Womens health Flashcards
1
Q
What is thrush
A
Vulvovaginal thrush(candidiasis) is symptomatic inflammation of the vagina and vulva caused by a superficial fungal infection.
2
Q
5 symptoms of thrush
A
- Vaginal discharge(cream coloured, thick and curd like, yeasty, odourless)
- Intense pruritis (burning itch)
- Vulval redness, discomfort or pain(skin excoriated and raw)
- Pain/discomfort on urination(due to scratching)
- Pain and discomfort during/after sexual intercourse
3
Q
What is reccurent thrush
A
Recurrent = ≥4 symptomatic episodes in one year
3
Q
Risk factors of thrush
A
Local irritants(toiletries)
Uncontrolled diabetes
Increased oestrogen levels(pregnancy, COC, HRT)
Immunosuppresion i.e HIV or corticosteriod use
Recent antibiotic course
4
Q
What the 5 infective differentials for thrush
A
Bacterial vaginosis
* Itch less prominent, discharge likely to be white and smell bad
Trichomoniasis
* Itchy + grey/green frothy discharge
Chlamydia
* Discharge and dysuria but not itchy
Gonorrhoea
* Pain, yellow/blood-stained discharge
Genital Herpes
* Acute vulval pain, redness, itching and ulceration
5
Q
What 6 non-infective differentials
A
Allergic dermatitis(or other skin conditions)
* Vulval itch
* Check for product they’re using or change of soaps, shower gels, washing powders
* Vaginal deodorants – allergy e.g., local anaesthetic in feminine itching products
Atrophic vaginitis- may cause discharge in postmenopausal women
Vulvodynia – vulval discomfort and no other symptoms
Cytolytic vaginitis – present with cheese-like discharge and itch but when a culture is done under a microscope there is no fungal culture
Presence of a Foreign body – e.g. retained tampon may cause thrush-like symptoms or malodorous vaginal discharge
Mechanical irritation – e.g. due to lack of lubrication in vaginal
Malignancy – can cause discharge
6
Q
What are the age range you should refer for thrush
A
Aged under 16 or over 60
7
Q
When should you refer thrush
(16 points)
A
First presentation
Symptoms not consistent with previous episode
Pregnant/suspected/ breastfeeding
2 episodes in last 6 months (recurrent) and has not consulted GP for more than a 1 year.
Previous history of STD/ Exposure to partner with STD
Abnormal/irregular vaginal bleeding
Blood-stained discharge
Vulval/vaginal sores, blisters or ulcers - Not indicative of thrush
Lower abdominal pain
Systemic symptoms
Uncertain of diagnosis.
Known hypersensitivity to vaginal antifungals
Redness, irritation, swelling due to treatment
No improvement within 7 days of tx
Diabetics
Immunocompromised
8
Q
What is firstline treatment for thrush
A
Oral fluconazole 150mg capsule(Single dose)
OR
Intravaginal clotrimazole 500mg pessary (Single dose)
9
Q
Can you offer thrush Tx to partners
A
Yes you can offer oral fluconazole to men
10
Q
What is adjunctive treatments to first line
A
Vulval topical imidazole creams for vulval symptoms.
Clotrimazole 1% or 2%
11
Q
How to use pessaries
A
- wash hands
- put pessary into plunger
- lie on back with knees bent OR squat
- Insert blunt end into vagina as far as it can go
- Push the plunger to release pessary
- use panty liner (chalky residue)
12
Q
How to use pessaries non pregnant
A
- Do not use the applicator
- Use fingers and thumb to hold pessary narrow end first and insert into vagina as high as comfortable.
- Use panty liner(chalky residue)
13
Q
When is the best time to use a pessary
A
Recommend to use pessary at night time – to allow to melt and not fall out.
14
Q
What treatments if oral or vaginal first-line treatment contra-indicated or not tolerate.
A
- Intravaginal clotrimazole cream 10% Single dose at night
- Clotrimazole 200mg pessaries (ON 3/7)
- POM treatments i.e econazole nitrate pessaries, itraconazole oral 200mg capsule, clotrimazole 500mg pessary day 1 and day 4(severe infection)
15
Q
What is thrush treatment for breastfeeding women
A
- must consult GP first
- avoid oral antifungals
- give topical
16
Q
What is thrush treatment for pregnant women
A
- Patient must consult GP or midwife first
- Avoid oral anti-fungal
- clotrimazole 500mg pessary for 7 consecutive nights WITHOUT APPLICATOR
17
Q
When do you treat patients partners
A
Only if they are symptomatic.
