OB/GYN CASES History taking: - Vaginal discharge - Vaginal bleeding - Amenorrhea - Infertility Counselling: - OCPs - HRT - C-section (wants

to have c-section or wants to have vag delivery after c-section) - Abortion - 24 weeks pregnant anti-natal counselling - 36 weeks pregnant HTN/+++ ptn in urine counsel for pre-eclampsia - PAP smear; 16 years old wants to arrange for a PAP smear - PAP smear: 38 year old had abnormal PAP smear

History taking in OB/GYN: Introduction CC Analysis of CC Os Cf D COCA Blood HPI Associated symptoms Menstrual M Gynecological G Obstetric O Sexual S PMH FH SH

Notes: - Acute abdomen in a female: OCD / PQRST / / associated symptoms (GIT / genito-urinary) / LMP: o Missed period: ectopic o Bleeding: abortion o Discharge: PID - Premenstrual dysphoric syndrome: monthly mood disorders

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MGOS history questions: Menstrual: - When was your LMP? First day? Was your LMP similar to the previous ones? - Are they regular or not? How often do you have periods? - How long does it last? How many days? - How about the amount? Is it large / small? How many pads/day? Any blood clots? - Are your periods painful? [not painful anovulatory (PCOS/infertility)] - Any spotting between periods? - When was your first period? Was it regular? For how long it was not regular? Gynecological: - Do you have history or were diagnosed with any gynecological disease (polyps)? - Do you have history of pelvic surgery or instrumentation (e.g. D&C)? - Do you use contraception? What method? Since when? When was the last time? Screening: - Have you ever had Pap smear before? When was the last time? Any reason (if long time)? What was the result? - (>40 yrs) have you had mammogram done before? When? (Is it painful doctor? Could be; we need to apply pressure on the breast to get better image) - (>65 yrs) have you had your bone mineral density (BMD) done? Any reason? Obstetrical: - Have you ever been pregnant before? Any abortions (termination)? Or miscarriages (spontaneous abortion)? - Number of babies you delivered? Any twins? Any children with congenital abnormalities? - For each delivery: was it full term or pre-term? Vaginal or CS? Any complications like high blood pressure / high blood sugar? - Family history of: repeated abortions / CS / congenital anomalies / twins Sexual history: - With whom do you live? - If (alone / with family): are you in any relationship? Are you sexually active? Have you ever been sexually active? - If with partner: how do you describe the relationship? Is it stable? Are you sexually active? Do you practice safe sex, and by that I mean using condoms every time? For how long you have been together? (> 6 months stable). And before that, were you sexually active? - When did you start sexual activity? - How many partners have you had for the last 12 months? - What is your sexual preference? Men/ women/ both? What type of sexual activity? - Have you screened or diagnosed before with STIs? HIV? Vaginal discharge? - How about your partner? Any fever? Discharge? Burning sensation? - Do you feel safe in this relation?

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History of pregnant lady third trimester Are you doing regular ante-natal follow-up visits?

NO

Yes

Social issue

Deal with the social issue

Last visit history / pre-eclampsia

Make sure the mother is stable

Make sure the baby is stable U/S

When was your last f/u visit? What was your BP? Was there any headache? Was there leg swelling? Weight gain? Any abdominal pain? Cramps? Vaginal bleeding? Discharge? Any gush of water? Is your baby kicking like before? > 6 in 2 hrs Have you done your U/S? How many times? When was the last time? Number of babies? Location of the placenta? Amount of fluids?

N.B. to make sure the mother and baby are stable: ABCDE Activity of the baby Bleeding Contractions / pain Dripping / Discharge EDD (expected date of delivery)

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VAGINAL DISCHARGE Teenager / 5 minutes case Introduction CC Analysis of CC

HPI

AS

G O S PMH

How can I help you?! Os Cf D COCA Blood / color / fishy odour? - LMP / regular / how often / similar to previous ones? - Related to periods - Related to sexual intercourse (if yes: cervical!) - Any pain? With intercourse? Same system - Itching? Redness? ? Candida - Any blisters / warts / ulcers1? - Urine changes? Urinary symptoms? Nearby systems - Bowel movements changes? GIT symptoms - Abdominal pain OCD/PQRST - ? PID - Dissemination to liver - Constitutional symptoms DD - Sore throat? Mouth ulcers? Diff swallowing? - Red eyes? Swollen joints? Skin rash? - IUD - PAP smear! Complete sexual history for both partners - Any medications? Recent use of antibiotics - Allergies - DM How do you support yourself? SAD

