Women's Health Cases And Contraception

Front 1

What are the main methods for female contraception?

Back 1

- Hormonal methods.
- Emergency contraception.
- Depo provera.
- Subdermal contraceptive implants.
- Mirena.
- Non-hormonal methods.

Front 2

What are the choices for emergency contraception?

Back 2

- High dose progesterone (levonorgestrel 750ug has an efficacy of 85%).
- Yuzpe method ethinyloest (efficacy of 76%).

Front 3

What is depo provera?

Back 3

- An injectable method of contraception containing medroxyprogerteron.
- 150mg every 12 weeks.
- Failure rate of less than 1%.

Front 4

What are the side effects of using depo provera?

Back 4

- Irregular bleeding in the first few months.
- By 12 months, 80% of women have amenorrhoea or occasional spot bleeding only.
- Bone mass returns to normal after depo is discontinued.

Front 5

Subdermal implants (implanon) involve what process?

Back 5

Progesterone (etongestrel) inserted via a trochar into the upper arm.

Front 6

How long does implanon (subdermal implant) usually last?

Back 6

3 years.

Front 7

What side effects may occur with the subdermal implant, implanon?

Back 7

Progestogenic side effects such as:
- Irregular bleeding (common).
- Weight gain.
- Acne.
- Amenorrhoea (50%)
- Troublesome bleeding in 10%.

Front 8

How long does it take for a woman to return to fertility after removal of a subdermal implant?

Back 8

1 day.

Front 9

What is the overall effectiveness of the combined OCP?

Back 9

95-99%.

Front 10

What might be another oral alternative to the combined OCP if contraindicated?

Back 10

Possibly the progestogen-only pill (mini pill) may work.

Front 11

What are the absolute contraindications to use of the combined oral contraceptive pill?

Back 11

- Focal migraines with neurological signs.
- Active liver disease.
- History of thromboembolism.
- Breast or gynaecological cancer.
- Lactation.
- History of CVA/CAD.
- Undiagnosed vaginal bleeding.
- Uncontrolled hypertension.

Front 12

What are the relative contraindications to use of the combined oral contraceptive pill?

Back 12

- Suspected pregnancy.
- Irregular vaginal bleeding.
- Common migraine.
- Hypertension.
- Obesity.
- Strong family history of thromboembolism disease.
- Concurrent med interactions e.g. rifampicin.

Front 13

What possible reasons could the OCP fail?

Back 13

- Non-compliance.
- Vomiting and diarrhoea.
- Drugs which may interact with the OCP.

Front 14

What is cystitis?

Back 14

Cystitis is an infection of the lower urinary tract.

Front 15

What symptoms can occur with cystitis?

Back 15

- Dysuria.
- Frequency.
- Urgency.
- Haematuria.
- Suprapubic pain.

Front 16

What is pyelonephritis?

Back 16

Pyelonephritis is infection of the upper urinary tract.

Front 17

What are some of the typical symptoms of pyelonephritis?

Back 17

- Kidney infection.
- Fever.
- Flank pain.
- N.V.

Front 18

What is the incidence of infection in premenopausal, sexually-active women?

Back 18

0.5-0.7 infections per person per year.

Front 19

What percentage of women experience cystitis in their lifetime?

Back 19

20-40%. Of those, 20% develop recurrence. The majority (90%) experience reinfection rather than relapse.

Front 20

UTI can exist without symptoms. True or false?

Back 20

True.

Front 21

Asymptomatic UTIs are common in what populations?

Back 21

- Sexually active women.
- Elderly.
- Those with urinary tract abnormalities.

Front 22

Asymptomatic bacturia leads to acute clinical UTI in what percentage of women?

Back 22

30% (exclude in early pregnancy).

Front 23

Mixed organisms in the urine indicates...

Back 23

A distal urethral origin of the UTI.

Front 24

Causes of pyuria:

Back 24

- Current bacterial infection.
- Incorrectly collected specimen.
- Treated UTI.
- Urethritis.
- Tumours.
- Stones.
- Glomerulonephritis.
- Anatomical abnormalities.
- Nephritis abnormalities.
- Analgesic nephropathy.
- Indwelling catheters.
- Genitourinary surgery.

Front 25

If a patient has an upper UTI, you have to be suspicious of...

Back 25

...an underlying UT abnormality. You need to investigate the renal tract of these patients.

Front 26

When would you do investigations for cystitis?

Back 26

If it recurs or persists (always consider chlamydia). Otherwise, just treat a clinical case of cystitis empirically.

Front 27

What would be considered a baseline rate of infection for a non-pregnant woman who suffers from recurrent cystitis?

Back 27

2 UTIs per year over many years.

Front 28

What are the main benefits of HRT?

