Postpartum haemorrhage (PPH) refers to abnormal bleeding after pregnancy. It is typically defined as primary (typically with 24 hours of delivery) or secondary (usually after discharge home). Primary postpartum haemorrhage is the most common type.

It is normal for some bleeding to occur after giving birth. Typically this blood comes from the uterine wall at the location of attachment of the placenta. Bleeding may continue for up to 12 weeks, and is typically small amounts, and becomes more borne coloured as time progresses.

Postpartum bleeding is considered abnormal when:

• Estimated to be >500mls within 24 hours of delivery (primary)
• Bleeding increases after discharge from hospital, or continues longer than 12 weeks (secondary)

Causes

Primary – “The four T’s”

• Tone – uterine atony, distended bladder
• Trauma – lacerations of uterus, cervix or vagina
• Tissue – retained placenta
• Thrombin – coagulopathy – either pre-existing condition, or acquired

Uterine atony and retained products are the most common causes

Secondary

• Endometritis
• Retained products of conception (RPOC)

Primary postpartum haemorrhage

Obstetric haemorrhage was in the past a major cause of maternal death at the time of childbirth. However, modern medicine has greatly reduced its mortality risk, and it is now only the 6th most common cause of maternal death.

Severe PPH is defined as blood loss >1000mls in the first 24 hours after delivery

Epidemiology and Aetiology

• Incidence of 5-10%
  • Severe PPH – around 1%
• Risk of death from PPH is about 1 in 100 000 in the UK
  • 9 deaths were reported between 2006-2008 in the UK

Risk factors:

• Antepartum haemorrhage in current pregnancy
• Placenta praevia – 12x risk
  • This is where the placenta is located in the lower segment of the uterus, and may cover the cervical os. A common cause of antepartum haemorrhage
• Placental abruption
  • This is where the placenta separates from the uterus prior to delivery. Also a common cause of antepartum haemorrhage
• Multiple pregnancy – 5x risk
• Pre-eclampsia – 4x risk
• Previous PPH
• Asian ethnic origin
• Maternal obesity
• Maternal age >40
• Maternal anaemia
• Factors in delivery
  • Emergency Caesarian section – 4x risk
  • Elective Caesarian section – 2x risk
  • Retained placenta
  • Induction of labour
  • Labour >12 hours
  • >4kg baby
  • Assisted vaginal delivery
• Pre-existing maternal factors
  • Known haemorrhage disorders
    • Haemophilia A
    • Haemophilia B
    • Von Willebrand’s disease

Presentation

General presents with continuous bleeding after delivery which fails to stop after the third stage.

Signs of shock may be apparent – especially if >1000mls blood los

• Tachycardia
• Hypotension
• Syncope / loss of consciousness
  • Or, drowsiness / confusion

Management

Primary PPH is an emergency. Often staff on postnatal wards receive particular training in how to manage a PPH emergency. The Royal College of Obstetricians and Gynaecologists recommends a 4-component, simultaneous approach:

• Communication
  • Alert the members of team responsible for care of PPH. In minor cases, this may just mean the lead midwife and the obstetrics team. In severe cases, this may also involve a haematologist, anaesthetist, and institute the mass transfusion policy
• Resuscitation
  • IV access – large bore (14-gauge) cannula – ideally x2
  • Minor cases – start IV fluids
  • Major cases – start transfusion as soon as possible – IV fluids may be used as a stop-gap whilst waiting for blood to arrive
  • Assess ABC
  • Consider recombinant factor VIIa (rFVIIa) to stop the bleeding
• Monitoring and investigations
  • FBC, coagulation screen, U+E, LFTs
  • Crossmatch 4 units of blood
  • Monitor – pulse, PB, urine output, respiratory rate, temperature
  • Consider arterial line and ICU transfer
• Stop the bleeding
  • Examination – to find the cause. If no obvious cause – consider uterine atony
  • If uterine atony
    • Bimanual massage of the uterus will stimulate contraction
    • Empty the bladder
    • Oxytocin 5U IV
      • Repeat if ineffective
      • Cosnider setting up oxytocin infusion
    • Ergometrine 0.5mg IV or IM
    • Carboprost 0.25mg IM – max 8 doses
      • Contraindicated in asthma
    • Misoprostol 1000 mcg rectally
      • Usually only if oxytocin is not available
    • If unsuccessful – consider surgical options
      • Ballon tamponade
      • Haemostatic suturing
      • Bilateral ignition of uterine arteries
      • Bilateral ligation of internal iliac arteries
      • Arterial emoblisation
      • Hysterectomy

Complications

• Hypovolaemic shock
• DIC – disseminated intravascular coagulation
• AKI – acute kidney injury
• Liver failure
• ARDS – acute respiratory distress syndrome
• Death

Secondary postpartum haemorrhage

Most cases are due to endometritis are retained products of conception (RPOC)

Endometritis occurs in 1-3% of pregnancies. It is a postpartum infection of the endometrium, and has its own endometritis article.

Presentation

• Fevers
• Abdominal pain
• Offensive vaginal discharge
• Abnormal vaginal bleeding
• Dyspareunia
• Dysuria
• On examination
  • Tachycardia
  • Fever
  • Tender suprapubically
  • Boggy, palpable fungus in RPOC

Investigations

• FBC
• Blood cultures
• MSU
• High vaginal swab for chlamydia / gonorrhoea
• Speculum examination
  • Can detect lacerations
  • Can detect and remove clot covering the os, which if removed, can allow the os to close
• Ultrasound – if suspected RPOC (not useful in endometritis)

Management

• If signs of sepsis – refer immediately to hospital
  • Fever >38 degrees
  • Tachycardia
  • Increased respiratory rate
  • Diarrhoea or vomiting
  • Generally unwell
• If endometritis is suspected:
  • Antibiotics. Oral in mild cases, IV in severe cases
  • Typically treated with Tazocin (piperacillin + tazobactam) IV, or co-amoxiclav (oral)
  • 90% of cases improve with antibiotics within 72 hours
  • If treating in primary care – review the patient after 48-72 hours to assess efficacy of treatment
• If RPOC suspected:
  • Typically requires surgical management – e.g. D&C
  • Risk of uterine perforation
• In all cases:
  • Assess for anaemia and consider iron supplementation to correct this if present

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
• Postpartum haemorrhage – patient.info

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Ovarian cancer refers to several types of tumour arising from the ovaries. It is the leading cause of gynaecological cancer death in the UK. 

The early symptoms are often mild and subtle, and as such, presentation can often be late, with advanced disease.

Any of the tissues of the ovary have the potential to become neoplastic. Ovarian “growths” (tumours) are common – but 94% of all ovarian tumours are benign – these are usually simple cysts.