FH SH

Blisters: HSN / warts: HPV / ulcers: syphilis

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VAGINAL BLEEDING Introduction CC Analysis of CC

Os Cf D COCA if large amounts anemia / dehydration symptoms - For the last few weeks, how do you distinguish between your M regular periods and the bleeding? Related to periods - LMP / regular / how often / similar to previous ones? - Related to sexual intercourse (if yes: cervical!) - First menstrual period? HPI - Any pain? With intercourse? Same system AS - Itching? Redness? - Any blisters / warts / ulcers? - Urine changes? Urinary symptoms? Nearby systems - Bowel movements changes? GIT symptoms - Abdominal pain OCD/PQRST (? PID) - Pelvic fullness / heaviness? - Constitutional symptoms DD - Bleeding disorders/ tendencies? - Blood thinners? Aspirin? - Thyroid problems? Symptoms? - Polyps / fibroids? G - Hx pelvic surgeries? Instrumentations? - Contraception history; OCPs / IUD / HRT - PAP smear! Was it normal? - Any previous pregnancies? Abortions? How O many? Route of delivery? - Number of partners / safe sex S - Hx of STIs PMH - Breast cancer / mammogram FH - Gynecological cancer SH - How do you support yourself? - SAD / HEAD SSS (if teenager) Vaginal bleeding cases: - Middle age / risky behaviour / old abnormal Pap smear cervical cancer. - A 52 years patient / constipation / HRT / no pregnancies2 endometrial cancer. - A 48 years patient with vag bleeding and all symptoms will be negative dysfunctional uterine bleeding (DUB); intermittent / no pain with periods. - A 62 years patient with intermittent bleeding / small amount / with secretions atrophic vaginitis; (menopausal symptoms / dyspareunia). Investigations: pregnancy test -HCG / progesterone challenge test / hysteroscope
2

Cervical cancer for prostitutes (risky behaviour) and endometrial cancer for nuns (no pregnancies)

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AMENORRHEA Introduction CC Analysis of CC M

HPI

AS

O S PMH FH SH -

Did not have periods for 6 months?! Did you seek medical attention? Any recent changes? During these 6 months; any irregular bleeding? Spotting? When was your first period? What age? Was it regular? For how long it was regular / not regular? When it was regular; was it painful? (painless anovulatory) Did you use any contraception? When did you stop? Why? Any chance you are pregnant? How do you know for sure? For how long have you been trying to get pregnant? Any nausea / vomiting / breast engorgement? Frequency? Any previous pregnancies? Abortions? Constitutional symptoms? Are you under stress? Hypothalamus Excessive exercise? Any concerns about your weight? (anorexia) Pituitary Any headache? Vomiting in the morning? Visual changes? Diff seeing to the sides? Milk secretions from breast? Hx of thyroid disease? Heat/ cold intolerance? Bowel movements? Moist/ dry skin? Do you have excessive hair growth? Acne? Ovarian Did you notice any weight changes? Hx of DM / thirsty / frequency? Fm Hx of PCOS? Hx of chemotherapy? Radiotherapy? Hot flushes? Vaginal dryness? Soreness? Any change in your voice? Muscle bulk? Uterine Any repeated surgical procedures? D&C? Pelvic surgeries? Instrumentations? PAP smear! Any previous pregnancies? Abortions? Hx of STIs Any medical conditions? Psychiatric illness? Any medications? Recent use of antibiotics Family hx of PCOS / infertility? How do you support yourself? SAD

Notes: Ovarian causes of amenorrhea: PCOS (poly-cystic ovarian syndrome) /+/ Premature ovarian failure /+/ Androgen-producing tumours In PCOS previous pregnancy / contraception hx Investigations: -HCG / progesterone challenge test / hormonal assay (estrogen / progesterone / FSH / LH / prolactin / thyroid) / U/S

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INFERTILITY Transitional statement before going in details with the history: In order for a couple to achieve pregnancy, both partners should be capable of having children and relatively healthy. For that reason, I am going to ask some questions about your health and your partner health; some of these questions are personal, but it is important to ask. And I would like to assure you that all the conversation is strictly confidential and I will not release any information without your permission! Introduction CC Analysis of CC HPI

