Women's health - Investigations and treatment Flashcards
(28 cards)
What do you give for urge incontinence?
Oxybutynin
Vaginal fistula
Investigations
Treatment
Investigations
- FBC, urinalysis - checking for infection
- Imaging - CT urogram, cystoscopy
Tx
- Antibiotics for infections
- Temporary catheterisation while the fistula heals
- SURGERY IS USUALLY REQUIRED to close the opening of the fistula
Postmenopausal bleeding
Investigations
Treatment
Dx
- >55 YEARS SHOULD UNDERGO （transvaginal) ULTRASOUND FOR ENDOMETRIAL CANCER WITHIN 2 WEEKS. - Endometrial lining thickness <5mm is acceptable (if >5mm, endometrial biopsy and hysteroscopy)
Tx
Once cancer has been ruled out.
1) Vaginal atrophy –> Topical oestrogen and lifestyle changes e.g. lubrication, HRT can be used also
2) HRT –> use a different HRT
3) Endometrial hyperplasia –> dilation and curettage to remove excess endometrial tissue
Menopause symptom management (treatment)
Symptoms typically last 7 years but may resolve quicker.
3 ways:
1) Lifestyle modifications
- Regular exercise
- Weight loss
- Maintain good sleep hygiene
2) Management with HRT
(however there are certain risks: VTE, stroke, CHD, breast cancer and ovarian cancer)
- CI in oestrogen sensitive cancer (breast, ovarian, uterine)
3) Management with non-HRT
Vasomotor sx: venlafaxine, fluoxetine
Vaginal dryness
- Vaginal lubricant
Psychological sc
- Self help groups, CBT
Vaginal atrophy - topical oestrogen
(bisphosphonate for osteoporosis)
Adenomyosis
Investigation
Treatment
Investigation
First line - Transvaginal ultrasound
(MRI alternative)
Tx
For symptoms
- Levonorgestrel IUD (reduce menorrhagia and dysmenorrhoea)
- Tranexamic acid (manage menorrhagia)
2nd line
- GnRH agonist (lowers estrogen –> thins endometrial lining + anti inflammatory effects)
3rd line
- Uterine artery embolisation (blocking blood supply to the fibroids, causing them to thin and die
Definitive
- Hysterectomy (often required)
Vulval cancer
Dx
Tx
Dx
GS: Excisional biopsy and histological diagnosis + staging
Chest x-ray, ECG, FBC, UnE (to check suitability for surgery)
Tx
- Early stage: Wide local excision (if no inguinal lymphadenopathy - as risk of spread is negligible)
- Later stages: Sentinel lymph node biopsy (the first lymph node that drains a certain part) - to assess presence of metastases
+ If positive, wide local excision and groin lymphadenectomy
+ If negative, then unilateral excision and lymphadenectomy
Vaginal cancer
Dx
Tx
Dx
- Pelvic examination (speculum)
- Colposcopy
GS: Biopsy
If biopsy positive - CT/MRI for staging
Tx
- Chemotherapy and radiotherapy
- Vaginectomy - for small vaginal cancers that haven’t spread.
Treatment for cervical intraepithelial neoplasia
Also known as cervical dysplasia - Precancerous cells (these are detected during cervical cancer screening. You need to have HPV to have CIN)
Large loop excision of transformation zone (LLETZ)
CIN can be prevented/reduced risk via vaccination against HPV 16 and 18.
Cervical cancer investigation and treatment
Determined by FIGO staging (confined to cervix, extension beyond cervix but not to the pelvic wall, extension beyond cervix and to the pelvic wall, extension beyond the pelvis)
To confirm diagnosis - Biopsy
To stage disease - Vaginal/rectal examination to assess size of the lesion and biopsy findings
Stage 1
- Hysterectomy with/without lymph node clearance - preferred in older women
- For stage 1a - Can be treated with cone biopsy - if patient wants fertility maintained - risk of lymph node spread is low
(Or radiotherapy + chemotherapy)
Stage 2/3/4x
- Radiation with chemotherapy (cisplatin)
(For recurrent tumours - chemo-radiotherapy if not used before)
Abnormal uterine bleeding
Investigations
Treatment
Dx
First line - Pregnancy test (should always be excluded first)
FBC - possible anaemia following heavy/prolonged AUB
Coagulation profile (normal - to exclude bleeding disorders)
Serum TSH - checking for thyroid abnormalities
Transvaginal ultrasound - excluding structural causes
- Hysteroscopy and endometrial biopsy (especially patients with a high risk of AUB caused by malignancy - BMI, diabetes, hypertension, PCOS, family history of cancer)
Tx
First line - Hormone therapy –> Intrauterine system (Progestin),
Hormone therapy - Oestrogen/COCP,
Tranexamic acid to manage the bleeding
NSAIDS - Mefenamic acid
Definite (surgical) - only when medicine don’t work/structural issues identified
- Endometrial ablation - destroys uterine lining (not preserving future fertility)
- Dilation and curettage (preserving fertility)
- Hysterectomy - larger fibroids
- Hysteroscopy - for polyps/fibroids
Endometrial cancer
Investigations
Treatment
Investigations
All women 55 years and above with postmenopausal bleeding should be referred using the suspected cancer pathway.
