1. Women’s Health Dr Emma Broughton GPwSI
Priory Medical Group, Vale of York CCG Clinical Director

2. Agenda Prolapse: primary care management and beyond
Including Ring Pessary fittings and conservative options
Cervical Polyps: management in primary care.
Demonstration
HRT and the Menopause
Counselling- Informed Choice- keeping it simple, yet evidence-based
Some top tips and reference

3. Prolapse https://cks.nice.org.uk/incontinence-urinary-in-women
leaflets/gynaecology/pi-pelvic-organ-prolapse.pdf

4. Cystocele
Grades mild-severe

5. Anterior Repair Consider risk factors to address:
Weight
Smoking
Constipation
Co-morbidities
Prior Women’s Health Physio
Complications

6. Rectocele Ring pessaries don’t work.
Shelf pessary or Gellhorn conservative options.

7. Posterior Repair

8. Uterine Prolapse Grade 1-4.
Procidentia- risks of ureteric Obstruction.
Improtant to establish if reducible.

9. Newer Types of Ring Pessary

10. Ring pessary with additional bladder neck support.

11. Prolapse- surgery vs conservative
Corrective. Informed Choice.
Major Operation: anaesthestic, bleeding, infection, urinary retention (and catheterisation), damage to organs, VTE risk.
1/3 will need a second repair operation,
Improved with prior PFE physio input.
Address factors, cough, constipation, weight in advance.
Conservative Options
Co-morbidities or patients simply not wanting surgery.
Still address lifestyle factors
Can be used in sexually active women.
Topical Estrogen
Guidance to use twice weekly.
Prevents hypergranulation and PMB.
Safe to use longterm.
Breast cancer hx- caution.
Options: Vagifem, Estring or Estriol Cream

13. Cervical Polyps
Common. Usually asymptomatic, incidental findings at smear tests.
Can be cause of PCB, discharge.
1-2 in 1000 cases will have pre-malignant changes or CIN. Upto 1% risk with symptoms.
Easy procedure to remove in primary care.
Refer if >1cm or unable to see base, ?endometrial polyp.
RSS link: update/cervical-polyps-feb-17.pdf

14. Menopause Diagnosis Menopausal symptoms
Menopausal symptoms include the following:
no or infrequent periods
hot flushes
night sweats
mood changes
memory and concentration loss
vaginal dryness
lack of interest in sex
headaches
joint and muscle stiffness.
Laboratory tests
FSH tests should not be routinely considered when diagnosing menopause in women aged over 45 years with menopausal symptoms.

15. Early Menopause Premature ovarian insufficiency
Menopause occurring before the age of 40 years, which is also known as premature ovarian failure or premature menopause. It can occur naturally or as a result of medical or surgical treatment.
Measuring FSH
Two blood samples taken 4 to 6 weeks apart.
Women with early menopause are offered either HRT or the combined contraceptive pill to help relieve their symptoms if these treatments are suitable for them.
Women having treatment to help with symptoms of the menopause have a review 3 months after starting each treatment, and then have a review at least once a year. The aim of a review is to check that the treatment is working and that side effects are not a problem.
Give information about contraception to women who are in the perimenopausal and postmenopausal phase. See guidance from the Faculty of Sexual & Reproductive Healthcare on contraception for women aged over 40 years.
Think Bones- DEXA scan.

16. Menopause Mx with Breast Cancer History
Menopausal symptom Management
Discontinue HRT in women who are diagnosed with breast cancer.
Do not offer HRT (including oestrogen/progestogen combination) routinely to women with menopausal symptoms and a history of breast cancer. HRT may, in exceptional cases, be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed.
Offer information and counselling for all women about the possibility of early menopause and menopausal symptoms associated with breast cancer treatment.
Tibolone or progestogens are not recommended for women with menopausal symptoms who have breast cancer.
The selective serotonin re-uptake inhibitor antidepressants paroxetine and fluoxetine may be offered to women with breast cancer for relieving menopausal symptoms, particularly hot flushes, but not to those taking tamoxifen.
Clonidine, venlafaxine and gabapentin should only be offered to treat hot flushes in women with breast cancer after they have been fully informed of the significant side effects.
Soy (isoflavone), red clover, black cohosh, vitamin E and magnetic devices are not recommended for the treatment of menopausal symptoms in women with breast cancer.

17. Management

18. HRT Counselling It’s licensed for symptom relief.
Has risks and benefits
Risks:
Breast cancer risk: if CC for more than 5yrs- 5-7/1000 women extra cases
BUT no evidence of increased mortality.
If risk factors: are they higher than population risk- NICE tool.
E2 only HRT- protective, less cases of BC.
VTE: only with oral HRT.
Risks are population rates with transdermal HRT.
Safer for BMI >30.
Additional VTE risk factors- A+G to haematology.
Stroke risk only with oral HRT (less so if started under age 60).

19. HRT Benefits Improves symptoms of the menopause.
Reduce Osteoporosis Risk
Topical Treatment- for urogenital atrophy symptoms
RCOG leaflet for counselling: nt-information-leaflets/gynaecology/pi-treatment-symptoms- menopause.pdf
What about alternatives:
Herb vs Medicine debate!