A 19-year-old female presents to the ED after she has been sexually assaulted the previous day. She does not wish to report the event to the police.
Which ONE of the following is TRUE regarding treatment options in this case?
Answer: A: There are two options for postcoital (emergency) contraception that should be given within 72 hours of unprotected sexual intercourse:
1. Progestin-only method (prevents 85% of the pregnancies that would be expected from unprotected mid-cycle sexual intercourse):
2. Yuzpe method (prevents 75% of pregnancies resulting from unprotected mid-cycle sexual intercourse):
Consists of four tablets of ethinyloestradiol 30 µg + levonorgestrel 150 µg with the same dose repeated 12 hours later. Approximately 60% of women will experience nausea with this regimen, so an antiemetic should be prescribed at the same time.
Australian guidelines currently recommend the following regimen of single-dose antibiotic prophylaxis:
Administration of post-exposure prophylaxis against HIV is not routinely recommended but should be considered if high-risk features for transmission are present after assessment of the risk of HIV transmission. The risk of HIV transmission should be assessed and is determined by: the method of exposure with its estimated risk/ exposure; the risk that the source is HIV positive; and cofactors associated with the source and exposed individuals. Initiation of prophylaxis should be the responsibility of, or with advice from, an infectious diseases clinician.
Hepatitis B virus (HBV) prophylaxis should be considered if the victim is not immune. Administer a dose of hepatitis B immunoglobulin (HBIG), as soon as possible after exposure (preferably within 24 hours). In addition, a course of immunization should be commenced as soon as possible (preferably within 24 hours).
References:
Regarding abdominal pain in a female of reproductive age, which ONE of the following is TRUE?
Answer: D: Ovarian cysts may become symptomatic due to rupture, torsion, bleeding into the cyst or local pressure effects. Rupture or bleeding into the cyst is mostly managed expectantly, whereas torsion is a surgical emergency. Although adnexal torsion can occur in normal ovaries, it is almost always associated with ovarian enlargement. Risk factors for developing ovarian torsion are pregnancy (enlarged corpus luteum cyst), presence of large ovarian cysts or tumours, and chemical induction of labour. Ultrasound with Doppler sonography remains the primary imaging modality for suspected torsion. However, the sensitivity of Doppler flow study is not considered adequate to confirm the diagnosis in all cases, and the clinician must maintain a high level of clinical suspicion to determine which patients need immediate surgical intervention.
Ultrasound is commonly used in the work-up of patients with suspected endometriosis and it may reveal endometriomata, or focal endometriotic lesions. However, transvaginal ultrasound is not useful in diagnosing the majority of cases of endometriosis because the peritoneal implants and adhesions involved are not detectable. A negative ultrasound does not confirm the absence of endometriosis. Laparoscopy is the gold standard investigation for diagnosing endometriosis and now provides the main tool of treatment.
Regarding Fitz-Hugh–Curtis syndrome, which ONE of the following is TRUE?
Answer: C: Fitz-Hugh–Curtis syndrome is an uncommon cause of abdominal or pelvic pain in females and is due to a perihepatitis secondary to PID. Usually it is an incidental finding in patients with PID, but occasionally it is the presenting symptom and there may be no clinical findings of PID on examination. Chlamydia is isolated from most patients, regardless whether they have symptoms of PID or not. Liver function studies are normal. Other than excluding other causes of abdominal pain, ultrasound is not helpful in making the diagnosis. Diagnosis is typically made with CT demonstrating perihepatic inflammation.
A 36-year-old female presents with prolonged vaginal bleeding of one month’s duration preceded by a 5-week period of amenorrhoea. She describes it as heavy with clots. She is haemodynamically stable with no organic causes for bleeding found. A pregnancy test is negative.
Which ONE of the following statements is MOST appropriate?
Answer: C: A diagnosis of anovulatory bleeding is classically made from the history of irregular menses with periods of amenorrhoea followed by heavy bleeding, in the absence of features suggesting a structural or histological uterine abnormality. The underlying pathology is a relative lack of progesterone (which is released by the corpus luteum after ovulation) to oppose the oestrogenic stimulation of the endometrium and so treatment should include progestin therapy to stabilize the endometrium.
The initial treatment for most cases of abnormal uterine bleeding should be commenced in the ED. But it is important that the patient be referred for ongoing management and further evaluation. Short-term hormonal manipulation allows the endometrium to stabilize with subsequent slowing or stopping of the bleeding. Various treatment regimes exist and the use of cyclical progestins is one of the treatment options. These are usually given for at least 10 days. Current guidelines recommend the use of medroxyprogesterone acetate 10 mg orally, 1–3 times daily for 12 days or norethisterone 5 mg orally, 2–3 times daily for 12 days for the first month. After treatment stops, the woman should experience a withdrawal bleed within 3–10 days and this should be explained to the patient. In subsequent cycles, progestins (medroxyprogesterone acetate 10 mg orally once daily or norethisterone 5 mg orally once daily) should be administered on days 12–25 of each cycle or every other month and will usually control anovulatory bleeding. Follow up management with the GP should be arranged to continue management. Medical therapy is usually successful in managing dysfunctional uterine bleeding and dilation and curettage are seldom used for treatment of menorrhagia.
Regarding dysfunctional uterine bleeding, which ONE of the following is MOST appropriate?
Answer: D: Ovulatory bleeding is usually occurs in regular cycles. However, a menstrual cycle of <21 days or >35 days, even if regular, is usually anovulatory. Thyroid function testing should not routinely be performed in women with abnormal uterine bleeding. Indications for testing are women with menorrhagia and anovulatory bleeding, with evidence of thyroid endocrinopathy.
The menstrual blood in women with abnormal ovulatory bleeding has been shown to have increased fibrinolytic activity and/or increased prostaglandins. Subsequently, NSAIDs and tranexamic acid are two drugs commonly used to control ovulatory bleeding. NSAIDs inhibit the local action of prostaglandins in the endometrium and reduce menstrual blood loss. The usual dose of mefenamic acid is 500 mg three times a day or ibuprofen 400 mg three times a day. Tranexamic acid is a plasminogen activator inhibitor that promotes local haemostasis. Tranexamic acid 1 g orally 6- to 8-hourly are typically given for the first 3–4 days of menstruation as over 90% of menstrual loss occurs in the first three days of menstruation. Despite concerns for the development of thromboembolism, large-scale studies have not shown any increased risk of venous thromboembolism. The main adverse effects are nausea and gastrointestinal upset. In addition to its use in ovulatory bleeding, both tranexamic acid and NSAIDs can be added to hormonal therapy for heavy anovulatory bleeding.
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