PMH

FH SH

How long have you been trying to conceive? Obstetric O Husband Coital hx Menstrual M Gynecological G Sexual S - Secondary causes of amenorrhea AS - Rule out endometriosis - Rule out malignancy / chemotherapy / radiotherapy - Recent use of antibiotics - Allergies - DM Infertility

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COUNSELLING PRE-ECLAMPSIA 36 weeks pregnant lady comes for f/u visit, BP 160/110, +++ protein in urine, Manage. Introduction Ethical challenge: travel permission History Like the B12 results case I will discuss results with you Last visit history / pre-eclampsia Make sure the mother and baby are stable U/S Obstetric hx PMH / SAD Explain what is pre-eclampsia Serious concerns with pre-eclampsia Hospitalize If insisting to leave sign a LAMA

Counselling Management

Introduction - Good afternoon Ms I am Dr I understand that your blood pressure was measured and urine test was done, I have the results with me and I will discuss it with you. However, because this is my first time to see you, I need to ask you some questions, to get a better understanding of your health condition, is that ok with you? - Is this you first time to have these checks during your pregnancy? - Are you under regular follow-up? o Yes proceed to history o No any reason? My husband had a car accident! I am sorry to hear that; was he hurt? Was anyone else hurt? When was that? It must be difficult, how did this affect your life? Ethical challenge: travel permission o Actually I am here to get a note. - What type of notes? o Travel note, I really need to travel. - It looks like it is an important trip for you; usually pregnant ladies do not travel during this time of pregnancy! o It is a business trip that would save our financials. - I see it is important for you, however, before we proceed, let me check your health condition first, and I will start by asking you some questions: History Last visit history / pre-eclampsia - When was your last f/u visit? - What was your BP? Was there any headache? - Was there leg swelling? Weight gain? Did they do urine test? - How about before being pregnant? Any hx of high blood pressure?

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Make sure the mother and baby are stable: ABCDE - Activity of the baby, is your baby kicking like before? - Bleeding - Contractions / pain - Dripping / Discharge - EDD (expected date of delivery) U/S - Have you done your U/S? How many times? When was the last time? - Number of babies? - Location of the placenta? - Amount of fluids? Obstetric history: any pregnancy before / any similar conditions? PMH: high blood pressure / SAD Counselling Explain what is pre-eclampsia - Your blood pressure is 160/110, which is high, and the urine test shows protein in large amount (+++) which is not normal, the most likely diagnosis is a medical condition called pre-eclampsia OR pregnancy-induced hypertension. - I would like to ask more questions to see how it affected you! o My dad had HTN, and lived wit hit, I am ok. - These are different conditions; your dad had HTN, but you have pregnancyinduced HTN, which is a serious condition, with very serious and may be fatal consequences. o Have you had hx of headache? OCD / PQRST o Nausea / vomiting o Change in your vision? Flashing lights? Flying objects? o Any abdominal pain in your upper right part of your abdomen? o Any bruises? Yellowish discoloration / itching / dark urine / pale stools? o Any chest pain / heart racing / SOB? o Any weakness / numbness? o Any swelling in your body / face/eyes? Did you feel your shoes tight? o Did you gain weight? o Any changes in the urine? Frothy? Burning sensation? Based on all this, the most likely explanation for your increased is preeclampsia; and this is a very serious condition, we need to admit you to the hospital to monitor you. Then, the obstetrician will assess you and may consider delivering the baby now. o But doctor, I need to travel, just 2 days and I will come back. I understand your concern about traveling, but we have a serious situation here. What is your understanding about pre-eclampsia? We do not know exactly why patients have pre-eclampsia. We believe it is imbalance of hormones, or it might be related to placenta, however the only treatment is delivering the baby.

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Serious concerns with pre-eclampsia - What happens is that there is a narrowing of blood vessels, this leads to the amount of blood reaching the baby, subsequently the amount of oxygen and nutrients. On the long term this will lead to some injury and even damage to the baby AND the mother. o This includes your heart and blood vessels, that is why you have BP, o This includes your kidney, that is why you have +++ protein in urine, o This includes your liver, that is why you may have abdominal pain, o This includes your brain, that is why you have headache, visual changes, o This includes your baby, that is why he is not kicking like before This is not because of your pregnancy; all of these are due to this condition. The concerns we have is that we can not predict the outcome, without the proper medical care, patients having pre-eclampsia will end up going to the next stage which is eclampsia; any idea what is eclampsia? A condition in which, the patient will start to seize, lose conscious, will not be able to breath and turn blue. The only resolution for this is delivering the baby. Imagine that I give you the note, and they allow you to take the trip, 2 hours later while you are in the plane, you start to fall down and seize. What will happen? Nobody will be able to help you. By this you endanger your life and your babys life.