There are several types of ovarian cancer, depending on which cell type the tumour arises from:

• Epithelial – 85-90%
• Germ cell – 5-7%
  • Derived from primitive embryonic germ cells
• Sex-cord stromal – 5-7%
  • Derived from other gonadal tissue

Epithelial Ovarian Cancer

Epidemiology

• Lifetime risk – 1 in 55
• Incidence – 22 per 100 000
  • 7000 new cases in the UK each year, resulting in 5400 deaths
• The most deadly gynaecological cancer – results in more deaths than all other gynaecological cancers combined.
  • Probably because it presents so late due to lack of symptoms
  • Most cases present late
• Average 5 year survival is 30%
• Typical onset in women aged >50
• Epithelial tumours can be sub classified into different types:
  • Serous – most common – about 50% of cases
  • Endometroid – 20%
  • Clear cell tumours – 6%
  • Mucinous – 10%
  • Brenner – rare
  • Undifferentiated

Aetiology

• Hormonal factors
  • Increased risk with low parity / infertility
    • Nulliparity increased risk 1.5x
  • Early menarche
  • Late menopause
  • Use of HRT
    • About 1% of cases are thought to be HRT related
    • Risk is less if combined (oestrogen and progesterone) HRT is used
• Lifestyle factors
  • Obesity – increased risk with high fat intake
  • Smoking
  • Lack of exercise
  • Talcum powder use pre-1975 (contained asbestos)
  • Occupation exposure to asbestos
• Medical history factors
  • Previous pelvic inflammatory disease
  • Previous cancers of breast or bowel
  • Risk increases with age
  • History of endometriosis – significant increase in risk
• Genetic factors can play a role
  • 5% of cases have a family history
  • 1% of cases follow an autosomal dominant inheritance pattern
    • BRCA1, BRCA2 and HPNCC often involved in familial cases
  • Presentation in FH disease is 10-15 years earlier than other cases
• Increased risk in developed world
  • Incidence is low in Africa in comparison with Europe and USA

Protective factors

• Use of oestrogen containing oral contraceptives is protective for ovarian cancer – but may slightly increase the risk of breast cancer.
  • Reduces the risk by 50%
• Childbearing
• Breast-feeding
• Hysterectomy

Why is the pill protective but early menarche is not?

• The risk is related to the number of ovulations
  • With the use of oral oestrogen containing contraceptives, ovulation is suppressed
  • Early menarche obviously increases the number of ovulations
• Thus, the risk is related to the number of ovulations, and not the direct result of exposure to oestrogen

Pathology

The surface of the ovary is covered in cuboidal epithelial layer that is continuous with the lining of the peritoneum. It is from these cells that the tumour arises.

Clinical presentation

60% of patients present with advanced disease – stages III and IV.

Ovarian cancer tends to present later than other gynaecological tumours

• In many other gynaecological tumours, there are often symptoms of vaginal discharge and blood, but in ovarian cancer, these are not present.

Symptoms are generally vague, and may be dismissed as IBS or other vague bowel symptoms:

• Vague abdominal distension, bloating
• Urinary frequency
• Dysuria
• Fever
• Weight loss
• Pelvic mass
  • May be painful or tender to examination
  • May cause dyspareunia (painful intercourse)
• Epigastric discomfort / early satiety
• Ascites – check for shifting dullness
• Abnormal uterine bleeding is not common but occasionally occurs
• Rupture / local peritonism can occur – particularly in the case of a large cyst
  • Rupture of a malignant cyst can result in the spread of malignant cells around the peritoneal cavity
  • Mucinous cyst adenomas – if these rupture, the cells contain within can escape around the peritoneam and continue to secrete mucous, resulting in a life-threatening ‘adhesion’ of the contents of the viscera, known as psudomyxoma peritonei.
• Torsion – only occurs in small, free to move tumours. If the tumour twists, then the venous supply may become occluded, but the arterial supply continues – and the tumour may engorge and become grossly enlarged, causing great pain.
  • The tumour can twist and untwist itself, and thus the history of pain may be intermittent.
• Endocrine / metastatic effects – e.g. may cause post-menopausal bleeding, or menstrual irregularities.
  • Metastasis can occur to the pelvic and paralytic lymph nodes, as well as the peritoneum

Differential diagnosis

• Benign ovarian tumours and cysts
• Fibroids
• Other pelvic malignancies
  • Endometrial cancer
  • Cervical cancer
  • Bladder cancer
  • Rectal cancer
• Endometriosis
• Other causes of vague bowel symptoms
  • IBS
  • Constipation
  • Coeliac disease
  • Inflammatory bowel disease
  • Gastroenteritis
  • Diverticulitis
  • Pelvic inflammatory disease

Investigations

Any patient with an abdominal or pelvic mass requires urgent specialist referral.

• Transvaginal USS
• Bloods
  • Serum CA-125
  • Consider other causes of raised CA-125 if USS is normal (endometriosis, PID, pregnancy, other gynaecological cancer, liver disease)
  • If under 40, consider aFP and BhCG to exclude germ cell tumours
• CT or MRI
  • May be used to assess spread of the disease
• Biopsy
  • Required to confirm the presence of a tumour (as opposed to e.g. a benign cyst).
• Usually, upon initial suspiscion, the GP will take a blood sample for CA125, and refer for transvaginal ultrasound.
  • CA125 – sensitive but highly unspecific. It can be raised in loads of benign and malignant conditions. It is useful to test the effectiveness of treatment, and to detect the relapse of disease.

Prognostic factors

• Stage of tumour, including spread
• Histological type

The patient decline seen in advanced disease is usually the result of extensive local spread, rather than metastatic disease.

Also, there is a relatively high cure rate (compared to other cancers) in advanced disease

Staging

• Stage I
  • Ia – Confined to one ovary, capsule intact, no evidence of ovarian surface
  • Ib – same as above, both ovaries affected
  • Ic – one/both ovaries with ruptured capsule / tumour on ovarian surface / malignant cells present in ascetic fluid or in peritoneal washing
• Stage II
  • IIa – Spread to the uterus / tubes
  • IIb – spread to other pelvic structures (broad ligament, pelvic wall, peritoneum, colon)
  • IIc – as IIa or IIb, plus malignant cells in ascetic fluid or peritoneal washing
• Stage III
  • IIIa – spread to abdomen, beyond the pelvis, e.g. peritoneal surface of liver
  • IIIb – Spread beyond pelvis, with mets >2cm diameter
  • IIIc – spread beyond the pelvis, with mets >2cm, and involvement of pelvic /para-aortic lymph nodes
• Stage IV – mets to lung, supraclavicular lymph nodes, malignant pleural effusion, mets in liver parenchyma (not surface)
• 75% of cases are stage III or IV at presentation
• For disease confined to the ovary (Stage Ic and below), survival after treatment is around 80%
• For metastatic disease confined to the peritoneal cavity, 5 year survival is around 30%
• For disease outside the peritoneal cavity, 5 year survival is 5-10%.
• Most patients will die from a relapse of their disease, even if the initial tumour was ‘cured’.

