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AMH Summary: Chapter 17 – Obstetric and Gynaecological 1

AMH SUMMARY: Chapter 17 – Obstetric & Gynaecological

- CONTRACEPTION -

DRUGS OF CHOICE FOR CONTRACEPTION


a) Combined oral contraceptives
b) Progestogens
c) Intrauterine devices IUD
d) Others

Emergency Contraception:
 LEVONORGESTREL – Postinor, Norlevo
- prevent or delay ovulation and induce transient changes in endometrium. It can’t disrupt an
implanted fertilized egg.
- repeat dose if vomiting occurs within 2 hours
- no limit in recurrent use
- take within 72 hours of unprotected sex (24 hours most effective but still has a contraceptive effect
when taken up to 120 hours afterwards).
- 1.5mg immediately or 750mcg q12h
- safe during breastfeeding

COMBINED ORAL CONTRACEPTIVES (pill)


Indications: Contraception, Moderate Acne (Loette), Androgenisation (hirsutism and acne) in women
(cyproterone – Brenda-35, Diane-35, Juliet-35, Estelle-35), menstrual disorders, period pain, endometriosis,
PMS

Contraindications: history of breast, endometrial cancer, migraines, pregnancy, viral hepatitis

Precautions: diabetes, hypertension (monitor), depression, epilepsy, migraine, cholestatic jaundice, smoking
(increases risk of thromboembolism), hyperlipidaemia

Side Effects: breakthrough bleeding, nausea, vomiting, changes in weight, breast enlargement and
tenderness, headache, mood changes (eg depression), changes in libido, fluid retention, acne, thrush

Dosage: start in the first week of active tablets on day 1-5 of menses to be protected immediately. If start
active pills after this time, use additional contraception or avoid intercourse until 7 active pills have been
taken.
- Missing pills: <24 hours – take it asap and take the next pill at usual time
- Missing pills: >24 hours – take it asap and next pill at usual time (i.e. 2 pills at one time) but need to
wait 7 days for protection. But if the 7 days extend into inactive pills, then you need to skip the
inactive pills and go straight to a new pack of active pills (so no periods for this month)

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 2

* If you missed active pills and need to take emergency contraceptive tablets, you should start taking your
pill again within 12 hours of taking the emergency contraceptive tablets. You will need to use additional
contraception, eg condoms, or avoid intercourse until you have taken active pills for 7 days.

Breakthrough Bleeding:
If breakthrough bleeding persists for >3 months and another cause cannot be identified (eg missed pills,
drug interaction), try the following (in order):
 change to a monophasic COC if taking a triphasic COC
 change the progestogen or increase dose (especially if bleeding occurs late in cycle)
 take active tablets for 9 weeks in a row
 change to a standard dose COC (with 30–35 micrograms ethinyloestradiol or 50 micrograms of
mestranol) if taking a low dose COC (with 20 micrograms ethinyloestradiol)
 change the progestogen again
 change to a high dose COC (with 50 micrograms ethinyloestradiol).

Drug Choice (Progesterone):


 Levonorgestrel, norethisterone: lower risk of venous thromboembolism (VTE).
 Gestodene, desogestrel: less androgenic activity than levonorgestrel but twice the risk of VTE.
Generally not first choice for new users.
 Dienogest: one-third anti-androgenic activity to that of cyproterone. Benefits acne.
 Drospirenone: anti-mineralocorticoid (mild diuretic and potassium retention) and anti-androgenic
activity.
 Cyproterone: progestogenic and anti-androgenic. Used with an oestrogen to treat women with
androgenisation (severe acne, hirsutism). Higher risk of VTE and is not indicated in the absence of
androgenisation.