Management - What we need now is to admit you to the hospital and arrange for obstetrical assessment. - If insisting to leave sign a LAMA (leaving against medical advice) - Try to suggest solution for her business travel, like giving a sick note that she needs to be hospitalized.

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CAESAREAN SECTION COUNSELLING wants to have CS Young 18-20 years old pregnant lady would like to have CS, counsel her. Introduction Any reason you want to have CS? History

Counselling Management

Social issue Last visit history / pre-eclampsia Make sure the mother and baby are stable U/S Obstetric hx PMH / SAD Address patient concerns Why not caesarean section? Refer to obstetrician Spend some time to think / stabilize

Introduction Any reason you want to have CS? - I understand that you are here to discuss the possibility of CS; we will discuss this in details, but before that I would like to ask you is there any reason you would like to have CS? o I do not want to have this severe pain! - How do you know it is painful? o I had previous abortion OR o I attended my sister delivery and it was very painful experience - When was that? Did you attend? o Congratulations! How is your sister doing? How is the baby? o I understand that you saw her in pain, but people differ! And within few minutes I will be explaining different options to control labour pains! History - Let me ask you some questions to assess the condition first! o How do you feel? How is your mood? o Are you under regular follow-up? NO! Any reason? There may be social issue here. Empathy: it looks like you are doing through difficult times! How are you coping? Offer social support: being pregnant lady without support, you have priority and there are a lot support and resources in the community. I will make sure to connect you with social worker who will help you with proper support (housing / financially / for both of you and the baby)

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Last visit history / pre-eclampsia - When was your last f/u visit? - What was your BP? Was there any headache? - Was there leg swelling? Weight gain? Did they do urine test? - How about before being pregnant? Any hx of high blood pressure? Make sure the mother and baby are stable: ABCDE - Activity of the baby, is your baby kicking like before? - Bleeding - Contractions / pain - Dripping / Discharge - EDD (expected date of delivery) U/S Have you done your U/S? How many times? When was the last time? Number of babies? Location of the placenta? Amount of fluids?

Obstetric history: - Any pregnancy before? Any abortions or miscarriages? - What were the circumstances? How many weeks? - How did you feel about it? How did you cope with that? PMH: SAD

Counselling Address patient concerns - I know that you are here to talk about CS. But first let me explain some facts about delivery. The natural route for delivery is the vaginal delivery, and if there is no real indication for CS we do not like to it. - However, I appreciate you concerns, if your concern is the pain there is a lot of options to control it. o We can start by learning some relaxation techniques o And then on the delivery day, when you go there, there are a lot of support groups; one of them is called doolas; they attend with you and they provide a lot of emotional support o Finally, when you start your labour, we have good measures; and I mean what we call epidural anesthesia; this is very effective and safe. Where the anesthesiologist puts a needle into your back and injects a freezing substance that helps you to go through the delivery without pain (this is like the dentist freezes your mouth before doing painful procedures). It might however cause headache, bleeding, and less likely infection.

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Why not caesarean section - I would like to ask you; what is your understanding of CS? - It is commonly used obstetrical intervention, used when there is a problem or contraindication for vaginal delivery and if there is an emergency situation that necessitates immediate delivery; and in these cases it is life saving; for both the mother and the baby! - However, it is a major surgery, has the risks of bleeding, higher risk of infection, and you stay longer in the hospital, and it will leave minor scar in your abdomen. Management - After all, I am not the person who makes the decision; this should be decided by the obstetrician. - I am going to refer you to the obstetrician; who will perform further and detailed assessment then discuss the results with you. - Meanwhile, I would recommend you spend some time to think about what I told you, try to stabilize yourself emotionally. I will give you some brochures and web sites so that you can read more about that. I will connect you with the social worker. And if at any time you have any questions or concerns, you can come to see me.

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CAESAREAN SECTION COUNSELLING does not want to have CS Middle aged pregnant lady (36 weeks) is here to have her file. Three years ago, she had urgent CS for cord prolapse. Now she would like to deliver at home with the midwife. Introduction Any reason you want to have your file?

