3: GYNAECOLOGY

Published on 27/05/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1638 times

CHAPTER 3 GYNAECOLOGY

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.

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.

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

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.

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.

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.

Management

• If blood tests are normal, amenorrhoea can be assumed to be hypothalamic and the woman can be reassured that her periods will return.

• Secondary amenorrhoea due to anorexia nervosa should be referred appropriately.

• Contraception should be discussed, if appropriate. If the patient is trying to become pregnant, consider referral and/or treatment with clomiphene (see p. 60).

• If blood tests are abnormal, refer as appropriate.

PELVIC PAIN

Diagnosis

Try to exclude the following diagnoses on history and examination:

• Appendicitis.

• Ectopic pregnancy: consider this in all sexually active women with pelvic pain. If appropriate, do an immediate pregnancy test and arrange an urgent pelvic ultrasound (a negative pregnancy test does not always exclude an ectopic pregnancy). Arrange immediate referral if in doubt.

• A ruptured ovarian cyst.

• Acute pelvic inflammatory disease.

• Other pelvic pathology, e.g. endometriosis. (This last should always be considered when recurrent episodes of pelvic pain fail to respond to antibiotic treatment.)

Management of acute pelvic inflammatory disease (PID)

An HVS and endocervical swab (both in bacterial transport media) and an endocervical chlamydia swab (see p. 46) should be taken.

Treatment with antibiotics is usually given without a definite diagnosis, and should cover Neisseria gonorrhoeae and Chlamydia (the two major causes), and mixed aerobic and anaerobic infections. Treat with ofloxacin 400 mg bd and metronidazole 400 mg bd for 14 days.

IUCDs can be left in situ during treatment unless the infection is severe or persistent. Sexual contacts should be treated with doxycycline 100 mg od for 10 days. Always seriously consider referral to a GUM clinic. Admit the patient if symptoms are severe.

VAGINAL DISCHARGE

The most common causes of vaginal discharge in general practice are Candida and Gardnerella (bacterial vaginosis – BV). Trichomonas is a less common cause. Chlamydia, gonorrhoea and herpes simplex are rarely associated with vaginal discharge (see also STIs, p. 46).

• It is reasonable to treat first or occasional episodes of candida according to clinical findings, without doing swabs.

• An HVS in transport medium is needed for culture of Candida, BV, Trichomonas and most bacterial causes of pyogenic infection. An endocervical swab in transport medium is needed for gonococcal culture. An endocervical chlamydia swab is needed for chlamydia diagnosis. All three swabs should be taken in those with STI risk factors (see p. 2), although referral to a GUM clinic for investigation is preferable.

• Vaginal discharge is not, in itself, an indication for chlamydia testing (see p. 46).

• Non-infective causes of vaginal discharge include a cervical lesion or a foreign body.

CANDIDA

Candida is usually harboured by the woman, but can be sexually transmitted. The classic symptom is pruritus. The curdy white discharge may be minimal. It is often associated with dysuria and dyspareunia.

Management

Occasional symptoms.

Treat with a topical imidazole, e.g. clotrimazole pessary 500 mg at night as a single dose. Clotrimazole 1% cream can be used in addition for vulval pruritus. Alternatively, treat with oral fluconazole 150 mg as a single dose. (All available OTC.)

BACTERIAL VAGINOSIS (BV)

BV is not considered to be sexually transmitted. The thin, grey discharge is usually fishy-smelling.

Management

• Metronidazole 400 mg bd for 5 days.

• If symptoms are recurrent it may be worth treating the partner concurrently.

SEXUALLY TRANSMITTED INFECTIONS

In all STIs the partner should also be treated and sexual intercourse should be avoided until treatment is complete. Other recent sexual partners should be advised to seek medical advice.

Investigations should be performed to exclude the presence of any other STI. Referral to a GUM clinic is recommended for full investigation and for treatment of the patient and their sexual contacts (see p. 2 for considering possible STI risk).

TRICHOMONAS

Trichomonas is generally considered to be sexually transmitted and is often associated with other STIs. The discharge is usually frothy and yellow. Symptoms may include vaginal itching and soreness.

Management

Metronidazole 400 mg bd for 5 days.