Back 28

HRT reduces the risk of:
- Hot flushes.
- Urogenital symptoms.
- Sleep problems.
- Osteoporotic fracture.
- Colorectal cancer.

Front 29

What are the main risks of HRT?

Back 29

HRT increases the risk of:
- DVT/PE.
- Stroke.
- Breast cancer (combined HRT).
- Endometrial cancer (oestrogen-only HRT).
- Ovarian cancer (eostrogen-only HRT).
- Cardiovascular events and dementia in older women.

Front 30

How does HRT affect weight gain, headache, and migraine?

Back 30

There is no evidence that it causes any change in risk of these.

Front 31

Is there good evidence of the efficacy of the CAM product 'black cohosh' in treating hot flushes?

Back 31

Yes.

Front 32

Is there good evidence of the efficacy of the soy products in treating hot flushes?

Back 32

No (level 1 no impact).

Front 33

Is there good evidence of the efficacy of the CAM product dong quai, evening primrose oil, red clovers and chinese herbs in treating hot flushes?

Back 33

No (level 2 no impact).

Front 34

Which is better for bone protection? HRT or bisphosphonates?

Back 34

Compared with HRT, bisphosphonates have stronger
evidence of efficacy for prevention of fractures in women with osteoporosis.

However, HRT is sometimes appropriate for bone protection if fracture risk is high and other medicines are intolerable.

Front 35

How long would you have to stay on HRT to have an increase in breast cancer risk?

Back 35

2 years, which is why short-term HRT (1-2 years) is a viable option for menopausal symptom relief.

Front 36

How do you cease HRT treatment?

Back 36

When ceasing HRT, it is important to reduce doses incrementally over a few months to prevent rebound symptoms.

Ceasing HRT during the cooler months may be helpful for
some patients.

Front 37

Women using HRT are likely to have a _____ fold increased risk for idiopathic
thromboembolism compared with non-users.

Back 37

Women using HRT are likely to have a 2-4 fold increased risk for idiopathic
thromboembolism compared with non-users.

Front 38

Would you recommend continuing HRT treatment?

Back 38

Understand and balance both the risks and benefits of HRT when making a recommendation as each woman's situation is different and there is no
one-size-fits-all solution.

Front 39

What complementary medicines might you recommend after ceasing HRT treatment on a post-menopausal woman?

Back 39

Black cohosh has the best evidence of commonly used alternatives, but there is a lack of uniformity in the components of the various preparations. The evidence of benefit applies only to the product used in trials (i.e. Remifemin).

Other products had placebo effects but that's it.

Front 40

When might HRT be recommended for longer than 2 years?

Back 40

HRT is sometimes appropriate for bone protection if fracture risk is high and other
medicines (i.e. bisphosphonates) intolerable. It is not recommended in women who are not at high risk of fracture.

Front 41

When should you review management after ceasing HRT treatment?

Back 41

6 weeks to check on wellbeing, general health and for return of menopausal symptoms.

Front 42

How frequently should you review a patient on HRT treatment?

Back 42

Review women using HRT for symptom relief 6-12 monthly and assess the need for
ongoing therapy.

Front 43

What essential things should a patient be recommended in having post-menopause?

Back 43

- Vitamin D.
- Calcium.
- Weight-bearing exercise.

Front 44

What are the major determinants of fracture risk?

Back 44

- Postmenopausal women.
- Low bone mineral density.
- Calcium and/or vitamin D deficient states.
- Previous minimal-trauma.
- Fracture or family history
of such a fracture.
- Long-term (> 3 months) oral corticosteroid therapy.
- Ageing.
- Cigarette smoking.
- Low body weight.

Front 45

How do you prevent falls in the elderly?

Back 45

- Assess personal aspects: visual deficits, cognitive
impairment, muscle weakness, gait or balance abnormalities.

- Assess environmental/home aspects: inadequate lighting,
hazardous rugs, slippery floors, the height of chairs and beds, the need for safety rails (e.g. in the bathroom or
on stairs), appropriate footwear.

- Review medication to identify drugs causing sedation (e.g. hypnotics, antidepressants), postural hypotension (e.g. antihypertensives, psychotropic drugs), hypoglycaemia, or drugs associated with osteoporosis (e.g. oral corticosteroids, anti-epileptic agents).

- Encourage exercise to improve muscle strength and balance.

Front 46

In poste-menopausal women, raloxifene is most effective in preventing...

Back 46

Vertebral fractures.

Front 47

What is the absolute contraindication for raloxifene use?

Back 47

History of venous thromboembolism.

Front 48

What are the main side effects of bisphosphonates and how can you prevent them?

Back 48

Oral bisphosphonates commonly cause gastro-intestinal
disturbances; severe oesophageal erosions and ulcers have been reported.

