1. Common Gynaecological Disorders Dr. Lee Chin Peng Honorary Clinical Associate Professor Department of Obstetrics and Gynaecology University of Hong Hong

2. Outline §General approach to gynaecological problems §Management and recent advances: l vaginal discharge l abnormal vaginal bleeding l dysmenorrhoea l uterine fibroid §Useful resources

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. Investigations §Pregnancy test §Swabs for culture §Cervical smear §Endometrial aspiration §Ultrasound pelvis

5. 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

6. Should investigations be done before referral ? 1. Affect decision to refer? 2. Delay the referral? 3. Reliable laboratory?

7. 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

8. 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

9. Vaginal Discharge §Physiological: l midcycle, premenstrual §Pathological: l odour, itchiness l blood stained §Postmenopausal: atrophic vaginitis May need to explore hidden anxiety, especially anxiety about STD

10. Vaginal Discharge §Speculum examination is necessary and digital examination preferred §Need to take culture swab? l Typical moniliasis: treat without culture, take swab if treatment fails §Need to screen for STD?

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

12. Vaginal Discharge In children: Think of foreign body and ? Sexual abuse May need referral

13. Abnormal vaginal bleeding §Postmenopausal bleeding (PMB) §Reproductive age group: l irregular l inter-, pre- or post-menstrual spotting l heavy bleeding (menorrhagia)

14. Abnormal vaginal bleeding §Malignancies? l Carcinoma of corpus l Carcinoma of cervix l Oestrogen producing ovarian tumour §Premaligant conditions? l Atypical endometrial hyperplasia l CIN (usually do not present with bleeding)

15. Abnormal vaginal bleeding §Benign conditions l Polyps: endometrial, cervical l Fibroid l IUCD? l Drug effect? l Systemic diseases l DYSFUNCTIONAL UTERINE BLEEDING IS THE MOST COMMOM

16. 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

17. Abnormal vaginal bleeding When 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. 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. 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. 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)

21. Abnormal vaginal bleeding: a practical approach (4) None of the above factors §consider investigations l cervical smear if sexually active and last smear more than 1 year ago l CBP if menorrhagia l ultrasound pelvis if PV not possible l thyroid function, coagulation only when history suggestive

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) l combined OC l progestogen only (21 days needed) §Non-hormonal (for menorrhagia) l NSAID l antifibrinolytic agent

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. Abnormal vaginal bleeding: a practical approach (7) Choice of medical treatment for menorrhagia l NSAID: 30% decrease in blood loss,relieve dysmenorrhoea as well l Antifibrinolytic (transamine): 50% decrease l Combined OC: effective but need to take through out the month, effective contraception as well l Progestogen only: less effective, need 21 days, not effective contraception l Haematinics: if anaemic §combinations can be used

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. Abnormal vaginal bleeding: other modalities of treatment §Levonorgesterol releasing IUCD (Mirena) §Endometrial ablation l pregnancy contraindicated after ablation §Hysterectomy

27. Abnormal vaginal bleeding Post-referral management §Pathology excluded §Treatment plan suggested, e.g l non-hormonal therapy l hormonal therapy usually for 6 months just follow the treatment plan refer back if treatment failure §Follow up after special treatment

28. Dysmenorrhoea §Primary §Secondary: l endometriosis l adenomyosis l chronic pelvic inflammatory disease l pelvic adhesions

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. Dysmenorrhoea §History §Physical examination: l Is pelvic examination needed? Recommended in all cases except in teenagers who are not sexually active with typical primary dysmenorrhoea

31. Dysmenorrhoea Investigations needed? §Ultrasound pelvis if l clinical pelvic examination abnormal l symptoms suggestive of secondary dysmenorrhoea but PV not conclusive or not possible §Laparoscopy l seldom needed

32. Dysmenorrhoea: role of laparoscopy §Subfertility §Chronic pelvic pain §Relieve the anxiety of patients §Treatment: l endometriotic cyst l medical treatment fail l subfertility

33. 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

34. Dysmenorrhoea Hormonal therapy: Primary dysmenorrhoea: combined OC pills (low EE) Endometriosis: progestogen only combined OC pills (low EE)

35. Uterine fibroids §Common §25-30% of women over 35 §Often asymtomatic §Incidentally detected on pelvic ultrasound

36. Uterine fibroids When to refer: §symptoms related to fibroids §size > 12 weeks (palpable per abdomen) §pain §uncertain diagnosis ?ovarian cyst §subfertility, recurrent miscarriage

37. Uterine fibroids Symptoms related to fibroids: §menorrhagia §irregular menstruation (only for submucosal fibroids) §urinary (frequency, retention) §abdominal distention

38. Uterine fibroids How to follow up asymptomatic fibroids? §Ultrasound? l Usually no needed §Check symptoms and uterine size clinically every 6 months or ask patient to return if symptomatic

39. Uterine fibroids: treatment §Surgical treatment remains the mainstay: l myomectomy (laparotomy, laparoscopy, hysterocopy) l hysterectomy §Medical treatment with GnRH analogue l shrink fibroids before surgery l buy time before menopause §Embolization: inadequate evidence on effectiveness and safety

40. Uterine fibroids Post-myomectomy follow up: §fibroids can recur after myomectomy §advice for pregnancy? l When? l Caesarean delivery needed?

41. 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

42. Useful resources Websites: §hhtp://www.bmj.com §hhtp://www.rcog.org.uk/guidelines §hhtp://www.hkcog.org.hk

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