Women’s problems in General Practice

Women’s problems in General Practice

Dr. Philippa Feldman

Facts and FiguresFacts and Figures Men consult 4 times per year Women consult 6 times per year 61% GP consults are with women Life expectancy women 1988 = 78 yrs Life expectancy men 1988 = 72 yrs Over 75 yrs 63% are women Over 85yrs 75% are women Women take more drugs than men

Reasons for consultationReasons for consultation

WOMEN Metabolic problems Blood disorders Reproductive Mental Circulation GU Muscular

MEN Accidents Poisonings Violence

Reasons for consultationReasons for consultation

If gender related problems are removed then

men and women consult at the same rate

Annual Consultation Rates per List of 2000

Annual Consultation Rates per List of 2000

Menstrual Problems 75 Contraception 60 Menopausal 30 Vaginitis 20 PMS 20 Breast conditions 15 Infertility 5

MenorrhagiaMenorrhagia

Eighth commonest hospital referral Presenting complaint in 1/3 of gynae referrals 73,000 hysterectomies per year 10,000 endometrial ablations per year 50 % of hysterectomies no obvious pathology Cycle length varies with age Most cases normal ovulation

Menorrhagia ManagementMenorrhagia Management

History Investigations– Cycle length - FBC– Heaviness– IMB / PCB

Examination– Abdo– PV– Smear

Menorrhagia TreatmentMenorrhagia Treatment

Treat yourself

– Under 40

– No PCB/ IMB

– Normal Hb

– Normal Examination

– Not too heavy

Menorrhagia TreatmentMenorrhagia Treatment

Tranexamic acid 1g tds 40%

mefenamic acid 500mg tds 29%

ibuprofen 400mg tds 16%

Levonorgestrel IUCD 88%

COC 50%

norethisterone 5mg bd -3.6%

Endometrial Resection

Hysterectomy

Myomectomy

Antifibrinolytics NSAIDS

Hormonal

Surgery

DysmenorrhoeaDysmenorrhoea

Secondary– Years after menarche

– Pain premenstrually until end of menses

– Associated with pelvic pathology

Primary– 6-12 months after

menarche

– Pain Day 1,2

– D & V

Dysmenorrhoea ManagementDysmenorrhoea Management

History– Primary / Secondary

Examination– Abdo / PV

Investigations– HVS

Dysmenorrhoea ManagementDysmenorrhoea Management

Treatment– Refer

» Abnormal exam

» Unresponsive secondary cases

– NSAIDS

– COC

IncontinenceIncontinence

Embarrassing -

Only 10% tell their spouse

< 10% tell a close friend

BUT 66% will consult their GP

Incontinence - TypesIncontinence - Types

Stress Incontinence Urge

– Motor– Sensory

Overflow Passive / Reflex Other e.g. Constipation, UTI, Anxiety

IncontinenceIncontinence

Stress:– Involuntary loss of urine on exertion in the absence

of bladder contraction Urge

– Involuntary loss of urine accompanied with a strong desire to void

» Motor - Unstable detrusor muscle

» Sensory - Hypersensitivity of bladder receptors

Incontinence differentiationIncontinence differentiation

Stress– Leaking when

» cough

» sneeze

» laugh

– Leaking when» Run

» Jump

» Sport

– Leaks small amounts

Urge– Frequency

» >6/day

» >3/night

– Urgency» Hurrying to get to toilet

» Leaking before toilet

– Wetting at night

Incontinence Examination/Investigation

Incontinence Examination/Investigation

Abdominal + PV / PR

Neurological Examination if indicated

Urinalysis

MSU

Incontinence Who to Refer?Incontinence Who to Refer?

Abnormal examination

– Prolapse, cystocoele, rectocoele,

– Pelvic mass

– Neurological signs

– Palpable bladder post micturition Unable to classify

Stress Incontinence ManagmentStress Incontinence Managment

Diet if obese

Pelvic floor exercises for life

Avoid heavy lifting

Refer if no improvement after 3/12

Urge Incontinence ManagementUrge Incontinence Management

Frequency volume chart Bladder retraining Drugs

– Oxybutynin 5mg tds

– Tolterodine 2mg bd

– Imipramine 10-25mg tds

Vaginal DishargeVaginal Disharge

Infective– Bacterial vag 56.5%– Candida 34.5%– Chlamydia 6.5%– Trichomonas 2.3%– Strep milleri 1.8%– Haemophillus 1.0%– Staph aureus 0.5%– Gonorrhoea 0.3%– Herpes virus 0.3%

