Women’s problems in General Practice

1. Women’s problems in General Practice

2. Menstrual /Uterine problems • Problems related to pregnancy • ?Hormonal problems • Infection • Cancer • Urinary symptoms

3. Urinary incontinence • NICE guidelines 2006 • Assess symptoms • Examination urinalysis • Stress/urgency/mixed • Treat predominant symptom. • Urge keep bladder diary for at least 3 days • Stress/mixed 3 months pelvic floor exercises • Urge/mixed 6 weeks bladder training then anticholinergics (oxybutinin 1st line) • Duloxetine can be offered second line for stress incontinence as an alternative to operative treatment • Referral for consideration of operative treatment (Mr Jackson /Mr Nichols) • Retropubic mid urethral tape (stress) • Botulinim toxin/sacral nerve stimulation (urge)

4. Endometrial carcinoma • PMB • Examination and ultrasound to assess endometrial thickness • >3mm hysteroscopy and endometrial biopsy • Episodes more then 6 mths apart should be reinvestigated • Tamoxifen increases the risk of endometrial carcinoma x6 in this instance USS difficult to interpret and need tissue diagnosis

5. Cervical carcinoma • Liquid based cytology recently introduced decrease in unsatisfactory smears • 1st invite age 25yrs • 25-49 yrs 3 yearly • 50-64 yrs 5 yearly • >65 yrs only if 1 in past 3 smears has been abnormal • 42% drop in cervical cancer since screening introduced • Prevents 500 deaths per year • If cervix looks suspicious refer colposcopy even if smear normal

6. Ovarian cysts in postmenopausal women • RCOG 2003 • Are very common • Assess with transvaginal USS and ca125 • Simple cyst unilateral unilocular <5 cm diam with normal ca 125 unlikely to be maligant and can be managed conservatively 50% will resolve within 3 mths • Aspiration of cysts not recommended in the postmenopausal and oophorectomy usually bilateral is operation of choice rather than cystectomy (risk of seeding if maligant) • High risk cysts should have treatment of TAH +BSO+ omentectomy and selective lymphadenectomy . Suspicious adhesions should be biopsied and peritoneal washings sent for cytology.

7. Ovarian cancer • May be associated with family history, assoc with BRCA1 and 2 genes (increased inc Ashkenazi Jews and Polish) • Persistent pelvic/abdominal pain • Increased abdominal size or persistent bloating • Difficulty eating and feeling full • Pelvic and abdominal examination • Pelvic USS and Ca125 if abnormal

8. Screening 3 yearly to women aged 50-70 Triple assessment at breast clinic Imaging 2ww Family history (NICE guidance 2006 currently being updated) Breast cancer

9. Menstrual/Uterine problems • Dysmenorrhoea • Primary usually young needs ovulatory cycles • Treatment • Analgesics/antispasmodics • Prostaglandin inhibitors • Combined oral contraceptive • Secondary • In older women can be assoc with dyspareunia • ? Chronic infection/endometriosis

10. Menorrhagia • Recent NICE guideline 2007 • Heavy regular periods • Severity rather subjective • History clots flooding • Examination fibroids tenderness • FBC

11. Surgical Endometrial ablation Uterine artery embolisation Hysteroscopic myomectomy Myomectomy Hysterectomy Treatments • Medical • Mirena • Tranexamic acid • NSAI/ • COC • Oral cyclical progesterone • Injectable progesterone • GnRH

12. Endometriosis • RCOG guideline 2006 • Endometrial tissue outside of the uterus which induces a chronic inflammatory reaction but may also be asymptomatic and a coincidental finding. • Diagnosis Can present with dysmenorrhoea, dysparunia, chronic pelvic pain, ovulation pain, cyclical premenstrual symptoms, infertility, chronic fatigue, pain on defaecation. Examination Pelvic tenderness, fixed retroverted uterus Laparoscopy which should be documented/ videoed and biopsies taken

13. Treatment • Empirical before definitive diagnosis • Analgesics • Progestogens • Combined oral contraceptive • Definitive treatment suppress ovarian function with COC/danazol/GnRH • At laparoscopy all visible disease should be removed this improves fertility, also can undertake tubal flushing and cystectomy for endometriomas on ovary>4cm

