1. Women’s Health 1 Dr Pamela Sides Tuesday 22nd March 2011 Dr Pamela Sides Tuesday 22nd March 2011

2. Aims & Plan To cover those parts of the curriculum where you have the greatest needs 2.00 introductions and agenda setting 2.05 presentation - pregnancy, menopause & hrt in general practice 2.30 small groups to discuss cases 3.00 discussion about cases 3.25 any questions,plenary and feedback To cover those parts of the curriculum where you have the greatest needs 2.00 introductions and agenda setting 2.05 presentation - pregnancy, menopause & hrt in general practice 2.30 small groups to discuss cases 3.00 discussion about cases 3.25 any questions,plenary and feedback

3. Pregnancy Not covering antenatal care Pre conception Fertility issues The 1st appointment Post natal Not covering antenatal care Pre conception Fertility issues The 1st appointment Post natal

4. Pre Conception Counselling Life Style SmokingAlcoholDiet Advice if under or over weight Consider illicit drugs Consider exposure to harmful substances in employment Life Style SmokingAlcoholDiet Advice if under or over weight Consider illicit drugs Consider exposure to harmful substances in employment

5. Pre Conception Counselling Medical Regular medication Mum’s (?Dad’s) medical history Family history Immunisation - rubella, ?varicella, ?? Hep B Medical Regular medication Mum’s (?Dad’s) medical history Family history Immunisation - rubella, ?varicella, ?? Hep B

6. Pre Conception Counselling Advice Folic acid - usually 400 micrograms until 12 weeks High risk PRESCRIBE 5mg Dietary - vit A, soft cheeses o/c medication Discuss time expected to conceive & when they should return. Advice Folic acid - usually 400 micrograms until 12 weeks High risk PRESCRIBE 5mg Dietary - vit A, soft cheeses o/c medication Discuss time expected to conceive & when they should return.

7. Pre Conception Counselling ICE As if I need to remind you! ICE As if I need to remind you!

9. Fertility Issues Ask How long have they been trying Previous pregnancies in this relationship or to either partner Consider Health, pmh, medication,smoking, etoh, wt Relevant gynae history Contraception - what & when stopped. Lmp & menstrual cycle Frequency of sex Need to examine - smear, chlamydia, fibroids Ask How long have they been trying Previous pregnancies in this relationship or to either partner Consider Health, pmh, medication,smoking, etoh, wt Relevant gynae history Contraception - what & when stopped. Lmp & menstrual cycle Frequency of sex Need to examine - smear, chlamydia, fibroids

10. Fertility Issues Investigations Her : fbc, tft, 21 day progesterone ?fsh/lh if irregular bleeding prolactin if need to exclude pituitary problems Him : semen count Investigations Her : fbc, tft, 21 day progesterone ?fsh/lh if irregular bleeding prolactin if need to exclude pituitary problems Him : semen count

11. Fertility Issues Refer - usually if > 1 year trying But also pre-conceptual advice as above. Refer - usually if > 1 year trying But also pre-conceptual advice as above.

13. 1st Appointment

14. Referral for Termination Treat as fast track Are you willing to sign the “blue form”? Try to be up to date with options eg - medical v surgical May need a dating scan Treat as fast track Are you willing to sign the “blue form”? Try to be up to date with options eg - medical v surgical May need a dating scan

16. Post Natal Her experience - the pregnancy,the birth & 1st few weeks feeding, bleeding, sleeping, coping etc How is she? Physically? Emotionally? The future -pregnancies/contraception and probably plans for return to work. Her experience - the pregnancy,the birth & 1st few weeks feeding, bleeding, sleeping, coping etc How is she? Physically? Emotionally? The future -pregnancies/contraception and probably plans for return to work.

17. Post Natal Examination BP & Wt ? Abdo/pv. Check scar if C section PV if still bleeding, concern about stitches OR she wants/expects one. Only cervical cytology - if it’s due and she’s not likely to return Examination BP & Wt ? Abdo/pv. Check scar if C section PV if still bleeding, concern about stitches OR she wants/expects one. Only cervical cytology - if it’s due and she’s not likely to return

19. Menopause - diagnosis and management By definition the menopause is the last period The climacteric covers the time leading up to the last period and the months or years afterwards when the woman is symptomatic The menopause can only be diagnosed retrospectively (after 2yrs if 50) Can we diagnose the climacteric and do we need to? By definition the menopause is the last period The climacteric covers the time leading up to the last period and the months or years afterwards when the woman is symptomatic The menopause can only be diagnosed retrospectively (after 2yrs if 50) Can we diagnose the climacteric and do we need to?