Spread

Like most cancers, ovarian cancer is likely to spread locally, and via lymph and blood. However, ovarian epithelial cancer also typically spreads to the greater omentum:

• The omentum usually plays a role in healing, by adhering to damaged tissue. Thus it expresses lots of adhesion proteins, making it an easy target for metastatic spread.

Other common sites of spread include:

• Liver, lungs, bone and cerebrum
• Lymph node involvement is common

Management

Most cases involve surgery (sometimes referred to as “debulking surgery” in advanced disease) followed by adjuvant chemotherapy.

Surgical

• More effective than chemotherapy (typically platinum agents) only if disease bulk diameter <2cm
• Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) – removal of ovaries and fallopian tubes
• Omentectomy – removal of the greater omentum

Medical

• Adjuvant chemotherapy (6 cycles) usually given in all cases. Carcoplatin + paclitaxel (Taxol) given. Carcoplatin is a platinum based drug, and paclitaxel improves its efficacy.
• These agents increase survival by around 10% in stage Ic tumours (from 70% to 80%)
• In more aggressive tumours, the median survival is 3 years with a combination of surgery and chemotherapy.
• Good prognostic indicators for the use of platinum drugs:
  • Disease bulk <5cm
  • Number of disease sites <3

Follow-up

• CA-125 levels can be monitored to see the effectiveness of treatment, as well as to detect a relapse

Prognosis

• Survival has doubled in the last 40 years
• Overall, 10 year survival is 35% and 5-year survival is 45%
• Best survival rates are in women aged <40
• Survival at 1-year by stage:
  • I – 97%
  • II – 94%
  • III – 71%
  • IV – 51%

Germ cell tumours

• Derived from primitive germ cells
• Account for 5-10% of all ovarian tumours
• Typically present in women aged <35
• Often curable – have high survival rates
• Typically present as a rapidly enlarging abdominal mass
  • May rupture
  • May undergo torsion

Sex cord stromal tumours

• Arise from connective tissue cells
• <5% of all ovarian cancers

References

• Ovarian Cancer – patient.info
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Vulvovaginitis is a clinical presentation which can have many causes. It typically presents with one or more of the following; vaginal itch, discharge, dyspareunia, burning, dysuria and swelling.

It is most commonly caused by vaginal thrush, but there are a wide range of other causes, including other infections (e.g. trichomonas, herpes simplex, other STIs), dermatological causes – e.g. psoriasis or eczema, and neurological causes.

Mixed pathology is very common – particularly the combination of vulval dermatitis and thrush.

The treatment typically involves a combination of avoiding irritant causes to the vulvovaginal area, and treating the underlying disorder.

History

• Discharge
  • Onset
  • Colour
  • Frequency
  • Consistency
  • Smell
  • Duration
• Itch
  • External
  • Internal
  • Associated sensations – burning, sharp pain
• Provoking factors
  • Always present at rest
  • Symptoms provoked by tampons, clothes, exercise
• Menstrual history
  • Are symptoms cyclical?
• Sexual history
  • New sexual partners
  • Assess STI risk
• Pregnancy
  • VERY importante because some of the treatments are contra-indicated in pregnancy
• Skin conditions
  • Any history of psoriasis or dermatitis?
• Medications
  • Recent antibiotics – predispose to thrush
  • Might have trialled over-the-counter treatments for thrush

Examination

• Examine external genitalia
  • Any skin lesions – e.g. herpes simplex, warts or molluscum contagiosum
  • Any signs of dermatitis
  • Any visible discharge
  • Any lichenifiaction?
    • This refieres to thickening of the skin
• Speculum examination
  • Examine cervix
  • Note the qualities of any discharge
• Bimanual examination
  • Note pain and tenderness

Differentials

Modified from a table in RACGP Check  – Women’s Health – Unit 530 – August 2016

Investigations

• Swab for MC+S
• Test for chlamydia and gonorrhoea – usually PCR from an appropriate swab. Urine PCR can also be performed but is less accurate
• Consider bedside pH testing of any discharge

Management

The management of vulvovaginitis will typically involve with below general measures, in addition to specific treatment for the underlying disorder.

Supportive measures:

• Loose fitting cotton clothing
• Clean the area once or twice daily without soap (wither water only, or emollient)
• Avoid cycling or horse riding until symptoms settle
• Avoid irritants
  • Soap
  • Hygiene wipes
  • Fragrances
  • Douche
  • Lubricant
  • Condoms
  • Sanitary pads or panty liners
  • Tight clothes
  • Swimming, saunas, spas

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Postpartum endometritis is a term used to describe inflammation (usually due to infection) in the uterus. It typically due to pregnancy, and can occur up to 6 weeks after delivery. It is more common after caesarian section.

• There is also a non-pregnancy related type of endometritis – although there is debate as to whether this is its own condition, or part of the spectrum that also includes PID.
• Normally when referring the endometritis we are referring to the pregnancy related variant – which is typically associated with pelvic inflammatory disease. Unless otherwise specified, this is the type referred to in this article.

It is thought that infection arises from the genital tract and travels up to the uterus, and can also progress onto the ovaries and fallopian tubes – causing saplingo-oophpritis.

• It is typically caused by the bugs that live in the lower genital tract, such as:
  • Group B Streptococcus
  • Peptostreptococcus
  • E. Coli
  • Klebsiella

Endometritis can be acute or chronic.

