Women's Health

Question 1

What is the most common cause of breast lump in women age 30-50?

Answer 1

Fibrocystic change
- Overreaction to hormone changes
- Smooth and mobile lumps
- Fluctuate in size with cycle
- Tenderness/aching (out + upper)
- Spontaneous green/brown d/c
- NO increased cancer risk
Mx
- Nil if mild. Mod analgesia, bra. Severe may need aspiration

Question 2

How are breast cysts investigated and managed?

Answer 2

• Can have single or multiple
• More common with age but prior to menopause (oestrogen related)
  IX: USS +/- biopsy if USS doubt
  MX: mild = nil, severe = drainedm (may refill and return)

Question 3

What benign lumps can affect the breast?

Answer 3

1. Fibrocystic changes: smooth and mobile lumps, tender, cyclical, 30-50
   - Alcohol, MHT, OCP, pre-MP
2. Fibroedenoma: younger, preg, feeding, HRT (hormone related). 15-40. Most shrink. Surg if large/pain
3. Breast cysts
4. Sebaceous cysts
5. Lipoma: soft, non-tender, mobile, can be slow-growing
6. Fat necrosis: due to trauma (injury, surgery, RT, bld thinners), can look like ca on scan. Can get cysts within. Usually self-resolves

Question 4

Describe physiological discharge?

Answer 4

• From endocervical cells, sloughed epithelial cells, products of n flora
• white, clear, min odour, 1-4ml/day
• > near ovulation, thicker after
• n pH 3.8-4.4 (lactobacilli)
• > alkaline in young and post-MP, menstruation, sex, meds, stress

Question 5

What is standard vulvovaginal hygeine advice?

Answer 5

• Avoid soaps, gels, shampoos etc
• Wash gently with tepid water
• Non-soap cleansers pH 5.5 ok
• Douching not recommended (alters pH, flushes bacteria up, >risk: PID, BV, ectopic, STI, HSV, HIV)

Question 6

What is BV? How is it managed?

Answer 6

W:
- Anaerobic replacement, pH >4
- ASSOCIATED with sexual activity, abx use, douching, IUD/S

Cx: misscarraige, PROM, STI, post-op infection

Sx: grey, watery, fishy d/c, >after sex
- Also: itch, irritation, pain

Ix: speculum/swab if not clear Dx
- ?STI ?Other Dx ?preg/TOP/miss, bleeding, pain, fever, persisting sx

Mx: 30% self-resolves
- Empiric: Sx, low STI risk, not preg
- No Sx (50%): treat if preg, pre-TOP
- Sx: Metronidazole 400mg BD 7/7 OR 2G STAT (>compliance, <effect)

Preg/breast: 7d only, re-test after 1mth

Persisting: ?Dx, course, STAT -> 7d, ?removed IUD
Recurrent: high -> swab

Question 7

What is VV candiasis? How is it managed? What are the options for recurrent candidiasis?

Answer 7

W:
- Found in 20-40% healthy women
- Risk: Abx, preg, DM, <immune, NOT clothing or vaginal habits

Sx: itch, stinging, burning, dysuria (Ext), dyspareunia. Cheesy/white d/c
Ex: erythema, swelling, fissuring

Mx:
- Empiric if classical Sx, no STI risks
- Clotrimazole 2% 3/7, 1% 6/7
CREAMS CAN WEAKEN CONDOMS
- Fluconazole 150mg STAT (quciker)

Recurrent: 4/year, try 10-14 days treatment OR 150mg monthly 6m

Question 8

Causes of vulval itch?

Answer 8

• Candidiasis
• Dermatitis
• Lichen sclerosus
• Lice, worms, scabies
• Warts
• Atrophic vulvovaginitis
• Psoriasis

Question 9

Who does lichen sclerosus effect? How is it investigated and managed?

Answer 9

W: AI origin, mostly >50
SX: severe itch and pain
EX: white, thickened skin, fissures
IX: biopsy if uncertain
MX: Refer derm for confirmation/FU
- potent steroid to reduce symptom
- reduce potency as improves
CX: increased risk of VIN and SCC

Lichen planus more rare. Similar Sx. Typically an erosive form. Difficult to control and may require PO Rx -> refer to derm. Also ca risk

Question 10

What are bartholins cysts? how are abscesses managed?