History

Counselling Management

Concern Deal with the patient concern What was the type of your CS? Last visit history / pre-eclampsia Make sure the mother and baby are stable U/S Obstetric hx PMH / SAD What is CS? The two types of CS Risks of vaginal delivery post CS Prepare a copy of the file Speak with your midwife

Introduction Any reason you want to have your file? - I under stand that you are here to have a copy of your file for the urgent CS you had 3 years ago. This is your right, and I will ask someone to prepare a copy for you. - But first I would like to ask you some question, is it ok with you! - Is there any reason you would like to have your file? o Yes, I would like to have delivery at home this time. A lot of my friends did it at home with the midwife and they say it is much easier and relax. - Are you seeing obstetrician? Are you doing any regular follow-up visits? Any reason for that? o No, I am going to follow up with the midwife. o I did not like last time when they did CS at the hospital! - What happened last time? o They told me the baby had cord prolapse! - Were there any consequences? o How is the baby doing? How old is he? What can he do? Walk? Talk? o How about you? Any complications? Infections? Scars? Deal with the patient concern: - What is your understanding of cord prolapse? - It is a condition where the umbilical cord goes into the birth canal before the head, and then gets stuck and squeezed by the head. - This is a very serious condition. The cord delivers blood and nutrients to the baby. If blocked for long time, the baby will suffer from brain damage. - That is why they had to do urgent CS, which was a life saving procedure for the baby, and it had to be done immediately. - Do you know what the type of your CS was? Classical!

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History - I understand your point of view, but first let me ask you some questions about your health and your pregnancy! Last visit history / pre-eclampsia - When was your last f/u visit? - What was your BP? Was there any headache? - Was there leg swelling? Weight gain? Did they do urine test? - How about before being pregnant? Any hx of high blood pressure? Make sure the mother and baby are stable: ABCDE - Activity of the baby, is your baby kicking like before? - Bleeding - Contractions / pain - Dripping / Discharge - EDD (expected date of delivery) U/S Have you done your U/S? How many times? When was the last time? Number of babies? Location of the placenta? Amount of fluids?

Obstetric history: - Other than the pregnancy that you had CS 3 years ago; any pregnancy before? Any abortions or miscarriages? PMH: SAD

Counselling What is CS? The two types of CS - I would like to ask you; what is your understanding of CS? - It is commonly used obstetrical intervention, used when there is a problem or contraindication for vaginal delivery and if there is an emergency situation that necessitates immediate delivery; and in these cases it is life saving; for both the mother and the baby! - There are two types of CS: o The transverse (done at the lower segment of uterus); it is the most common type; its advantages include: smaller scar and better healing. o The classical or vertical type; it is done less common; as we cut through the muscle fibers of the uterus it produces weaker scar; but it is indicated and actually needed in urgent case, like yours. As it allows quick access and fast delivery, because in some cases (like cord prolapse) we can not afford even few minutes more.

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Risks of vaginal delivery post CS - Due to the scar formed after the CS procedure; it is always recommended to deliver by CS, to avoid the tearing pressure of the uterine contractions during vaginal delivery. - If you decide to go for vaginal delivery, my concern is that the scar might undergo severe tearing pressure and might rupture. This is an obstetrical emergency that necessitates immediate intervention. - I do not want to scare you, but the risks of having uterine rupture after classical CS is 12%, of which 10% of cases end up losing their lives. - For that reason: once classical CS, it is always CS. In case of counselling transverse CS: - Risks of having uterine rupture after transverse CS is 1%. - Even though, if you want to try vaginal delivery, we can do this in the hospital, so that just in case any emergency might happen, we can intervene in the proper time.

Management - I will ask someone to prepare a copy of your file - Speak with your midwife: - I am sure that your midwife is highly trained and qualified, and we share the same guidelines. I would recommend that you take your file and speak with your midwife, and I am sure she will explain the situation to you. I will give you some brochures and web sites so that you can read more about that. And if at any time you have any questions or concerns, you can come to see me.