Table: Monophasic and Triphasic COCs


Monophasic = fixed dose of estrogen and progesterone in each active pill
Triphasic = both estrogen and progesterone content varies – more complex and high risk of fluid retention
and PMS

Monophasic Low Dose Monophasic Standard Dose Monophasic High Dose

Loette, Microgynon 20 Levlen, Microgynon 30, Microgynon 50 (ethinyloestradiol


(ethinyloestradiol Monofeme, Nordette 50 mcg/levonorgestrel 125 mcg)
20 mcg/levonorgestrel 100 mcg) (ethinyloestradiol
30 mcg/levonorgestrel 150 mcg)
Yaz (ethinyloestradiol Brevinor, Norimin
20mcg/drospirenone 3mg) (ethinyloestradiol
35 mcg/norethisterone 0.5 mg)
Brevinor-1, Norimin-1 Triphasic
(ethinyloestradiol
35 mcg/norethisterone 1 mg)

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 3

Marvelon (ethinyloestradiol Logynon, Trifeme, Triphasil, Triquilar


30 mcg/desogestrel 150 mcg) (ethinyloestradiol
30 mcg/40 mcg/30 mcg levonorgestrel
50 mcg/75 mcg/125 mcg)
Valette (ethinyloestradiol Improvil, Synphasic (ethinyloestradiol
30 mcg/dienogest 2 mg) 35 mcg/35 mcg/35 mcg/norethisterone
0.5 mg/1 mg/0.5 mg)
Yasmin (ethinyloestradiol Qlaira (oestradiol 3mg/2mg/2mg/1mg
30 mcg/drospirenone 3 mg) dienogest nil/2mg/3mg/nil)
Femoden, Minulet
(ethinyloestradiol
30 mcg/gestodene 75 mcg)
Norinyl-1 (mestranol
50 mcg/norethisterone 1 mg)
Brenda-35, Diane-35, Estelle-
35, Juliet-35 (ethinyloestradiol
35 mcg/cyproterone 2 mg)

 CYPROTERONE with ETHINYLOESTRADIOL – Brenda, Diane, Juliet, Estelle


 DESOGESTREL with ETHINYLOESTRADIOL – Marvelon
 DIENOGEST with ETHINYLOESTRADIOL - Valette
 DIENOGEST with OESTRADIOL - Qlaira
 DROSPIRENONE with ETHINYLOESTRADIOL – Yasmin, Yaz
 GESTODENE with ETHINYLOESTRADIOL – Femoden, Minulet
 LEVONORGESTREL with ETHINYLOESTRADIOL – Loette, Microgynon 20ED; Microgynon 30ED,
Levlen; Monofeme, Nordette; Logynon, Triquilar ED; Trifeme, Triphasil
 NORETHISTERONE with ETHINYLOESTRADIOL – Brevinor, Normin, Improvil
 NORETHISTERONE with MESTRANOL – Norinyl

PROGESTOGENS (minipill)
Indications: contraception when can’t use oestrogen (breastfeeding, history of thromboembolism, smokers),
menstrual disorders

Contraindications: breast cancer, hepatitis

Side Effects: menstrual irregularity, prolonged bleeding, spotting, amenorrhoea, depression, weight gain

 ETONOGESTREL – Implanon implant


- protection occurs within 1st day of insertion if inserted on day 1-5 of cycle; if inserted another time,
then additional contraception is required for 7 days after insertion.
- insert every 3 years

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 4

 LEVONORGESTREL – Microlut, Norlevo-2, Levonelle-1, Postinor-1; Mirena IUD


- Side Effects: Emergency contraception, nausea, vomiting, breast tenderness, vaginal bleeding,
headache
Levonorgestrel IUD, irregular bleeding, reduced menstrual flow, amenorrhoea, expulsion of device
(particularly in the first year), reversible ovarian cysts
- Use additional contraception for 48 hours if not starting within 1-5 day of menstruation. There are no
inactive pills like the COC so must be taken continuously. If you miss a pill and its over 3 hours, you
are not protected. Take it as soon as you remember but use additional contraceptive methods for the
next 48 hours.
- The minipill is less effective than COCs.
- Mirena IUD: Insert within first 7 days after start of menstrual cycle or 6 weeks after delivery; may be
replaced by new IUD at any time in cycle; replace every 5 years. Contraceptive effect is immediate if
inserted on day 1–7 of cycle otherwise use extra protection for the next 7 days.

