Download Emergency or Postcoital Contraception – Ze

INDEX CASE WEEK 1
Emergency or Postcoital Contraception – Ze
Four methods available:
1. 1.5 mg levonorgestrel (Postinor)
 Single dose, or two 750 ug doses, 12 hours apart
 Available without prescription
 Alternative method is 25 minipills (30 ug levonorgestrel) twice, 12 hours apart
 85% effective
 $27.99
2. 50 ug ethinyl oestradiol/250 ug levonorgestrel (Yuzpe method)
 Two doses 12 hours apart
 Taken with anti-emetic
 Significant side-effects (nausea/vomiting)
 75% effective
 Not available commercially anymore. 2xCOCP = 1 dose
 COCP only available on prescription
3. Copper IUD
 Not if woman is nulliparous, due to cervical trauma and possibility of infertility
 Invasive procedure, relatively long-lasting
 90% effective
 Approx. $100, plus $51.50 cost of insertion under MBS
All methods are more effective the earlier they are administered. Can be used up to 120 hours after
unprotected sex, but recommended within first 72 hours.
If vomiting occurs, within two hours, the regime must be started again.
Methods are designed to prevent implantation.
In some countries mifepristone (RU486) is used. Can be as emergency contraception or abortive
agent.
Drugs and Foetal Development
Alcohol
 No known safe levels in pregnancy.
 Heavy consumption (>12 standard drinks a day) associated with:
o Foetal growth restriction
o Developmental delay and neurological complications in baby
o Foetal Alcohol Syndrome (FAS): set of characteristics including low set ears,
elongated midface, small head and upturned nose, skeletal and cardiac
malformations. They are usually smaller. Incidence is compounded by smoking and
other drug abuse.
 No known safe levels in pregnancy. Although 7 standard drinks, with no more than 2 in one
day does not appear to have any damaging effects on foetus.
 Limit consumption particularly in the first trimester, where there concern over
neurodevelopment (especially with numerical problem solving and reading proficiency).
Effect seems to be dose dependent.
Heroin and other opiates
 Passed through placenta. When mother feels withdrawal symptoms, so does the baby –
increases chance of:
o Premature birth
o Spontaneous miscarriage
o Still birth
 Intra-uterine growth restriction (IUGR)
 Sharing needles increase chance of Hep C and HIV
 Heroin not directly associated with physical abnormalities (apart from growth restriction)
 The unknown substances it is ‘cut’ can be harmful.
 Following delivery, the baby should be monitored for signs of drug withdrawal:
o Restlessness
o Tremors
o High-pitched screaming
o Yawning
o Sweating
Tobacco
 During pregnancy increases chance of:
o Spontaneous abortion
o Low birth weight
o Premature birth
 After birth, increases risk of SIDS and respiratory
conditions in the baby
Cocaine and amphetamines are very harmful to developing foetus - especially in the first trimester
where organogenesis occurs.
Cocaine (heavy use)
 Intra-uterine growth restriction (IUGR)
 Placental abruption
 Stillbirth
 Developmental delays
Amphetamines (heavy use):
 Cleft palate
 Hypertension and preeclampsia
 IUGR
 Premature delivery
The Menstrual and Ovarian Cycles (Caroline)
Definitions:
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Menstruation: the cyclic uterine bleeding occurring in women of reproductive age, usually
lasting 3 -7 days with average menstrual blood loss being 80 mL. The menstrual cycle lasts
between 24-35 days (average, 28).
Menarche: the onset of menstruation, usually occurring at about 12 years (normal range 816 years).
Menopause: menstrual cessation, usually occurring at about 51 years (normal range 45-55
years).
Luteinising hormone (LH): released by pituitary; stimulates ovarian androgen production by
ovarian theca cells.
Follicular stimulating hormone (FSH): released by pituitary; stimulates follicular development
and aromatase activity (required to convert ovarian androgens to oestrogens in the ovarian
granulose cells; stimulates release of inhibin from ovarian stromal cells, which inhibits FSH
release.