Women do not catch from asymptomatic partners
18
Q
How do you treat partners for thrush
A
Azole cream bd to penis & under foreskin for 6 days
OR
oral fluconazole
19
Q
Thrush lifestyle advice DOs
A
- use water and simple emollients(E45) as a soap substitute to wash and moisturise the vulva area
- Dry properly after washing
- Wear cotton underwear
- Wipe front to back
20
Q
Thrush lifestyle advice DONTS
A
- Avoid contact with irritants: Do not use soaps or shower gels or perfumed products, feminine hygiene products
- Avoid tight fitting clothing
- Avoid sex until thrush has resolved
- Avoid vaginal douches or deodurants on your cagina
- Avoid complementary therapies such as live yoghurt, probiotics and essentials oil - not reccomended
21
Q
What might antifungal creams do to condom and diaphragms
A
Damage them
22
Q
What is bacterial vaginosis
A
An overgrowth of predominantly anaerobic organisms which causes the vagina to loses its acidity
23
Q
Is bacterial vaginosis an STI
A
NO but increases risk of getting STI
24
What is the prevalence of BV
Most common cause of abnormal discharge
Increased risk in women who have sex with women
25
Are all women with BV symptomatic
No only half are symptomatic
26
What the 3 symptoms of BV
Watery discharges(greyish-white in colour)
Strong fishy smell(strongest after sex)
No itching or soreness
27
What should you do for a patient presenting with BV
Patients presenting of with symptoms of bacterial vaginosis should be referred to the GP for testing and confirmation.
28
What are the risk factors for BV
Sexually active
Multiple or Recent change in sexual partner
Hx of STI
Women who have sex with women
Having the Copper IUD contraceptive
Douching
Using bubble bath or antiseptic in bath - can increase vaginal pH(More alkaline)
Menstruation(heavy periods or at end of periods)
Hormonal changes leading to increased vaginal alkalinity
Smoking
Ethnicity – Black women have BV prevalence of 45-55% compared with 5-15% in Caucasian women.
29
What are the complications of BV
Increased risk of acquiring other STI
* 2x HIV risk, 1-1.5x risk of chlamydia and gonorrhea, 9x risk trichomonas
Small increased risk of obstetrics complications.
30
What can pharmacies offer for BV
1. self testing kits
2. Symptomatic treatment
31
What is the symptomatic treatment options for bv
Canes balance Vaginal gel
And
Replens MD vaginal gel
32
what does Canes balance Vaginal gel do for BV
Relieves symptoms of abnormal odour and discharge
Combination of prebiotics(glycogen) & postbiotics(lactic acid) which rebalances pH and restricts growth of bad bacteria
Inserted into vagina using applicator
33
What is the POM treatment for Symptomatic BV
1. Reduce exposure to contributing factor i.e douching
2. Metronidazole 400 mg BD for 5- 7 days OR 2g single dose(if concerns with adherence)
3. Topical treatment – (cannot tolerate oral metronidazole):
- Intravaginal metronidazole gel 0.75% OD for 5 days
- Intravaginal clindamycin cream 2% OD for 7 days
34
What should pregnant women do after POM treatment for Symptomatic BV
Repeat test after 1 month
35
Do you need to screen partners for BV
No unless recurrent BV but may consider testing lesbian female parter
36
BV lifestyle Dos(3)
1. Use water and plain soap to wash genital area
2. Showers instead of baths
3. Use barrier protection during sex(semen increases alkalinity of vagina)
37
BV lifestyle Don'ts (5)
1. Avoid perfumed soaps, bubble baths, shampoos in the bath
2. Use vaginal deodorants or douching
3. use perfumed lubricants during sex
4. Avoid smoking
5. Wear thongs or nylon tights for long periods
38
Does BV clear on its own
Yes sometimes it does
39
Is BV reccurent
Yes common to be reccurrent
40
What should you do if BV recurrent
1. Check adherence
2. Enquire contributory factors and re-enforce self care advice and trigger avoidance.
3. Reconsider diagnosis (any new symptoms)
4. GP to perform speculum exam
5. Treat current episode(off label treatment with metronidazole gel may be indicated where symptoms recur despite appropriate management)
6. Consider removal of IUD and initiation of alternative contraceptive for women with BV
7. Consider testing and treating female partner in same sex relationship(Male partner screening not routine indicated
8. Where diagnosis is confirmed, and regular recurrence discuss management with gynaecologist or GUM specialist. )
41
What age group are at increased risk of STI
Under 25s
42
How should you assess vaginal discharge PC
1. Characteristics (colour, texture, smell)
2. New? reccurent? time frame?
3. Other symptoms(itch, soreness, blisters, pain dsyuria, bleeding)
4. Exacerbating factors i.e post coital?
5. previous tx and effective?