14. Fertility • NICE guideline 2004 • 84% of couples conceive in 1yr • Half of those who do not conceive will do so in the following year • Female fertility decreases with age esp >35yrs • Pretreatment rubella and cervical screening, start folic acid supplements

15. Infertility • Definition the failure to concieve within 2years in the absence of known reproductive pathology • However after 1yr further investigation should be offered, or earlier if there is known pathology/ increased maternal age • Semen analysis • Assessment of ovulation

16. Semen analysis • Vol>2ml • Sperm conc>20m/ml • Total number>40m • Motility>50% • If test abnormal repeat after 3 months

17. Assessment of ovulation • History • 21 day progesterone • If irregular cycle FSH/LH

18. Investigation • No known pathology hysterosalpingography • Known pathology Lap and dye • Chlamydia screening should be undertaken prior to uterine instrumentation

19. Treatment • Male • Hypogonadotrphic hypogonadism treat with gonadotrophins • Obstructive azoospermia surgery • Treat ejaculatory failure • Intrauterine insemination effective treatment for male factor infertility • Intracytoplasmic sperm injection use in severe semen defects/obstructive and non obst azoospermia but genetics especially Y chromosome must be tested first

20. Female • Oligo/amenorrhoea/unexplained • Clomiphene • PCOS ? Metformin off license/ovarian drilling • Gonadotrophins if clomiphene does not induce ovulation • IUS if ovulating but has not achieved pregnancy in 6 mths • Tubal disease ,surgery including catheterisation cannulation and division of adhesions • IVF • Success >20% 23-35 • 15% 36-38 • 10% 39 • 6% >40 yrs

21. Early pregnancy loss • RCOG 2006 • Miscarraige occurs in 10-20% of pregnancies • 50,000 admissions/yr • Early pregnancy assessment clinics • Threatened/complete/recurrent • Rh negative women require antiD if ectopic pregnancy, miscarraige over 12 weeks or where require uterine evacuation medical or surgical or if under 12 weeks but with pain and heavy bleeding

22. Treatment • STI screening in women with surgical intervention • Surgical evacuation if • Patient choice • Persistent bleeding • Haemodynamically unstable • Retained tissue • Suspected trophoblastic disease • Suction curettage is the preferred method • If infection is suspected surgery can be delayed to allow 24hrs of iv ab • Medical treatment with progestogens • Expectant management can be effective in incomplete miscarraige • Can bleed for up to 3 weeks • Must have 24hr access to emergency care

23. Recurrent miscarraige • RCOG 2003 • Loss of 3 or more pregnancies • Affects 1% of women • Maternal age and previous miscarriage are risk factors • Peripheral blood karyotype of couple • If abnormal (3-5%)genetics referral for counselling • 40-50% chance of live birth if naturally conceive • Analysis of products of conception • Expensive • If abnormal greater chance of a normal outcome next time • Anatomical factors • Higher in late miscarraige • Pelvic USS to assess anatomy • Surgical treatment • Risk of uterine rupture during delivery • Cervical circlage • DM thyroid progesterone hyperprolactin

24. Antiphospholipid syndrome • Diagnosis requires 2 positive tests 6 weeks apart for lupus anticoag/anticardiolipin ab • If APS chance of positive outcome improved by treatment with aspirin and heparin but remains a high risk pregnancy • Accounts for 15% of recurrent miscarraige

25. Ectopic pregnancy • RCOG 2004 • Incidence 11/1000 pregnancies • 32000 in 3 years resulting in 13 maternal deaths • Pelvic pain associated with amenorrhoea and a positive pregnancy test with or without vaginal bleeding although 50% do not present in this way • Laparoscopic treatment salpingectomy if healthy alternate tube • Laparotomy if haemodynamically unstable • Medical management with im methotrexate +serial HCG if serum HCG<3000 and minimal symptoms • Expectant management if asymptomatic initial HCG<1000 and dropping

26. PCOS • Common 6-7% of women Suspect if Oligomenorrhoea, amenorrhoea, infertility Hirsutism, acne , male pattern baldness Evidence of insulin resistance (central obesity) Positive family history Commoner in women of South Asian origin