First line - Transvaginal ultrasound (normal endometrial thickness = <4mm)
GS - Hysteroscopy with endometrial biopsy
Tx
Localised disease
- Total (laparoscopic) hysterectomy with bilateral salpingo-oopherectomy
If lymph nodes positive - postoperative radiotherapy
(Progestogen therapy for elderly women not suitable for surgery)
Endometrial/intrauterine polyps
Investigations
Treatment
Investigations
- Transvaginal ultrasound
- Hysteroscopy
Tx
- Uterine polypectomy during hysteroscopy (e.g. diathermy)
Endometriosis
Investigations
Treatment
Dx
First line - Transvaginal ultrasound
GS - Diagnostic laparoscopy - (visualisation +/- biopsy)
- Active lesions = red vesicles, less active lesions = white scars/brown spots
- Extensive adhesions indicate severe endometriosis
Tx
Symptomatic relief
- NSAID +/- paracetamol - analgesia
If analgesia doesn’t help
- Hormonal therapy = COCP/progestogen (symptoms regress during pregnancy - so this treatment mimics pregnancy)
2nd line
- GnRH analogues - lowers estrogen levels
FOR WOMEN TRYING TO CONCEIVE –> Surgery –> LAPAROSCOPIC EXCISION/ablation of endometriosis (with adhesiolysis)
Last line - hysterectomy
Fibroids (leiomyomata)
Investigations
Treatment
Dx
- Transvaginal ultrasound
- Hysteroscopy
- MRI - if diagnosis is unclear
Tx
- Asymptomatic - no treatment, periodic review for monitoring
For menorrhagia
- NSAIDS - mefenamic acid
- Tranexamic acid
- Levonorgesterol IUS - thins uterine lining (synthetic progesterone) - means less bleeding
- COCP
- Oral progestogen
For fibroid management
Medical
- Short term treatment = GnRH agonist –> can cause menopausal symptoms (hot flush, night sweats) and loss of bone mineral density
- Surgical –> Myomectomy (preserves fertility), hysteroscopic resection or hysterectomy
Hyatidiform mole/molar pregnancy
Investigations
Treatment
Dx
- Pelvic ultrasound –> Snowstorm appearance of the uterine cavity (swollen villi and moles - abnormal growths)
- Serum hCG - elevated (persistently high could indicate malignancy)
GS - histological examination of placental tissue
– Irregular villi architecture, trophoblast hyperplasia
Tx
- Suction curettage
+ Oral contraceptives (to prevent new pregnancy which would raise hCG further)
What treatment to give for malignant molar pregnancy post suction curettage?
Low risk
- Methotrexate and folic acid
High risk (gestational trophoblastic neoplasm)
- Combination chemotherapy
Ovarian cancer
Investigations
Treatment
Dx
1st line - CA125 test. If raised –> URGENT abdo-pelvis ultrasound
Gs - Diagnostic laparotomy
Tx
- Combination of surgery (hysterectomy and bilateral salpingo-oopherectomy) and platinum based chemotherapy
(All stage 5 year survival is 46%)
Primary peritoneal cancer and fallopian tube cancer are treated the same way as the epithelium that covers them are the same.
Ovarian cyst
Dx
Tx
Investigation and management
- Serum CA 125 –> if elevated, transvaginal ultrasound
- Laparoscopy (if not suspicious for malignancy)/Laparotomy (surgical exploration if acutely ill/suspicious of malignancy) to confirm diagnosis (histology to distinguish benign from malignant)
Pelvic inflammatory disease
Investigations
Treatment
Dx
- Pregnancy test to exclude ectopic pregnancy
- Endocervical swab for chlamydia and gonorrhoea
- Blood culture
- ESR and WBC may be raised
- Transvaginal ultrasound (may show tubal wall thickness)
(Laparoscopy is gold standard but rarely performed)
Tx
(There is a low threshold for treatment due to difficulty in making accurate diagnosis)
First line - STAT IM ceftriaxone + 14 days of oral doxycycline + oral metronidazole
(Can lead to perihepatitis in 10% of cases- Fitz Hugh Curtis syndrome - RUQ pain (differential of cholecystitis)
Polycystic ovary syndrome
Investigations
Treatment
Investigations
+++ It is a diagnosis of exclusion
- Transvaginal pelvic ultrasound
- LH:FSH ratio - raised
(Prolactin and TSH tests as well to exclude other diagnosis)
- Testosterone - normal/elevated
- Serum DHEA - elevated
- Sex hormone binding globulin - normal to low
Diagnostic criteria - Rotterdam criteria (a diagnosis can be made with 2 of the following 3 present)
- Infrequent/no ovulation/menstruation
- Signs of hyperandrogenism (e.g. hirsutism, acne, elevated testosterone)
- Polycystic ovaries on ultrasound (>/=12 follicles in one/both ovaries) and possibly increased ovarian volume >10cm3
Treatment
- Weight reduction
- COCP to help regulate cycle,
For hirsutism and acne
- 3rd gen COCP/co-cyprindiol - has antiandrogen action(but increases risk of venous thromboembolism)
- Otherwise - topical eflornithine
For infertility
- Weight reduction
- Anti-oestrogen therapy eg. clomifene (triggers ovulation via HPA axis)
- (Metformin can be used in combination - more so in obese patients)
2nd line - gonadotrophins
Depression
Dx
Tx
Dx
Depression identification questions
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last months, have you often been bothered by having little interest of pleasure in doing things?