20. Menopause - diagnosis What investigations would you perform? Bloods ?hormones - fsh/lh fbctftfbslipids ?Bone density - in particular if early menopause (<45) What investigations would you perform? Bloods ?hormones - fsh/lh fbctftfbslipids ?Bone density - in particular if early menopause (<45)

21. Menopause - symptoms Sweats/flushes Dry vagina Mood changes Aching joints Memory loss etc etc etc Sweats/flushes Dry vagina Mood changes Aching joints Memory loss etc etc etc

22. Menopause - Management Reassure and inform. Offer leaflets and/or websites. Cover contraception Self help Discuss alternative therapies Prescribed medication Reassure and inform. Offer leaflets and/or websites. Cover contraception Self help Discuss alternative therapies Prescribed medication

23. Menopause - Management Self help www.menopausematters.co.uk nhs direct numerous books SWEATS - minimised by light clothing and especially consider temperature of bedroom avoiding stress (!), cutting down alcohol, caffeine and spicy foods and of course - stop smoking VAGINAL DRYNESS - lubricants Replens, Senselle and Durex OSTEOPOROSIS - weight bearing exercise and plenty of dietary calcium Self help www.menopausematters.co.uk nhs direct numerous books SWEATS - minimised by light clothing and especially consider temperature of bedroom avoiding stress (!), cutting down alcohol, caffeine and spicy foods and of course - stop smoking VAGINAL DRYNESS - lubricants Replens, Senselle and Durex OSTEOPOROSIS - weight bearing exercise and plenty of dietary calcium

24. Menopause - Management Alternative Therapies None are proven to be effective Remember phytoestrogens may have adverse effects Patients may have tried : Soya products Red Clover Black Cohosh Evening Primrose Ginkgo Biloba St John’s Wart Alternative Therapies None are proven to be effective Remember phytoestrogens may have adverse effects Patients may have tried : Soya products Red Clover Black Cohosh Evening Primrose Ginkgo Biloba St John’s Wart

25. Menopause - Management Prescribed Medication usually for sweats & flushes HRT c lonidine B blockers anti depressants - particularly ssri & snri ? gabapentin Also osteoporosis calcium bisphosphonates strontium Prescribed Medication usually for sweats & flushes HRT c lonidine B blockers anti depressants - particularly ssri & snri ? gabapentin Also osteoporosis calcium bisphosphonates strontium

26. Hormone Replacement Therapy Minimum dose Shortest time At least annual review Minimum dose Shortest time At least annual review

27. HRT Has she got a uterus? If not : oestrogen only (caution if the hysterectomy was for endometriosis) If she has : Oestrogen & progestagen Is she clearly > 1 yr post menopausal If not : will need cyclical bleed (double script charge) If she is : probably try bleed free Oral? Patches? Gel? Vaginal? Has she got a uterus? If not : oestrogen only (caution if the hysterectomy was for endometriosis) If she has : Oestrogen & progestagen Is she clearly > 1 yr post menopausal If not : will need cyclical bleed (double script charge) If she is : probably try bleed free Oral? Patches? Gel? Vaginal?

29. HRT Lots to choose from Appears confusing Get familiar with one preparation for each scenario If the 1st doesn’t work - change the progestogen cks.nhs.uk/menopause lists preparations & costs What follows is MY table - not necessarily a recommendation. Lots to choose from Appears confusing Get familiar with one preparation for each scenario If the 1st doesn’t work - change the progestogen cks.nhs.uk/menopause lists preparations & costs What follows is MY table - not necessarily a recommendation.

