2. Women’s problems in General Practice Dr. Philippa Feldman

3. Facts and Figures n Men consult 4 times per year n Women consult 6 times per year n 61% GP consults are with women n Life expectancy women 1988 = 78 yrs n Life expectancy men 1988 = 72 yrs n Over 75 yrs 63% are women n Over 85yrs 75% are women n Women take more drugs than men

4. Reasons for consultation WOMEN n Metabolic problems n Blood disorders n Reproductive n Mental n Circulation n GU n Muscular MEN n Accidents n Poisonings n Violence

5. Reasons for consultation n If gender related problems are removed then men and women consult at the same rate

6. Annual Consultation Rates per List of 2000 n Menstrual Problems 75 n Contraception60 n Menopausal30 n Vaginitis20 n PMS20 n Breast conditions15 n Infertility5

7. Menorrhagia nEnEighth commonest hospital referral nPnPresenting complaint in 1/3 of gynae referrals n7n73,000 hysterectomies per year n1n10,000 endometrial ablations per year n5n50 % of hysterectomies no obvious pathology nCnCycle length varies with age nMnMost cases normal ovulation

8. Menorrhagia Management n HistoryInvestigations –Cycle length- FBC –Heaviness –IMB / PCB n Examination –Abdo –PV –Smear

9. Menorrhagia Treatment nTnTreat yourself –U–Under 40 –N–No PCB/ IMB –N–Normal Hb –N–Normal Examination –N–Not too heavy

10. 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 n Antifibrinolytics n NSAIDS n Hormonal n Surgery

11. Dysmenorrhoea nSnSecondary –Y–Years after menarche –P–Pain premenstrually until end of menses –A–Associated with pelvic pathology n Primary –6-12 months after menarche –Pain Day 1,2 –D & V

12. Dysmenorrhoea Management n History –Primary / Secondary n Examination –Abdo / PV n Investigations –HVS

13. Dysmenorrhoea Management n Treatment –Refer »Abnormal exam »Unresponsive secondary cases –NSAIDS –COC

14. Incontinence n Embarrassing - n Only 10% tell their spouse n < 10% tell a close friend n BUT 66% will consult their GP

15. Incontinence - Types n Stress Incontinence n Urge –Motor –Sensory n Overflow n Passive / Reflex n Other e.g. Constipation, UTI, Anxiety

16. Incontinence n Stress: –Involuntary loss of urine on exertion in the absence of bladder contraction n Urge –Involuntary loss of urine accompanied with a strong desire to void »Motor - Unstable detrusor muscle »Sensory - Hypersensitivity of bladder receptors

17. Incontinence differentiation n Stress –Leaking when »cough »sneeze »laugh –Leaking when »Run »Jump »Sport –Leaks small amounts n Urge –Frequency »>6/day »>3/night –Urgency »Hurrying to get to toilet »Leaking before toilet –Wetting at night

18. Incontinence Examination/Investigation n Abdominal + PV / PR n Neurological Examination if indicated n Urinalysis n MSU

19. Incontinence Who to Refer? n Abnormal examination –Prolapse, cystocoele, rectocoele, –Pelvic mass –Neurological signs –Palpable bladder post micturition n Unable to classify

20. Stress Incontinence Managment n Diet if obese n Pelvic floor exercises for life n Avoid heavy lifting n Refer if no improvement after 3/12

21. Urge Incontinence Management n Frequency volume chart n Bladder retraining n Drugs –Oxybutynin5mg tds –Tolterodine 2mg bd –Imipramine 10-25mg tds

22. Vaginal Disharge n Infective –Bacterial vag56.5% –Candida34.5% –Chlamydia6.5% –Trichomonas2.3% –Strep milleri1.8% –Haemophillus1.0% –Staph aureus0.5% –Gonorrhoea0.3% –Herpes virus0.3% n Non Infective –Cervical ectropion –Cervical polyps –Atrophic vaginitis –Genital tract Ca –Retained tampon

23. Vaginal Discharge History n Previous discharge n Odour - itch n IUD n Recent gynae surgery n Lower abdo pain n PMH - STD n Recent change of partner n Partner with urethral symptoms n Blood stained discharge

24. Vaginal Discharge Investigations n Cervical Swab Stuarts medium –GC - will usually pick up vaginal infections eg »Bacterial vaginosis »Candida »Trichomonas n Endocervical swab –Chlamydia »Use cotton tipped swab rotated for 10 secs in endocervix

25. Vaginal Disharge Management n Thrush –Clotrimazole pes 500mg. stat n Recurrent Thrush –Treat partner –Clotrimazole pes 100mg for 14 days –Fluconazole 50mg/day for 7 days –Intermittent prophylactic treatment n Advice –Wear loose clothes –Avoid vaginal deodorants, bubble baths, soaps

26. Vaginal Discharge Referral n Lower abdo pain n PMH - STD n Recent change of partner n Partner with urethral symptoms n Blood stained discharge

27. Vaginal Dishcharge Chlamydia n One episode of chlamydial cervicitis:- –PID in 20% of these »20% develop chronic pelvic pain »15% will be infertile »5% ecotopic pregnancy n Frequency –Found in 6.5% of women with GU symptoms n Diagnostic tests - not highly accurate

28. Premenstrual Syndrome Definition n 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

29. PMS - Who complains? n 90% of women get cyclical change at some time n All social classes n Social Class I and II more likely to consult

30. PMS Management n 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 n Moderate –Anxiety management –Cognitive therapy

31. PMS Management n 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 ?

32. The Menopause n Menopause –‘Date of last period’ n Climacteric –‘Gradual decrease of Ovarian function over several years n Mean age = 50 years –Cigarette smoking decreases by 2 years n Cultural and Social attitudes important

33. Menopause - Diagnosis n Oestrogen deficiency –Periods decrease in frequency and stop –Hot flushes –Vaginal dryness and atrophy –Urethral syndrome n Investigations –Usually unnecessary –FSH > 20 iu/L

34. Reasons for HRT n Removal of Ovaries before menopause n Menopause < 45 yrs n Hysterectomy before menopause n Hot flushes n Sexual difficulties - Atrophic vaginitis n High risk of Osteoporosis n High risk IHD

35. Contraindicatioins to HRT n Absolute –CA breast –CA endometrium –Thromboembolic disease –Severe Liver or Renal disease n Relative –Breast Lump –Pelvic Mass –IMB / PCB –Menorrhagia –Gall Bladder disease –Otosclerosis –Previous problems OCP

36. Treatment n Post - hysterectomy –Oestrogen alone »tablets, patches or gel n Uterus intact –Opposed oestrogen »oestrogen tablets, patches or gel + progestogen tablets or patches –One year post menopause or age 54+ »Premique »Tibolone

37. Treatment II n Implants n Vaginal creams n SSRI

38. HRT n 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

39. HRT n Beneficial effects per 100.000 users –6 fewer women develop colon cancer –5 fewer break a hip