Common Gynaecological Disorders

Dr. Lee Chin Peng

Honorary Clinical Associate Professor

Department of Obstetrics and Gynaecology University of Hong Hong

OutlineGeneral approach to gynaecological

problemsManagement and recent advances:

vaginal discharge abnormal vaginal bleeding dysmenorrhoea uterine fibroid

Useful resources

History and physical examination

Menstrual history, LMPContraceptionCervical smear historyCan the patient be pregnant?Obstetric historyPatient’s concernsIs pelvic examination necessary?

Investigations

Pregnancy testSwabs for cultureCervical smearEndometrial aspirationUltrasound pelvis

Need referral?

Reasons for referral:

1. Unsure diagnosis

2. Special diagnostic tests

3. Treatment

4. Second opinion

Many common gynaecological problems can be managed by GP

Should investigations be done before referral ?

1. Affect decision to refer?

2. Delay the referral?

3. Reliable laboratory?

Referral letter

Name and age of the patientReason for referralAny investigations and treatment before the

referralWish to continue post-referral care

Ix reports, copies of X-ray, ultrasound images are very helpful

Reply from hospital specialist, follow up

1. Confirm with patient: diagnosis, treatment and plan of management

2. Clarify with specialist if needed

3. Your feedback is welcomed

Vaginal Discharge

Physiological: midcycle, premenstrual

Pathological: odour, itchiness blood stained

Postmenopausal: atrophic vaginitis

May need to explore hidden anxiety, especially anxiety about STD

Vaginal Discharge

Speculum examination is necessary and digital examination preferred

Need to take culture swab? Typical moniliasis: treat without culture, take

swab if treatment fails

Need to screen for STD?

Vaginal Discharge

Need to refer? Recurrent Blood stained and not midcycle Fail to response to treatment Uterine or cervical pathology suspected Postmenopausal and fails to respond to HRT

Vaginal Discharge

In children:

Think of foreign body and

? Sexual abuse

May need referral

Abnormal vaginal bleeding

Postmenopausal bleeding (PMB)Reproductive age group:

irregular inter-, pre- or post-menstrual spotting heavy bleeding (menorrhagia)

Abnormal vaginal bleeding

Malignancies? Carcinoma of corpus Carcinoma of cervix Oestrogen producing ovarian tumour

Premaligant conditions? Atypical endometrial hyperplasia CIN (usually do not present with bleeding)

Abnormal vaginal bleeding

Benign conditions Polyps: endometrial, cervical Fibroid IUCD? Drug effect? Systemic diseases DYSFUNCTIONAL UTERINE BLEEDING IS

THE MOST COMMOM

Abnormal vaginal bleeding

Assessment of the endometrium (not needed for women with very low risk of Ca endometrium)

endometrial aspirateultrasound pelvis (transvaginal) to assess

endometrial thicknesshysteroscopy

Abnormal vaginal bleeding

When to refer:over the age of 40high risk of endometrial Ca (obesity, DM,

PCOD)uterus > 10 week size or irregularcervical pathology suspectedno response to medical treatment

Abnormal vaginal bleeding:a practical approach (1)

History:agepattern of bleedingrisk factors for endometrial Capregnant?drugprevious treatmentlast cervical smear

Abnormal vaginal bleeding:a practical approach (2)

Physical examinationgeneral: obesity? thyroid? pallor? pulse?abdomen: palpable mass?pelvis: cervical or vaginal lesion? uterine

size

Abnormal vaginal bleeding:a practical approach (3)

Over 40

or high risk of endometrial Ca

or genital tract lesion suspected (except cervical polyp), including uterus big

or previous medical treatment fail

REFER (or endometrial aspiration and TV USG)

Abnormal vaginal bleeding:a practical approach (4)

None of the above factorsconsider investigations

cervical smear if sexually active and last smear more than 1 year ago

CBP if menorrhagia ultrasound pelvis if PV not possible thyroid function, coagulation only when history

suggestive

Abnormal vaginal bleeding:a practical approach (5)

Medical treatment (for women under 40 with no suspicion of organic lesions)

Hormonal (for irregular bleeding as well as menorrhagia) combined OC progestogen only (21 days needed)

Non-hormonal (for menorrhagia) NSAID antifibrinolytic agent

Abnormal vaginal bleeding:a practical approach (6)