6. cyclic symptom - menstrual cycle
7. exposure to irritants/triggers i.e douching
43
How should you assess the medical history of vaginal discharge PC
- Contraceptive Use? IUD, COC?
- Medical Conditions?
- Immunosuppression, diabetes?
- Pregnant or Breast-feeding?
- Smoker?
44
How should you assess the sexual history of vaginal discharge PC
- Having condomless sex with new or casual partners?
- New partner or more than one partner in last 12 months?
- Previous STI?
45
What are the 3 key symptoms of lower urinary tract symptoms
Dysuria
New Nocturia
Cloudy urine
46
What 4 other possible symptoms of UTI
Increased Frequency,
Urgency,
Suprapubic pain or tenderness,
Visible blood
47
What are 7 differentials for Lower UTI
1. Pyelonephritis(flank pain + fever)
2. Delirium(other cause)
3. urethritis(non infective, cause by sexual contact, physical activity
4. Skin conditions(irritant or contact dermatitis)
5. pregnancy(inc ectopic) pelvic pain
6. other infections (STI, BV, threadworm)
7. Gynecological malignancy
48
Refferal for UTi
Under 16 (Safeguarding )
Men - uncommon
Elderly above 64
Urinary cathetger
possible undiagnosed or uncontrolled Diabetes
Reccurent UTI symptoms
Systemic symptoms indicative of pyelonnephritis
Deterioation signs
Symptoms suggesting UTI
Vaginal discharge
49
How should you treat mild symptoms of UTI
- Possibly self-limiting
- Offer simple analgesia and self-care
50
How should you treat moderate to severe symptoms of UTI
1. Assess patient via pharmacy first
2. refer to GP
51
Should you reccomend OTC cranberry products and alkalinising agents
No
- No evidence of efficiency
52
What is the 7 DOs for UTI
1. Wipe back to front
2. Urinate asap after sex
3. Stay hydrated 6-8 glasses daily - pale urine and should not feel thirsty
4. Have showers rather than baths
5. Wash vulva with water before and after sex
6. Chnage soiled nappies/incontinence pads regulary
7. Keep genital area clean
53
What are the 6 don'ts for UTI
DON'T
1. Use scented soaps, bubble baths, or talcum powder
2. use spermicide with diaphragms or condoms
3. delay going to urinate when you feel the urge
4. Rush when urinate - fully empty bladder
5. Drink lots of alcohol or caffeine irritates the bladder
6. Consume lots of sugary food and drink
54
What is the pharmacy first treatment for UTI
Nitrofurantoin 100mg MR capsules BD for 3 days
OR
Nitrofurantoin 50mg immediate release capsules QDS (every 6 hours)
55
How soon should someone return to pharmacy if no improvement in UTI symptoms with taking nitrofurantoin
48 hours
56
What is Urinary incontinence
Involuntary leakage of urine.
57
Complications of Urinary Incontinence
Impact on work and leisure
Psychological distress e.g. low self-esteem, embarrassment and anxiety
Social isolation – unable to leave home for worry of not being able to access a bathroom.
Sexual problems and reduce intimacy.
Poor sleep
Increased falls and fractures
Financial burden (including cost of incontinence products)
58
What are the 4 classifications of urinary incontinence
Stress UI
Urgency UI
Mixed UI
Overflow UI
59
What stress incontinence
involuntary leakage on effort, exertion, sneezing, or coughing.
risk factors: obese, pregnant, constipation
60
What is urgency UI
Leaking with/or after sudden urge to pass urine
61
What is mixed urinary incontinence
Both stress and urgency UI
- Involuntary leakage associated with stress and physical urgency
62
What is overflow incontinence
Results of urinary retention, where contractabillity of the bladder is decreased(ACEi or Antimuscarinics) or bladder outlet obstructed
63
How should you question a patient with urinary continence
1. Refer to GP for full assessment
2. Symptoms impacting physical and mental health
3. Other symptoms
4. Red flags?
64
What incontinence products are there
Pads and Pants
Beds and chair protection
Catheter and penile sheaths
Skincare and hygiene products
Specially adapted clothing and skin care
65
What are incontinence pads and pull ups
They are absorbent pads worn inside the underwear to soak up urine.
Have a hydrophobic layer which draws urine away from the surface of the product to keep skin dry
66
6 lifestyle advice for urinary Incontinence
1. Reduce Caffeine intake
2. Maintain normal fluid intake – Patient should be discouraged from drinking excessive or reduced amounts of fluid. Should still aim Aim for 6-8 glasses of water per day.