30. Pamela’s table Estradiol Progestogen ORALPatches Periods Bleed freeOestogen only PeriodsBleed freeOestogen only Norethisterone Elleste duet 1mg & 2mg Elleste duet conti 2mg (Kliovance) 1mg Elleste Solo 1mg & 2mg Evorel Sequi Evorel conti Evorel Levonorgestrel Nuvelle 2mg Climaval 1mg & 2mg FemSeven Sequi FemSeven Conti Elleste solo MX Dydrogesterone Femoston 1mg & 2mg Femoston conti 1mg Zumenon 1mg & 2mg Femapak (patches & tablets) FemSeven Drospirenone Angeliq

31. Pamela’s table Conjugated Oestrogen Progestogen ORALPatches Periods Bleed freeOestogen only PeriodsBleed freeOestogen only Medroxy- progesterone Premique cycle 0.625mg Premique low dose 0.3mg Premique 0.625mg Premarin 0.3mg, 0.625mg & 1.25mg Norgestrel Prempak-C 0.625 & 1.25 mg

32. HRT other systemic preparations Cyclo-progynova - tablet free week = flushes come back Tridestra - quarterly bleed Trisequens - lower level oestogen week 4 Tibolone (Livial) - oestrogenic & progestogenic with weak androgenic activity. May improve libido. Oestrogel - apply measures of gel to arms or thighs. Oestrogen only Mirena coil - can be used to supply continuous progestogen. Needs changing after 4 years (not 5 as when contraceptive) Cyclo-progynova - tablet free week = flushes come back Tridestra - quarterly bleed Trisequens - lower level oestogen week 4 Tibolone (Livial) - oestrogenic & progestogenic with weak androgenic activity. May improve libido. Oestrogel - apply measures of gel to arms or thighs. Oestrogen only Mirena coil - can be used to supply continuous progestogen. Needs changing after 4 years (not 5 as when contraceptive)

33. HRT local preparations Ostrogen only RingPessaryCreamTablets Estring - replace every 3 months. Max 2 years Ortho-gynest pessary or cream - daily then weekly Ovestin cream - daily then weekly Vagifem - daily then twice weekly Premarin - daily for 3 weeks, then week without All except ring need review at 3 - 6 months Minimal absorption - but consider progestagen challenge Ostrogen only RingPessaryCreamTablets Estring - replace every 3 months. Max 2 years Ortho-gynest pessary or cream - daily then weekly Ovestin cream - daily then weekly Vagifem - daily then twice weekly Premarin - daily for 3 weeks, then week without All except ring need review at 3 - 6 months Minimal absorption - but consider progestagen challenge

34. Menopause - Management Clonidine 25 microgram tabs2 bd, increasing to 3 bd drowsiness, dry mouth, dizziness, nausea, sleeplessness. Caution with pvd and depression B blockers may be worth trying if likely to be other benefits (^BP, anxiety) SSRI & NSRI venlafaxine at low dose or other ssri’s Gabapentin usually start at 300 mg and increase dose slowly Clonidine 25 microgram tabs2 bd, increasing to 3 bd drowsiness, dry mouth, dizziness, nausea, sleeplessness. Caution with pvd and depression B blockers may be worth trying if likely to be other benefits (^BP, anxiety) SSRI & NSRI venlafaxine at low dose or other ssri’s Gabapentin usually start at 300 mg and increase dose slowly

35. Any questions about the menopause or HRT?

37. Case 1 Miss SG is aged 17 and attends complaining that she been bleeding for 5 weeks. She wants to start depo provera for contraception. She stopped microgynon 30 (coc) 3 months ago. She had a normal withdrawal bleed, and then a period one month later. a)What would you cover in this consultation? b)Would you request any investigations? c)How would you manage her bleeding? d)Can she have depo? Miss SG is aged 17 and attends complaining that she been bleeding for 5 weeks. She wants to start depo provera for contraception. She stopped microgynon 30 (coc) 3 months ago. She had a normal withdrawal bleed, and then a period one month later. a)What would you cover in this consultation? b)Would you request any investigations? c)How would you manage her bleeding? d)Can she have depo?

38. Case 2 Mrs ST is aged 50 and complains her periods “are all over the place” She had a regular cycle (5-7/26) until about 1 yr ago. This year her periods have been infrequent and very heavy - described as “flooding” She’s about to go away for a special holiday. a) Do you need any further information from her? b) Would you carry out any investigations? c) Can you help her for her holiday? Mrs ST is aged 50 and complains her periods “are all over the place” She had a regular cycle (5-7/26) until about 1 yr ago. This year her periods have been infrequent and very heavy - described as “flooding” She’s about to go away for a special holiday. a) Do you need any further information from her? b) Would you carry out any investigations? c) Can you help her for her holiday?