Progesterone:
Oestradiol:
Dysmenorrhoea: painful menstrual cramps of uterine origin, affection up to 50% of women.
Menorrhagia: abnormally heavy menstrual bleeding (>80mL per period).
Amenorrhoea: the absence or cessation of menstrual periods.
Oligomenorrhoea: the reduction in number of menstrual periods and/or amount of
menstrual flow.
Phases of the menstrual cycle:
1. Menstrual phase (day 1 to ~4): period of shedding of endometrial lining.
2. Proliferative phase (end of bleeding to ovulation, day 4-14): endometrial thickening and
ovarian follicular maturation occurs.
3. Secretory (luteal) phase (ovulation to end of cycle): endometrial lining is maintained by
progesterone and oestradiol. If plantation does not occur progesterone levels fall and cycle
begins again.
Phases of the ovarian cycle:
1. Follicular phase:
a. Recruitment of follicles (days 1-5): about 200 follicles start to develop for the next
cycle.
b. Selection of follicles (days 5-8): selection of the dominant follicle occurs as the other
follicles apoptose.
c. Dominance (days 8-14): dominant follicle secretes the most oestradiol, plus some
inhibin α and β to balance FSH production.
2. Ovulation (day 14): about 36 hours after LH surge (caused by change to positive feedback
system with GnRH) follicle ruptures and ovum is expelled. Corpus luteum remains in the
ovary and secretes progesterone and some oestradiol.
3. Luteal phases:
a. Dominance (days 14-25): corpus luteum maintains endometrial cells in case a
fertilised ovum reaches the uterus by secreting progesterone and some oestradiol.
b. Regression (days 25-28): corpus luteum regresses to form the corpus albicans if the
ovum is not fertilised
STI Screening
Common STIs
Disease
Diagnosis
Notification
Chlamydia
Swab tests (samples from endocervix, urethra) for culture,
YES
immunofluorescence and PCR
First catch urine PCR or LCR (ligase chain reaction) – may
give false positives
Genital herpes
PCR from swabs or scrapings of lesion (≈100% sensitivity) ±
NO
culture (slower, more difficult and more expensive)
Gonorrhoea
Culture – swabs from site (endocervix, urethra, throat,
YES
abscess, etc.) - Gram stain useful (gram negative
intracellular diplococci; culture confirms
Urine PCR
Should also test for Chlamydia
Syphilis
Primary: biopsy of chancre – dark field microscopy (for
YES
spirochetes)
Secondary/Tertiary: serology (TPHA, VDRL, RPR) ± CSF if
possible neurosyphilis
All pregnant women should be screened antenatally (RPR
to screen, TPHA to confirm)
HPV
Direct examination
NO
Histological examination (exclude malignancy if suspicious)
HIV/AIDS
HIV antibodies (ELISA) – screening test: antibodies appear
about 3 months after infection
Antigen testing – PCR, Western blot assay and culture
Viral load and CD4 count to monitor
Note: contact tracing is essential for all STIs; only some require notification by law
YES
Syphilis Serology
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TPHA (T. pallidum haemagglutination assay) – Dx first infection (still +ve after Rx)1; specific
for syphilis
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VDRL (venereal disease reference laboratory) or RPR (rapid plasma regain) – regain tests;
useful in follow up Mx; non-specific (can get false positives) but fall in titre or become nonreactive after Rx
Screening
Population
Screen
Asymptomatic heterosexual
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First void urine - chlamydia PCR
man
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Serology – Hep B, syphilis, HIV
Asymptomatic homosexual
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Anal, throat, urethral swabs for gonococcal culture