CHLAMYDIA

See also p. 15 for opportunistic screening.

Chlamydia is a major cause of PID, tubal infertility and ectopic pregnancy. It is the commonest curable STI in the industrialised world. Most women with chlamydia are asymptomatic. An endocervical chlamydia swab should be taken. Standard regimens for treatment of PID will cover chlamydia (see p. 44). Refer to a GUM clinic.

Management

• Doxycycline 100 mg bd for 7 days or azithromycin 1 g as a single dose. If pregnant or breast-feeding, erythromycin 500 mg qds for 7 days or 500 mg bd for 14 days.

• A test of cure investigation should be performed after treatment.

GONORRHOEA

Gonorrhoea is a major cause of PID. Patients should be referred to a GUM clinic. Remember chlamydia.

Management

• Treatment should be coordinated by the GUM clinic.

• Treat with e.g. single-dose ciprofloxacin 500 mg or ofloxacin 400 mg.

GENITAL WARTS

Genital warts are diagnosed by clinical appearance. They are caused by human papilloma virus (HPV).

Management

Treatment is usually coordinated by the GUM clinic

• Podophyllin paint is applied only to the warts. (Podophyllin should be avoided in pregnancy.) It should be left on for 4–6 hours, washed off, and reapplied every 3–7 days.

• Imiquimod cream is applied only to the warts, three times per week.

• Consider cryotherapy as an alternative treatment for external warts.

• Annual smears are recommended after a diagnosis of genital warts.

GENITAL HERPES

Genital herpes is usually diagnosed by symptoms and clinical appearance. Patients should know that one-third of genital herpes infections are acquired from a mouth lesion rather than via sexual contact, that the delay between contact and symptoms may be long, e.g. years, and that they are more likely than not never to have a further attack. A swab of suspicious lesions should be sent in viral transport medium.

Advice.

Salt water baths and ice packs are helpful for painful lesions.

Management

• Analgesia, as appropriate.

• Treat with e.g. valaciclovir 500 mg bd for 5 days started as early as possible, but certainly within 7 days of the onset of symptoms.

Treatment of recurrent symptoms.

Depending on the degree of severity, the following may be used: simple analgesia alone, aciclovir cream or oral valaciclovir (as above) within 48 hours of onset, or, if recurrences are severe or frequent, continuous low-dose oral aciclovir 200–400 mg bd may be prescribed, usually on consultant advice.

A pregnant woman with a past history of genital herpes should have viral swabs taken in late pregnancy, as neonatal herpes can occur even when the mother has no overt signs of herpes.

HIV AND AIDS

HIRSUTISM

In the vast majority of cases hirsutism is constitutional, especially in southern European women. Most hirsute women have increased androgen metabolism, at the high end of the spectrum of normality.

Diagnosis

Consider the following:

• a drug-related cause (e.g. phenytoin, corticosteroids, androgenic COC)

• a generalised endocrine disorder (e.g. hypothyroidism, Cushing’s disease, acromegaly)

• inappropriate androgen production (raised serum testosterone and reduced SHBG) and polycystic ovarian syndrome (see below).

POLYCYSTIC OVARIAN SYNDROME

The features of this common syndrome are polycystic ovaries on ultrasound together with irregular or absent periods and signs of excess androgens. Twenty per cent of asymptomatic women are found to have polycystic ovaries on ultrasound without the features of the syndrome. POS is thought to be related to insulin resistance. The patient often presents in her late teens or early twenties with some or all of the following symptoms:

• virilisation with acne and hirsutes

• irregular or absent periods

• infertility (ovulation is sporadic or absent).

Investigations.

Blood results may show: raised LH, increased LH/FSH ratio, raised prolactin and raised testosterone. Ultrasound shows characteristic ovaries. Also check fasting blood sugar and serum cholesterol (POS patients have higher rates of ischaemic heart disease (IHD), hypertension and diabetes).

BREAST SCREENING

The government-funded National Breast Screening Programme offers routine 3-yearly mammography to all women aged 50–64, by invitation. Women aged 65 and over may receive 3-yearly mammography, but only on request.