Epidemiology

• Occurs in 1-3% of vaginal births, but 25% of caesarian sections
  • Greater risk if HIV-positive
• Prophylactic antibiotics reduce the risk by 60-70%
  • All women undergoing caesarian section should receive prophylactic antibiotics and vaginal cleaning with a povisdone-iodine solution.
  • Neither of these things is recommended for women with vaginal delivery

Aetiology

• Usually 2 or 3 different organisms are involved in the infection, often a mix of both aerobic and anaerobic bacteria
• Common organisms include:
  • Gram positive – Staph aureus, Group A and Group B streptococcus
  • Gram negative – E. Coli, Klebsiella, chalmydia, enterobacter, Neisseria
  • Anaerobic – bacteroides, Peptostreptococcus
• Risk factors:
  • HIV
  • Prolonged rupture of membranes
  • Severe meconium staining
  • Long labour
  • Retained products of conception
  • Obesity
  • Maternal anaemia
  • Diabetes
  • History of previous pelvic infection
  • Bacterial vaginosis
  • Group B strep infection

Pathophysiology

• Usually, the uterus is sealed-off from the lower genital tract (vagina and cervix) by a mucus plug in the cervix
• This creates both a physical barrier, and also has antibiotic properties
• In normal delivery during labour, the mucus plug is passed through the cervix into the vagina around the same time that the membranes rupture
• It is around this time that bacteria may enter the uterus and cause endometritis
• As such, certain conditions around labour increase the risk of endometritis. These include:
  • Prolonged rupture of membranes (PROM) / prolonged labour
  • Retained products (of pregnancy)
  • Caesarian section

Presentation

• Fever
• Pelvic pain
• Offensive vaginal discharge
  • “Lochia” is the name given to the physiological vaginal discharge seen after pregnancy
  • In endometritis – this often becomes purulent and foul smelling
• PV bleeding (postpartum haemorrhage)
• Dyspareunia
• Dysuria
• Tachycardia

It can also exists in a chronic form:

• Often asymptomatic
• May occasionally present with features of the acute presentation

Late onset endometritis is defined at >7 days since delivery

• Accounts for about 15% of cases
• More likely to be due to chlamydia

Investigations

Typically a clinical diagnosis. Investigations may support the diagnosis, or an endometrial biopsy can be definitive but is rarely required.

• FBC (raised WCC)
• Blood culture
• MSU
• High vaginal swab for chlamydia / gonorrhoea
• Endometrial biopsy is occasionally performed
  • Will typically show neutrophil (or in chronic cases, plasma cell) infiltration into the endometrium
• USS is not usually useful but often performed as it may rule out other differentials – and can usually see retained products if present

Differential Diagnosis

• Pelvic inflammatory disease
• Appendicitis
• Pyelonephritis / UTI

Management

• Antibiotics
  • Local guidelines vary – consult yours for most accurate information
  • Typical regimen might include clindamycin and/or gentamicin. For example eTG Australia recommends:
    • Gentamicin 3-5mg/Kg, PLUS
    • Metronidazole 500mg IB BD, PLUS
    • Amp/amoxicillin 2g IV QID
  • Or, in penicillin allergy:
    • Gentamicin 3-5mg/Kg IV
    • Clindamicin 600mg IV TDS
  • In those suitable for oral treatment, co-amoxiclav (augmentin) may be used
• Usually hospital admission and IV antibiotics are required
  • Presence of fever, tachycardia, hypotension or other abnormal vital signs usually indicate the need for hospital admission
• Patients usually improve rapidly – within 48-72 hours
• In mild cases, patients may be treated as an outpatient with amoxicillin + clavulanate 875 + 125mg (co-amoxiclav / augmentin) PO BD for 7 days
• Dilation and curettage (D&C)
  • May be required if there are any retained products
  • A procedure where a curette is inserted into the uterus via the vagina and is used to remove retained profits of pregnancy

Complications

• Sepsis
• Peritonitis
• Pelvic absces
• Haematoma

Non-pregnancy related endometritis

• Typical causes might include chlamydia, gonorrhoea or TB
• Often asymptomatic
• Often associated with PID
• In chronic endometritis – often causes by TB, Asherman’s syndrome can result.
  • This causes fibrosis, scarring and adhesions of the endometrium, which can prevent the normal endometrial response to hormonal changes (and amenorrhoea), and can completely obliterate the endometrial cavity – both of which can cause infertility

References

• Postpartum Endometritis – patient.info
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• <a href="
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

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Abnormal uterine bleeding is a common presenting problem in general practice

• Accounts for about 4% of presentations to general practice
• 20% of women complain of heavy period bleeding – however about 50% of these have a normal amount of blood loss when investigated – perception is not reliable
• Heavy menstrual bleeding is the most common cause of iron deficiency in the developed world
• Don’t forget about possible pregnancy and its complications when presented with a patient with abnormal uterine bleeding!
• Non-menstrual bleeding (postcoital, intermenstrual and postmenopausal) always warrant further investigation and consider early referral to gynaecology

In this article we discuss a brief overview of abnormal uterine bleeding. Individual types of abnormal uterine bleeding are discussed separately.

Types of abnormal uterine bleeding 

• Menorrhagia (heavy menstrual bleeding)
• Intermenstrual bleeding
• Postcoital bleeding
• Postmenopausal bleeding
• Oligomenorrhoea and amenorrhoea
• Dysfunctional uterine bleeding (see below)
• Irregular menstrual cycle (see below)

The normal cycle

• 30-40mls average blood loss per cycle
• <80mls is considered “normal”
• >80mls is considered menorrhagia / heavy menstrual bleeding (HMB)
• The two most common causes of HMB are fibroids and adenomyosis
• Many drugs can alter menstrual bleeding, including steroids, anticoagulants and cannabis
• Keeping a menstrual diary can be a good way to estimate blood loss – there are now lots of apps that can help to record this data

Defining normal

• Menarche usually occurs between the ages of 10-16 (mean age 13)
  • Periods can be irregular for up to three years after menarche
  • Irregular periods after this time is considered abnormal
• Normal range of cycle – 21-35 days
  • Mean 26-28 days
• Menstrual flow – 2-7 days
  • Mean 3-4 days
• Normal blood loss 20-80ml
  • Mean 30-40mls
• Estimating volume – any flow such that menstrual pads are not able to absorb the flow is considered abnormal
• Normal endometrial thickness – 6-12mm
• Anovulatory cycle – defined as serum progesterone >20nmol/L in the mid-luteal phase (5-10 days before menses)
• Abnormal uterine bleeding is more common at the extremes of reproductive age. Cancer is a more likely cause in women at the upper end of the range, and is less than 1 in 100 000 in women under 35

Dysfunctional Uterine Bleeding (DUB)

• Defined as excessive uterine bleeding for which no organic cause can be identified.
• Diagnosis of exclusion
• Common – 10-20% of women will suffer it at some stage
• Usually ovulatory rather than anovulatory
• Common in late 30s and early 40s
• Up to 40% of patients initially diagnosed as DUB will ultimately have fibroids, endometrial polyps or some other organic cause later identified

Presentation

• Heavy bleeding, saturated pads, “accidents”, “flooding” clots
• Prolonged bleeding
  • Menstruation >7 days, OR
  • Heavy bleeding > 4 days
• Frequent bleeding – more often than every 21 days
• Usually do not have pelvic pain or tenderness