Answer 10

W: glands produce mucous
Sx: lump 1-3cm size, no sx
- Larger cysts cause discomfort
- Develop abscess if infected
Mx
- Warm compress, saline baths
- I&D under LA or excision
- Abx (broad) if systemic symptoms

Question 11

Who does VIN affect?

Answer 11

W: post-MP, >30-40, 90% SCC
- Can also be BCC, melanoma
- Risks: lichen, HPV, HIV
SX: can be asymptomatic, itch, lump, pain, ulcer, bleeding
EX: inner edges of labia most common

Question 12

How is vulvodynia managed?

Answer 12

W:
- Vulvodynia, pain at introitus, burning, triggered by contact
- Constant more likely to be neuro
MX
- HX and EX
- Treat any cause (infection, lesions)
- Refer to specialist. Pelvic floor PT
- Topical gels at night and for sex
- TCA, gabapentin

Question 13

Vulvovaginitis in young girls?

Answer 13

W:
- low eos, higher pH, thin/flat labia (reduced barrier), close anus
- Think r/e worms (night itch), abuse, lichen sclerosus, trauma
Sx:
- Itch, erythema, d/c, bleeding
Hx:
- Sx, toileting, hygeine, meds, SH
- MOST = local irritants -> dermatitis

Question 14

What are the management options for pre-menstrual symptoms?

Answer 14

W:
- Symptoms + impact + cyclical (not just exacerbate pre-existing issue) + 2 succesive cycles
- Severe symptoms 3-8% cases
- Mood, behavioural, somatic Sx
- 2d to 2w, worst 2d before period

Risks: trauma, cigs, obesity

IX: PSST questionnaire

Mx:
- Non-Rx: exercise, intake complex carbs (slow burning -> Seretonin), stress management, calcium, vit B6
- SSRI mid-cycle to menses
- Benzo if severe anxiety, insomnia
- Hormonal: COCP with <androgen

Question 15

How is GORD managed during pregnancy?

Answer 15

W: 30-50%, start end 1st trim
- inverse to maternal age, >twin
Mx:
- lifestyle, dietary change
- then antacid
- then PPI if affecting QOL
- Can also be taken in breastfeeding
Px:
- Resolves after birth

Question 16

What types of ovarian cancer are there?

Answer 16

1. Epithelial 90%
2. Sex cord-stromal
3. Malignant germ cell (<40, 20s most common)

Question 17

What are the risk factors for ovarian cancer?

Answer 17

1. Lifetime number of cycles
   - early menarche, late MP, no preg
   - OCP, preg, early MP protective
2. FH (BRCA, lynch)
3. Pacific
4. Obesity, Cigarettes
5. Endometriosis / PCOS/ PID may
6. MHT if >5years

Note more common than cervical but less than endometrial
Highest mortality of gynae cancers as detected late

Question 18

What are the symptoms and signs of ovarian cancer?
How is it investigated and treated?

Answer 18

SX: 90-95% will have symptoms
- 3-5 visits before diagnostic tests
- Pain, bloating, anorexia, satiety, PU

EX:
- abdo exam (mass, ascites)
- bimanual for adnexal mass

IX:
N exam -> ca125
- <35: W&W
- 35-200: rpt 6w OR scan if post-MP, falling then ok, up/same -> scan
- >200: pelvic USS -> gynae if ABN
ABN exam -> both -> refer either AB

MX
- BRCA: surgery after childbearing, ideally between 35-40. prevent 90%
Refer with. Hysterectomy if lynch or if wish to have oes only MHT

Meigs: benign ovarian mass with ascites and pleural effusion

Question 19

What do you need to ask for AUB?

Answer 19

1. Pregnancy?
2. N frequency, duration, flow
3. Timing, character of bleeding
4. IMB, PCB, PMB
5. • pain/sex, d/c, itch, rash, fever
6. Products, CP, thinners, OTC meds
7. Sexual health
8. BG: obs, surgical

Question 20

What are the expected mensturation cycle times?

Answer 20

Freq:
<23d
n 24-38
>38d

Duration
n <9
Long >8

Regularity (short-longest)
reg 1 week

Flow subjective

Question 21

What do look for on exam with AUB?