39. Case 1 a) full menstrual & sexual history. Risk of pregnancy. Any imb/pcb? b) probably fbc & pregnancy test c) norethisterone 5mg tds until bleeding stops d) I would prefer her to have 3 months of regular periods 1st. a) full menstrual & sexual history. Risk of pregnancy. Any imb/pcb? b) probably fbc & pregnancy test c) norethisterone 5mg tds until bleeding stops d) I would prefer her to have 3 months of regular periods 1st.

40. Case 2 a) full menstrual history - in particular asking about imb/pcb b) probably examine her. CS if due. Bloods might need USG - depending on findings c) norethisterone 5mg tds starting 3 days before she goes, and continuing until she’s prepared to bleed. a) full menstrual history - in particular asking about imb/pcb b) probably examine her. CS if due. Bloods might need USG - depending on findings c) norethisterone 5mg tds starting 3 days before she goes, and continuing until she’s prepared to bleed.

41. Management of Menorrhagia

42. Case 3 Mrs LV is aged 44 and attends to report her last period was about 11 months ago. She has a high powered job which is being affected by her sweats and irritability. She comments that she ’ s not sleeping well, and is uncharacteristically weepy. Her question is “ how far through the menopause am I? ” a) what else do you need to know? b) what investigations would you perform? c) how would you answer her question? You can assume investigations suggest she is menopausal. d) how would you manager her? Mrs LV is aged 44 and attends to report her last period was about 11 months ago. She has a high powered job which is being affected by her sweats and irritability. She comments that she ’ s not sleeping well, and is uncharacteristically weepy. Her question is “ how far through the menopause am I? ” a) what else do you need to know? b) what investigations would you perform? c) how would you answer her question? You can assume investigations suggest she is menopausal. d) how would you manager her?

43. Case 3 a) full medical & gynae history - including use of contraception b) PREGNANCY TEST plus bloods c) Impossible! d) she hasn’t come back - but I would be willing to prescribe HRT. Her bone density was fine in 2007. Incidentally her cholesterol was >8 - so she will be chased up. a) full medical & gynae history - including use of contraception b) PREGNANCY TEST plus bloods c) Impossible! d) she hasn’t come back - but I would be willing to prescribe HRT. Her bone density was fine in 2007. Incidentally her cholesterol was >8 - so she will be chased up.

44. Case 4 Ms KS is aged 56. HRT was started 4 years ago when she hadn’t had a period for 6 months and was she was being disturbed by sweats/flushes. Elleste Duet 1mg has been prescribed with good symptom relief and cycle control. She had vv surgery 2 years ago - hrt was stopped pre op with recurrence of her sweats. She’s now keen to stop HRT because she’s concerned about the long term risks. a) How would you advise her? Ms KS is aged 56. HRT was started 4 years ago when she hadn’t had a period for 6 months and was she was being disturbed by sweats/flushes. Elleste Duet 1mg has been prescribed with good symptom relief and cycle control. She had vv surgery 2 years ago - hrt was stopped pre op with recurrence of her sweats. She’s now keen to stop HRT because she’s concerned about the long term risks. a) How would you advise her?

45. Case 4 She’s already on a low dose preparation Prescribe oestrogen only - alternate days, then every 3rd day and slowly tailing off. Progestagen challenge at least 3 monthly. She’s already on a low dose preparation Prescribe oestrogen only - alternate days, then every 3rd day and slowly tailing off. Progestagen challenge at least 3 monthly.

46. Case 4 Stopping HRT Advise then to come off slowly Step 1 move stepwise to lowest dose Step 2prescribe unopposed oestrogen advise reducing frequency of tablets or spacing patch changes further apart They must report any unexpected bleeding Challenge with progestagen at least quarterly Climanor 5mg (medroxyprogesterone) 2 daily 14 days ( £ 3.27) OR Utrogestran 200mg (progesterone) 1 daily 12 - 14 days( £ 5.70) Think again if it takes longer than 6 months Stopping HRT Advise then to come off slowly Step 1 move stepwise to lowest dose Step 2prescribe unopposed oestrogen advise reducing frequency of tablets or spacing patch changes further apart They must report any unexpected bleeding Challenge with progestagen at least quarterly Climanor 5mg (medroxyprogesterone) 2 daily 14 days ( £ 3.27) OR Utrogestran 200mg (progesterone) 1 daily 12 - 14 days( £ 5.70) Think again if it takes longer than 6 months