3. * Weight-loss support for patients with BMI ≥ 30 kg/m2
4.Stop Smoking
5. reduce Alcohol intake
6. Pelvic floor exercises – GP can refer patient for trial of pelvic floor muscle training.
67
What are the POM management options for Urinary incontience
1. Antimuscarinics e.g. Oxybutynin, Solifenacin, Tolterodine, and Trospium.
2. Desmopressin
3. Duloxetine
4. Mirabegron
5. Intravaginal oestrogen
68
When does ovulation occur
Day 14
69
How long can sperm live
5 days
70
How long is the ova viable for
24 hours
71
When is emergency hormonal contraception indicated from after childbirth
indicated after unprotected sex from Day 21 after childbirth(unless all criteria for lactational amenorrhoea are met).
72
When is emergency contraception indicated from after miscarriage, abortion, ectopic pregnancy, or uterine evacuation
is indicated from Day 5
73
What the 3 types of emergency contraception
1. Copper Intrauterine Device (Cu-IUD)
2. Ulipristal
3. Levonorgestrel
74
What is the most effective EHC
Copper IUD
75
What is the mode of action of copper IUD
1. Copper affects the motility and viability of sperm
2. causes endometrial inflammatory reaction with prevents implantation
76
When should Cu IUD be inserted?
1. Must insert within 5 days of first UPSI in cycle
2. or within 5 days of earliest date of ovulation
77
When is Cu IUD Contraindicated
1. current chlamydia or gonorrhea infection
2. previous ectopic pregnancy
3. 48h-28 days after child birth(risk of uterine perforation)
78
Is copper IUD impacted by weight/BMI
No
79
Does Cu IUD have drug interactions
None
80
What are the breast feeding considerations for CU IUD
Higher risk of uterine perforation during insertion but absolute risk if low
81
What are the S/E of Cu IUD
1. Heavier periods
2. spotting
3. discomfort during sex
4. Expulsion of IUD
5. perforation of uterus
82
What is ulipristal acetate
A selective progesterone modulator - acts on receptors in the hypothalamus and pituitary gland, blocking the progesterone effect. This suppresses the LH surge AND delays ovulation
83
What is the dose of ulipristal acetate
30mg single dose
84
When can ulipristal acetate be taken
No later that 120 hours after UPSI
85
What is the efficacy of Ulipristal acetate
effective within 120 hours(no significant reduction in that time frame)
Delays ovulation after LH surge BUT Not effective after start of LH peak
86
What are contra indications for Ulipristal acetate
1. Severe asthma controlled with oral steroids
2. severe hepatic impairment
87
How does weight impact ulipristal acetate
Possibly reduce efficacy if weight over 80kg or BMI over 30.
Do not GIVE double dose just inform them of reduced efficacy
88
What drug interactions are there with ulipristal acetate
1. Enzyme inducers(carbamazepine, phenobarbital, phenytoin, rifampicin, St. John's Wort and glucocorticoids)
2. Progesterone products
89
Breast feeding considerations for UPA - EC
Excreted into milk,
Advise to discard milk for one week after taking UPA
90
What are the side effects of UPA-EC
1. N/V
2. Abdominal discomfort
3. Headache, Dizziness, Mood swings, Muscle pain, Tiredness
91
What is the OTC product of UPA-EC
EllaOne
92
What is the mode of action of Levonorgestrel EC
Inhibits ovulation by preventing/delaying the follicular rupture. Ovulation delayed for 5 days with makes sperm unviable
93
Dose of LNG-EC
1.5mg single dose
94
When must LNG-EC be taken
Within 72 hours of UPSI
95
What is the efficacy of LNG-EC
Ineffective in late follicular phase, after start of LH surge.
No significant post ovulation efficacy seen.
Recommend to be taken ASAP after UPSI- as efficacy may decrease with time
96
Contraindications for LNG-EC
Severe hepatic impairment - must discuss risk with clinican and pregnancy also poses risk to patient
97
Impact of weight/BMI for LNG-EC
< 70kg or BMI 26 Offer double dose(3mg)
98
What are drug interactions for LNG-EC
Enzyme inducers(see bnf)
- Carbamazepine, phenytoin, phenobarbital etc
99
What are breast feeding considerations for LNG-EC
Limited exposure to infant, literature suggests no adverse effects.