 MEDROXYPROGESTERONE – Depo-Provera inj, Depo-Ralovera inj, Provera


- Indications: Contraception (IM depot), dysfunctional uterine bleeding, endometeriosis, HRT
- SE: IM, 50% become amenorrhoeic within 12 months, delayed return of menstrual periods after
stopping (may take >6 months), decreased bone mineral density, depression, weight gain
- Practice points: delayed return of fertility
- Dose: 10mg tds (endometriosis); 5-10mg d for 10-14 days of cycle (dysfunctional bleeding)
- Dose: 150mg IM every 3 months. Give first dose within 5 days after start of menstrual cycle. Delay
until 21 days after delivery if not breastfeeding and until 6 weeks if breastfeeding. Contraceptive
effect immediate if injected within first 5 days of cycle. It has a delayed return of fertility up to one
year.

 NORETHISTERONE – Micronor, Noriday-28, Locilan-28; Primolut N


- Indication: delay menstruation, HRT, endometriosis, uterine bleeding.
- Dose:
Contraception: 350mcg d start first day of cycle;
Delay of menstruation: 5mg tds for up to 14 days starting 3-5 days before expected menstruation
(bleeding starts 2-3 days after stopping tablets);
Dysfunctional uterine bleeding: 5mg tds for 10 days to stop bleeding OR 5mg d-bd for days 16-25 of
cycle.
Endometriosis: 5-10mg daily; continue treatment for at least 4-6 months.
HRT: 1.25mg d for 10-14 days of each month with continuous estrogen.

IUD
 COPPER IUD – Multiload IUD
- SE: period pain, increased menstrual flow with possible menorrhagia, expulsion of device
(particularly in the first year)
- Replace every 5 years
- The copper IUD can be used as an emergency contraceptive (not the Mirena IUD).

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 5

VAGINAL RING
 ETONOGESTREL with ETHINYLOESTRADIOL – NuvaRing
- Side Effects: vaginitis, vaginal discharge, irregular bleeding, headache, nausea, weight gain, breast
tenderness, mood changes, device-related problems (eg foreign body sensation, expulsion of ring)
- Insert ring into vagina during first 5 days of cycle and leave for 3 weeks; remove for a 1 week break,
then insert a new ring. Periods should start 2-3 days after ring is removed, insert a new one 1 week
after regardless of period or not.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 6

- MENOPAUSE: HRT -
Indications: Short term relief of menopausal symptoms eg. hot flushes, night sweats (up to 5 years)
Oestrogen relieves symptoms (hot flushes, night sweats, urogenital atrophy). Progestogen reduces risk of
endometrial cancer associated with unopposed oestrogen.

Contraindications: thromboembolism, uterine bleeding, severe liver disease, breast cancer, coronary artery
disease

Side Effects: breast enlargement and tenderness, abnormal mammogram, headache, depression, change in
libido, weight change, irregular or breakthrough bleeding, spotting, endometrial hyperplasia (oestrogen-only
HRT), leg cramps, dry eye syndrome (oestrogen-only HRT)

Types of Treatment
- Oestrogen-only HRT: for women post-hysterectomy with no history of endometriosis.
- Vaginal oestrogen: first choice for urogenital symptoms. Stop treatment annually to see if its still
required.
- Combined HRT: for women with intact uterus, use combined HRT as oestrogen-only HRT increases
risk of endometrial cancer. But combined HRT has increased risk of breast cancer.

Practice Points
- tell doctor if there’s blood clots (swollen leg, difficulty breathing, chest pain), breast changes,
changes in vaginal bleeding
- use HRT at lowest effective dose for the shortest time possible. (2-3 years is sufficient in most
women)
- Review at least annually.
- Choose vaginal preparations for women who only have urogenital symptoms

Oestrogens
 CONJUGATED EQUINE OESTROGENS – Premarin, Premia Continuous
 OESTRADIOL – Estrofem, Progynova, Aerodiol spray, Vagifem pessary, Sandrena gel, Climara patches,
Femtran patches, Menorest patches, Trisequens tab, Estalis patches
 OESTRIOL – Ovestin tab, pessaries, cream
- Indications: menopausal symptoms, adjunct to vaginal surgery
 PIPERAZINE OESTRONE SULFATE – Ogen

Oestrogen/progestogen
 TIBOLONE – Livial
- Do not start tibolone until at least 12 months after last period to avoid increased irregular bleeding.