Investigations

As for heavy menstrual bleeding

Management

• Menstrual calendar
• Ensure no iron deficiency anaemia
• Reassurance about the absence of identified pathology
• Consider drug therapy
  • First line are antiprostaglandins – NSAIDs and tranexamic or mefanamic acid. Start as soon as bleeding starts and continue for 5 days. Between 60-80% of patients can control symptoms with one of these agents alone
  • Contraceptive pill is second line – about 80% of patients will respond to COC
  • Hormonal IUD (Mirena) is the most effective hormonal agent – reduces bleeding by 95%
  • Progesterone reduced bleeding by 85% – although pill preparations usually much less effective. Depo-provera will induce amenorrhoea in about 50% of patients within 1 year
  • COC reduces bleeding by 50%
  • Tranexamic acid reduces bleeding by 40%
  • NSAIDs reduce bleeding by 30%
• In extreme cases – consider surgical management if medical management is unsuccessful and fertility is no longer desirable
  • Endometrial ablations
  • Hysterectomy
• EMERGENCY TREATMENT
  • Tranexamic acid 1-1.5g PO TDS until bleeding stops

Irregular menstrual cycle

• Usually hormonal in origin
• Only rarely is there an organic cause in patients under 35
  • Consider PCOS – particularly if there are any other features present
• COC or POP often used to treat symptomatically
• Patients over 35 need thorough investigation for an organic cause – usually endometrial biopsy +/- hysteroscopy

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

Read more about our sources

The post Abnormal Uterine Bleeding appeared first on almostadoctor.

Introduction

Intermenstrual bleeding (IMB) is a presentation, rather than a diagnosis, and can be indicative of a number of underlying disorders.

It refers to vaginal bleeding at any time during the cycle, except during menses.

Breakthrough bleeding is a separate term that refers to vaginal bleeding whilst on hormonal contraception at a time other than the withdrawal bleed seen with the pill.

It is often considered together with postcoital bleeding (PCB), as the two symptoms may present together and have overlapping causes, although differentiating between the two can help to narrow down the possible differentials.

Intermenstrual bleeding is important because cerrvical cancer should always be considered, although in reality, this is rare – especially in young women.

Epidemiology

• About 15% of women experience abnormal uterine bleeding
• Two-year cumulative incidence for IMB is about 25%
• Up to half of cases resolve spontaneously
• The association with uterine cancers is low, but is often a concern for patients
• Many women present with a combination of IMB and PCB

Causes

• Infection
  • PID / chlamydia
  • Especially if there is associated discharge
• Cervical ectropion (aka cervical erosion)
  • More common in younger women, and those on the pill
• Cervical or endometrial polyps
• Contraception
  • IUD
  • Oral contraceptive pill
• Cancers
  • Cervical
  • Endometrial
  • Vaginal
  • Ovarian (especially if oestrogen secreting
• Atrophic vaginal change
• Physiological
  • 2% of women will have spotting around ovulation
• Breakthrough bleeding when taking hormonal contraception
  • More common with progesterone only methods, or combined methods with <30 micrograms of ethinylestradiol (oestrogen)
• Rarer causes(more commonly associated with menorrhagia rather than intermenstrual bleeding)
  • Uterine fibroids
  • Endometriosis
  • Adenomyosis

History

• Menstrual history
  • Last menstrual period (LMP)
  • Cycle regularity and length
  • Duration of bleeding
  • Heaviness of bleeding
  • Any menorrhagia?
  • Any vaginal discharge?
  • Any fevers?
  • Any pelvic pain?
• Contraceptive history
  • What is she using?
  • For how long
  • Any correlation with symptoms?
  • History of cervical screening tests
• Sexual history
  • History of STI screening tests
• Reproductive history
  • Previous pregnancies and deliveries
  • Is she currently breastfeeding?
• Confirm bleeding is from the vagina
  • If uncertainty – use a tampon next time bleeding occurs to confirm

Examination

• Abdominal exam
  • Check for pelvic masses
• Vaginal examination
  • Polyps?
  • Presence of blood or a bleeding site
  • Cervical ectropion
  • Discharge
  • Cervicitis
    • Usually caused by chlamydia, less commonly gonorrhoea
    • Herpetic cervicitis often has multiple ulcers
    • Trichonmonas vaginalis can cause a friable inflamed cervix also
• BMI – if high – this is an independent risk factor for endometrial cancer

Investigations

• Cervical smear and HPV testing
• Consider STI screening (i.e. high vaginal swabs) if any vaginal discharge, pain, or risk factors for STI
• Pregnancy test – ALWAYS confirm no pregnancy in the context of abnormal uterine bleeding
• Referral to gynaecology for colposcopy if no cause apparent with the above
• USS
  • Transvaginal is most accurate
  • Ideally done immediately after the end of the period – as endometrial thickness can be measured at this point
  • Any endometrial thickening (>12mm in pre-menopausal women and >5mm in peri-menopausal women) requires prompt referral to gynaecology
• Endometrial biopsy
• Women with ongoing heavy intermenstrual bleeding should be referred for hysteroscopy with endometrial biopsy

When to refer for specialist assessment

• Abnormal cervical appearance – need an urgent referral for cervical cancer assesment
• Cervical polyp that cannot be easily removed on speculum examination
• Pelvic mass on abdominal examination or USS
• Those at high risk of cervical cancer
  • FHx of cervical cancer
  • On tamoxifen
  • Heavy intermentrual bleeding
• ANY woman aged over 45 with persistent symptoms (>3 months duration)

Management

Overall, about half of cases resolve spontaneously.

Otherwise, treatment depends on the cause:

• Suspected cancer – urgent referral to gynaecology
• Infection – treat the infection
• Breakthrough bleeding
  • Ensure the contraceptive method is being used correctly
  • Is normal in the first 3 months of use of any type of hormonal contraception
  • Consider increasing the oestrogen content of the contraception used – e.g. if on a pill with 20mcg daily of ethinylestradiol, increase this to 30-35mcg
  • If using the IUS or depot injection – consider also adding combined hormonal contraceptive pill for 3 months
  • Mefanamic acid or tranexamic acid can be used for symptom control as required
• Cervical ectropion
  • Usually resolve if the pill is stopped
  • Can be cauterised with silver nitrate
  • May also be treated with diathermy, laser or microwave therapy
• Cervical and endometrial polyps
  • Can be removed during speculum examination if visible – but twisting and pulling at the stem (this is usually painless). They should be sent for histology
  • Cervical cancer risk for polyps:
    • 1-2% for pre-menopausal women
    • 5% for post-menopausal women
• Fibroids
  • Can be removed during hysteroscopy
  • Uterine artery emobilisation is alo effective

References

• Intermenstrual and Postcoital bleeding – patient.info
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

Read more about our sources

The post Intermenstrual Bleeding appeared first on almostadoctor.