Take dose after feed and avoid nursing for 8 hours after
100
What are S/e of Levonorgestrel
Nausea, abdominal pain, headache, dizziness fatigue, amenorrhoea
101
What factors must be taken into consideration when choosing EHC
* Must exclude possibility of pregnancy
* Medical eligibility criteria
* Patient preference
* Current contraceptive use.
* Medication/Medical Hx
* Previous EHC use in current cycle.
* Contra-indications
*. BMI/weight
* Timing of UPSI
* Risk of STI/Safeguarding concerns?
102
What is the time frame for if a patient vomits on LNG-EC for repeat dose
Come back to pharmacy if patient vomits in 2 hours
103
What is the time frame for if a patient vomits on UPA-EC for repeat dose
Come back to the pharmacy in 3 hours
104
When should a patient take a pregnancy test after EHC
Three weeks after last episode of unprotected sex.
105
Do under 16s have capacity for consent
No they must demonstrate their capacity
106
What guidelines can be used for assessing capacity to consent
Fraser guidelines(specific to sexual health)
And
Gillick competency
107
Under 13 asks for EHC
CANNOT CONSENT TO SEXUAL ACTIVITY
report to social services unless there is extreme circumstances where disclosing this information should not be done
108
What is Hana and lovima
Oral progesterone only contraceptives
109
What is the active ingredient in hana and lovima
Desogestrel
110
Is desogestrel able to be brought OTC
Yes - Hana and Lovima
Changed from POM to P in 2021
111
How does desogestrel work
Inhibits ovulation and increases the thickness of cervical mucus making it unfavourable for sperm.
112
How do you take hana
75mg(one tablet) daily - same time each day
113
When is the missed pill rule apply
If you take a pill more than 12 hours late
114
Efficacy of desogestrel
99% if taken perfectly, typical use is 91%
115
What two conditions is desogestrel contraindicated in
Acute porphyrias and current breast cancer
116
What 8 conditions is desogestrel cautioned in
1. Cardiac dysfunction
2. Hx of ca breast
3 Hx of stroke
4 Hx of DVT
5. Ischaemic heart disease
6. Liver disease
7. Diabetes
8. Uncontrolled HTN
117
Is desogestrel affected by weight
No
118
What are drug interactions for desogestrel
CYP34A inducers(carbmazepine, phenytoin, phenobarbitol)
CYP34A inhibitors (anti-fungals, macrolides)
119
Does desogestrel interact with ulipristal acetate.
They decrease the efficacy of each other
120
Side effects of Desogestrel
- Bleeding and spotting
- Breast tenderness
- Altered mood
- Nausea
-Weight gain
- Headache
121
When is the best time to start desogestrel
Day 1 of new cycle
122
What should you do if a patient starts desogestrel on days 2-5 of period
additional barrier contraceptives for 7 days
123
Desogestrel POM to P switcher?
Start taking it the day after last prescription POP(will not need cover)
124
COC/ implant or IUS to P desogestrel
Start taking it the day after last active combined pill tablet, ring,cap etc
OR day of removal
If there is break after ending, then use additional barrier method for 7 days
125
When should you refer a person whos asking for desogestrel P medicine
Active or history of thrombosis
Active or history of Liver disease or cancer.
Current or past-history of breast-cancer.
Undiagnosed vaginal bleeding.
Diabetes
Uncontrolled hypertension.
Allergy or intolerance to lactose.
Allergy or intolerance to soya or peanut (Lovima)
126
What is the 10 counselling points for desogestrel
1. What it is, how it works, how to use
2. Take same time every day (24h)
3. When pack is finished go straight onto next pack with no break
4. Missed pill rule < 12hr still protected, more than 12hr not protected so use barrier method for 7/7 or consider EHC
5. Diarrhoea and vomiting what to do
6. Side effects
7. Sexual health advice - STIs, condoms use, breast exams, cervical screening
8. health promotion: diet and exercise - baseline BP and BMI
6. Interactions
7. check with pharmacist before starting any new medicines
8. refferals,
9. Further supplies
10. inform gp you are taking
127
first supply of Desogestrel (OTC) What Quantity should I supply?
Each blister of 28 tablets provides 1 month supply
First supply: only Up to 3 months' supply can be provided.
128
Repeat supply of Desogestrel (OTC) What Quantity should I supply?
Repeat supply: Up to 12 months’ supply can be provided
129
what is the quantity limit for supply of desogestrel OTC to under 18s
3 months’ supply
130
What questions should you ask a person requesting repeat supply of desogetrel
1. Any changes to medical/ social HX or medications?
2. Period changes that concern then?
3. any side effects or symptoms?