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OCPs / CONTRACEPTION COUNSELLING Introduction Concerns

Available methods

History

What do you know about contraception? Available methods? Any concerns? Any previous contraception? Definition: birth control is an umbrella term for several techniques and methods used to prevent fertilization Hormonal (OCPs / implants / injections) IUD (contragestion: prevents the implant) Barrier methods (condoms / diaphragms) spermicidal Behavioural (fertility awareness/timing) / coitus interruptus Post-coital contraception Sterilization (male / female) Menstrual: ? Painful periods / ? irregular Gynecological Obstetrical: IUD is not recommended in nullipara Sexual: if risky behaviour OCPs will not protect against STIs
Contraindications Pregnancy Un-dx vag bleeding Cerebro-vascular disease / CAD Active liver disease Hormone-dep Ca Smoker > 35 yrs Hx of DVT Migraine Pregnancy Un-dx vag bleeding Structural uterine anomalies Hx of PID(s) Risky behaviour Hx of ectopic pregnancy NO absolute contraindications Side effects Breast tenderness Weight gain Headache Nausea risk of DVT Available Combined pills (E+P): low dose estrogen (20, 35, 50)
Failure rate

Advantages OCPs Regulate periods Menstrual pain Benign breast lesions Ovarian cysts Longevity Independence to coitus or compliance Dysmenorrhea Effective Independence Longevity Effective Independence to coitus or compliance -

0.1% 5%

IUD

- Heavy periods - Copper - If hormonal coated: prog side - Hormone effects: headache / wt gain / coated mastalgia

0.6% 2%

IM Injection SC implants

Un-dx vag bleeding Acute liver disease Thrombophlebitis Thromboembolic disease

Irregular bleeding Amenorrhea after 1 year Delayed post-use fertility Irregular bleeding Headaches Mood changes

Every 3 months Every 5 years

< 1%

< 1%

Condoms
Diaphragm
Behavioural

14% 20% - High failure rates up to 25% - To decrease the failure rate, can combine 2 methods

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FAQ: Failure rates are very high with behavioural methods: o Because it depends largely on the knowledge, experience of user and the usage technique; perfect-use versus typical-use failure rates. What happens if I missed 1 or 2 pills (OCPs)? o 1 missed pill take 2 pills the next day o 2 missed pills take 2 pills a day, for the next 2 days o If missed more than 2 consecutive pills: use a backup method of contraception simultaneous to finishing up packet of pills (2 pills a day) until next menses Woman comes to request sterilization (tubal ligation) 1- Discuss various other alternatives, make sure she knows everything about all of them (OCPs, IUDs, diaphragm, condoms, vasectomy) 2- Counsel the patient on the permanent nature of the procedure, the operative risks, and the chance of failure (1 in 200)
Counsel about the risks of regret for the decision (young age, recent emotional trauma, family coercion)

3- Bring the patient back after 1 month for the bilateral tubal ligation procedure, preferably immediately after menstruation to decrease possibility of pregnancy

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HRT COUNSELLING Introduction / overview Symptoms and effects of menopause Forms of therapy Indications for hormone therapy Contraindications to hormone therapy Pre-treatment evaluation Hx / PE / baseline investigations Adverse effects and risks of hormone therapy Uncertain effects of hormone therapy Effect on (cardio-vascular diseases / ovarian cancer / dementia and cognition) is considered protective but needs proof Introduction / overview: - The reproductive years of a womans life are regulated by production of the hormones estrogen and progesterone by the ovaries. Estrogen regulates a woman's monthly menstrual cycle and secondary sexual characteristics (e.g. breast development and function). In addition, it prepares the body for fertilization and reproduction. Progesterone concentrations rise in a cyclical fashion to prepare the uterus for possible pregnancy and to prepare the breasts for lactation. - Toward the end of her reproductive years when a woman reaches menopause, circulating levels of estrogen and progesterone decrease because of reduced synthesis in the ovary, which may lead to several symptoms, the severity of which can vary widely. - Hormone therapy (HT) involves the administration of synthetic estrogen and progestogen. HT is designed to replace a woman's depleting hormone levels and thus alleviate her symptoms of menopause. However, HT has been linked to various risks, and debate regarding its risk-benefit ratio continues Common presenting symptoms of menopause: - Irregular menstrual cycles - Vasomotor symptoms: sweating / hot flashes (hot flushes) / palpitations - Uro-genital symptoms: vaginal dryness / soreness / superficial dyspareunia / urinary frequency and urgency - Neurologic symptoms: mood changes / insomnia / depression / anxiety Forms: - Local preparations: creams / pessaries / rings - Systemic formulations: oral drugs / trans-dermal patches and gels / implants Hormonal products available may contain the following ingredients: - Estrogen alone - Combined estrogen and progestogen - Selective estrogen receptor modulator (SERM) - Gonadomimetics, which contain estrogen, progestogen, and an androgen