Introduction

Menorrhagia describes abnormally heavy menstrual bleeding (often associated with increased period pain) during periods.

Menorrhagia is a common presenting compliant, and a cause is not always found. Endometrial carcinoma should always be considered as a differential.

In a typical period, the average blood loss is 30-40ml. Bleeding usually lasts 7 days or less, and a ‘normal’ cycle length is 21-35 days. Up to 30% of women report having “heavy” periods, however only about 5% of women will consult their GP for the problem.

• It is no longer typically recommended to try to estimate the amount of blood loss – instead it is enough to make a diagnosis of menorrhagia on the basis of the women’s perception of a large amount of bleeding, and the impact on her life.

Menstrual disorders are the second most common reason for gynaecology referral.

Epidemiology

• 30% of women report heavy periods
  • When measuring menstrual loss, and using a cut-off of 80mls per menses, the prevalence of menorrhagia is between 10-15%
• About 50% of cases then present medically have no cause identified – and as such are diagnosed as Dysfunctional Uterine Bleeding (DUB) – a diagnosis of exclusion

Causes of heavy menstrual bleeding

• Ovulatory Dysfunctional Uterine Bleeding (DUB)
  • This essentially refers to a type of menorrhagia where no underlying cause is identified
  • Anovulatory DUB – is more rare and occurs at the extremes of child-bearing age
• Fibroids
• Complications of hormonal therapy
  • Combined hormonal contraceptive pill
  • IUD
• Adenomyosis
• Endometriosis
• PCOS
• Rare, but serious
  • Pregnancy, including its complications (e.g. miscarriage, abortion, ectopic)
  • Cancer – cervical, endometrial, ovarian, leukaemia
  • Endometrial polyps / endometrial hyperplasia
  • PID / STI
• Other rare things
  • Pelvic congestion syndrome
  • SLE
  • Thyroid disorders
  • Bleeding disorders
  • Liver disease
• Drugs
• There is an association with anxiety and depression and heavy menstrual bleeding – which is probably more likely related to a perceptual problem
• SMOKING – 5x more likely to have abnormal menstruation

Red Flags

• Heavy bleeding with haemodynamic instability (an emergency!)
• Postmenopausal
• During pregnancy
• Pelvic mass
• Findings on USS
  • Endometrium >12mm thick in pre-menopausal women
  • Endometrium >5mm thick in peri-menopausal women

History

• Menarche
  • Have periods always been heavy? (consider a bleeding disorder)
• Menstrual history
  • What is the normal pattern?
  • When did the heavy bleeding start?
  • What sanitary products does she use and how often are they changed?
  • Note there is no direct correlation between length of period and total blood loss
• Could she be pregnant?
• Cervical screening history
• Effect of symptoms on every day life
  • Is she having regular time off work?
• Any hirsutism (PCOS signs or symptoms)
• Sexual history
• Trauma
• PMHx
  • Bleeding disorder
  • Thyroid disorder
• FHx
  • Endometrial cancer
  • Bowel cancer
• Cancer
• Hormonal therapy – e.g. contraceptive pill, IUD

Definition

Defining heavy bleed can be difficult. A “normal” cycle has bleeding that lasts 7 days or less, with a cycle length of between 21 and 35 days.

Consider that heavy bleeding is present if:

• >80ml per cycle (hard to determine!)
• If tampons / pads / cups need to be changed around every hour
• Having to use two sanitary products in combination
• Passing large clots. Clots often cause pain as they pass through the cervix
• If bleeding lasts >1 week
• The woman perceives that she has heavy bleeding

Examination

• If very heavy and acute bleeding – ensure haemodynaically stable
  • HR
  • BP
• Abdominal / pelvic examination (bimanual examination)
  • Feel for masses – particularly pelvic masses
• Consider speculum examination +/- pap smear +/- swabs for STI if indicated
  • Consider if appropriate in young girls with no sexual history as can be a traumatic experience

Investigations

• Bloods
  • FBC
  • Iron studies
  • Coags – INR / PT / APTT / fibrinogen / platelets
  • B-hCG
  • TFTs
  • Autoantibodies – e.g. ANA for SLE
  • Consider hormones  – LH, FSH, estradiol, prolactin
• Consider pelvic / transvaginal USS
  • Ideally should be reserved for women who fail conservative management, or are at high risk of endometrial cancer
  • Perform in first half of cycle when endometrial thickness can be measured
    • >12mm in premenopausal or >5mmin post menopausal women requires endometrial biopsy

Management

Acute:

• If haemodynamically unstable – refer to emergency department
• If haemodynamically stable but Hb <80 – refer for urgent gynaecology assessment (also consider going via emergency department)
• To stop acute bleeding, choose one of the following
  • Tranexamic acid 1g to 1.5g PO every 8 hours – until bleeding ceased
  • Progesterones:
    • Norethisterone 5-10mg PO every 4 hours until bleeding stops
    • Medroxyprogesterone 10mg PO every 4 hours until bleeding stops
• Consider urgent USS

Non-acute:

• Consider prompt USS
• Treat any iron deficiency
• If USS is normal, age <35 and no red flags, can treat in the community. Choose one of the following options:
  • Intra-uterine device (e.g. Mirena)
    • Recommended first line in the UK
    • Studies show women reported a greater improvement in quality of life with mirena compared to other treatments
    • However – has a high rate of removal – about 30% by 2 years
  • Combined hormonal contraceptive (provided no contra-indications). May choose to run packets together to avoid periods altogether – this is safe to do for up to 12 months at a time
  • Tranexamic acid 500mg PO BD or TDS for 2-3 days with periods
  • NSAIDs
    • Ibuprofen 400mg TDS
    • Naproxen 500mg stat dose, and then 250mg TDS
    • Mefanamic acid 500mg TDS
  • Progestins are considered third line, after IUS, CHC / NSAIDs / tranexamic acid
    • Norethisterone – note this is not contraceptive. Start at 5mg TDS. Usually short term use (1-2 months only)
    • Depo-provera injection
      • Suppresses ovulation
      • Beware of reduced bone density and weight gain
      • Repeat every 12 week
  • Endometrial ablation
  • Hysterectomy may be considered as a last resort in women who are certain they do not want any (more) children
• If no cause is identified, no red flags, and patient is aged <35, and symptoms respond to treatment – you can make a diagnosis of dysfunctional uterine bleeding (DUB)
• If any red flags, or USS abnormalities, or age >35, refer to gynaecology. USS abnormalities include:
  • Thickened endometrium
    • >12mm in pre-menopausal women
    • >5mm in pro-menopausal women
  • Fibroids – especially if >10cm
  • Endometrial polyps

Flashcard

References

• Menorrhagia – patient.info
• Menorrhagia – HealthPathways
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

Read more about our sources

The post Menorrhagia appeared first on almostadoctor.