131
What is the NHS advanced contraception service
Community pharmacy NHS service that provides COC and POP for free to eligible patients
132
What are the tiers to the NHS advanced contraception service
Tier 1: continuation of GP initated contraceptive
Tier 2: initiation of COC/POP by pharmacist
133
What physical examinations are carried out in NHS advanced contraception service
BP and BMI at each supply
134
what is Dysmenorrhoea
Lower abdominal cramping pain associated with menstruation. It occurs shortly before and/or during menstruation.
135
What is Primary Dysmenorrhoea
Primary dysmenorrhoea – Pain in the absence of pelvic/uterine disease(no underlying pathology)
136
What is secondary Dysmenorrhoea
Secondary dysmenorrhoea – Pain associated with/caused by pelvic/uterine disease
137
When does primary dsymenorrhoea start
Starts in teenagers 6-12 months after menarche.
Peak incidence 17-25 years of age
Less common after childbirth
138
When does secondary dsymenorrhoea start
Most common in >30s – several years after painless periods
Rare in women <25
139
What causes periods
Progesterone levels drop which cause prostaglandins to be released from endometrial cells which stimulate uterine contractions to shed endometrium. Blood vessels also constrict
140
Primary dsymenorrhoea aetiology
Prostaglandin overproduction or oversensitivity of uterus to prostaglandins
This leads to over-contraction which reduces blood supply to endometrium causing pain
141
Main Symptoms of primary dsymenorrhoea
Cramping lower abdominal pain Radiate to back and inner thigh.
Starts at or day before period
Eases as bleeding progresses
Lasts up to 72 hours.
142
Associated symptoms of dsymenorrhoea
GI symptoms due to prostaglandins acting on smooth muscle - Nausea, vomiting, diarrhoea,
Fatigue, irritability, dizziness, bloating, headache, lower back pain and emotional symptoms e.g. tearfulness
143
Secondary Dysmenorrhoea Symptoms
The pain is not consistently related to menstruation and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
Pain during sex
Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge
144
Secondary Dysmenorrhoea can be caused by
Endometriosis
Fibroids
Pelvic Inflammatory Disease(bacterial infection affecting reproductive organs)
IUD insertion (3-6 months after insertion, longer heavier periods)
Ovarian cancer
Cervical cancer
145
What questions to ask for dysmenorrhea
1. Age
2. Nature of pain (cramping Vs non-cramping and severity)
3. Timing of pain(when in menstrual cycle, cyclic or non cyclic, associated with sex)
4. Bleeding (Heavier than normal, after sexual intercourse, between periods)
5. Associated symptoms - do these fit diagnosis of primary dysmenorrhea? Fever? Vaginal discharge?
6. Taking oral contraceptives - refer
146
First line treatment for primary dysmenorrhea
NSAIDS
Inhibit prostaglandin synthesis/ activity to reduce menstrual pain, blood loss
147
What 4 NSAIDS are used for primary dysmenorrhoea
Ibuprofen
Naproxen (OTC 9 tablets)
Mefenamic acid (POM)
Flurbiprofen tablets (POM)
Avoid NSAIDS if renal impairment, GI bleed/ulceration
Advise to take after food
148
What is an alternative first line treatment for dysmenorrhea in women who do not want to conceive
3–6-month trial of COC
Recommend 30-35 micrograms of ethinylestradiol and norethisterone/ levonorgestrel
149
What is Premenstrual Syndrome (PMS)
Condition characterised by variety of symptoms which are characterised as psychological physical and behavioral symptoms that occur during the luteal phase(before period)
150
Psychological symptoms of PMS
Depression, irritability, low mood, anxiety, loss of confidence
151
Physical symptoms of PMS
breast swelling and tenderness, abdominal bloating, swelling of the feet or hands, weight gain, headache
152
Behavioral symptoms of PMS
reduced cognitive ability, aggression
153
What are the 3 types of PMS
core PMDs – most common, include non specific symptoms which recur during ovulatory cycle and present during luteal phase but goes away with menstruation.
Variant PMD – Induced by HRT or COC
Pre-menstrual dysphoric disorder(PDD) – severe form, women suffer from at least 5 distinct psychological symptoms strictly during the luteal phase
154
Aetiology of PMS
Several theories
1. Progesterone affects serotonin and GABA pathways
2. Exaggerated immune inflammatory response causing symptoms
155
How are women with PMS managed
Treat according to what their symptoms are
headache - simple analgesic
Provide lifestyle advice for all
156
What is lifestyle advice for PMS
1. Regular, small, balanced meals rich in complex carbohydrates
2. Regular exercise
3. Regular sleep
4. Stress reduction
5. Smoking cessation
6. Alcohol restriction
157
What is the advice on complementary treatments and dietary supplements for PMS
Advise that there is limited evidence to support the use of complementary treatments and dietary supplements
158
What is an firstline treatment for moderate PMS if the women doesn't want to conceive
1. New-generation COC (Off label if only for PMS symptoms). Eloine® (drospirenone/ethinylestradiol) is most effective, specificallyy at lower doses. Continuous use rather than cyclical use.
