Gynaecology Top Tips for GP’s 19 January 2012 Dr’s Percival/McGuiness/Overton/Smith

1. Gynaecology Top Tips for GP’s19 January 2012Dr’s Percival/McGuiness/Overton/Smith

2. Vulval/Vaginal Symptoms Examine/swabs. pH paper can be useful for BV Consider Herpes with recurrent vulval/vaginal symptoms Think contraception eg COCP/depo-provera. Hypo-oestrogen effect Try adding vagifem i pv nocte for 2 weeks & then twice weekly for 6 weeks

3. Vulval/Vaginal Symptoms If suspicious of recurrent thrush try 1/12 thrush suppression. Exclude BV. Exclude diabetes and immune suppression. Treat the partner with cream at the same time

4. Recurrent candidiasis Treatment against candida may have to be extended for six months in recurrent vulvovaginal candidiasis. Recommended regimens in the BNF (all unlicensed) include Fluconazole by mouth 150mg every 72 hours for 3 doses then 150mg every week for six months Clotrimazole 500mg vaginally once every week for 6 months Itraconazole by mouth 50-100mg daily for 6 months

5. Vulval/vaginal symptoms BV Oral or topical metronidazole (5-7 days) or topical clindamycin (7 days) For recurrent BV can try vaginal lactate gels e.g. Balance activ (Boots/Chemists/Online). Vulval care rules given to patient. See hand-out

6. Vulvodynia/Vulval Vestibulitis Remember to examine – exclude organic vulvodynia - Estrogen deficiency, infection, dermatitis etc History – burning but NOT itch, rawness, irritation Vaginal dilators, biofeedback, pelvic floor/kegal exercises, amitriptyline, gabapentin Local anaesthetic → instillagel, lidocaine ointment. How to use and counselling.

7. Patient information http://vulvalpainsociety.org/index.php?page=vulvodynia

8. Lichen Sclerosus et Atrophicus Chronic lymphocytic mediated inflammation – probably autoimmune. 45-60yrs usually but can affect pre-pubertal girls Does not affect vagina/cervix. Starts as red, irritating, sore, itchy patch then becomes white and sclerotic and eventually loss of the vulval architecture. Symptoms worse at night but can be asymptomatic. Causes fissuring/dyspareunia. 2-4% may develop vulval cancer Biopsy is only required if there is a failure to respond to treatment or a clinically suspicious lesion Topical steroids (dermovate) for three months, then reducing to betnovate and ¼ strength betnovate for maintenance. Soap substitutes and vulval care. Review two weeks and then 6 – 12 monthly.

10. Problematic bleeding Nulliparous women can have Mirena Examine the cervix, exclude chlamydia and consider a pregnancy test. Vaginal scan for endometrium and structural abnormality. Consider changing the pill. Add provera 10mg for 21 out of 28 days (with or without the pill)

11. Early pregnancy problems Pregnancy tests are highly sensitive and accurate (but not quantitative) Refer if pain requires more than paracetamol If ultrasound scan has confirmed an intrauterine pregnancy, slight bleeding can be managed expectantly Confidential Enquiry lessons – D&V

12. Pelvic pain Identify and treat causes of pelvic pain (chlamydia, constipation, IBS) Assume endometriosis if cyclical pelvic pain Refer early if pelvic examination or scan is abnormal & symptoms suggestive of severe endometriosis If tests are all normal treat first before referral Explain bicycling/tricycling/Mirena/4 day break

13. Severe endometriosis Deep dyspareunia everytime (an occasional “ouch” can be normal) Dyschezia (“bread knives”) esp around a period Blood in the stool or urine Severe dysmenorrhoea Missing work because of pain

14. Not sure whether the pill is contraindicated? http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf Same as MREC

15. Secondary Amenorrhoea Amenorrhoea assessment – TSH, Prolactin, FSH, LH, Testosterone, SHBG Progestagen challenge – consider doing in all cases in primary care. Provera 10mg daily for 5 days. If bleed more than light spotting then adequately estrogenised, just not ovulating. Aim for 4 bleeds a year naturally or using progestagen for 10 days or cocp Very rarely need to refer PCOS unless subfertility.

16. Endocrine enquiry Unusual headaches/abnormal vision Greasy hair, skin, acne Hirsutes Voice change Galactorrhea New striae General wellbeing

17. PCOS When & what to test for the metabolic syndrome? BMI > 30, strong family history of type II diabetes or over 40 Annual Fasting blood sugar And if >5.6 Glucose tolerance test Blood pressure

18. Metformin • Unlicensed to treat PCOS • Ensure that other endocrinopathies have been excluded • Start metformin 500mg once daily after evening meal • After two weeks increase to 500mg twice daily

19. Metformin • If unacceptable side effects (diarrhoea & nausea are common on starting), delay increasing the dose to bd • Stop metformin 48 hours before a general anaesthetic, with a positive pregnancy test and before binge drinking (5 units in 24 hours = ½ bottle wine, 2 ½ pints, 5 shots)

20. Metformin • Treats the symptoms of PCOS • Aids weight loss • May result in periods returning (contracpetion required if not planning pregnancy) • After six months reduces hirsutes

21. Use of Clomifene Some referrals were purely to access information about helping patients with PCOS trying to conceive Green light on traffic light system If amenorrheic check pregnancy test is negative Progestagen withdrawal bleed (provera 10mg od for 5 days) Start clomifene 50mg for 5 days from day 2 of the bleed Monitor by scan or luteal progesterone No period then repeat the above and increase clomifene to 100mg

22. Use of clomifene If no period, then repeat the above and increase clomifene to 100mg Maximum 6 cycles Risk of multiple pregnancy (twins 1 in 20 pregnancies and triplets or more) Risk of ovarian hyperstimulation syndrome Maximum 6 cycles and then refer if not pregnant

23. For guidance on metformin or clomifene http://www.repromed.avon.nhs.uk/Professionals%2Dinfertility/FARMS/Documents.htm

24. PMS Symptom diary Exercise and CBT, vitamin B6 Care with progesterone containing treatments as often mimic PMS symptoms. Good options are Yasmin, cilest, Mirena, Oestrogen patches 100 micrograms & cyclical provera 10mg days 17-28 or Mirena SSRI continuously or luteal phase

25. PMS patient information www.rcog.org.uk/managing-premenstrual-syndrome-pms-information-you

26. Ultrasound scan Uterine length = size in weeks Adenomyosis is benign. Treat symptoms Ignore small fibroids less than 3cm unless submucosal or uterus palpable abdominally Normal endometrial thickness 6mm post-period and up to 18mm luteal Ovaries not seen, no masses = small and normal

27. Urinary incontinence Physiotherapy Trial of medical treatment for overactive bladder solifenacin 5-10mg once daily or oxybutinin 2.5-5mg tds Associated with prolapse, does a ring pessary help? Urinary stress incontinence – duloxetine 20mg bd increasing to 40mg bd

28. Abnormal bleeding on HRT Allow some irregular bleeding on HRT in the first 3 months If this persists consider changing to sequential bleed Look for a specific cause (examine, NAATS) Ultrasound scan for endometrial thickness (allow up to 8mm)

29. Postmenopausal bleeding Allow endometrial thickness up to 5mm Consider family history, BMI & whether the bleeding was “one-off” or continuing If continuing a scan is not reassuring – refer 2ww

30. Thank you!E mail tim.percival@gp-L81133.nhs.ukcaroline.overton@uhbristol.nhs.uknicola.mcguinness@gp-L81090.nhs.ukt