• Menopause is the permanent cessation of the menstrual cycle
• Menopause usually occurs between the ages of 45 and 55
• Typical age is 51.5
• Premature menopause is defined as menopause before the age of 40 – aka premature ovarian insufficiency
• The process of going through the menopause can be split into the premenopause – a time of irregular periods, and menopause – the time when the periods cease. The total time spent passing through these changes varies between 2 and 5 years
• Postmenopause is said to begin at 12 months after the final period
• Menopause has many physiological effects, but one of the main pathological consequences is the predisposition for osteoporosis
• As well as being a physiological process, menopause is induced by surgical removal of the ovaries, or by damage to ovarian function with radiotherapy or chemotherapy

Physiology

• As the menopause approaches, the number of primary follicles declines
• Levels of FSH and LH rise dramatically
• The ovary produces very little oestrogen or progesterone, but continues to produce androgens
• Diseases for which risks increases after menopause:
  • Osteoporosis
  • Cardiovascular disease
  • Diabetes
  • Cancer
    • Breast
    • Ovary
    • Cervix
• Premature menopause occurs in
  • About 1% of women <40 years as a result of genetic or autoimmune disease. These patients require specialist investigation
  • About 5% of women <40 due to oophorectomy or chemotherapy
  • Women age 40-45 have physiologically significant “premature menopause” and don’t necessarily require further work-up

Presentation

The symptoms of menopause are due to tissue sensitivity to lower oestrogen levels. This mainly affects the brain. Symptoms vary widely – some women experience none at all, whilst other are severe debilitated by their symptoms. About 80% of women will experience some symptoms. 50% of women will experience some symptoms for at least 7 years.

• Hot flushes – 80%
• Night sweats – 70%
• Palpitations – 30%
• Dizziness
• Lethargy / tiredness
• Migraine / other headaches
• Psychological
  • Irritability
  • Depression
  • Anxiety
  • Poor short term memory
  • Sleep disturbance
• Urogential
  • Vaginal dryness (45%)
  • Atrophic vaginitis
  • Dyspareunia (pain on sexual intercourse)
  • Reduced libido
  • Bladder dysfunction
  • Stress incontinence (e.g. frequency, dysuria)
  • Prolapse
• Skin
  • Dry skin
  • Sensation of insects crawling on skin (formication)
  • Facial har
  • Breast tissue atrophy

The oestrogen deficiency symptoms are hot flushes and the urogenital symptoms. These are important to elicit in the history, as these are the symptoms most effectively treated with HRT.

• Vasomotor symptoms (hot flushes and night sweats) are at their height in the perimenopause and early post menopausal stage, before resolving with time
• Urogenital atrophy symptoms tend to worsen with age

Investigations

In a typical-age patient (age 45-55), no specific investigations are required – the diagnosis is usually clinical. However, several investigations may be performed to rule out other differentials. Differentials include:

• Thyroid disorders
• Dysfunctional uterine bleeding
• Anaemia
• Depression

Investigations to help discern these differentials would include:

• Urinalysis
• FBC
• TSH
• LFTs
• Iron studies
• B-hCG (!)

Investigations are not necessary to confirm diagnosis of menopause in women aged >45.

In possible early menopause (age <45), the following hormonal test may confirm the diagnosis:

• Serum FSH – high – (around 25 U/L))
• Serum oestradiol – low – (<100 pmol/L)
• Two readings should be taken 6 weeks apart (or 3 months apart if has a mirena (IUD))
• These investigations are NOT intended to diagnose menopause in women >45
• FSH is not always elevated early in the perimenopausal period

Other investigations to consider around the perimenopausal period include:

• Fasting lipid profile (for cardiovascular disease risk)
• Mammogram – particularly remember to consider this 3 months after starting HRT
• Hysteroscopy – if abnormal uterine bleeding
• Pap smear and mammography
• Bone density – if risk factors (consider using risk calculator – such as FRAX)

Management

Patient education

• Emphasis that the menopause is a natural physiological process
• Some lifestyle factors can trigger the vasomotor symptoms – including caffeine, alcohol, spicy foods
• Lifestyle factors have been shown to reduce the severity of symptoms
  • Healthy diet
  • Healthy weight
  • Regular exercise
  • Smoking cessation
  • Reduce caffeine intake
  • Alcohol intake within recommended safe limits
  • Stress reduction and relaxation (consider mindfulness)
• Screen for anxiety and depression and treat these if present
• Give advice about bone health
  • 1300mg calcium per day
  • 150 minutes of moderate intensity exercise weekly
  • Vitamin D – either supplementation or sun exposure
  • Smoking cessation
  • Safe drinking limits (alcohol)

Sex

• Advise it is normal to need additional vaginal lubrication
• Advise to continue contraception for 12 months after the last period in women >50 and 2 years in women <50
• The combined oral contraceptive pill (low dose preparations) can be used up to the age of 50 if there are no contraindications (see UKMEC guidelines for contraindications). After the age of 50, condoms and progesterone only preparations are recommended.

Hormone replacement therapy

Hormone replacement therapy (HRT) should be considered for any patient with moderate to severe vasomotor symptoms (hot flushes, night sweats, palpitations).

For patients with urogenital symptoms – consider topical oestrogen preparations:

• e.g. – Oestradiol 1mg/g with applicator
  • Once at night for three weeks, then 2-3x per week thereafter
  • OR
  • Oestradiol 10mg pessary – at night daily for 3 weeks, then x2 per week at night after that

These topical vaginal preparations will:

• Reduce vaginal dryness, itching and pain
• Reduce dyspareunia
• Reduce risk of recurrent UTIs
• Take 6-8 weeks to be effective
• Avoid added progestins – can increase the risk of endometrial cancer
• Contraindicated in undiagnosed vaginal bleeding, endometrial cancer
• Some gynaecologists recommend against their use after a diagnosis of breast cancer

For vasomotor symptoms, consider preparations with systemic effects (e.g. oral medications, patches, implants, gels). Use the smallest dose possible to receive symptoms. 

Examples of oestrogen preparations include:

• Patches – applied weekly – typical dose 50mcg
• Transdermal topical gel applied to the skin
• Implant – 50-100mg – given every 3-12 months
• Oral preparations – no need to stop dosing for one week each month (unlike in pre-menopausal women)
  • Oral oestrogen carries significant VTE risk and should not be used in those with personal history or 1st degree relative history of VTE
  • Non-oral oestrogen does NOT have these contraindications and can still be used in these patients

However – unopposed oestrogen (i.e. without progesterone) therapy causes hypertrophy of the uterus and a 5-10x increased risk of endometrial carcinoma.