The screening programme is reducing breast cancer mortality by 20–40%. No significant reduction in mortality has been shown in women under 50 years of age, following screening.

Mammography is not a tool for investigating established breast lumps.

BREAST AWARENESS

Most breast cancers are discovered by women themselves. Routine, formalised breast self-examination is no longer advocated, as it has not been shown to reduce breast cancer mortality and can cause considerable unnecessary anxiety. A more general breast awareness should be promoted. This encourages women to recognise what is normal, to know what changes to look out for, and to seek medical advice about these changes without delay.

BREAST LUMPS

THE MENOPAUSE/CLIMACTERIC

The menopause is the process of inevitable ovarian failure leading to oestrogen deficiency. The average age of onset is 50.

HORMONE REPLACEMENT THERAPY (HRT)

HRT is indicated for:

• menopausal symptoms (see above) – the benefits of short-term HRT outweigh the risks in the majority of women

• the prophylaxis of osteoporosis in women with an early menopause, i.e. <50 years (not as first-line treatment for the prevention of osteoporosis in women >50).

Contraindications

• Oestrogen-sensitive malignancies (breast or endometrium).

• Major thromboembolic disease (in view of minor adverse effects on clotting factors and platelet function).

• Severe kidney or liver disease.

• Gall bladder disease.

• Otosclerosis (may worsen on HRT).

First appointment

History.

See diagnosis of the menopause.

Examination

• Discuss breast awareness.

• Consider vaginal examination.

• Check smear status.

• Mammography should be arranged for women with a family history of breast cancer (see also p. 51).

Advice

• Offer general advice relating to the menopause (see p. 52) and osteoporosis (see p. 244).

• Discuss contraception if appropriate (see p. 18). HRT is not a form of contraception.

• HRT is associated with a small increased risk of breast carcinoma, within 1–2 years of starting treatment, and related to duration of use. The risk is highest with combined preparations, less with tibolone (see below), and even less with oestrogen-only preparations, e.g. for 1000 women aged 50–64, taking combined HRT for 5 years there would be six extra cases of breast cancer. Any excess risk disappears within about 5 years of stopping.

• HRT is, in addition, associated with a small increase in the rates of stroke and thromboembolic disease, and a small decrease in the rates of colorectal and endometrial cancer.

• HRT does not prevent cognitive decline or coronary heart disease.

Prescribing.

(The lowest effective maintenance dose should be prescribed.)

Only hysterectomised women may be treated with unopposed oestrogens.

• Continuous daily oestrogen should be prescribed for hysterectomised women, e.g. Premarin 0.625–1.25 mg daily.

• Oestrogen/progestogen preparations should be prescribed for women with an intact uterus (unopposed oestrogens may cause hyperplasia of the endometrium and possible endometrial cancer). Continuous oestrogen with 12–13 days of progestogen at the end of each monthly cycle (cyclical HRT), producing a regular monthly bleed, is commonly prescribed in the perimenopause, e.g. Nuvelle or Prempak-C. Amenorrhoeic regimens (using continuous combined oestrogen and progestogen) may be used for women who are at least 1 year postmenopausal, e.g. Premique or Kliofem. Irregular bleeding is a common side-effect of these regimens during the early treatment stages. If it continues, endometrial abnormality should be excluded, and consideration given to cyclical HRT instead.

• Oestrogen can be given as a transdermal patch or subdermal implant.

• The low-dose COC alleviates perimenopausal symptoms. In fit non-smokers it can be prescribed up to the menopause.

• Tibolone combines weak oestrogenic, progestogenic and androgenic activity. It is useful for women who cannot take oestrogen, for osteoporosis prophylaxis and symptom control. It does not produce withdrawal bleeds, but spotting is a common side-effect.

• Vaginal oestrogen creams, e.g. oestriol 0.1%, are useful for women with atrophic vaginitis. The smallest effective amount should be used to minimise systemic effects. Modified-release vaginal tablets and an impregnated vaginal ring are also available.

CERVICAL CANCER

Cervical cancer kills 1000 women in the UK per year.

Discussion points for primary prevention of cervical cancer

• Stopping or reducing smoking lessens the risk of cervical cancer.

• An increased number of sexual partners (for both men and women) increases the risk.