Side Effects: abdominal pain, bloating, weight increase, vaginal bleeding or spotting, vaginal discharge and
itching, vaginitis, breast pain, hypertrichosis

Dosage: 2.5mg daily

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 7

Progestogens
 MEDROXYPROGESTERONE – Provera, Depo-Provera etc
Indications: contraception (IM depot); uterine bleeding (oral); secondary amenorrhoea (oral); endometriosis

Precautions:
Adolescents—reduction in BMD with IM depot (during the period when peak bone mass is usually attained)
may be more significant than in adults; only use if other contraceptive methods are considered unsuitable or
unacceptable.

Side Effects: IM, 50% become amenorrhoeic within 12 months, delayed return of menstrual periods after
stopping (may take >6 months), loss of BMD, weight gain

Dosage:
Contraception: IM 150mg very 12 week. Protection immediate if given within 5 days after start of
menstrual cycle. Delay until 21 days after delivey if not breastfeeding or until 6 weeks if
breastfeeding.
Endometriosis: IM 50mg each week, or 100mg every 2 weeks for months; oral 10mg tds
Dysfunctional uterine bleeding: 5-10mg d for 10-14 dys during assumed second half of cycle.
Secondary amenorrhoea: 5-10mg d for 5-10 days during assumed second half of cycle.
HRT: 5-10mg d for 10-14 days of each month with continuous oestrogen, or 1.25-5mg d with
continuous oestrogen.

- delayed return of fertility (1 year)


- the repeat injection can be given up to 2 weeks early or late without the need for additional
contraceptive protection

 NORETHISTERONE – Micronor, Noriday, Locilan, Primolut N


Indication: contraception; HRT as adjunct to oestrogen; endometriosis; delay of menstruation; dysfunction
uterine bleeding

Dosage:
Contraception: 350mcg d beginning first day of menstruation
Delay of menstruation: 5mg bd-tds for up to 14 days, start 3-5 days before expected menstruation.
Dysfunctional uterine bleeding: to stop bleeding – 5mg tds for 10 days. To regulate bleeding – 5mg
d-bd for days 16-25 of cycle.
Endometriosis: 5-10mg d; continue treatment for at least 4-6 months.
HRT: 1.25mg d for 10-14 days of each month with continuous oestrogen.

Practice Points:
- There are no inactive pills so must be taken continuously.
- If forget to take a pill, take it as soon as you remember. If more than 3 hours, you are not protected.
Resume normal pill taking, but use additional contraceptive methods for the next 48 hours.
Emergency pill should be used if unprotected intercourse has occurred.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 8

- Less effective than the COC.


- Effective if started on first day of period; but use additional methods for 48 hours if started any other
time.

- DYSFUNCTIONAL UTERINE BLEEDING –

NSAIDs & Tranexamic acid


- can be used together
- NSAIDs started at onset of bleeding and taken regularly for 3-5 days. Tranexamic acid (Cyklokapron) is
used for 3-5 days during periods.
- dosage: 1-1.5g tds for 3-5 days.

COCs

Progestogens
- Levonorgestrel IUD (Mirena) is effective long term. It may be taken for 6 months before full benefit is seen.
Side effects include spotting and breast tenderness and may take 3-6 months to settle.
- Depot medroxyprogesterone (Depo-Provera): use in amenorrhoea is limited.

Danazol (Azol)
- poorly tolerated due to androgenic side effects. Must be used with effective non-hormonal contraception.

GnRH Agonists
- poorly tolerated due to hypo-oestrogenic side effects and can be costly. Must be used with effective non-
hormonal contraception

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 9

- ENDOMETRIOSIS –
Endometriosis is the presence of endometrial tissue outside the uterus. Patients may be asymptomatic or
have pelvic pain, menstrual changes, bowel symptoms or infertility.

NSAIDs
NSAIDs may be adequate for symptom relief in some women and can be used with other treatments. They
are effective in relieving dysmenorrhoea, however, evidence is inconclusive regarding their effect on pain
due to endometriosis.