man
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First void urine for chlamydial PCR
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Serology – Hep B, A, syphilis, HIV
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Endocervical swab or first void urine for chlamydia PCR
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Serology – Hep B, syphilis, HIV
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Pap smear
High risk asymptomatic
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Endocervical swab or first void urine for chlamydia PCR
women
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Serology – Hep B and C, syphilis, HIV
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Pap smear
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Vaginal swab for trichomonas
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Endocervical swab for gonococcal
Asymptomatic women
(e.g. sex workers)
1
and swabs for chlamydia PCR
May be negative in very early infection or immunodeficiency (HIV)
Management
Chlamydia
 Mx
o Erythromycin 800mg BD or Doxycycline 100mg BD for 10d or Azithromycin 1g single
dose
o If PID is suspected, azithromycin 1g single dose and metronidazole 400mg BD 10d +
doxycycline 100mg BD for 10d
o Check for other STI (especially Gonorrhoea)
Gonorrhoea
 Mx
o Penincillin
o If resistant (Neisseria gonorrhoeae)
 Ceftriaxone 250mg IM single dose
 Amoxycillin 1g single dose OR
 Spectinomycin 2g single dose OR
 Ciprofloxacin 500mg single dose
o Follow-up 1w
Syphilis
 Mx
o
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Procaine penicillin 1.2mg (IM) for 12d OR
Doxycycline 100mg BD for 14d
Erythromycin 500mg QD for 14d
Genital Herpes
 Mx
o Primary infection
 Acyclovir 200mg PD OR
 Valaciclovir 500mg BD – both can cause headache and nausea
 Lignocaine 2% jelly + analgesia
o Recurrent infection
 Acyclovir 200mg TD (400mg BD)
 Valaclovir 500mg daily
 Famciclovir 250mg BD 3-4 months
Genital Warts
 Mx
o CIN grading via pathology
o Podophyllin/5-fluorouracil/interferon/imiquimod
o Cautery/Laser/Cryotherapy
o Excision
Bacterial Vaginosis
 Mx
o Metronidazole 400mg BD for 5d or single dose of 2g
HIV/AIDS
 Treatment
o Rising viral load with lowered lymphocyte counts indicates the need to start on antivirals
o Combination of many antivirals
 2 nucleoside analogue reverse transcriptase inhibitors: zidovudine or didinasine
 1 non-nucleoside reverse transcriptase inhibitor: nevirapine
 1 protease inhibitors: nelfinavir
o Co-trimoxazole for PCP
Prevention
Abstinence is the key but if sex is a priority, a few tips can be recommended:
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Have sex with someone who doesn’t have STIs.
Practice safe sex e.g condoms.
Limit the number of sex partners.
Scrutinise or screen your partner.
Wash genitals with soap and water and urinate soon after you have sex.
Contraception
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Pills
◦ combined pill (oestrogen + progestogen)
▪ 21 hormone pills, 7 sugar pills
▪ takes 1-12 days before effect
▪ 99.7% effective if taken correctly daily
◦ mini pill (progestogen)
▪ 28 mini pills, no sugar pills
▪ takes effect after first 3 pills
▪ 99.7% effective if taken correctly daily
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Fit and forget
◦ contraceptive injection (Depo Provera)
▪ synthetic progestogen injected every 12 months
▪ prevents ovum release, thickens mucus
▪ 99.7% effective, 97% with late injections
▪ period irregularity and hormonal changes possible (breast tenderness, weight
changes, headaches, mood changes, etc.)