Answer 21

1. Obs
2. Abdo exam: mass
3. Pelvic and bimanual IF not obvious e.g. younger on CP
4. Thyroid, acne, alopecia, acantho, galactorrhoea, petechiae

Question 22

How is heavy menstrual bleeding defined?

Answer 22

• Defined by patient
• change products 1-2 hours
• using 2 types sani products
• involves clothes or bedding
• clots

Question 23

How is HMB classed? How is it investigated?

Answer 23

Structural:
- Fibroids
- Polyps
- Adenomyosis
- Endometrial hplasia, ca

Others:
- Iatrogenic: CP, tamoxifen, MHT, Rx
- Dysfunction: stress, kg, ET, PCOS
- Coag issues: vWBD

IX:
- HCG
- CBC +/- ferritin
- TSH if symptoms
- Coag if concern
- Pipelle if ca expected
- USS if structural expected (AGE)

Question 24

What are the risk factors for endometrial cancer?

Answer 24

1. Age >45
2. Age >35 +
   - BMI, DM, HTN, Oes only
   - Nulliparity, infertility, PCOS
   - MAPAS
   - FH endometrial, CRC, renal ca
   - Tamoxifen

Question 25

What are the treatment options for HMB?

Answer 25

Hormonal
- 1st if need LARC: 60% get less
- COCP cont if want preg / No CIx
- Depot/POP but can be erratic
- Cyclical prog d5-25, less good, double dose if spotting (>SEs)

Non-hormonal
- 1g TDS TDS 1-4d @ start bleeding. NOT with OCP as >VTE risk
- Mefanamic 500mg TDS 3-4d

Question 26

What are common causes of IMB/Unscheduled bleeding? How is it investigated?

Answer 26

W: between or breakthrough outside of withdrawal bleed for MHT/CP. Random OR cylic.
- Ovulation
- STI
- Polyps, hyperplasia, malignancy

IX
- Pregnancy test
- STI test
- Smear (>6-12 months ago)
- Pelvic USS if persists or abn exam
-> gynae if abnormal results

Unscheduled
- COC: increase eos, or change prog
- If cont COC >3d, pause for 4d
- Prog bleeding may not settle

Question 27

How are primary amenorrhoea and secondary amenorrhoea defined?
How are they managed?

Answer 27

Primary
- No development by 13
- No menses by 5y after breasts
- No menses by 15

Most common: constitutional delay if no secondary characteristics
Also think r/e anorexia, else W&W

Infrequent is common just after menarche and peri-MP

Secondary:
- Cessation >3m if regular (preferred definition) inc if after coming of COCP
- Cessation >6m if irregular
Oligomenorrhoea = <9 cycles per year

Most common is pregnancy.
Also: anovulatory cycles, PCOS, functional (>ET, anorexia, stress, Rx, Thyroid, >PRL)
All of above apart from PCOS will have low oestradiol = <bone health, fractures, pains

Primary ovarian insufficiency
- <40, irregular, MP symptoms

Hx:
- menstural: age of start, cycle like, contaception, G+P
- eating regularly, excercise, nutrition, sleep, shift work
- stress levels, mental health

Ex:
- Obs + BP
- PCOS features, weight
- Thyroid features

Ix:
- bHCG, consider mechanical, control centre vs ovaries
- FSH/LH < then hypothalamus even if lowN, > then ovarian e.g. primary ovarian insufficiency
- check PRL if FSH/LH low. If low -> TSH. If both normal then likely functional (stress etc)
- Normal with LH touch high e.g. PCOS. Check testosterone.
FLAGS: raised FSH recheck 4w (POI), PRL >1000
- PCOS + amenorrhoea => do USS ?endometrial thickness as >ca risk. INDUCE W/D BLEED

Mx:
- lifestyle
- PCOS - w/d bleed e.g. COCP if want contraception
- FHA - bone health e.g. fractures, dexa. Might consider HRT (better than ocp for bone)

Question 28

How is PCB defined? What causes it? How is it investigated?

Answer 28

W: bleeding in 24hrs after sex
C:
- STI
- ectropion/polyps
- atrophic vaginitis
- cancers
- trauma

IX:
- HCG
- STI test
- Smear if >6-12m
- USS if exam abn

Mx:
- Single ep + n Ex/smear -> W&W
- Post-MP: top eos, lube, emollient
- Colposcopy if persists/abn Ix

Question 29

How is PMB defined? How is it investigated? Managed?