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Indications of HRT: - Vasomotor symptoms: sweating / hot flushes / palpitations. The effectiveness of this treatment was proven in placebo-controlled randomized studies. - Uro-genital symptoms: both topical and systemic estrogens have been shown to improve the menopausal symptoms of vaginal dryness, superficial dyspareunia, and urinary frequency and urgency. Achievement of these beneficial effects requires long term therapy. Symptoms may recur after HRT is stopped. - Osteoporosis: one in 3 postmenopausal women develops osteoporosis. HT is commonly prescribed to help prevent this condition, and HT appears to be particularly effective if it is started during first 5 years after onset of menopause. Contra-indications of HRT: No absolute contraindications of hormone therapy have been established. However, HT is relatively contraindicated in certain clinical situations: - A history of breast cancer - A history of endometrial cancer - Severe active liver disease - Hypertriglyceridemia - Thromboembolic disorders - Undiagnosed vaginal bleeding - Endometriosis / Fibroids Required baseline investigations - CBC Urinalysis - Evaluation of fasting lipid profile Measurement of blood sugar levels - Electrocardiography - Pap test - Ultrasonography to measure endometrial thickness and ovarian volume - Mammography - Determination of serum estradiol levels / serum follicle-stimulating hormone (FSH) levels. Possible adverse effects are as follows: - Nausea Bloating - Weight gain (equivocal finding) Fluid retention - Mood swings (associated with use of relatively androgenic progestogens) - Breakthrough bleeding - Breast tenderness - HT may slightly increase the risk for breast cancer - There is association between HT and uterine hyperplasia and cancer - There is increased risk of thromboembolism with HT

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NEEDLE STICK COUNSELLING - HIV You are about to see Mrs 33 years old female nurse, upset because she had just had needle stick after she gave an IV injection to a patient. Counsel her. Introduction Concerns HIV infection / fatal disease / will impact her family History - Can you tell me what happened? - Complete immunization record, including tetanus and hepatitis B - Previous occupational exposure to body fluids - Intravenous drug abuse - Sexual history Inform the - What is HIV? Major pathogens of concern! patient First of all; let me tell you the transmission rates: (no accurate studies) about HIV - Risk of blood tx is: 0.3% for percutaneous exposure - Risk of female to male tx is: 0.03% - Are you pregnant? Risk of intrauterine tx is: 3% with treatment and 30% without treatment - Advancement of HIV treatment Address pregnancy concerns: - Patient should receive ttt (not teratogenic) - HIV positive mothers should not breastfeed their babies Plan - I will speak with the patient, explain the whole situation and ask him to consent for HIV status - If he agrees; we will know possibility of tx to you. If he is HIV negative, NO post-exposure prophylaxis is needed - If he refuses or if he is HIV +ve; we will have to assess what is called exposure code and match it with HIV status code; to simplify this, guidelines state we should assume you were exposed and give prophylaxis treatment: 4 weeks of 2 anti-virals (the basic regimen) Workup - Blood tests for the patient if possible and for the exposed - I am going to speak with the patient now, and I will come back to you with his decision. - Any other questions or concerns? What is HIV? - Human immunodeficiency virus (HIV) is a blood-borne, sexually transmissible virus (see the image below.) The virus is typically transmitted via sexual intercourse, shared intravenous drug paraphernalia, and mother-to-child transmission (MTCT), which can occur during the birth process or during breastfeeding. - The major pathogens of concern in occupational body fluid exposure are HIV, hepatitis A, hepatitis B, hepatitis C, and hepatitis D. These pathogens are viruses that require percutaneous or mucosal introduction for infectivity. The major target organs are the immune system (HIV) and the liver (hepatitis).