◦ contraceptive rod (Implanon)
▪ soft subcutaneous rod containing progestogen
▪ >99.9% effective
▪ period irregularity and hormonal changes possible
◦ IUDs (copper and hormonal)
▪ small plastic device with nylon string placed in uterus
▪ >99% effective
▪ lasts 5-10 years
▪ possible higher risk of infection
◦ vaginal ring (NuvaRin)
▪ flexible ring containing oestrogen + progestogen
▪ sits inside vagina for 3 out of 4 weeks
▪ 99.7% effective if used correctly every time, 92% otherwise
▪ possible smoking and medication reactions
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Barriers
◦ diaphragm
▪ rubber cap covering cervix
▪ 94% effective if used correctly every time, 85% otherwise
▪ must be fitted by experienced doctor or sexual health nurse
◦ female condom
▪ soft, polyurethane barrier inside vagina
▪ reduces STI risk
▪ 95% effective if used correctly every time, 79% otherwise
▪ family planning clinics and some chemists
◦ male condom
▪ reduces STI risk
▪ 98% effective if used correctly every time, 85% otherwise
▪ supermarks, chemists, etc. (inexpensive)
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Other
◦ natural family planning
▪ e.g. calendar-based, symptoms-based (body temperature, cervical mucus,
cervical position) and lactational amenorrhoea
▪ 75-95% effective
▪ avoiding sex at time of ovulation
▪ natural, cheap, acceptable in all religious beliefs
◦ sterilisation (vasectomy / tubal ligation / tubal occlusion) – permanent
▪ >99% effective
▪ tubal ligation effective immediately
▪ vasectomy and tubal occlusion are minor 15-minute procedures
▪ no protection from STIs
◦ emergency contraception (see above)
Ethical issues involving minors, homelessness and prostitution
These minors can be classified as
 drug dependent youth
 street kids
 homeless youth
 sexually exploited youths (often by drug dealers)
ETHICAL ISSUES
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Competency and legal status
As minors they are not legally capable of running their own affairs. This is left to other adults
who act as guardians for them. With parents/guardians having unlimited authority over
them, they have limited legal rights and this causes them to be especially vulnerable. Their
lack of rights can mask the ways adults may abuse and exploit them, leading to other issues
such as child poverty, lack of education and child labour.
Vulnerability
Minors are physically smaller and weaker when compared to adults. Having less experience,
they are more easily influenced are also more easily coerced into doing actions they do not
wish to do.
Economic weakness
Children are inherently economically weak because of their legal ‘minor’ status. Their lack of
employability (physical strength and job experience) also limits their opportunities to
income. While some children may be trafficked for the purpose of exploitation e.g.
prostitution or slavery, others may enter such trades for financial reasons.
Work relationships
Some relationships are complicated as the girl’s ‘boyfriend’ may act as a pimp, living off her
earnings and protecting her while she works. While only a few years older than the girl, they
expect her to work to support their drug habits. These relationships point to more complex
issues concerning exploitation or procuration.
Background of sexual abuse
It has been established that most women who turn to prostitution have had a history of
sexual abuse. This has led these women to believe that sex is a means of attracting male
attention. These young women are reportedly often unable to differentiate between
appropriate and inappropriate sex. Youth workers estimate that majority of young people
they work with, especially in St. Kilda, are victims of incest or at least inappropriate sexual
conduct by someone known to them.
Potential for further sexual abuse
Because the more dangerous forms of sex work are illegal and the juveniles are working
illegally anyway, sex workers lack redress to the law when they are the victims of sexual
abuse or property offences.
Homelessness
There is a link between family conflict, abuse and homelessness. Many choose homelessness
over the life they lead back home.
Young people, particularly women, choose to exchange sex for a bed for the night. Some
youth workers commented that these young women do not see this as prostitution or as
exploitation but as part of 'life on the streets'.
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Destruction of self worth
Intrafamilial sexual abuse of the young has been found to result in feelings of self blame and
low self esteem by the victim.
In arrests, the pimps and clients should be arrested, not just prostitutes. Arresting the
prostitute alone will only increase her sense of self-worthlessness. But if we do nothing, we
allude to the fact that prostitution is the only form of lifestyle she may part take in or bring
about any value or self-worth. Sex should be something emotionally charged between two
consenting, private individuals. A price tag should not be attached to the notion of sexual
intercourse.
Normal Pregnancy
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By Alan Ho
Basics
o LMP (last menstrual period) and EDD (estimated date of delivery)
 Naegele’s rule= LMP (1st day) + 9 months + 7 days
o EDD can be more accurately estimated if an Ultrasound was done during the first
trimester
o Timeline1
 Week 7
 The baby´s heart is beginning to develop. Morning sickness and
other side effects of early pregnancy may take hold.