2. CBT if appropriate
159
Severe PMS treatment
1. Hysterectomy.
2. Initial 3-month trial SSRI (off-label) Continuous or just during luteal phase (days 15-28 of menstrual cycle) only continue if beneficial; review and assess for anxiety, thoughts of self-harm, side effects
3. CBT if appropriate
160
what is Menorrhagia
Excessive (heavy) uterine bleeding occurring at regular menstrual intervals
161
How long does menorrhagia last for?
May last more than 7 days
162
Is menorrhagia measurable
Used to be defined, > 80 ml blodd loss and/or a duration of more than 7 days and/or passage of ≥2.54cm clots.
Not really measurable as subjective
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What is the prevalence of menorrhagia
Prevalence increases with age, peaking at 30-49 years.
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What is dysfunctional Menorrhagia
Menorrhagia without a known underlying medical cause
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What are the firstline treatment options for menorrhagia
1. levonorgestrel intrauterine system (LNG-IUS)
2. Tranexamic acid - 1g TDS 4/7
3. NSAIDs (unlicensed)
4. COC or cyclic POP(POM)
5. Surgical options
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What is tranexamic acid
Anti-fibrinolytic
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How does tranexamic acid work?
Prevents fibrinolysis by inhibiting plasminogen which is key for fibrinolysis. Thus stabilising clots(thrombosis) --> less blood loss
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how long does tranexamic acid take to work
24 hours
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Is tranexamic acid available to buy to OTC
Yes P medicine
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What are the requirements for tranexamic acid to be supplied OTC
1. over 18 years old
2. regular 21- to 35-day cycles
3. no more than 3 days individual variability in cycle duration
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When should you refer a women taking P medicine Tranexamic acid for menorrhagia
If not reduced after 3 menstrual cycles refer
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What are ADR of tranexamic acid
GI (N/V, diarrhoea) – lower dose/first 3 days of bleeding
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what are contraindications for Tranexamic acid
1. renal impairment
2. irregular menstrual bleeding
3. active or previous thromboembolic event
4. pregnancy & breastfeeding
5. anticoagulants
6. OC
7. haematuria
8. hypersensitivity
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What is endometriosis
Growth of endometrium-like tissue outside uterus.
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Where do the endometrial deposits grow
Commonly distributed in pelvis- on ovaries, rectum, sigmoid colon, bladder
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What is retrograde menstruation
a cause of endometriosis where endometrial cells flow backwards through the fallopian tubes and implant on pelvic organs where they can grow.
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What are the 3 causes/mechanisms of endometriosis
1. Retrograde menstruation
2. Through lymphatic system
3. Metaplasia cells in pelvic and abdominal cavity , which differentiate to germinal epithelium cells
4. Hormone mediated
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Endometriosis - 6 Symptoms
1. Chronic pelvic pain
2. Dsymenorrhea affecting daily activities
3. Deep pain during/after sex
4. Period-related/ cyclical GI symptoms (painful bowel movements)
5. Period-related cyclical urinary symptoms (pain passing or blood in urine)
6. Infertility
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Endometriosis Diagnosis
Early transvaginal ultrasound in all people with suspected endometriosis, even if the pelvic or abdominal examination is normal.
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Endometriosis - Management of pain
Simple analgesics (paracetamol/ NSAID)- 3-month trial
Hormonal treatment e.g. COC/ POP, Nexplanon, Depo-provera, Sayana press, Mirena coil – unless trying to conceive.
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When should endometriosis be reffered to secondary care (3)
Severe, persistent, or recurrent symptoms
Pelvic signs of endometriosis
Treatment is not effective
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What is secondary care treatment for Endometriosis
surgical treatment- excision, ablation, hysterectomy, may combine with hormonal treatment
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What are uterine fibroids
Hard, round, benign tumours in myometrium
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How large can they be
Vary from a few mm to 30cm+
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Do uterine fibroids always cause symptoms
Commonly asymptomatic and diagnosed accidentally during ultrasounds
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What are symptoms of uterine fibroids
* Heavy menstrual bleeding
* Pelvic pain, pressure, discomfort
* Abdo discomfort, bloating
* Back pain
* Urinary symptoms: frequency, urgency, incontinence, retention
* Bowel symptoms: bloating, constipation, painful defecation(if fibroids in the bowel)
* Reduced fertility in some cases
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Where are submucosal, Intramural, subserosal fibroids
Submucosal fibroids –Inner mucosal layer of the uterus and extended into the uterine cavity.
