women’s problems in general practice dr. philippa feldman
TRANSCRIPT
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