Women’s problems in General Practice

1. Women’s 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. WOMEN Metabolic problems Blood disorders Reproductive Mental Circulation GU Muscular MEN Accidents Poisonings Violence Reasons for consultation

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. 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 Menorrhagia Treatment

10. 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

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 • < 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. 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 differentiation

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. 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 Disharge

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. 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 ? PMS Management

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 > 20 iu/L

33. Reasons 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

34. 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 Contraindicatioins to HRT

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