Cgd 2


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Cgd 2

  1. 1. Common GynaecologicalDisorders Dr. Lee Chin Peng Honorary Clinical Associate Professor Department of Obstetrics and Gynaecology University of Hong Hong
  2. 2. Outline General approach to gynaecological problems Management and recent advances: vaginal discharge abnormal vaginal bleeding dysmenorrhoea uterine fibroid Useful resources
  3. 3. History and physical examination Menstrual history, LMP Contraception Cervical smear history Can the patient be pregnant? Obstetric history Patient’s concerns Is pelvic examination necessary?
  4. 4. Investigations Pregnancy test Swabs for culture Cervical smear Endometrial aspiration Ultrasound pelvis
  5. 5. Need referral?Reasons for referral:1. Unsure diagnosis2. Special diagnostic tests3. Treatment4. Second opinionMany common gynaecological problems can be managed by GP
  6. 6. Should investigations be donebefore referral ?1. Affect decision to refer?2. Delay the referral?3. Reliable laboratory?
  7. 7. Referral letter Name and age of the patient Reason for referral Any investigations and treatment before the referral Wish to continue post-referral careIx reports, copies of X-ray, ultrasound images are very helpful
  8. 8. Reply from hospital specialist,follow up1. Confirm with patient: diagnosis, treatment and plan of management2. Clarify with specialist if needed3. Your feedback is welcomed
  9. 9. Vaginal Discharge Physiological: midcycle, premenstrual Pathological: odour, itchiness blood stained Postmenopausal: atrophic vaginitisMay need to explore hidden anxiety, especially anxiety about STD
  10. 10. 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?
  11. 11. Vaginal DischargeNeed 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
  12. 12. Vaginal DischargeIn children:Think of foreign body and? Sexual abuseMay need referral
  13. 13. Abnormal vaginal bleeding Postmenopausal bleeding (PMB) Reproductive age group: irregular inter-, pre- or post-menstrual spotting heavy bleeding (menorrhagia)
  14. 14. 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)
  15. 15. Abnormal vaginal bleeding Benign conditions Polyps: endometrial, cervical Fibroid IUCD? Drug effect? Systemic diseases DYSFUNCTIONAL UTERINE BLEEDING IS THE MOST COMMOM
  16. 16. Abnormal vaginal bleedingAssessment of the endometrium (not needed for women with very low risk of Ca endometrium) endometrial aspirate ultrasound pelvis (transvaginal) to assess endometrial thickness hysteroscopy
  17. 17. Abnormal vaginal bleedingWhen to refer: over the age of 40 high risk of endometrial Ca (obesity, DM, PCOD) uterus > 10 week size or irregular cervical pathology suspected no response to medical treatment
  18. 18. Abnormal vaginal bleeding:a practical approach (1)History: age pattern of bleeding risk factors for endometrial Ca pregnant? drug previous treatment last cervical smear
  19. 19. Abnormal vaginal bleeding:a practical approach (2)Physical examination general: obesity? thyroid? pallor? pulse? abdomen: palpable mass? pelvis: cervical or vaginal lesion? uterine size
  20. 20. Abnormal vaginal bleeding:a practical approach (3)Over 40or high risk of endometrial Caor genital tract lesion suspected (except cervical polyp), including uterus bigor previous medical treatment failREFER (or endometrial aspiration and TV USG)
  21. 21. Abnormal vaginal bleeding:a 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
  22. 22. 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
  23. 23. 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)
  24. 24. 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
  25. 25. 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
  26. 26. Abnormal vaginal bleeding:other modalities of treatment Levonorgesterol releasing IUCD (Mirena) Endometrial ablation pregnancy contraindicated after ablation Hysterectomy
  27. 27. 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
  28. 28. Dysmenorrhoea Primary Secondary: endometriosis adenomyosis chronic pelvic inflammatory disease pelvic adhesions
  29. 29. 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
  30. 30. Dysmenorrhoea History Physical examination: Is pelvic examination needed? Recommended in all cases except in teenagers who are not sexually active with typical primary dysmenorrhoea
  31. 31. DysmenorrhoeaInvestigations needed? Ultrasound pelvis if clinical pelvic examination abnormal symptoms suggestive of secondary dysmenorrhoea but PV not conclusive or not possible Laparoscopy seldom needed
  32. 32. Dysmenorrhoea: role of laparoscopy Subfertility Chronic pelvic pain Relieve the anxiety of patients Treatment: endometriotic cyst medical treatment fail subfertility
  33. 33. DysmenorrhoeaMedical 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
  34. 34. DysmenorrhoeaHormonal therapy:Primary dysmenorrhoea: combined OC pills (low EE)Endometriosis: progestogen only combined OC pills (low EE)
  35. 35. Uterine fibroids Common 25-30% of women over 35 Often asymtomatic Incidentally detected on pelvic ultrasound
  36. 36. Uterine fibroidsWhen to refer: symptoms related to fibroids size > 12 weeks (palpable per abdomen) pain uncertain diagnosis ?ovarian cyst subfertility, recurrent miscarriage
  37. 37. Uterine fibroidsSymptoms related to fibroids: menorrhagia irregular menstruation (only for submucosal fibroids) urinary (frequency, retention) abdominal distention
  38. 38. Uterine fibroidsHow 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
  39. 39. 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
  40. 40. Uterine fibroidsPost-myomectomy follow up: fibroids can recur after myomectomy advice for pregnancy? When? Caesarean delivery needed?
  41. 41. Useful resourcesReferences used for this presentation:HKCOG: Guidelines on investigation of women with abnormal uterine bleeding under the age of 40, HKCOG Guidelines 5, May 2001Pretence A: Medical management of menorrhagia, BMJ 1999;319:1343-5Pretence A: Endometriosis, BMJ 2001;323:93-5
  42. 42. Useful resourcesWebsites: hhtp:// hhtp:// hhtp://
  43. 43. Thanks to:Schering (Hong Kong) Ltd.Subsidiary of Schering AG Germany