Combined oral contraceptives


Combined oral contraceptives can be taken long term and are usually well tolerated. Both cyclical and
continuous regimens are used but there is no evidence that one regimen is more effective than the other.
However, 'tricycling' (having a pill-free interval once every 3 months) may be useful in women with
dysmenorrhoea.

Progestogens
Norethisterone, dydrogesterone and IM or oral medroxyprogesterone can all be used long term. Adverse
effects include irregular bleeding and weight gain. Continuous oral progestogens and IM
medroxyprogesterone also provide contraception if no doses are missed.

Limited evidence suggests the levonorgestrel IUD may also be effective in reducing pain associated with
endometriosis.

Danazol, gestrinone
Danazol and gestrinone both have androgenic adverse effects that limit their use: duration of treatment is 6–
9 months with danazol and 6 months with gestrinone. An effective non-hormonal method of contraception
must be used during treatment.

Gonadotrophin-releasing hormone agonists


The GnRH agonists, goserelin (Zoladex) and nafarelin (Synarel spray), are associated with hypo-
oestrogenic adverse effects such as hot flushes, vaginal dryness and decreased BMD. Duration of
treatment is limited to 6 months due to loss of BMD. Adding combined HRT allows treatment for up to
2 years (reduces these adverse effects and protects against BMD loss while maintaining efficacy). An
effective non-hormonal method of contraception must be used during treatment (to avoid pregnancy in the
event of missed doses).

GOSERELIN: 3.6mg implant every 4 weeks(up to 6 months for endometriosis)

NAFARELIN: 200mcg bd for 6 months (1 spray in one nostril in the morning and 1 spray in the other nostril
at night); may be increased up to 400mcg bd.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 10

- DELAY LABOUR –
Delay delivery for 24-48 hours

 NIFEDIPINE - Adalat
- relaxes uterine smooth muscle
Indication: preterm labour (<34 weeks gestation)

Dosage: initially 20mg. repeat after 30min if uterine contractions persist. If contractions continue after 3
hours, give 20mg every 3-8 hours until contractions cease. Maximum 160mg/day. Maintenance after 72
hours if necessary, give daily dose until 34 weeks gestation.

 SALBUTAMOL – Ventolin inj


- note oral nifedipine is preferred

Side Effects: maternal tachycardia, hypokalaemia, hyperglycaemia, exacerbation of diabetes, dyspnoea,


palpitations, anxiety, oliguria; fetal tachycardia

Dosage: IV 100-250mcg

- PRE-ECLAMPSIA & ECLAMPSIA –


Pre-eclampsia (hypertension with proteinuria or other disorders of the liver, kidneys, clotting system, brain,
placenta usually developing 20 weeks gestation). Eclampsia (pre-eclampsia with 1 or more seizures) is a
serious complication can result in poor intrauterine growth and early delivery.

Treatment: consider delivery of baby depending on gestational age and condition. Magnesium sulfate is the
drug of choice to prevent seizures in women with pre-eclampsia.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 11

- LABOUR -
- Ripen cervix and induce labour: Prostaglandins (mainly dinoprostone PGE2 gel)
- induction of uterine contraction: oxytocin, ergometrine, prostaglandins
- post partum haemorrhage: oxytocin, ergometrine, prostaglandins
- delivery of placenta: oxytocin, misoprostol

OXYTOCIC DRUGS
 CARBETOCIN – Duratocin inj
Indication: prevents postpartum haemorrhage (PPH)
Side Effects: nausea, vomiting, abdominal pain, itch, flushing, feeling of warmth, sweating, dizziness,
hypotension

- has longer duration of action than oxytocin


- give by slow IV injection over 1 minute.

 ERGOMETRINE inj
Indication: PPH; third stage labour (in combination with oxytocin) – not appropriate for labour induction.
Side Effects: nausea and vomiting
Dosage: 200mcg IM following delivery of placenta for prevention; or IV 25-50mcg every 2-3 minutes for
treatment.

 OXYTOCIN – Syntocinon inj


Indication: induction of labour; prevents and treats PPH (in combination with ergometrine)
Side Effects: nausea and vomiting

- note: combination with ergometrine may increase likelihood of side effects and has little advantage
over oxytocin alone.