 Week 10
 A scan at 10-13 weeks is recommended to pin down the date of the
pregnancy.
 Week 15
 Screening for Down’s syndrome (Trisomy 21) is offered about now.
A simple blood test is carried out first then further tests may be
offered.
o If +ve: an Ultrasound to check nucheal thickness and
amniocentesis or chorionic villus sampling will be used to
confirm the Dx of Down’s syndrome
 Week 17
 The foetus can hear noises from the outside world. By this stage the
mother is visibly pregnant and the uterus is rising.
 Week 20
 Half way through pregnancy now. Almost all mothers are offered a
routine scan to check anatomy. The gender of the baby may be
determinable at this stage
 Week 25
 All organs are now in place and the rest of the pregnancy is for
growth. Preeclampsia is a risk from here onwards.
 Week 28
 Routine checkup to test for preeclampsia. Women with Rhesus
negative blood will also be tested for antibodies.
 Gestational Diabetes occurs around this time. A Glucose Challenge
Test is performed followed by OGTT (oral glucose tolerance test)
 Week 30
 Braxton Hicks contractions may begin around now. They are practice
contractions which don’t usually hurt.
 Week 34
 The mother may find it more difficult to eat full meals as the
expanded uterus presses on her stomach.
 Week 37
 The baby´s lungs are practically mature now and it can survive
unaided. The final weeks in the womb are to put on weight.
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Week 40
 In theory the baby should be born this week. The mother´s cervix
prepares for the birth by softening.
Lifestyle
o Stop smoking2: associated with lower birth rate, increased chance of cleft lip, cleft
palate, problems with bowel, eyes, ears and spinal cord
o Caffeine: associated with lower birth rate (not fully confirmed)
o Alcohol: ideally none, at least keep consumption to a minimum (<1 standard
drink/day)
o Diet3: Energy needs is greater but only a small amount. The key is to have food rich
in nutrients and satisfy your appetite. A normal weight gain is about 10-13 kg.
 Look for food with rich folate, iron, iodine, and vitamins
 Avoid fish with mecury
o Exercise3: walking, swimming, cycling… most are compatible with pregnancy. Avoid
contact sports and any sports that involves lying on the back (after 20 weeks)
Medications
o Teratogenic medications should be stopped/substituted with a safe one, if not
possible they should reduced in dosage to minimize risks
o Category A4
Drugs which have been taken by a large number of pregnant women and
women of childbearing age without any proven increase in the frequency
of malformations or other direct or indirect harmful effects on the fetus
having been observed.
o
Category C
Drugs which, owing to their pharmacological effects, have caused or may
be suspected of causing, harmful effects on the human fetus or neonate
without causing malformations. These effects may be reversible.
Accompanying texts should be consulted for further details.
o
Category B1
Drugs which have been taken by only a limited number of pregnant
women and women of childbearing age, without an increase in the
frequency of malformation or other direct or indirect harmful effects on the
human fetus having been observed.
Studies in animals have not shown evidence of an increased occurrence of
fetal damage.
o
Category B2
Drugs which have been taken by only a limited number of pregnant
women and women of childbearing age, without an increase in the
frequency of malformation or other direct or indirect harmful effects on the
human fetus having been observed.
Studies in animals are inadequate or may be lacking, but available data
show no evidence of an increased occurrence of fetal damage.
o
Category B3
Drugs which have been taken by only a limited number of pregnant
women and women of childbearing age, without an increase in the
frequency of malformation or other direct or indirect harmful effects on the
human fetus having been observed.
Studies in animals have shown evidence of an increased occurrence of
fetal damage, the significance of which is considered uncertain in humans.
o
Category D
Drugs which have caused, are suspected to have caused or may be
expected to cause, an increased incidence of human fetal malformations or
irreversible damage. These drugs may also have adverse pharmacological
effects. Accompanying texts should be consulted for further details.
Category X
o
o
Drugs which have such a high risk of causing permanent damage to the
fetus that they should not be used in pregnancy or when there is a
possibility of pregnancy.