Answer 29

W: after 12m of amenorrhoea
- RED FLAG for endometrial ca

Ix:
- Smear if >6-12m ago
- STI if risk
- Pipelle, USS
- Hysteroscopy if tamoxifen

ALL not on MHT recently -> USS
+ hysteroscopy if on tamoxifen

Question 30

What symptoms are there with the menopause?

Answer 30

Vasomotor: flushing, sweats
Vaginal: dryness, bleeding
Mood and sleep
Muscle and jount pains
Bone loss (<oes)

Question 31

How can MHT be prescribed?

Answer 31

Start within 10 years of menopause

CI:
- unexplained bleeds, breast/endom ca,
- CHD, CVA, BG/FH VTE, dementia

Continuous IF >12m since last period
Cyclical: transition <12m / still bleeding
- reduces breakthrough bleeding
- common in 1st 6m
- After 6m should be IX for ?Ca
- prog 10-14d each month (bleed)

Before:
- Hx + Ex, check screening
- Ix unexplained vaginal bleeding

Risks
- VTE
- Small >breast ca (higher if prog/ longer use)
- CVD neutral, stroke higher if risks

Benefits:
- most effective Rx for vasomotor
- reduces vaginal dryness
- reduces risk of fractures

Topical: if <absorb, VTE, migraine, CVD/LD, obese, high lipids, T2DM

SE’s
- Prg: mood, bloat, head/breast pain

No limit to duration unless SEs/CIs

Question 32

What are the options for starting MHT?

Answer 32

Oestrogen
- 25mcg estradot patch 2x/week (funded)
- 1mg Progynova (funded), estrofem can be devided to 500mcg but partly funded

Progestogen
- Oral for 14d or continuously
- IUS, good if need contraception

Stopping contraception
- IF periods
>55 or >1yr over 50, >2 year under 50
- If IUS/implant/pill
>55 or >50 if FSH >30 then stop 1yr later

Combos partly funded

Persistent symptoms -> increase dose/switch
Breast tender -> <oes, change prog, tibolone
Bleeding <3m -> W&W, cyclical, >prog, to IUD
Bleeding >6m -> Ix for endom ca

Question 33

What other options are there for menopause symptoms other than MHT?

Answer 33

Lifestyle change:
- avoid triggers, no smoking, <kg, ET
- CBT, mindfullness, hypnosis

Cream:
- Vaginal: replens (moisture) - not funded -> 0.1% estriol cream or pessary - funded

Pharma:
- SSRI, clonidine, gabas, oxybutynin

Question 34

What are the complications of PCOS? How is it diagnosed?

Answer 34

W:
- most common endo young F
- 5-10%, often not diagnosed

Cx: INSULIN RESISTANCE
- IGT, metabolic, HTN, lipid, CVD
- OSA independent of BMI
- Fertility problems
- Endometrial hyperplasia -> Ca

Dx: 2/3:
- oligo/anov
- clinical/IX androgenism
- USS folicles

Question 35

What investigations should be requested for PCOS diagnosis and then subsequently?

Answer 35

Initial:
- PT (most common cause x period)
- Pelvic USS (if x make clinical dx)
- Testosterone (further Ix if v high)

After diagnosis:
- HbA1, fast bsl >5.5, random >7.7
- Lipids, fasting for high TGL
- >LH/nFSH = high ratio

If suspicion:
- PRL if x periods, galactorrhoea
- TSH if other thyroid symptoms
- Oes + FSH if <40 and MP signs
- 24hr cortisol: striae, moon face

Question 36

How is PCOS managed?

Answer 36

1. Weight (if high BMI)
   - even 5% will help cycle
2. Androgenism
   - Acne, hair removal
   - COCP a/o spironalactone
3. Cycle regulation
   - Weight loss, COCP
   - Metformin
4. Specialist referral for fertility

Question 37

What skin conditions are associated with pregnancy?