PROSTAGLANDINS
Side Effects: nausea, vomiting, diarrhoea, back pain, transient hypertension or hypotension,
bronchoconstriction, headache, epigastric pain, vasovagal symptoms, blurred vision, facial flush, fever,
altered fetal heart rate, uterine hypercontractility and hypertonus

Prostaglandin E1 analogue
 GEMEPROST - Cervagem
Indication: Termination of pregnancy in second trimester
Side Effects: vaginal bleeding and uterine pain in the interval between pessary insertion and surgical
intervention (severity increases if interval is >3 hours)
Dosage: insert 1 pessary every 3 hours until effect. Maximum 5 pessaries in 24 hours.

 MISOPROSTOL – Cytotec
Indication: termination of second trimester; medical management of miscarriage; intrauterine fetal death

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 12

Dosage: 400mcg sublingual every 3 hours up to maximum 3 doses.

Prostaglandin E2
 DINOPROSTONE – Prostin E2 Vaginal Gel; Cervidil pessary
Indication: induction of labour
Dosage: 1-2mg of vaginal gel q6h; insert one pessary and remove when contractions begin.

Prostaglandin F2 alpha
 DINOPROST – Prostin F2 alpha inj
Indications: rarely used in termination; severe PPH refractory to other measures.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 13

- LACTATION –
Lactation Suppression
Dopamine agonists: cabergoline & bromocriptine
 CABERGOLINE – Cabaser, Dostinex
- preferred over bromocriptine due to fewer side effects
Dosage: 0.5mg each week in 1-2 doses

 BROMOCRIPTINE – Kripton, Parlodel


Side Effects: erythromelalgia, leg cramps
Dosage: 1.25mg bd-tds

Lactation Stimulation
Dopamine antagonists: metoclopramide & domperidone

 METOCLOPRAMIDE – Maxolon, Pramin


Side Effects: restlessness, drowsiness, dizziness, headache
Dosage: 10mg tds, taper dose over 7-10 days before stopping

 DOMPERIDONE – Motilium
Side Effects: dry mouth, headache
Dosage: 10mg tds, taper dose over 7-10 days before stopping.

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 14

- VAGINAL INFECTIONS –
THRUSH
For acute episodes use clotrimazole, miconazole or nystatin. Single doses are usually effective for first or
infrequent episodes. They may damage contraceptive diaphragms and latex condoms.
Oral antifungals (fluconazole) is effective for acute episodes and should be considered if creams have failed.
Antifungal prophylaxis with weekly oral fluconazole for up to 6 months is indicated in women with recurrent
thrush (4+ episodes in 12 months) or severe symptoms.
Pregnancy – use vaginal antifungals for 1 week (vaginal applicators may be used with care). A single
150mg fluconazole appears safe and may be used if vaginal antifungals have failed.

BACTERIAL VAGINOSIS
Symptoms: vaginal discharge without soreness, itching or irritation.
Treatment with oral metronidazole or clindamycin (vaginal/oral). Aci-Jel may be used to reduced symptoms
and prevent recurrence.

TRICHOMONIASIS
Women may have symptoms of vaginal discharge, itching and irritation and is sexually transmitted. Treat all
individuals with a single dose of metronidazole or tinidazole.

- PMS (Premenstrual Syndrome) –


Symptoms: mood or behavior changes, cognitive disturbances and physical problems during menstruation.
Symptoms may begin up to 14 days before and resolve within 3 days of, the beginning of a period.

TREATMENT
 Increase calcium intake to 1200-1500mg daily.
 Use 50-100mg daily of pyridoxine (vitamin B6)
 Monophasic COCs
 SSRIs (fluoxetine, sertraline)

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AMH Summary: Chapter 17 – Obstetric and Gynaecological 15

Reference

Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2011

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All rights reserved. Apart from any use permitted under the Copyright Act 1968 of Australia, material in this publication must not be reproduced or
stored in any way without prior written permission of the publishers.

While every effort has been made to ensure this publication is as accurate as possible, the Medicine Box team does not accept any responsibility for
any loss which the user may suffer as a result of errors or inaccuracy of information contained in this publication.

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