Note: For drugs in the B1, B2 and B3 categories, human data are lacking
or inadequate and subcategorisation is therefore based on available animal
data. The allocation of a B category does NOT imply greater safety
than the C category. Drugs in category D are not absolutely
contraindicated in pregnancy (e.g. anticonvulsants). Moreover, in some
cases the 'D' category has been assigned on the basis of 'suspicion'.
o
References
1. BBC NEWS | Health | Pregnancy timeline
http://news.bbc.co.uk/2/hi/health/4121411.stm
2. Smoking in Pregnancy (Pregnancy, Birth and Beyond)
http://www.pregnancy.com.au/resources/topics-of-interest/pregnancy/smoking-inpregnancy.shtml
3. Better Health Channel
http://www.betterhealth.vic.gov.au/
4. Prescribing medicines in pregnancy
http://www.tga.gov.au/docs/html/medpreg.htm
EMBRYOLOGY
Definitions
1.
2.
3.
Gestational age = duration of pregnancy dated from the first day of LMP which precedes ovulation
and fertilization by around 2 weeks.
Embryo = from fertilization to 10 weeks of gestation (8 weeks post-conception)
Fetus = from 10 weeks to birth
Follicular development, Ovulation and Fertilization
Primary follicle
Primary oocyte
Phase
Chromosomes No.
Prophase I
46, XX
Completes meiosis I under the influence of FSH during follicular phase of menstrual cycle.
Secondary follicle
Graafian follicle
Secondary oocyte
23, X
Extrusion of 1st polar body
23, X
Secondary oocyte
Enters meiosis II.
Suspended in
metaphase II.
23, X
Ovulation in mid-cycle due to LH causes extrusion of secondary oocyte into abdominal cavity.
– Fertilization by single spermatozoon (23,X or Y) in fallopian tube.
 Completion of meiosis II by secondary oocyte.
Fusion of male and female pronuclei to form zygote.
Preimplantation embryo development (week 1)
1.
2.
3.
Segmentation or cleavage i.e. mitosis of zygote gives rise to daughter cells called blastomeres.
a. In fallopian tube: 2-cell  4-cell  8 cell  etc
As blastomeres continue to divide, a solid ball of cells is produced known as the morula.
Morula enters uterine cavity around 3-4 days after fertilization. The accumulation of fluid between
blastomeres results in formation of a fluid-filled cavity, converting the morula to a blastocyst.
a. A compact mass of cells (the inner cell mass) collect at one pole of the blastocyst. These cells
are destined to produce the embryo (embryoblast).
b. The outer rim of trophectoderm cells are destined to become the trophoblast (placenta).
Implantation
1.
2.
Usually occurs in the upper posterior part of uterus.
The blastocyst expands as hydrostatic pressure of fluid increases within its cavity and it hatches out of
the zona pellucida (day 5).
3. It then adheres to the endometrium. This is known as apposition.
4. Implantation is usually completed by day 24-25 of gestation (day 10-11 post conception)
Early embryo and fetal development (weeks 2-8 post conception)
1.
2.
By day 24-26 of gestation, the embryonic disc is bilaminar, consisting of epiblast and hypoblast.
Hypoblast becomes the endoderm while epiblast will later differentiate into embryonic ectoderm and
endoderm.
3. Cellular proliferation in the embryonic disc results in midline thickening known as the primitive streak.
Cells then spread out laterally from the primitive streak between the endoderm and ectoderm to
form the mesoderm. This results in a trilaminar embryonic disc (a.k.a. gastrulation)
4. These 3 germ layers give rise to all the organs of the embryo.
a. Endoderm (innermost)  GIT and derivatives (pancreas, liver, thyroid), lungs, bladder
b. Mesoderm (middle)  muscles, skeleton, connective tissue (blood)
c. Ectoderm  nervous system, skin
5. Trophoblast cells cells continue to invade uterine wall in the process of early placentation (villi
formation)
Fetal period
1.