Answer 37

Linea nigra
- increase in pigmentation, 90%
- first trimester
- mostly fades after delivery

Striae

Melasma
- second half, 70%, >darker skin
- usually fades, UV protection

Melanocytic naevus
- May change -> Ix if ?ca

Spider naevi: disappear after
Palmar erythema: 70% >light skin
Pyogenic granuloma: 5%

PUPPP/polymorphic eruption
- 3rd trim, 1/150 pregs, >in 1st preg
- Stretching -> immune response
- usually resolves 4-6 weeks
- emolient, top steroid, po severe, hist

Question 38

What are the risk factors for breast cancer?

Answer 38

• Weight, alcohol
• MHT, OCP
• Nulliparous, early start / late MP
• Dense breasts

Question 39

What are the different types of miscarriage and their features?

Answer 39

Threatened
- Minimal pain
- Light bleeding
- Cervix closed
- Uterus = dates, FH ok

Inevitable
- Pain ++
- Heavy bleeding
- Cervix open
- Uterus = dates, FH x/ok

Complete
- No pain
- Light bleeding
- Cervix closing
- Uterus = dates, FH empty

Incomplete
- Pain minimal or +
- Heavy bleeding
- Cervix open
- Uterus = </dates, x FH/retained

Missed
- No pain
- Minimal bleeding
- Cervix closed, uterus small, no FH

Question 40

How long does it take to make sperm?

Answer 40

74-78 days
- hence why repeat sperm sample in a couple of months if abnormal

Question 41

Causes of impotence?

Answer 41

Antihypertensives
- Thiazides then bb’s
- ACE are best
Hypogonadism
Vascular disease
Anxiety
Diabetes mellitus
Cigarette smoking

Question 42

What is the supressive dose of fluconazole for Candida?

Answer 42

Fluconazole 150mg weekly for 6 months

Question 43

What is the supressive dose of valciclovir for genital herpes?

Answer 43

Valaciclovir 500mg orally, daily for 12 months

Question 44

When is HIV untransmissible?

Answer 44

After maintaining an undetectable viral load for 6 months

Question 45

How can you change contraceptive pills if issues?

Answer 45

POP and COCP = affective
- <0.3% preg if use properly
- 9% chance with typical use

Start: <35 eos + lev/noreth
- COCP preferred as less strict with times
- non-con: cyproterone >VTE

VTE risk highest in first few months. W/o other risks, risk is 7-10/10,000 per year. Preg is 20-30.

COCP, X if:
- Current/Hx VTE, clotting dx
- Major surgery, >35 + >15 cigs /day
- If surgery, stop 4 week prior, restart 2 weeks after
- other risks for stroke/MI: IHD, AF, CHF, uncontrolled HTN, DM + vasc, multiple risks, migraine + aura OR new during use of COCP
- Current breast Ca/cervical
- >50 as risks > benefits

COCP, Cautioned if”
- VTE 1st deg <45
- Obese >35
- Age >35 + <15 cigs per day

Travel >3hrs: mobilise, stockings if other risks. >4500m for >1wk -> SWITCH

Post-partum
- 3w if not breastfeeding
- 6w if breastfeeding

Starting:
- 1st 5 days: no condom
- >5d: 7day
- pregnancy test 21d after
- no health benefits to pill free week. Only extra risk is breakthrough bleed - < over time. If happens, stop 4d then resume

Issues:
- Acne: >oes, deso / cypro
- Bloat: <oes, drospirenone
- Bleed: >oes, levon/deso
- Breast: <oes, levon
- Headache: <oes, levon
- Nausea: <oes -> POP

• Mood: reported but <proof
• Weight: no proof

POP
- CI: unexplained bleeding, liver disease, breast ca
- Caution: IHD/stroke
- Take within 3 HOURS
- SE: bleeding, MAY settle

Question 46

What are the missed pill rules?

Answer 46

COCP:
1: take when remember
>1: 1x when remember, condoms until 7x pills taken. Week 1 or during pill free week: ECP. Week 3: omit gap

POP
- >1, 48hr condom. If unprotected sex within 48hr missed pill -> ECP

Vomiting
<2hrs post taking pill - take another. If POP >3hrs after intended dose then condom 48hrs

Question 47

What is standard pre-conception advice?

