Women’s Health 1
Dr Pamela Sides
Tuesday 22nd March 2011
Aims & Plan
• To cover those parts of the curriculum where
you have the greatest needs
• 2.00
• 2.05
introductions and agenda setting
presentation pregnancy, menopause & hrt in general practice
• 2.30
• 3.00
• 3.25
small groups to discuss cases
discussion about cases
any questions,plenary and feedback
Pregnancy
• Not covering antenatal care
• Pre conception
• Fertility issues
• The 1st appointment
• Post natal
Pre Conception Counselling
• Life Style
• Smoking
Alcohol
Diet
• Advice if under or over weight
• Consider illicit drugs
• Consider exposure to harmful
substances in employment
Pre Conception Counselling
• Medical
• Regular medication
• Mum’s (?Dad’s) medical history
• Family history
• Immunisation - rubella, ?varicella, ?? Hep B
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.
Pre Conception Counselling
•ICE
• As if I need to remind you!
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
Fertility Issues
• Investigations
• Her : fbc, tft, 21 day progesterone
?fsh/lh if irregular bleeding
prolactin if need to exclude pituitary problems
Him : semen count
Fertility Issues
• Refer - usually if > 1 year trying
• But also pre-conceptual advice as
above.
1st Appointment
Dr, I think I'm pregnant
Do you need to confirm?
GOOD NEWS
BAD NEWS
Back to preconception counselling. Refer to midwife as practice protocol
Are you prepared to discuss the options?
Yes
No
Let her/them talk.
Make sure they are able to see someone who is.
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
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.
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
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. After 1 yr if > 50)
• Can we diagnose the climacteric and do we need to?
Menopause - diagnosis
• What investigations would you perform?
• Bloods
?hormones - fsh/lh
fbc
tft
fbs
lipids
• ?Bone density - in particular if early menopause (<45)
Menopause - symptoms
• Sweats/flushes
• Dry vagina
•
•
•
•
Mood changes
Aching joints
Memory loss
etc etc etc
Menopause - Management
• Reassure and inform. Offer leaflets and/or websites.
Cover contraception
• Self help
• Discuss alternative therapies
• Prescribed medication
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
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
Menopause - Management
Prescribed Medication
usually for sweats & flushes
HRT
clonidine
B blockers
anti depressants - particularly ssri & snri
? gabapentin
Also osteoporosis
calcium
bisphosphonates
strontium
Hormone Replacement Therapy
• Minimum dose
• Shortest time
• At least annual review
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?
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.
Pamela’s table
Estradiol
Progestogen
Norethisterone
Levonorgestrel
Dydrogesterone
Drospirenone
ORAL
Patches
Periods
Bleed
free
Oestogen
only
Periods
Bleed free
Oestogen
only
Elleste duet
1mg & 2mg
Elleste duet
conti
2mg
(Kliovance)
1mg
Elleste
Solo
Evorel
Sequi
Evorel
conti
Evorel
1mg & 2mg
FemSeven
Sequi
FemSeven
Conti
Elleste solo
MX
Zumenon
Femapak
1mg & 2mg
(patches &
tablets)
Nuvelle
2mg
Femoston
1mg & 2mg
1mg & 2mg
Climaval
Femoston
conti
1mg
Angeliq
FemSeven
Pamela’s table
Conjugated Oestrogen
Progestogen
Medroxyprogesterone
ORAL
Periods
Bleed
free
Oestogen
only
Premique
cycle
Premique
low dose
Premarin
0.625mg
0.3mg
Premique
0.625mg
Norgestrel
Patches
Prempak-C
0.625 & 1.25
mg
0.3mg,
0.625mg &
1.25mg
Periods
Bleed free
Oestogen
only
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)
HRT
local preparations
• Ostrogen only
• Ring
Pessary
Cream
Tablets
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•
•
•
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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
Menopause - Management
Clonidine
25 microgram tabs
2 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
• Any questions about the menopause or
HRT?
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)
b)
c)
d)
What would you cover in this consultation?
Would you request any investigations?
How would you manage her bleeding?
Can she have depo?
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?
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.
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.
Management of Menorrhagia
Menorrhagia
reassure
nsaid
Primary Care
Secondary Care
investigate/examine
investigate/examine
haemostatics
tranexamic acid
etamsylate
(cyklokapron)
(dicynene)
500mgx2 tds
500mg qds
while bleeding
while bleeding
hormones
oral
coc
progestagens
systemic
mirena
depo
hormones
endometrial ablation
hysterectomy
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?
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.
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?
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.
Case 4
Stopping HRT
Advise then to come off slowly
Step 1
move stepwise to lowest dose
Step 2
prescribe 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
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?
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?!!!!
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?
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.
Psychosexual Problems
What & Who?
• What
•
•
•
•
Reduced libido
Differing levels of desire
Failure to reach orgasm
Pain
• Who
•
•
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New mums
Perimenopausal
Teenagers - unlikely to be their initial complaint except pain
?Widows
Psychosexual Problems
How can you help in 10 minutes
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Listen
Possibly examine - mainly for pain
Reassure
Provide information
Recommend self help
Be prepared to discuss medication
Refer
Psychosexual Problems
Self Help & Referral
• Teenage magazines
• Healthy Sex
Miriam Stoppard
• Treat Yourself to Sex Brown & Faulder
• Relate Guide to Sex
Litvinoff
• Vaginal lubricants - Replens
• relate.org.uk
• Refer to Relate
Sylk
Durex
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