2.
3.
The fetal period (9-36 weeks) is about continued differentiation of organs and tissues, most
importantly this period is about growth both in size and weight.
a. Fetal length change (i.e. crown-rump, CR in mm) is
greatest in the middle period (2nd trimester)
b. Fetal weight change is greatest in final weeks of
development (3rd trimester).
This period is also a time of ongoing differentiation of organ
systems established in the embryonic period.
Some systems (respiratory, cardiac, neural) will not have their
final organization and function determined until after birth.
Note:
– Carnegie stages are based on the external and/or internal morphological development of the embryo, and
are not directly dependent on either age or size.
– The Embryological period (1st trimester) is about organogenesis, organ and tissue formation, while the
longer Fetal period (2nd and 3rd trimester) is mainly growth and differentiation
– “Clinical weeks” => from LMP while “embryonic weeks” => from fertilization, 2 weeks later.
– Picture below shows critical developmental stages sensitive to insult. For more information on the
development of the various systems, look at the following website:
http://embryology.med.unsw.edu.au/sysnote.htm
Useful links on embryology 
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http://embryology.med.unsw.edu.au/#Medicine2009
http://itmweb.med.monash.edu.au/public/sathembryoart/Embryology%20Update4/INTRO%20
EMBRYOLOGY2.htm
Female Sexual History
Relationships
Do you currently have a sexual partner? How long have you been together? How many?
Sexual activity
How old were you when you became sexually active?
Do you have any physical or emotional problems with sex?
When you have sex, do you usually have a male or female partner, or both? / Do you have sex with the opposite sex or with a
same sex partner? (If prefers female partner) Have you ever had sex with a man?
Are you happy with your sex life? Do you enjoy sex?
How are things sexually? Is everything okay? Do you have any problems with orgasms or libido?
Dyspareunia
Do you get any pain with intercourse? If so is this a superficial burning on entry or a deeper pain inside?
Safety & Contraception
What contraception are you using?
Are you happy with that method? Are you having any problems with it?
Have you tried any other methods before? Why did you change?
Do you practice safe sex? Do you insist on using a condom?
Fertility
Do you want to get pregnant soon? Are you currently trying to become pregnant? (If no contraception method stated) How long
have you been trying?
Have you had any problems falling pregnant?
(If so) Have you had any treatment for infertility?
STDs
Have you had any sexually transmitted diseases?
What kinds of symptoms did you have?
Have you noticed any bumps or sores on your genitals? Where? How long? How often?
Have you noticed any rash on your genitals? What is it like?
Have you ever had an abnormal pap smear?
What were the results? Did you have any follow up or procedures done?
Menstrual history
Age of menarche/menopause
Usual duration of each period and length of cycle
First day of the last period
Amount of blood loss – heavy (menorrhagia) or scant (oligomenorrhoea)? Number of sanitary pads or tampons used
Passage of clots
Abnormal bleeding Inter-menstrual (Do you ever have bleeding between periods?), Post-coital (Have you noticed any bleeding
after sex?)
Dysmenorrhoea – Do you get period pain?
Abnormal Discharge
Have you noticed any change in the discharge from your vagina?
Colour What colour is it?
Consistency Is it thick / liquid / lumpy?
Itch Is the discharge itchy?
Smell Have you noticed a smell? What does it smell like?
Do you have problems with vaginal dryness?
Pap Smear
Do you have regular pap smears?
When was your last test?
Was it normal?
Has it always been normal?
What happened when you found the abnormal result?
What treatment did you have?
Urinary Symptoms (Frequency, Urgency, Nocturia, UTIs)
How often do you need to go?
Are you going more often than usual?
Can you hold on or do you need to go immediately?
How often do you get up at night to go?
Have you ever had a bladder infection?
How often do you get them?
Do you wipe from front to back?
Lower abdominal pain
When, where, why, how?
Relation to menses How does the pain appear in relation to your period?
Treatment Have you done anything to relieve the pain?
