Risk of endometrial cancer
Menorrhagia - medications
Hormonal
Mirena - 52mg in uterus, replace 5 yearly
● Possible irregular bleeding in first few months
Combined OCP
● Prolonged or continuous use can minimise withdrawal bleeding
Oral progesterone
● Not recommended
● Can be used for short-term
● Regular cycles: Need to be given 21 out of 28 days of the menstrual cycle
● Irregular cycles: Take for 12 days at the same time each calendar month
Depot - medroxyprogesterone 150mg IM every 12 weeks
Non-hormonal
Tranexemic acid - 1 to 1.5g 6-8 hourly for first 3-5 days of each cycle
● More effective than NSAIDs
NSAIDs - naproxen 500 mg initially, then 250mg every 6-8 hours
Hormonal replacement therapy - key points, factors to consider
Key points
● Starting systemic HRT contraindicated in >60 yrs (but can be continued if started earlier)
● Individuals with increased risk of VTE can use transdermal but not oral
● All individuals with migraine have an increased risk of stroke - transdermal is preferred
Factors to consider: presence of uterus, individual preferences and tolerance.
Hormonal replacement therapy - medical options and regimes
Options:
Oestrogen
- Forms: oral, patch, implant, infection, topical.
- Goal: prescribe the lowest dose possible to relieve symptoms.
Progesterone
- Must be used with oestrogen if the woman has a uterus.
- Can be given continuously or cyclical.
- Avoid continuous use in perimenopausal women because of heavy irregular bleed.
Testosterone (50mg implant
3-12 monthly)
- Reserved for patients whose libido does not improve with HRT.
- Should be given concurrently with oestrogen.
Tibolone (2.5mg PO daily)
- Unsuitable for perimenopausal women.
- Should be considered for women who are surgically postmenopausal or who have had not a natural menstrual bleed for at least 12 months.
- May improve libido.
- Not associated with increased risk of VTE.
Regimes
** Refer to page 185 of GP Study Notes
Hormonal replacement therapy - contraindications, benefits vs. harms
Contraindications
- Oestrogen-dependent tumour
- Recurrent thromboembolism
- Uncontrolled hypertension
- Undiagnosed vaginal bleeding
- Active SLE
- Pregnancy
- Otosclerosis
Benefits Reduces risk of: ● Fractures ● Diabetes ● Colorectal cancer ● Vasomotor symptoms
Harms Increases risk of: ● Breast cancer ● Stroke ● VTE ● Gallbladder issues ● Demential ● Urinary incontinence ● CHD
Menopause - non-hormonal options
Non-hormonal options for vasomotor symptoms: ● SSRI: Paroxetine 10mg PO daily ● SNRI: Venlafaxine 37.5mg daily ● Gabapentin 100-300mg PO nocte ● Clonidine 25 microg BD
Hyperthyroidism in pregnancy
Key points:
● Low or suppressed TSH during first trimester not usually cause for concern
● Self-limiting as hCG concentration declines (TSH receptor hypersensitive to hCG)
● Graves disease = +ve TSH-receptor antibody +/- thyroid peroxidase antibody or thyroglobulin
