Women

1
Womens problems in General Practice

• Dr. Philippa Feldman

2
Facts 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

3
Reasons for consultation

• WOMEN
• Metabolic problems
• Blood disorders
• Reproductive
• Mental
• Circulation
• GU
• Muscular

• MEN
• Accidents
• Poisonings
• Violence

4
Reasons for consultation

• If gender related problems are removed then men
  and women consult at the same rate

5
Annual Consultation Rates per List of 2000

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

6
Menorrhagia

• 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

7
Menorrhagia Management

• History Investigations
• Cycle length - FBC
• Heaviness
• IMB / PCB
• Examination
• Abdo
• PV
• Smear

8
Menorrhagia Treatment

• Treat yourself
• Under 40
• No PCB/ IMB
• Normal Hb
• Normal Examination
• Not too heavy

9
Menorrhagia 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

10
Dysmenorrhoea

• 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

11
Dysmenorrhoea Management

• History
• Primary / Secondary
• Examination
• Abdo / PV
• Investigations
• HVS

12
Dysmenorrhoea Management

• Treatment
• Refer
• Abnormal exam
• Unresponsive secondary cases
• NSAIDS
• COC

13
Incontinence

• Embarrassing -
• Only 10 tell their spouse
• lt 10 tell a close friend
• BUT 66 will consult their GP

14
Incontinence - Types

• Stress Incontinence
• Urge
• Motor
• Sensory
• Overflow
• Passive / Reflex
• Other e.g. Constipation, UTI, Anxiety

15
Incontinence

• 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

16
Incontinence differentiation

• Stress
• Leaking when
• cough
• sneeze
• laugh
• Leaking when
• Run
• Jump
• Sport
• Leaks small amounts

• Urge
• Frequency
• gt6/day
• gt3/night
• Urgency
• Hurrying to get to toilet
• Leaking before toilet
• Wetting at night

17
Incontinence Examination/Investigation

• Abdominal PV / PR
• Neurological Examination if indicated
• Urinalysis
• MSU

18
Incontinence Who to Refer?

• Abnormal examination
• Prolapse, cystocoele, rectocoele,
• Pelvic mass
• Neurological signs
• Palpable bladder post micturition
• Unable to classify

19
Stress Incontinence Managment

• Diet if obese
• Pelvic floor exercises for life
• Avoid heavy lifting
• Refer if no improvement after 3/12

20
Urge Incontinence Management

• Frequency volume chart
• Bladder retraining
• Drugs
• Oxybutynin 5mg tds
• Tolterodine 2mg bd
• Imipramine 10-25mg tds

21
Vaginal 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

22
Vaginal 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

23
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

24
Vaginal 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

25
Vaginal Discharge Referral

• Lower abdo pain
• PMH - STD
• Recent change of partner
• Partner with urethral symptoms
• Blood stained discharge

26
Vaginal 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

27
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

28
PMS - Who complains?

• 90 of women get cyclical change at some time
• All social classes
• Social Class I and II more likely to consult

29
PMS 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

30
PMS 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 ?

31
The 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

32
Menopause - Diagnosis

• Oestrogen deficiency
• Periods decrease in frequency and stop
• Hot flushes
• Vaginal dryness and atrophy
• Urethral syndrome
• Investigations
• Usually unnecessary
• FSH gt 20 iu/L

33
Reasons for HRT

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

34
Contraindicatioins 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

35
Treatment

• 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

36
Treatment II

• Implants
• Vaginal creams
• SSRI

37
HRT

• 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

38
HRT

• Beneficial effects per 100.000 users
• 6 fewer women develop colon cancer
• 5 fewer break a hip