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Advancement of HIV treatment: - It used to be fatal - Currently, it is not cured, but controllable, may be in the future they can develop a cure to it - A lot of anti-virals were developed since 1990s till now, with efficacy and side effects, we started by giving many pills q4h, now it is once or twice a day - We follow the guidelines with monitoring of what is called viral load and cell counts of the patient immunity cells. To decide when to start treatment Workup: - Source patient (if available) o HIV o Hepatitis B antigen o Hepatitis C antibody - Victim/health care worker o HIV; testing now, at 1 month, and at 3-6 months o Hepatitis B surface antibody o Hepatitis C antibody; testing at 2 weeks, 4 weeks, and 8 weeks - Prior to initiating retrovirals: o Pregnancy test (stat) if she is not pregnant o CBC count with differential and platelets o Serum creatinine/BUN levels o Urinalysis with microscopic analysis o AST/ALT levels / Alkaline phosphatase level o Total bilirubin level The ethical questions that might arise: - We can solve all this by calling the lab and adding HIV status check for the list of blood works of the patient, we had just send his blood to the lab! o You are right, this will save us the whole prophylaxis plan, however, we need to speak to the patient first; we can not do this HIV status test with the patient knowledge and consent. o What I am going to do to help you is that after we finish, I will go to speak with the patient, explain the whole situation to him, and ask his permission that we do this HIV statue test. - Even if the patient refused, we can ask Dr , his surgeon, may be he knows! o May be Dr knows the patient status or may not, but if the patient refuses to let us know, it is patient confidentiality, we can not ask Dr about this information unless the patient consents we can ask the surgeon.

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Counselling PAP smear Introduction CC I understand you are here because you have some inquiries/worries about your last PAP test, is this right? How can I help you today? HPI MBP DdoUyouCsee SOOS: Menstrual history /+/ Bleeding /+/ Pain /+/ Discharge (vaginal) /+/ Urinary symptoms /+/ Contraceptive history /+/ Surgical / hospital / procedures (including PAP tests) /+/ Obstetrical history /+/ Others: breast / axilla / inguinal region /+/ Sexual history RISK factors for cervical dysplasia: - Early age of sexual activity - Risky behaviour: unprotected sex / multiple partners - Smoking AS Constitutional symptoms PMH If teenager: HEAD SSS FH Gynecological tumours SH COUNSELLING: - What do you know about ? What would you like to know? - Have you had any experience with in the past? - Have you [read / talked to someone / searched the internet] about this issue? Worried about PAP results - PAP smear or test is done to screen for any changes that might happen in the cervix, before it turns to serious disease (to early detect pre-malignant lesions). - For LG-SIL (low grade squamous intra-epithelial lesion), OR for HG-SIL (high grade squamous intra-epithelial lesion), we will refer you to the gynaecologist who will perform a colposcopy, during this procedure, the gynaecologist will take a biopsy, and send it for further investigations; o If the biopsy is negative, we will repeat the PAP after 6 months o If the biopsy is positive, we will do more investigations to establish a diagnosis and may need to do another larger biopsy called cone biopsy Colposcopy Colposcopy is a magnification of the cervix (10-12 times), the procedure may cause some discomfort but is not painful. The gynaecologist will insert a speculum (the same instrument used for PAP test), then she/he will use a special magnification device (the colposcopy) to visualize the cervix, the gynaecologist will apply acetic acid (vinegar) that helps make the vascular patterns more visible, application of this acetic acid may give an itchy sensation, then if the gynaecologist suspects a lesion, she/he will need to take a biopsy, you will feel a punching sensation, and you might experience a little discomfort and spotting for few days. You need not to have anything inserted into your vagina for 24 hours before and 2 days after the procedure (no vaginal intercourse, no douching), and you might need to take some OTC medications (Advil) for few days after the procedure.

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General template history taking in any Ob/Gyn case ID: CC: HPI: Good evening Mrs I am Dr , I understand you are here for , is this right? How can I help you today? Analysis of the CC: o OSCD (onset, setting, course, duration) o COCA (colour, odour, contents/consistency, amount) Associated symptoms (OB/GYN screening) MBP DdoUyouCsee SOOS o Menstrual history o Bleeding o Pain o Discharge (vaginal) o Urinary symptoms o Contraceptive history o Surgical history / procedures (including PAP tests) o Obstetrical history o Others: breast / axilla / inguinal region o Sexual history Differential diagnosis: o o o

+ Review of systems / fever / energy / weight changes + Social history: - Occupation, place of living, family life and support - ONLY for teenagers: DESS; diet, education, suicide, sex - SAD: o Smoking o Alcohol o Drugs (street drugs) + Surgical history / procedures / hospitalization / injuries or trauma + Medications history /+/ Allergies + Family history

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