To minimise these adverse effects, bisphosphonate tablets should be taken with a full glass of water, with the patient in an upright position and remaining upright for 30 minutes.

Front 49

Bisphosphonate absorption can be impaired by other substances. What should the patient do to avoid it?

Back 49

Bisphosphonate tablets must be taken 30–120 minutes
before food, drink (other than water), or medications
containing calcium, magnesium, iron, or aluminium salts as absorption is impaired.

Front 50

Men with osteoporosis or vertebral fractures tend to have an underlying medical conditions. What medical conditions could it be?

Back 50

- Hypogonadism.
- Oral corticosteroid use.
- Excess alcohol use.

Front 51

What are the most common symptoms associated with pelvic inflammatory disease?

Back 51

- 60% subclinical/asymptomatic.
- Abnormal vaginal discharge.
- Lower abdominal pain.
- Dyspareunia with adnexal tenderness.
- Cervical motion tenderness.
- Cervicitis.

For those with more severe disease:
- Fever.
- Nausea.
- Vomiting.

Front 52

Why may there been a decline of acute PID in response to recent increases in reports of chlamydial infection?

Back 52

This may represent improved and earlier treatment or increased testing of chlamydia.

Front 53

What proportion of PID infections are derived from STIs such as gonorrhoea and chlamydia?

Back 53

One third to one half of PID infections.

Front 54

Non-sexually acquired PID may result from what?

Back 54

Procedures such as intrauterine device (IUD) insertion, dilatation and
curettage, and operative termination of pregnancy (TOP) that breach the protective cervical barrier and introduce bacteria
from the vagina or cervix directly into the endometrial cavity.

Front 55

How long does the risk of PID last with insertion of an IUD?

Back 55

Risks associated with IUD insertion have been shown
to be limited to the 4 weeks following insertion in women
at low risk of STIs.

Front 56

What is the 'gold standard' for diagnosis of PID?

Back 56

The ‘gold standard’ for diagnosis is laparoscopy,
however this is invasive, costly and impractical in addition to underestimating rates of mild disease that present without overt tubal hyperaemia, oedema and exudate.

Front 57

The Centre for Disease Control guidelines suggest treatment for PID in what patients with what signs and symptoms?

Back 57

The Centre for Disease Control guidelines suggest
treatment for PID when uterine/adnexal tenderness or
cervical motion tenderness is present in sexually active
young women at risk of STIs where no other cause is
identified.

Front 58

What are the common signs and symptoms of PID?

Back 58

Symptoms:
- Lower abdominal pain/discomfort.
- Vaginal discharge.
- Abnormal vaginal bleeding.
- Dyspareunia.

Signs:
- Lower abdominal tenderness/guarding/rebound.
- Adnexal tenderness or a mass.
- Cervical motion tenderness.
- Raised temperature.

Front 59

What is the differential diagnosis of lower abdominal and pelvic pain?

Back 59

- PID.
- Endometriosis.
- Ruptured ovarian cyst.
- Dysmenorrhoea.
- Ectopic pregnancy.
- Appendicitis.
- IBS.
- UTI.
- Gastroenteritis.

Front 60

What potential complications are there for patients with PID?

Back 60

- Tubal factor infertility (20%).
- Chronic pelvic pain (20%).
- Ectopic pregnancy (10%).

Front 61

What are the useful investigations for the management of PID?

Back 61

Microbiological tests for possible specific bacterial aetiology:
• Chlamdyia trachomatis PCR (vaginal self collected/first catch urine/endocervical).
• Neisseria gonorrhoea culture (endocervical) or gonorrhoea PCR (vaginal/
cervical/urine) (beware false positives).
• Endocervical swab microscopy/sensitivity/culture.
• High vaginal swab and wet mount or gram stain
• Bacterial vaginosis: vaginal pH and ‘whiff’ test

Tests to assess severity:
• Full blood count.
• ESR or C-reactive protein.

Tests to exclude other causes of pelvic pain:
• Pregnancy test.
• Mid stream urine.
• +/- pelvic ultrasound.

Front 62

What does outpatient treatment of PID entail for young sexually active women with no predisposing factors?

Back 62

Azithromycin + Doxycycline + Metronidazole + Ceftriaxone.

Front 63

What does outpatient treatment of PID entail for post-procedural PID (including IUD insertion, operative TOP)?

Back 63

Doxycycline OR Amoxycillin
+
Metronidazole.

Front 64

In what circumstances would you consider hospital admission for PID?

Back 64

• Tubo-ovarian abscess is suspected.
• The patient is pregnant.
• Nonresponsive to oral antibiotic treatment.
• Unable to tolerate or follow outpatient oral regimen.
• Suffering severe illness (eg. nausea, vomiting or febrile).
• Surgical emergencies such as appendicitis cannot be excluded.