47. Case 5 Mrs JW is aged 65 and comes (with her husband) complaining about flushing++. She ’ s waking 7 or 8 times every night. HRT was prescribed in her early 50 ’ s - and her memory is that it was wonderful. Review of her records shows she had to try several preparations (prempak, estracombi, tibolone & elleste). Breast cancer was diagnosed at routine mammography in 2005. She has responded well to treatment and has no evidence of metastatic disease. She is not currently taking any medication. a) what are her options? Mrs JW is aged 65 and comes (with her husband) complaining about flushing++. She ’ s waking 7 or 8 times every night. HRT was prescribed in her early 50 ’ s - and her memory is that it was wonderful. Review of her records shows she had to try several preparations (prempak, estracombi, tibolone & elleste). Breast cancer was diagnosed at routine mammography in 2005. She has responded well to treatment and has no evidence of metastatic disease. She is not currently taking any medication. a) what are her options?

48. Case 5 She agrees that re-starting HRT is not an option. Self help etc have not improved her symptoms. B blocker - no effect Clonidine - some improvement, but abdo pain & diarrhoea Venlafaxine - “15% improvement” but she doesn’t think the benefit outweighs the disadvantages of taking an antidepressant. What next?!!!! She agrees that re-starting HRT is not an option. Self help etc have not improved her symptoms. B blocker - no effect Clonidine - some improvement, but abdo pain & diarrhoea Venlafaxine - “15% improvement” but she doesn’t think the benefit outweighs the disadvantages of taking an antidepressant. What next?!!!!

49. Case 6 Mrs PS is aged 75 and attends to report “bleeding down below”. She was last seen complaining about vaginal discomfort about a month previously, but had no bleeding at that time. She was thought to have either thrush or senile vaginitis. A swab was negative. Pmh - breast Ca 10 yrs previously, followed by tamoxifen for 5 years. a) how would you manage her? b) what is the likely diagnosis? Mrs PS is aged 75 and attends to report “bleeding down below”. She was last seen complaining about vaginal discomfort about a month previously, but had no bleeding at that time. She was thought to have either thrush or senile vaginitis. A swab was negative. Pmh - breast Ca 10 yrs previously, followed by tamoxifen for 5 years. a) how would you manage her? b) what is the likely diagnosis?

50. Case 6 a) examine her - blood clearly coming from cervical os fast track referral - which would have been indicated even if the blood hadn’t been seen b) senile vaginitis v endometrial ca Actually had a large benign endometrial polyp. a) examine her - blood clearly coming from cervical os fast track referral - which would have been indicated even if the blood hadn’t been seen b) senile vaginitis v endometrial ca Actually had a large benign endometrial polyp.

52. Psychosexual Problems What & Who? What Reduced libido Differing levels of desire Failure to reach orgasm Pain Who New mums Perimenopausal Teenagers - unlikely to be their initial complaint except pain ?Widows What Reduced libido Differing levels of desire Failure to reach orgasm Pain Who New mums Perimenopausal Teenagers - unlikely to be their initial complaint except pain ?Widows

53. Psychosexual Problems How can you help in 10 minutes Listen Possibly examine - mainly for pain Reassure Provide information Recommend self help Be prepared to discuss medication Refer Listen Possibly examine - mainly for pain Reassure Provide information Recommend self help Be prepared to discuss medication Refer

54. Psychosexual Problems Self Help & Referral Teenage magazines Healthy SexMiriam Stoppard Treat Yourself to SexBrown & Faulder Relate Guide to SexLitvinoff Vaginal lubricants - Replens SylkDurex relate.org.uk Refer to Relate Teenage magazines Healthy SexMiriam Stoppard Treat Yourself to SexBrown & Faulder Relate Guide to SexLitvinoff Vaginal lubricants - Replens SylkDurex relate.org.uk Refer to Relate

55. Psychosexual Problems Prescribing Viagra etc - not licensed for women Livial Testosterone patch = Intrinsa only in women who have had total hysterectomy Vaginal oestrogens for atrophic vaginitis Viagra etc - not licensed for women Livial Testosterone patch = Intrinsa only in women who have had total hysterectomy Vaginal oestrogens for atrophic vaginitis