Answer 47

KP
- 50% pregnancies x planned
- Fertility reduces after 35y
- Risks increase after 40y

First
- regular sex throughout cycle
- optimal: 5d before ov + 1 after
- start folic acid 4w b4 until 12/40
- check immunity rubella/varicella
- UTD smear and STI check
- Check LTR meds
- Smoking, alcohol, drugs, nutrition
- X soft cheese, raw, unwashed, deli

?Ref: >12m if <35, >6m if >35
- 85% 1st year. Extra 50% next 36m
- 1-2 days during fertile phase
- Ov is 14d before next period so sex end of period, until 10d b4 next

Folate:
- 5mg if: Hx neural tube, FH of, anti-epileptic, diabetes, obese

Iodine:
- From pregnancy onwards
Iron:
- Need adequate stores b4. Supplement before 1st trimester

Smoking:
- Risks: abrupt, miscarry, prem, SGA
- Associated w CVD, T2DM, obesity
- NRT much smaller risk to baby
- NOT bupropion / champix

Weight: optimum 20-25
- BMI >35 = 2x time to conceive
- BMI >27 - GDM, HTN, >labour, LGA
LGA -> shoulder dystocia

Exercise: >7hr strenuous <fertility

Men:
- Sperm takes 74-78d so cx take 3m
- BMI <39, ETOH <2SD/d, x drugs
- Meds: CCB, steroids, sulphasal
- Avoid >temp of testes (limited)
- Best 2-3d between ejaculation
- Menevit benefit in trial 4 <fertile

Question 48

Vulvovaginal health

Answer 48

pelvic floor muscles are oestrogen -dependent. Reduced vasculaity, secretions. More basic pH. Progressive atophy.
-> prolapse, incontinence, UTI, BV, C
-> Increased STI risk

Only 20-25% will seek help from GP
-> embarassed, think n, unaware

Mx:
- oestriol cream 0.1% / 500mcg pess
- nocte until better (2-3w) then 2/wk
SE: stinging, burning, usually 2wk
+/- Replens (not funded) / lubricant

Refer:
- ?Ca
- Failed to respont to treatment

Question 49

Prolapse management

Answer 49

1. Estriol cream
2. Pelvic floor PT
3. Pessary -> refer for fitting
4. Surgery

Refer:
- failed 6m conservative
- outside hymen
- associated with incontinence, incomplete voiding or recurrent UTIs

Question 50

Vulval dermatitis

Answer 50

W: most likely to be contact dermatitis e.g. soap, fragrance, over-washing, urine. X atopic.

If chronic can develop lichen simplex

Mx:
- remove irritant
- emolient, topical hydrocortisone
- sedating antihist nocte / TCA

Strategies:
- Cut nails short, gloves nocte
- Luke warm baths
- White, unscented TP
- NO wet wipes
- Treat urine incontinence
- Specific pads, rinse with water
- Petrolleum jelly for barrier
- Naked at night unless need pads

Question 51

Lichen simplex

Answer 51

W: excessive scratching/rubbing of area with underlying condition
- HAIR-BEARING SKIN

Sx: thickened, itchy +++, nocte/heat
- also: lower legs, arms, wrists, neck

Mx:
- emolient, cold pack
- sedating antihist/TCA to x cycle
- potent steroid, reducing potency over 4-6 weeks. Ultra only if biopsy
- refer to derm if not working

Question 52

Lichen Sclerosus

Answer 52

W: AI, inflammatory, >50 mostly
- 20% other AI disease
- HAIRLESS SKIN

Sx: asymptomatic or itch
-> can get adhesions, fissures

Mx
-> refer for biopsy
- Associated with VIN/scc 5%
- Review skin anually
- Potent/ultrapotent steroid + eostrogen cream
- Dilators if narrowing

Question 53

Lichen Planus

Answer 53

W: similar to LS but less common
- More likely to affect other areas
- 30-60 mostly

Sx: itch, pain
- Cutaneous: purple papules in hear-bearing areas
- Mucosal: painless, itchy, white
- Erosive: marked redness with white broder -> scarring, pain ++ and BLOODY DISCHARGE

Mx: refer, ca risk also
- Similar treatment but may need immuno meds + PO steroids

Question 54

VIN

Answer 54

W: most post-men
- 90% SCC

Sx: asymmetrical, papules, erosions, plaques.

Mx: Refer

Question 55

Sexual health post-menopause

Answer 55

Are you sexually active?