PHQ-9 (score 16 or more = more severe depression)
DSM - 5 criteria
5 or more symptoms are present in the same 2 week period.
- Depressed mood
- Decreased interest/pleasure
- Significant weight loss
- Insomnia
- Fatigue
- Inability to concentrate
Tx
(Antidepressant medication should not be offered as first line treatment for less severe depression unless that is the patient’s preference)
Treatment options (in order)
For less severe depression
- Guided self-help (low intensity CBT)
- Group CBT
- Individual CBT
- Group exercise
- SSRIs
- Counselling
For more severe depression
- Combination of individual CBT and an antidepressant
- Counselling
- Short term psychodynamic psychotherapy
Antidepressants include
1st line - SSRI - citalopram, fluoxetine, sertraline (due to having the fewest side effects)
SNRI - Venlafaxine
NDRI - Bupropion
(Upon remission of symptoms, the antidepressant should be continued for at least 6 months to reduce the relapse rate)
For those that do not respond to antidepressants, people who have severe depression or strong suicidal intent, electroconvulsive therapy may be an option. (causes a brief seizure under GA)
Side effects: loss of memory, confusion, headache, nausea.
Ectopic pregnancy
Dx
Tx
Dx
- Pregnancy test to confirm pregnancy
THEN transvaginal ultrasound to determine the location of the pregnancy
In the event where the pregnancy can’t be located –>
- Serum bHCG levels >1,500 points toward an ectopic pregnancy.
Tx
1) If <35mm, unruptured and asymptomatic with hCG < 1000 IU/L then EXPECTANT management – monitor patient over 48 hours and if B-hCG levels rise/symptoms manifest then perform intervention
2) If size <35mm, unruptured and hcg 1000< x <1500 IU/L then MEDICAL management with methotrexate
3) If size >35mm, ruptured, significant pain, visible fetal heartbeat of hCG >5000 IU/L, SURGICAL management - First line Salpingectomy for women with no other risks of infertility
If have risks, then salpingotomy (+ further treatment with methotrexate/salpingectomy in 20% of women)
Miscarriage
Dx
Tx
Dx
- Transvaginal ultrasound - to differentiate between different stages and types of miscarriage (confirms viability of pregnancy)
- Serum hCG - a drop >50% in 48 hours is suggestive of a failing pregnancy.
Tx
First line - Expectant management
= waiting for 1-2 weeks for misscarriage to complete spontaneously
- GIVE ANTIEMETICS AND ANALGESIA.
- PREGNANCY TEST SHOULD BE PERFORMED 3 WEEKS AFTER INTERVENTION
For patients with increased risk of haemorrhage (late first trimester/has coagulopathies), previous traumatic experience associated with pregnancy or evidence of infection, move straight to second line.
2nd line - Medical management
1) Missed miscarriage
- Oral MIFEPRISTONE (progesterone receptor antagonist) - induces uterine contractions — THEN 48 hours later MISOPROSTOL, a prostaglandin analogue which binds to myometrial cells to induce contractions to expel products of conception.
2) Incomplete miscarriage
- Single dose of misoprostol
Surgical management
1) Vacuum aspiration (suction curettage) - local anaesthetic
2) Surgical management in theatre - general anaesthetic
Management of multiple pregnancies
1) Early ultrasound for diagnosis and checking for chorionicity (dichorionic = dividing membrane is thicker, monochorionic = dividing membrane is thinner) + monthly/serial ultrasound checks
Intrapartum
- Cardiotocography due to increased risk of intrapartum hypoxia (especially for the 2nd twin)
- C-section if first twin is not cephalic
- Ventouse or breech extraction if fetal distress
(if twins not delivered by 38 weeks, birth should be induced)
After delivery
- Iron and folic acid supplementation
- Prophylactic oxytocin infusion to prevent post-partum haemorrhage
