Common Gynaecological Disorders

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Common Gynaecological Disorders

• Dr. Lee Chin Peng
• Honorary Clinical Associate Professor
• Department of Obstetrics and Gynaecology
  University of Hong Hong

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Outline

• General approach to gynaecological problems
• Management and recent advances
• vaginal discharge
• abnormal vaginal bleeding
• dysmenorrhoea
• uterine fibroid
• Useful resources

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History and physical examination

• Menstrual history, LMP
• Contraception
• Cervical smear history
• Can the patient be pregnant?
• Obstetric history
• Patients concerns
• Is pelvic examination necessary?

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Investigations

• Pregnancy test
• Swabs for culture
• Cervical smear
• Endometrial aspiration
• Ultrasound pelvis

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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

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Should investigations be done before referral ?

• 1. Affect decision to refer?
• 2. Delay the referral?
• 3. Reliable laboratory?

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Referral letter

• Name and age of the patient
• Reason for referral
• Any investigations and treatment before the
  referral
• Wish to continue post-referral care
• Ix reports, copies of X-ray, ultrasound images
  are very helpful

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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

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Vaginal Discharge

• Physiological
• midcycle, premenstrual
• Pathological
• odour, itchiness
• blood stained
• Postmenopausal atrophic vaginitis
• May need to explore hidden anxiety, especially
  anxiety about STD

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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?

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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

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Vaginal Discharge

• In children
• Think of foreign body and
• ? Sexual abuse
• May need referral

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Abnormal vaginal bleeding

• Postmenopausal bleeding (PMB)
• Reproductive age group
• irregular
• inter-, pre- or post-menstrual spotting
• heavy bleeding (menorrhagia)

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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)

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Abnormal vaginal bleeding

• Benign conditions
• Polyps endometrial, cervical
• Fibroid
• IUCD?
• Drug effect?
• Systemic diseases
• DYSFUNCTIONAL UTERINE BLEEDING IS THE MOST COMMOM

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Abnormal vaginal bleeding

• Assessment of the endometrium (not needed for
  women with very low risk of Ca endometrium)
• endometrial aspirate
• ultrasound pelvis (transvaginal) to assess
  endometrial thickness
• hysteroscopy

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Abnormal vaginal bleeding

• When to refer
• over the age of 40
• high risk of endometrial Ca (obesity, DM, PCOD)
• uterus gt 10 week size or irregular
• cervical pathology suspected
• no response to medical treatment

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Abnormal vaginal bleedinga practical approach
(1)

• History
• age
• pattern of bleeding
• risk factors for endometrial Ca
• pregnant?
• drug
• previous treatment
• last cervical smear

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Abnormal vaginal bleedinga practical approach
(2)

• Physical examination
• general obesity? thyroid? pallor? pulse?
• abdomen palpable mass?
• pelvis cervical or vaginal lesion? uterine size

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Abnormal vaginal bleedinga 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)

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Abnormal vaginal bleedinga practical approach
(4)

• None of the above factors
• consider 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

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Abnormal vaginal bleedinga 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

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Abnormal vaginal bleedinga 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)

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Abnormal vaginal bleedinga 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

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Abnormal vaginal bleedinga practical approach
(8)

• When to consider medical treatment as failure?
• Failure to relieve patients symptoms after 3
  months
• Remains anaemic after 3 months

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Abnormal vaginal bleedingother modalities of
treatment

• Levonorgesterol releasing IUCD (Mirena)
• Endometrial ablation
• pregnancy contraindicated after ablation
• Hysterectomy

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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

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Dysmenorrhoea

• Primary
• Secondary
• endometriosis
• adenomyosis
• chronic pelvic inflammatory disease
• pelvic adhesions

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Primary dysmenorrhoea

• Onset a few years after menarche
• Regular cycles
• Pain for less than 2 days
• Cramping pain
• Nausea, other GI symptoms
• radiation to thigh
• relieved after childbirth, but may recur after
  some years

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Dysmenorrhoea

• History
• Physical examination
• Is pelvic examination needed?
• Recommended in all cases except in teenagers who
  are not sexually active with typical primary
  dysmenorrhoea

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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

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Dysmenorrhoea role of laparoscopy

• Subfertility
• Chronic pelvic pain
• Relieve the anxiety of patients
• Treatment
• endometriotic cyst
• medical treatment fail
• subfertility

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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

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Dysmenorrhoea

• Hormonal therapy
• Primary dysmenorrhoea
• combined OC pills (low EE)
• Endometriosis
• progestogen only
• combined OC pills (low EE)

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Uterine fibroids

• Common
• 25-30 of women over 35
• Often asymtomatic
• Incidentally detected on pelvic ultrasound

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Uterine fibroids

• When to refer
• symptoms related to fibroids
• size gt 12 weeks (palpable per abdomen)
• pain
• uncertain diagnosis ?ovarian cyst
• subfertility, recurrent miscarriage

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Uterine fibroids

• Symptoms related to fibroids
• menorrhagia
• irregular menstruation (only for submucosal
  fibroids)
• urinary (frequency, retention)
• abdominal distention

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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

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Uterine fibroids treatment

• Surgical 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

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Uterine fibroids

• Post-myomectomy follow up
• fibroids can recur after myomectomy
• advice for pregnancy?
• When?
• Caesarean delivery needed?

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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 19993191343-5
• Pretence A Endometriosis, BMJ 200132393-5

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Useful resources

• Websites
• hhtp//www.bmj.com
• hhtp//www.rcog.org.uk/guidelines
• hhtp//www.hkcog.org.hk

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