• Ninety-five per cent of cervical cancer is caused by HPV infection (HPV vaccine is available to girls before sexual activity starts).

• Barrier methods of contraception are probably protective.

• Patients should avoid intercourse with partners with genital warts, unless a condom is used.

National cervical screening guidelines

• Invitation for first screening at age 25.

• Women aged 25–50 should be screened every 3 years.

• Women aged 50–65 should be screened every 5 years.

• Screening is unnecessary for women who have never been sexually active.

• Women aged 65 or over who have had regular negative tests do not need further screening. Women aged 65 or over who have never been screened, or who have not been screened since age 50, should be encouraged to do so.

• Instructions for follow-up or colposcopy referral will be given on smear reports.

Negative smear reports sometimes reveal incidental findings which require action as follows.

Specific infections

• Trichomonas: treat (see p. 46).

• Candida: treat if symptomatic (see p. 45).

• Actinomyces-like organisms (ALOs): these may colonise the genital tract in the presence of an IUCD. If the woman is asymptomatic, discuss the possible risk of pelvic infection. Leave the IUCD in situ and arrange 6-monthly follow-ups, including bimanual examination. Alternatively, remove or exchange the device (this usually leads to disappearance of ALOs) and repeat the smear after 6 months. If the woman is symptomatic (i.e. pelvic pain, dyspareunia or discharge), remove the IUCD, send the threadless device for culture and take an endocervical swab. If ALOs are found, treat with high-dose penicillin (2–3 g per day) or erythromycin for at least 2 weeks. Arrange an alternative method of contraception.

• Herpes simplex: no action.

• Inflammatory changes: no action, or consider taking swabs (see PID, p. 44) and treat as appropriate.

Clinical suspicion of cervical pathology should prompt referral for colposcopy, even if a cervical smear is normal.

INFERTILITY

Infertility is common, affecting about 15% of couples. It is important to note that 25% of cases of infertility remain unexplained.

The main causes of infertility are:

• disorders of spermatogenesis

• ovulation disorders

• tubal/pelvic pathology

• others, e.g. endometriosis, sperm/mucus problems.

Diagnosis

History

• Confirm regular intercourse during the fertile period. The fertile period is from day 8 to day 17 in a normal 28-day cycle (see calendar method, p. 16).

• Ninety per cent of women of proven fertility will conceive within 12 months. Investigation is therefore not usually undertaken until the couple have been attempting to conceive for 12 months or more.

• The couple should ideally be seen together.

Investigations.

Before referral, the GP can arrange for semen analysis and confirmation of ovulation.

A fresh warm specimen, produced after 48 hours of abstinence, should be examined in the laboratory within 2 hours of production.

• volume >2 ml

• count >20 million/ml

• motility >50%

• normal morphology >50%.

Management

Clomiphene may be given to women who have been shown not to be ovulating, while awaiting hospital assessment. Their partner must have a normal semen analysis. Prescribe clomiphene 50 mg daily for 5 days starting on day 2. Ovulation can be confirmed by a rise in day 19 to day 21 progesterone. In the absence of ovulation, a second course of 100 mg daily for 5 days can be given. Three courses constitute an adequate therapeutic trial.

TERMINATION OF PREGNANCY REQUEST

The 1967 Abortion Act (revised in 1991) allows the following grounds for termination of pregnancy:

1. risk to the life of the woman or risk of grave permanent physical or mental injury to the woman (no time limit)

2. risk of injury to the physical or mental health of the woman (only legal up to 24 weeks)

3. risk of injury to the physical or mental health of existing child(ren) (only legal up to 24 weeks)

4. substantial risk of the child being born with serious abnormalities (no time limit).

(Most TOPs are performed under point 2.)

Management

• Help the woman to make a decision about the future of her pregnancy.

• Give information about the different methods of TOP, if appropriate, and refer to a gynaecologist:

– surgical treatment

– medical treatment with RU486 (mifepristone) and prostaglandins (only suitable for use in pregnancies of less than 9 weeks’ gestation).

• Discuss future contraceptive plans.

• Arrange follow-up 2 weeks after the termination.

Related

Churchills Pocketbook of General Practice