3: GYNAECOLOGY

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CHAPTER 3 GYNAECOLOGY

Premenstrual syndrome
Intermenstrual (or postcoital) bleeding
Postmenopausal bleeding
Irregular periods
Dysmenorrhoea
Menorrhagia
Amenorrhoea
Pelvic pain
Vaginal discharge
Sexually transmitted infections
Urethral syndrome
Hirsutism
Polycystic ovarian syndrome
Breast screening
Breast awareness
Breast cancer
Breast lumps
The menopause/climacteric
Hormone replacement therapy (HRT)
Cervical cancer
Infertility
Termination of pregnancy request

PREMENSTRUAL SYNDROME

Diagnosis

The diagnosis of premenstrual syndrome requires that the symptoms occur only in a particular phase of the ovarian cycle, nearly always at some time between ovulation and the onset of full menstrual flow.

Tip

The distinction between PMS and psychological disorders that become worse in the premenstrual phase is often difficult. Examination is unnecessary.

Management

Advice

• Support and reassurance are vital, as there is undoubtedly a strong placebo effect.
• A menstrual diary, kept for at least 3 months, is useful.
• Exercise should be encouraged. (Increased endorphin release may improve symptoms.)
• A healthy, well-balanced diet should be encouraged in order to maintain steady blood glucose levels.

Prescribing

• NSAIDs are useful for pain symptoms and often improve mood and bloating.
• Pyridoxine (vitamin B6) 10 mg per day from day 14 to the onset of menstruation is often used initially. Its efficacy is in doubt. It is prescribable on FP10, and available OTC.
• Evening primrose oil (gamolenic acid) as a daily dose may be recommended. It is available OTC.
• Oestrogens may be used. (The rationale for their use is that cyclical ovarian activity is necessary for the symptoms of PMS, and oestrogens may suppress ovulation.)

– The COC may be given. (Symptoms occasionally become worse.)
– Transdermal oestradiol patches (25–100 μg) may be used twice a week, or consider an oestradiol implant (100 mg). Give concomitant treatment with a progestogen, e.g. norethisterone, 5 mg per day from day 19 to day 26, to prevent endometrial hyperplasia. Sequential combined oestrogen/progestogen patches are available.

• Progesterone and progestogens are often used, but there is no evidence of benefit. Treatment is given during the luteal phase only.

– Natural progesterone has poor oral absorption and is therefore given PR or PV, 100–800 mg daily.
– Synthetic progestogens (oral), e.g. dydrogesterone 10 mg bd or norethisterone 5 mg tds may be given. (The POP may be helpful.)

• SSRIs often help to relieve all aspects of PMS.
• Diuretics can be helpful for fluid retention in the luteal phase.
• Bromocriptine 2.5 mg od in the luteal phase can be helpful for cyclical breast pain.

INTERMENSTRUAL (OR POSTCOITAL) BLEEDING

Single episodes of non-menstrual bleeding are often innocent; the patient can usually be reassured and reviewed if the bleeding is persistent.

Tip

Persistent non-menstrual bleeding suggests a carcinoma until proven otherwise.

Diagnosis

History.

Ask about:

• the duration of symptoms
• the amount and pattern of bleeding, e.g. postcoital, sporadic or regular
• contraception: if the woman is on the COC or the POP, query her compliance
• the possibility of pregnancy.

Examination.

Examine the cervix and perform a smear and bimanual examination.

Investigations.

Arrange a pregnancy test, if appropriate.

Management

• Ask about STI risk factors (see p. 2) and consider chlamydia screening (see p. 15). (Infection with chlamydia may cause a blood-stained discharge.) Consider referral to a GUM clinic.
• If the woman is on the COC and she has experienced breakthrough bleeding for more than 3 months, consider changing her pill to one with a higher progestogen content.
• If there is an IUCD in situ consider removing it if the symptoms persist for more than 3 months.
• Spotting may occur for up to 6 months after IUS insertion.
• Cervical erosions, if symptomatic, e.g. causing postcoital bleeding, can be treated with a silver nitrate stick, prescribable on FP10, or referred for treatment.
• Cervical polyps can be twisted and avulsed and sent for histology. Silver nitrate may be used on the resultant raw area. Always consider referral, especially if the base of the polyp is endocervical.

Women over 40 should always be referred, unless the bleeding settles after removal of the presumed cause, e.g. a polyp. All women should be referred if the bleeding is persistent.

POSTMENOPAUSAL BLEEDING

Postmenopausal bleeding is any bleeding which occurs 1 year after the LMP.

Examination.

Examine the vagina for, e.g. atrophic vaginitis (see p. 54), and the cervix, and perform a bimanual examination. Take a cervical smear, if appropriate.

Management

Women taking HRT should be referred for any significant unscheduled bleeding or consider review after stopping HRT.

Always refer to exclude malignancy, unless the bleeding is due to vaginitis which improves with treatment.

IRREGULAR PERIODS

Irregular periods are almost always a non-pathological variant of normal. They are most common at the extremes of reproductive life. The patient can usually be reassured. Irregular periods are a feature of POS (see p. 49). This symptom may progress to amenorrhoea (see p. 43).

DYSMENORRHOEA

Dysmenorrhoea, or painful menstruation, is common and can be severe, causing absence from school or work. It is usually fairly easy to differentiate between primary and secondary dysmenorrhoea.

PRIMARY DYSMENORRHOEA

(That is, there is no pelvic pathology.)

