Women's Health Flashcards
What is the most common cause of breast lump in women age 30-50?
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
How are breast cysts investigated and managed?
- 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)
What benign lumps can affect the breast?
- Fibrocystic changes: smooth and mobile lumps, tender, cyclical, 30-50
- Alcohol, MHT, OCP, pre-MP - Fibroedenoma: younger, preg, feeding, HRT (hormone related). 15-40. Most shrink. Surg if large/pain
- Breast cysts
- Sebaceous cysts
- Lipoma: soft, non-tender, mobile, can be slow-growing
- Fat necrosis: due to trauma (injury, surgery, RT, bld thinners), can look like ca on scan. Can get cysts within. Usually self-resolves
Describe physiological discharge?
- 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
What is standard vulvovaginal hygeine advice?
- 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)
What is BV? How is it managed?
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
What is VV candiasis? How is it managed? What are the options for recurrent candidiasis?
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
Causes of vulval itch?
- Candidiasis
- Dermatitis
- Lichen sclerosus
- Lice, worms, scabies
- Warts
- Atrophic vulvovaginitis
- Psoriasis
Who does lichen sclerosus effect? How is it investigated and managed?
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
What are bartholins cysts? how are abscesses managed?
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
Who does VIN affect?
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
How is vulvodynia managed?
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
Vulvovaginitis in young girls?
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
What are the management options for pre-menstrual symptoms?
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
How is GORD managed during pregnancy?
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
What types of ovarian cancer are there?
- Epithelial 90%
- Sex cord-stromal
- Malignant germ cell (<40, 20s most common)
What are the risk factors for ovarian cancer?
- Lifetime number of cycles
- early menarche, late MP, no preg
- OCP, preg, early MP protective - FH (BRCA, lynch)
- Pacific
- Obesity, Cigarettes
- Endometriosis / PCOS/ PID may
- MHT if >5years
Note more common than cervical but less than endometrial
Highest mortality of gynae cancers as detected late
What are the symptoms and signs of ovarian cancer?
How is it investigated and treated?
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
What do you need to ask for AUB?
- Pregnancy?
- N frequency, duration, flow
- Timing, character of bleeding
- IMB, PCB, PMB
- pain/sex, d/c, itch, rash, fever
- Products, CP, thinners, OTC meds
- Sexual health
- BG: obs, surgical
What are the expected mensturation cycle times?
Freq:
<23d
n 24-38
>38d
Duration
n <9
Long >8
Regularity (short-longest)
reg 1 week
Flow subjective
What do look for on exam with AUB?
- Obs
- Abdo exam: mass
- Pelvic and bimanual IF not obvious e.g. younger on CP
- Thyroid, acne, alopecia, acantho, galactorrhoea, petechiae
How is heavy menstrual bleeding defined?
- Defined by patient
- change products 1-2 hours
- using 2 types sani products
- involves clothes or bedding
- clots
How is HMB classed? How is it investigated?
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)
What are the risk factors for endometrial cancer?
- Age >45
- Age >35 +
- BMI, DM, HTN, Oes only
- Nulliparity, infertility, PCOS
- MAPAS
- FH endometrial, CRC, renal ca
- Tamoxifen
What are the treatment options for HMB?
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
What are common causes of IMB/Unscheduled bleeding? How is it investigated?
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
How are primary amenorrhoea and secondary amenorrhoea defined?
How are they managed?
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)
How is PCB defined? What causes it? How is it investigated?
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
How is PMB defined? How is it investigated? Managed?
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
What symptoms are there with the menopause?
Vasomotor: flushing, sweats
Vaginal: dryness, bleeding
Mood and sleep
Muscle and jount pains
Bone loss (<oes)
How can MHT be prescribed?
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
What are the options for starting MHT?
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
What other options are there for menopause symptoms other than MHT?
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
What are the complications of PCOS? How is it diagnosed?
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
What investigations should be requested for PCOS diagnosis and then subsequently?
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
How is PCOS managed?
- Weight (if high BMI)
- even 5% will help cycle - Androgenism
- Acne, hair removal
- COCP a/o spironalactone - Cycle regulation
- Weight loss, COCP
- Metformin - Specialist referral for fertility
What skin conditions are associated with pregnancy?
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
What are the risk factors for breast cancer?
- Weight, alcohol
- MHT, OCP
- Nulliparous, early start / late MP
- Dense breasts
What are the different types of miscarriage and their features?
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
How long does it take to make sperm?
74-78 days
- hence why repeat sperm sample in a couple of months if abnormal
Causes of impotence?
Antihypertensives
- Thiazides then bb’s
- ACE are best
Hypogonadism
Vascular disease
Anxiety
Diabetes mellitus
Cigarette smoking
What is the supressive dose of fluconazole for Candida?
Fluconazole 150mg weekly for 6 months
What is the supressive dose of valciclovir for genital herpes?
Valaciclovir 500mg orally, daily for 12 months
When is HIV untransmissible?
After maintaining an undetectable viral load for 6 months
How can you change contraceptive pills if issues?
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
What are the missed pill rules?
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
What is standard pre-conception advice?
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
Vulvovaginal health
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
Prolapse management
- Estriol cream
- Pelvic floor PT
- Pessary -> refer for fitting
- Surgery
Refer:
- failed 6m conservative
- outside hymen
- associated with incontinence, incomplete voiding or recurrent UTIs
Vulval dermatitis
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
Lichen simplex
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
Lichen Sclerosus
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
Lichen Planus
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
VIN
W: most post-men
- 90% SCC
Sx: asymmetrical, papules, erosions, plaques.
Mx: Refer
Sexual health post-menopause
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
BRCA
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)
When are hormone tests due in fertility investigation?
FSH and oestradiol on day 2-4 of cycle, progesterone 6-8 days before menses
Sexual harm disclosure
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.
Ovarian cyst
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
Pregnancy UTI
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