How effective was that treatment?
Social History
Smoking, alcohol and illicit drugs
Living arrangements
Domestic issues (e.g. relationships)
Psychological issues
Have you ever been abused physically, emotionally or sexually?
Source: SASU – Taking a Sexual History
Female Sexual Examination
Introduction, consent
Female chaperone should be present for any intimate examination
General examination
Examine hands & mucous membranes for signs of anaemia
Examine supraclavicular node for Virchow’ node (abdominal malignancy)
Palpate thyroid gland
Examine chest and breasts (breast tumour)
Abdominal examination
Patient should empty bladder before examination
Patient should be lying semi-recumbent, with a sheet covering her from the waist down, but the area from the xipihisternum to
the pubic symphysis should be left exposed.
Inspection

Surgical scars (umbilicus for laparoscopy scars; pubic symphysis for Pfannenstiel scars used for Caesarean section,
hysterectomy), dilated veins, striae gravidarum (stretch marks), herniae (ask patient to raise head and cough)
Palpation

Tenderness, peritonism, masses, liver, spleen, kidneys. (A mass you cannot palpate below is likely to be a pelvic
mass)
Percussion

Fluid thrill/shifting dullness, enlarged bladder (urinary retention)
Auscultation

Not specifically useful for the gynaecological examination. Listen for bowel sounds if patient presents with acute
abdomen
Pelvic examination
Patient should be in dorsal position, with hips flexed and abducted and knees flexed.

Left lateral position is used for examination of prolapse or to inspect the vaginal wall with a Sims’ speculum
Inspection

Inspect the vulva (the external genitalia)

Ask patient to strain down to enable detection of any prolapse and also to cough to show signs of stress incontinence

After this, a bivalve (Cusco’s) speculum is inserted to visualise the cervix.
o
Warm the speculum with warm water unless it is plastic. Lubricate the edges with jelly.
o
Spread labial folds apart with one hand, and hold speculum in the other hand
o
Insert closed, with blades parallel to the labia, up to the hilt
o
When it is in, rotate it and open it and make sure you visualise the cervical os.
o
At this point, a Pap smear can be taken.
Palpation (Bimanual digital examination)

Use the left hand to separate the labia minora to expose the vestibule (the part of the vulva between the labia
minora) and insert the index and middle fingers of the right hand into the vagina.

Palpate the cervix, looking for any hardness or irregularity

Place the tips of the vaginal fingers beneath the posterior cervix, and then place the left hand on the abdomen just
below the umbilicus. The fingers of both hands are then used to palpate the uterus
o
Note the size, shape, position, mobility and tenderness of the uterus

Place the tips of the vaginal fingers into each lateral fornix, place the left hand on the same side of the abdomen, and
examine the adnexae (Fallopian tubes and ovaries). These are not usually palpable.
SOURCES: Gynaecology by Ten Teachers, Oxford Handbook of
Clinical Specialties
SOCIAL SUPPORT SERVICES
Victorian Centres Against Sexual Assault
http://www.casa.org.au/index.php?page_id=1
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Services provided:
o Emergency or crisis care
 Crisis Line: 1800 806 292
o Information and advocacy
o Counselling and support
o Research projects
o Resource development
o Community education and training
 Community/Women’s and Mental Health Services
 Protection Services
http://www.cyf.vic.gov.au/__data/assets/pdf_file/0019/450523/sexual-assault-support-servicesfact-sheet-august-2010.pdf
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Fact sheet provided by the government outlining support services in Victoria
Melbourne Citymission
http://www.melbournecitymission.org.au/
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Services provided
o Early Intervention programs
 Family reconciliation
 Young and Pregnant parenting program
o Frontyard Youth Services
 Provides information and referrals to emergency accommodation
 Put you in contact with health and legal services
 Helps to mediate family reconciliation
 Available to anyone between the ages of 12 and 25 and is free
o Homelessness support
 Life skills workshops
 Accomodation programs
 Youth Refuges