Choice of medical treatment for irregular vaginal bleeding:

combined OC gives much better cycle control (start with a preparation containing 50ug EE)

progestogen only (when oestrogen contraindicated)

Abnormal vaginal bleeding:a practical approach (7)Choice of medical treatment for menorrhagia

NSAID: 30% decrease in blood loss ,relieve dysmenorrhoea as well

Antifibrinolytic (transamine): 50% decrease Combined OC: effective but need to take through out

the month, effective contraception as well Progestogen only: less effective, need 21 days, not

effective contraception Haematinics: if anaemic

combinations can be used

Abnormal vaginal bleeding:a practical approach (8)

When to consider medical treatment as failure?

Failure to relieve patient’s symptoms after 3 months

Remains anaemic after 3 months

Abnormal vaginal bleeding:other modalities of treatment

Levonorgesterol releasing IUCD (Mirena)Endometrial ablation

pregnancy contraindicated after ablation

Hysterectomy

Abnormal vaginal bleedingPost-referral management

Pathology excluded Treatment plan suggested, e.g

non-hormonal therapy hormonal therapy usually for 6 months

just follow the treatment plan

refer back if treatment failure

Follow up after special treatment

Dysmenorrhoea

PrimarySecondary:

endometriosis adenomyosis chronic pelvic inflammatory disease pelvic adhesions

Primary dysmenorrhoea

Onset a few years after menarcheRegular cyclesPain for less than 2 daysCramping painNausea, other GI symptoms radiation to thigh relieved after childbirth, but may recur after some years

Dysmenorrhoea

HistoryPhysical examination:

Is pelvic examination needed?

Recommended in all cases except in teenagers who are not sexually active with typical primary dysmenorrhoea

Dysmenorrhoea

Investigations needed?Ultrasound pelvis if

clinical pelvic examination abnormal symptoms suggestive of secondary

dysmenorrhoea but PV not conclusive or not possible

Laparoscopy seldom needed

Dysmenorrhoea: role of laparoscopy

SubfertilityChronic pelvic pain Relieve the anxiety of patientsTreatment:

endometriotic cyst medical treatment fail subfertility

Dysmenorrhoea

Medical treatment for dysmenorrhoea:Simple analgesics: paracetamol, NSAID

indicated for primary and secondary dysmenorrhoea without associated subfertility, or ovarian cysts

Hormonal therapy: as a second line when simple analgesia fails

Dysmenorrhoea

Hormonal therapy:

Primary dysmenorrhoea: combined OC pills (low EE)

Endometriosis:progestogen only

combined OC pills (low EE)

Uterine fibroids

Common25-30% of women over 35Often asymtomaticIncidentally detected on pelvic ultrasound

Uterine fibroids

When to refer:symptoms related to fibroidssize > 12 weeks (palpable per abdomen)painuncertain diagnosis ?ovarian cystsubfertility, recurrent miscarriage

Uterine fibroids

Symptoms related to fibroids:menorrhagiairregular menstruation (only for submucosal

fibroids)urinary (frequency, retention)abdominal distention

Uterine fibroids

How to follow up asymptomatic fibroids?Ultrasound?

Usually no needed

Check symptoms and uterine size clinically every 6 months or ask patient to return if symptomatic

Uterine fibroids: treatmentSurgical treatment remains the mainstay:

myomectomy (laparotomy, laparoscopy, hysterocopy)

hysterectomy

Medical treatment with GnRH analogue shrink fibroids before surgery buy time before menopause

Embolization: inadequate evidence on effectiveness and safety

Uterine fibroids

Post-myomectomy follow up:fibroids can recur after myomectomyadvice for pregnancy?

When? Caesarean delivery needed?

Useful resources

References used for this presentation:

HKCOG: Guidelines on investigation of women with abnormal uterine bleeding under the age of 40, HKCOG Guidelines 5, May 2001

Pretence A: Medical management of menorrhagia, BMJ 1999;319:1343-5

Pretence A: Endometriosis, BMJ 2001;323:93-5

Useful resources

Websites:hhtp://www.bmj.comhhtp://www.rcog.org.uk/guidelineshhtp://www.hkcog.org.hk

Thanks to:Schering (Hong Kong) Ltd.Subsidiary of Schering AG Germany