Do you have any questions or problems with sex that you would like to discuss?

Libido: medicines, ?MH, counselling

Discomfort/dry: lube, topical eos

Pain: Ix/Mx, lube, eos, floor exercise

Incont: Mx factors, pads, excercises,

Lack of privacy, e.g. in a residential care setting; encourage discussion with carers

Self-esteem issues; encourage discussion and coping strategies, offer referral for counselling

Relationship issues, e.g. new partner, pressure to have sex; encourage discussion, consider referral for counselling

Inadequate knowledge about STIs; educate about STIs, testing, appropriate protection and possible symptoms

Question 56

BRCA

Answer 56

Breast
- Begin screening from 25-30
<40: MRI
>40: MRI + Mam OR USS + Mam
- Pre-men: tamoxifen, post-men: that or raloxifene or aromatase inhibitors
- BL mastectomy, timing based on scoring

Ovarian/uterine: NOT uss/Ca125
- BRCA1: 35-40 for surgical SO
- BRCA2: 30-45
Only + hysterectomy if wish to use oes only MHT to minimise breast ca risk

Pancreas only if history in family (1 or 2nd deg)

Question 57

When are hormone tests due in fertility investigation?

Answer 57

FSH and oestradiol on day 2-4 of cycle, progesterone 6-8 days before menses

Question 58

Sexual harm disclosure

Answer 58

W: uncommon without being probed. 94% don’t go to Police.
- 1/4 females. 1/6 - 1/12 men
- Mapas/deprived, young women, LGBT, drugs/alcohol, CSW

HX:
1. Confidential UNLESS… I would always let you know
2. Ensure have time… may need to delay other consults
3. I can see that you look distressed… do you feel able to tell me what happened? -> closed or short replies -> probe
- Thank you for telling me this - very brave of you. I’m really sorry this has happened to you. BELIEVE IT.
- Whatever happens is going to be your choice, I will talk through options but it will be your decision.
- Is this person known to you? Are you safe to go home? threatened with violence?
4. Routinely ask, enquire. May still NOT get disclosure. NOT if someone else in room, including child >2
- we ask all patients as part of a sexual history….
- have you had any encounters where you felt unsafe or where consent hasn’t seemed clear
- consent: w/d any time, can change, not if asleep/unconcious/unwell/alcohol/drugs/intellectual impairment/misled

Outcomes:
- Immediate: injury (30% in SI), strangulation, pregnancy (eMCP), STI, mental health especially if previous Hx
- Safety: Who? waiting room, safe to leave
- Long-term: relationships, pelvic pain/migraine/IBS, resistant depression, PTSD

Referrals:
- Support and listen. Refer ALL to sexual assault.
- Any time frame for advice.
- Within 7-10d forensic. Have support there. Advise can take support person. Doesn’t mean need to involve police etc. Haven’t decided or wants police - avoid exam, e+d, pu, take clothes in paper bag. Can hold for 6 months to decide.
- Nearly everybody wants referral. Offer phone call at least if don’t want to be seen. Take time to make decision as initial shock.
- At pohutukawa: There for a few hours. brief history, doctor, nurse, specific questions about body, talked through examination, provide new clothes and have shower if needed. May take blood and samples from nails and hair. Genital exam for injury/samples. Only will do exam feel comfortable with. Then support worker. They will then FU 1-2w, 2-3m.
- FU after at GP: 1-2w, FREE with ff.
- ACC can be done later, sensitive claims. If physical injury then easier as long as happy to be documented on ACC45. Specialised counsellors can do rest. Don’t need to fill in before person sees trauma-focused counsellor.

Question 59

Ovarian cyst

Answer 59

Pre-men:

Simple
<5cm - no FU
5-7cm - USS/yr, FU if 3x
>7cm: non-acute gynae

Complex:
- Gynae if unclear dx
- dermoid: ok <5cm / x Sx
- endometrioma: FU USS 3m ?haemorrhagic cyst

Post-MP:
- <5cm refer if persists
- BL/Sx/Ca125 -> refer
- >5cm -> advice

Question 60

Pregnancy UTI

Answer 60

Test of cure 1w after completing abx and repeat MONTHLY until pregnancy completed

May need supressive treatment. Amox or cef best. No TMP 1st trim. No nitro after 36w