Diagnosis

History

• It is common in young girls.
• It usually appears within 12 months of the menarche.
• Pain tends to occur within the first 2 days of the period.
• Enquire into factors that have been associated with dysmenorrhoea: smoking, overweight, alcohol and stress.

Management

• Prostaglandin synthetase inhibitors, e.g. mefenamic acid 250–500 mg tds or naproxen 250–500 mg bd are usually helpful.
• The COC is especially useful, particularly when contraception is required.

SECONDARY DYSMENORRHOEA

(That is, the dysmenorrhoea is associated with pelvic pathology, e.g. endometriosis, pelvic inflammatory disease or adenomyosis.)

Diagnosis

History

• The dysmenorrhoea usually starts several years after the menarche.
• There is often a clear change in the degree and timing of the pain.
• The pain often starts well before the period and may continue throughout the period.
• Discuss the significance of the dysmenorrhoea and the effect of the pain on the patient’s lifestyle, e.g. time off work.

Examination.

Perform a speculum and bimanual examination to exclude any obvious pelvic pathology.

Management

• Consider removing an in situ IUCD.
• If the symptoms are suggestive of PID, see p. 44.
• Patients should be referred in order to exclude pelvic pathology.

ENDOMETRIOSIS

Endometriosis is a common cause of dysmenorrhoea, dyspareunia, pelvic pain and menorrhagia. Diagnosis is by laparoscopy. Women with infertility and worsening symptoms should be referred. Hormonal treatment aims to suppress ovulation for 6–12 months, during which time the lesions atrophy. Endometriosis usually resolves at the menopause. Pelvic pain may be treated with:

• prostaglandin synthetase inhibitors, e.g. mefenamic acid 250–500 mg tds, prn
• the COC (usually one with a high progestogen content, e.g. Eugynon 30), prescribed either with a pill-free break or continuously
• progestogens, e.g. norethisterone 10–15 mg daily on a continuous basis
• danazol 200–800 mg daily, adjusted to achieve amenorrhoea (inhibits gonadotrophin release). The dose can be titrated by balancing symptom control against side-effects, which are mainly androgenic
• GnRH analogues, e.g. buserelin nasal spray 300 μg tds for a maximum of 6 months (produces a reversible artificial menopause)
• surgery, e.g. local excision/diathermy of endometriotic tissue, or total hysterectomy and bilateral salpingo-oophorectomy.

MENORRHAGIA

Menorrhagia (regular heavy periods) is common at the extremes of reproductive life. Regular bleeding is relatively unlikely to be due to pelvic pathology.

Diagnosis

History.

Ask about:

• the passing of clots
• symptoms of anaemia.

Examination and investigations

• Check the haemoglobin.
• Perform a bimanual examination to exclude an organic cause, e.g. an ovarian or uterine tumour. Arrange a pelvic ultrasound scan if appropriate.
• Check the serum FSH if the menopause is suspected.

Management

Treatment

• Advise the woman to keep a menstrual diary.
• If there is an IUCD in situ, consider its removal.

Prescribing

• Antifibrinolytics, e.g. tranexamic acid 1–1.5 g tds or qds at the start of heavy bleeding for 3–4 days.
• Mefenamic acid 250–500 mg tds: this should be taken during the worst few days of the period (it is used mainly for pain, and can be used in conjunction with tranexamic acid).
• COC: pills with a high progestogen content are more effective.
• To control torrential bleeding: prescribe norethisterone up to 10 mg tds. The bleeding should stop within 48 hours. The dose can then be reduced to 5 mg bd for 12 days. The patient will experience a bleed on stopping treatment.
• The IUS should be considered, particularly for women also requiring contraception (see p. 16).

Referral

If there is no response to treatment or if symptoms warrant it, consider referral for transcervical resection of the endometrium (TCRE), endometrial laser ablation (ELA) or hysterectomy.

Menorrhagia: referral criteria

Refer all women for gynaecological assessment if:

• the onset of menorrhagia is sudden
• there is a suggestion of an organic cause (e.g. an ovarian or uterine tumour, endometriosis, pelvic inflammatory disease).

AMENORRHOEA

A woman with absent periods is usually concerned about abnormal body function and future fertility, or about possible pregnancy.

Primary amenorrhoea.

(i.e. when the menarche has not started by the age of 16 years):

• Causes: familial, structural (e.g. imperforate hymen), genetic (e.g. Turner’s) and endocrine.
• Examine the external genitalia, and look for the development of secondary sexual characteristics.
• Check weight to exclude anorexia nervosa.
• Refer to a gynaecologist.

Secondary amenorrhoea.

The usual cause is recent rapid weight loss, emotional upset or post-hormonal contraception, i.e. hypothalamic. (A common scenario is a young student starting college, having left home.) Always exclude pregnancy. The cause is otherwise nearly always hormonal.

Diagnosis

History.

Ask about:

• date of the menarche
• LMP
• the normal cycle
• weight loss/eating disorder/stress
• drugs (e.g. the COC)
• galactorrhoea (this occurs in hyperprolactinaemia)
• menopausal symptoms (e.g. premature ovarian failure)
• hirsutism (this occurs in polycystic ovarian syndrome)
• general health (symptoms of, e.g. hypothyroidism, might be elicited).

Investigations

• Serum prolactin (raised in hyperprolactinaemia).
• Serum FSH/LH (raised in premature menopause).
• Serum testosterone (slightly raised, along with LH and sometimes prolactin, in polycystic ovarian syndrome).
• TFTs

Management

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