27. Diagnosis • 2 or more of • Polycystic ovaries • Oligo/anovulation • Clinical/biochemical hyperandrogenism • Raised LH not diagnostic • Screen TFT, prolactin and free androgen index (total testosterone/SBGx100) if >5nmol/L measure 17 hydroxyprogesterone and screen for androgen secreting tumours • Pelvic USS

28. Treatment • Advice re diet and exercise • Offer GTT if BM>30 or fh of DM • Assess cardiovascular risk • Ask re sleep apnoea • If have oligo/amenorrhoea at greater risk of endometrial ca and should be offered cyclical progesterone • Use of drugs to help weight reduction • Ovarian electrocautery for some with anovulation • No role for starting metformin in primary care • Hirsutism dainette/ yasmin/ eflornithine

29. Premenstrual syndrome • Affects 5% of women • Symptoms include depression, anxiety, irritability, loss of confidence bloating and mastalgia • Definition ; A condition which manifests with distressing physical, behavioural and psychological symptoms in absence of organic/psych illness regularly recurs during luteal phase of each cycle and disappears/ regresses by the end of menstruation.

30. Graded mild/mod/severe • Symptom diary • Treatment • Exercise, weight reduction, stress reduction, COC ,vit B6 , low dose SSRI • Oestradiol patch and progesterone, high dose SSRI • Gnrh analogues+HRT • TAH+ oophorectomy+HRT

31. Vaginal discharge in young women • 64% of women take unnecessary self medication • Low diagnostic sensitivity in clinicians • Most women who visit their GP fear serious illness or STI • In 90% of women the causes are either bacterial vaginosis, trichomoniasis or candidiasis.

32. Bacterial vaginosis • Risk factors IUD, non white race and prior pregnancy • Unpleasant fishy smelling discharge-more noticeable after unprotected SI • Discharge is thin off white no assoc itch or inflammation • Not sexually transmitted • pH6-7 • Clue cells on microscopy • Treatment metronidazole

33. Vulvovaginal candidiasis • Can be linked to orogenital sex, young age at first intercourse and intercourse >4 times a month • Diagnosis difficult 20% of asymptomatic women carry in vaginal flora • pH 4-4.5 • Thick white discharge • No smell • Recurrent if over 4 attacks in 1 year • Confirmed on at least 2 cultures • Treatment weekly fluconazole 100mg for 3-6 mths

34. Trichomoniasis • Sexually transmitted • High prevalence of other STI inc HIV • Risk factors IUD smoking and multiple partners • 20-50% asymptomatic • pH elevated • Contacts need treatment refrain from SI until both partners cured • Oral metronidazole

35. Other causes of vaginal discharge • Physiological • Allergy • FB • Cervicitis

36. Management of vulval skin conditions • RCOG guideline 2011 • Very common 1/5 of all women have symptoms • Be suspicious ! Intractable symptoms in postmenopausal woman but can affect both sexes at any age . • 25% of those attending a vulval skin clinic will have lichen sclerosis • History important to enquire skin disorders at other sites ,FH,DH • PMH/FH of atopy and autoimmune illnessses • Examination

37. Dermatitis check ferritin • LS check for autoimmune illness • May require biopsy to confirm the diagnosis • Treatment strong steroids if does not respond tacrolimus • Shared care • 2-4% risk of developing vulval ca

38. Acute PID • RCOG 2003 • 1 in 60 general practice consultations in women younger than 45 • Delay in diagnosis increases morbidity • Causes chlamydia, gonorrhoea, mycoplasma, anaerobes and other organisms

39. Symptoms and signs • Low abdominal pain/tenderness • Deep dyspareunia • Abnormal vaginal/ cervical discharge • Cervical excitation/ adenexal tenderness • Fever

40. Treatment • Take endocervical swabs for chlamydia/ gonorrhoea • Initiate treatment with ofloxacin 400mg bd and metronidazole 400mg tds for 14 days • Admit if uncertain diagnosis , severe disease, pregnancy, not responding or intol to treatment. • Iucd does not need removed except in severe disease • Contact trace partner and partners within prev 6 mths • If screening not available treat empirically but refer to GUM • Women on COC with BTB should be screened for STI