Intramural fibroids – within the myometrium and affect the constriction of blood vessels during menstruation.
Subserousal fibroids - outer surface of uterus and extend into peritoneal cavity.
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How should asymptomatic women with uterine fibroids be managed
No medical review or follow up is needed.
She should arrange medical review if there are new symptoms or features occur
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What is symptomatic treatment for Uterine fibriods
NSAIDs, tranexamic acid, COC/POP - symptoms
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What treatments shrink fibroids
1. GnRH analogues (goserelin) - induces state of medical menopause
2. Esmya (UPA) - MRHA prevents this use now - only use now intermittently if surgery is not possible or failed due to high risk of liver failure. must monitor LFT, before, during and after
3. radiology or surgical procedures
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When should you refer to specialist for
Referral to specialist
* Suspected malignancy
* Suspected fertility issues
* Confirmed fibroids ≥3cm
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What is PCOS
is a heterogeneous endocrine disorder that appears to emerge at puberty. It is characterised by hyperandrogenism, ovulation disorder and polycystic ovaries.
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What disrupts ovulation in PCOS
High levels of androgens cause follicles to accumulate in the ovaries which disrupts develop of follicles.
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how does PCOS affect insulin
Women with PCOS often have higher levels of insulin and insulin resistance
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What are the clinical features of PCOS
1. polycystic ovaries(Detected on US)
2. Hyperandrogenism (Hirutism, Acne)
3, Ovulation (Infrequent or No ovulation)
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What are complications of PCOS
T2DM
CVD
Infertility
Pregnancy
Increased risk of endometrial cancer
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How do you manage PCOS
Managing symptoms and risks
- Promote healthy lifestyle
- Smoking cessation
- CVD, T2DM screening
- Combined Oral Contraceptives can help with ovulation disorders
- Ovulation disorders - cyclical progestogen, levornogestrel IUD
- Acne - topical retinoids, antibiotics
- Metformin (unlicenced)
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What is self care advice for urinary incontinence
Be prepared – e.g. when travelling.
Take care of skin – wash regularly and dry carefully
Change pads regularly.
Report broken skin.
Stay hydrated, avoiding excessive or reduced fluid intake (caffeine, fizzy drinks, alcoholic drinks, artificially sweetened drinks may irritate bladder)
Smoking cessation – smoking irritates the bladders and coughing causes weak bladder control
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What is firstline treatment for urinary incontinence
1. Antimuscarinics e.g. Oxybutynin, Solifenacin, Tolterodine, and Trospium.
2. Desmopressin
3. Duloxetine
4. Mirabegron
5. Intravaginal oestrogen
200
What is bladder catheterisation
cathether inserted into bladder to drain urine
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when is bladder catheterisation indicated
if there is persistent urinary retention and it's causing incontinence, symptomatic infections, or renal dysfunction, and also when urinary incontinence just cannot be corrected.
202
What is intermittent self catherisation
Intermittent self-catheterisation (ISC) – usually recommended, inserted through urethra several times a day to drain bladder; used to treat bladders that do not fully empty.
203
What is Indwelling catheter
urethral catheter changed at least every 3 months.
204
how should patients store catheters
to store catheters in a cool dry place, lied flat or straight and pt should not use catheters that are damaged.
205
What are the 3 types of catheter for intermittent self catherisation
Coated (hydrophilic coating)
Non-coated (washed, re-used and must be lubricated)
Pre-Lubricated - single use with pouches of water, may have drainage bag
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What catheter size should be used for ISC
Smallest size possible
Average size used in women is 10FR to 12FR
207
What 4 risks of catheters
1. UTI
2. Blockages
3. Bladder spasms
4. Narrowing or injury to urethra following repeated use
208
What 4 hygiene measures are there for catheters
1. Wash skin where catheter enters
2. Wash hands with soap and use gloves
3. Ensure equipment remains clean
4. Check catheters for discolouration or damage
209
What 5 other measures are there for catheters to reduce risks
1. Well hydrated
2. Avoid constipation
3. Avoid kinks/bends in cather
4. ensure urine collection bags are kept below the level of catheter
5.Report signs of UTI