Non Infective– Cervical ectropion

– Cervical polyps

– Atrophic vaginitis

– Genital tract Ca

– Retained tampon

Vaginal Discharge HistoryVaginal Discharge History

Previous discharge Odour - itch IUD Recent gynae surgery Lower abdo pain PMH - STD Recent change of partner Partner with urethral symptoms Blood stained discharge

Vaginal Discharge Investigations

Vaginal Discharge Investigations

Cervical Swab Stuarts medium– GC - will usually pick up vaginal infections eg

» Bacterial vaginosis» Candida» Trichomonas

Endocervical swab– Chlamydia

» Use cotton tipped swab rotated for 10 secs in endocervix

Vaginal Disharge ManagementVaginal Disharge Management Thrush

– Clotrimazole pes 500mg. stat Recurrent Thrush

– Treat partner– Clotrimazole pes 100mg for 14 days– Fluconazole 50mg/day for 7 days– Intermittent prophylactic treatment

Advice– Wear loose clothes– Avoid vaginal deodorants, bubble baths, soaps

Vaginal Discharge ReferralVaginal Discharge Referral

Lower abdo pain

PMH - STD

Recent change of partner

Partner with urethral symptoms

Blood stained discharge

Vaginal Dishcharge ChlamydiaVaginal Dishcharge Chlamydia

One episode of chlamydial cervicitis:-– PID in 20% of these

» 20% develop chronic pelvic pain

» 15% will be infertile

» 5% ecotopic pregnancy

Frequency– Found in 6.5% of women with GU symptoms

Diagnostic tests - not highly accurate

Premenstrual Syndrome Definition

Premenstrual Syndrome Definition

Magos 1990– Distressing Physical psychological and behavioural

symptoms not caused by organic disease which regularly recur during the same phase of the menstrual cycle and which significantly regress during the remainder of the cycle

PMS - Who complains?PMS - Who complains?

90% of women get cyclical change at some

time

All social classes

Social Class I and II more likely to consult

PMS ManagementPMS Management

Mild– Discussion/talking acknowledge problem– Attention to health/lifestyle - decrease smoking

and alcohol increase exercise– rearrange work schedules to allow for PMS– Self help groups

Moderate– Anxiety management– Cognitive therapy

PMS ManagementPMS Management

Severe– SSRI Fluoxetine 20mg/day

– Oestrogen therapy - HRT doses and increase, use cyclical progestogen in women with uterus - dydrogesterone or medoxyprogesterone ? mirena

– COC

– TAH + BSO + HRT

– Euthanasia ?

The MenopauseThe Menopause

Menopause – ‘Date of last period’

Climacteric – ‘Gradual decrease of Ovarian function over several

years Mean age = 50 years

– Cigarette smoking decreases by 2 years Cultural and Social attitudes important

Menopause - DiagnosisMenopause - Diagnosis

Oestrogen deficiency– Periods decrease in frequency and stop– Hot flushes– Vaginal dryness and atrophy– Urethral syndrome

Investigations– Usually unnecessary– FSH > 20 iu/L

Reasons for HRTReasons for HRT

Removal of Ovaries before menopause Menopause < 45 yrs Hysterectomy before menopause Hot flushes Sexual difficulties - Atrophic vaginitis High risk of Osteoporosis High risk IHD

Contraindicatioins to HRTContraindicatioins to HRT

Absolute– CA breast

– CA endometrium

– Thromboembolic disease

– Severe Liver or Renal disease

Relative– Breast Lump

– Pelvic Mass

– IMB / PCB

– Menorrhagia

– Gall Bladder disease

– Otosclerosis

– Previous problems OCP

TreatmentTreatment Post - hysterectomy

– Oestrogen alone» tablets, patches or gel

Uterus intact– Opposed oestrogen

» oestrogen tablets, patches or gel + progestogen tablets or patches

– One year post menopause or age 54+» Premique» Tibolone

Treatment IITreatment II

Implants

Vaginal creams

SSRI

HRTHRT

Adverse effects per 10,000 users

– 7 extra women develop hear disease

– 8 extra women have a CVA

– 8 extra women have PE

– 8 extra women develop breast cancer

HRTHRT

Beneficial effects per 100.000 users

– 6 fewer women develop colon cancer

– 5 fewer break a hip