• As a result, any woman on HRT who still has her uterus should be on a progestin
• Can be given as a 14 day on-off cyclical regimen – however this often causes withdrawal bleeds which many post-menopausal women would prefer to avoid
• Can also be given continually
• The sole purpose of giving a progestin is to prevent endometrial hypertrophy and reduce risk of endometrial carcinoma
• Examples of progestins include:
  • Dydrogesterone 10-20mg daily
  • Medroxyprogesterone acetate 10 mg daily
  • Norethisterone 1.25mg – 5mg daily

Many preparations come as combined oestrogen and progestin combinations. Some of these are cyclical (best in perimenoapusal women) and other are continuous best in post menopausal women – i.e. >12 months since the last period. The most commonly prescribed method is transdermal patch. These may cause localised skin irritation. Transdermal methods of oestrogen are generally preferred because they have a reduced risk of VTE compared to oral preparations.

HRT improves quality of life in the short term. It has widespread and complicated risks for various disease – some increased and some decreased.

In 2002, the Women’s Health Initiative (WHI) trial results were released. This raised concerns amongst prescribers around the world, as it showed that in women who used oestrogen containing oral HRT preparation for >5 years there is an increased risk of:

• Breast cancer – 1.26x risk
• Coronary heart disease – 1.29x risk
• Stroke – 1.41x risk
• Pulmonary embolus – 2.13x risk

and also reduces the risk of:

• Bowel cancer
• Osteoporosis
• Fractures

Prior to this study, HRT was much more widely used. In the wake of this study, new recommendations advised to:

• Not use HRT solely for osteoporosis prevention in asymptomatic women
• Women using HRT should slowly reduce their dose over 2-3 months when stopping treatment
• It is advisable to limit treatment to <5 years
  • There is no proven associated risk of an increase in breast cancer in women who use HRT <5 years
• Risks are greatest in women >60 using HRT

Principles of HRT

• If perimenopausal – use the combined oral contraceptive pill (if <50) or the IUD
• If menopause – use specific HRT preparations (as above and table below)
  • Combined therapy for all women with a uterus
  • Oestrogen only therapy for women without a uterus
  • Start with a small dose and titrate upwards
• Perform mammography 3 months after starting treatment
• Then, review at 6 monthly intervals
• Duration of treatment
  • Aim to cease treatment at 2 years
  • If unable to tolerate symptoms at this point – continue for up to 5 years. Be aware that up to 50% of patient swill suffer vasomotor symptoms (at least temporarily) on cessation of treatment
  • Balance risk vs benefits if you plan to continue past 5 years – ensure informed consent

• E = Oestrogen
• P = Progesterone
• Patches may be preferred over pills due to lower VTE risk

Contraindications to HRT

• Oestrogen dependent tumours
  • Endometrial carcinoma
  • Breast cancer
  • Ovarian cancer
• VTE
  • Contrainidcation for oral oestrogen preparations only
  • Personal or first degree relative history
• Ischaemic heart disease / coronary artery disease
• Previous TIA / CVA
• Uncontrolled HTN
• Undiagnosed vaginal bleeding
• Liver disease
• SLE
• Pregnancy (!)

Examples of HRT preparations

HRT therapies containing both an oestrogen and progestin are known as ‘combined HRT’. There are two types – cyclical and non-cyclical. Cyclical should be used in those who are perimenopausal (<12 months since last period) and non-cyclical can be used in those who are menopausal.

Some examples include (don’t worry about memorising this table – but perhaps know a couple of options):

NB – based on brands available in Australia in 2020. 

Testosterone

• May be given to relieve reduced libido
• Usually given as a 50mg implant – which lasts 3-12 months
• Should be given with concurrent 50mg oestrogen implant
• Limited data as to its safety

Tibolone

• A synthetic hormone with combined oestrogen, progestin and testosterone effects
• Can be used in post-menopause women – particularly useful in patients without a uterus and those whose last period was >12 months ago
• Useful for vasomotor symptoms (but probably less effective than conventional HRT)
• Useful for low libido (better than conventional HRT)
• Less likely to cause bleeding than conventional HRT
• In perimenopausal women may cause irregular bleeding – so avoid

“Bioidentical hormones”

• Available at some private clinics and unregulated online
• Variable preparations and strengths of oestrogen and progesterone
• Marketed as being “safer” than traditional HRT
• There is no evidence that they are safer – and in fact due their unregulated nature are inherently less safe and not well studied
• No evidence that they are more effective than conventional HRT
• Frequently raised by patients who are struggling with menopausal symptoms

Correcting bleeding problems

• Heavy bleeding – reduce oestrogen
• Breakthrough bleeding – Increase progestrogen
• Irregular bleeding – investigate
• Patient can’t tolerate bleeding – use continual regimen
• No bleeding – normal

SSRIs

• Should be considered as second line – and are particularly effective for treatment of hot flushes (vasomotor symptoms)
  • Contrary to some belief – they are not recommended in menopause because of their mood boosting efects
• More effective than placebo in clinical trials
• E.g.:
  • Venlafaxine 37.5mg increasing to 75mg daily
  • Paroextine 10mg increasing to 20mg daily

Other non-hormonal medications

• Gabapentin 100 – 300mg PO OD, slowly can increase dose to maximum of 300mg TDS
• Clonidine 25mcg PO BD, can increase to 50mg BD after 2 weeks

When to refer

Refer to gynaecology if:

• Patient aged <40 and symptoms of menopause, OR
• Pharmacological treatment is required in menopausal women whose menopause is secondary to cancer or chemotherapy

Flashcard

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Menopause – Health Pathways
• HRT – Health Pathways
• Menopause – patient.info

Read more about our sources

The post Menopause appeared first on almostadoctor.

185,000 TOPs are carried out per annum in England and Wales, with 12,500 a year in Scotland. The highest rate of termination of pregnancy is among women 18-24 years old.

60% terminations are before 9 weeks, 13% carried out in second trimester.

The Abortion Act 1967 (1991)

This act states that termination of pregnancy may be carried out if:

1. the continuance of the pregnancy would involve risk to the life of the pregnant woman
2. the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
3. the pregnancy has not exceeded its 24^th week and continuing the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman
4. the pregnancy has not exceeded its 24^th week and continuing it would involve risk of injury to the physical or mental health of the existing child(ren) of the family of the pregnant women
5. there is a substantial risk that if the child were born it would suffer from such phsical or mental abnormalities as to be seriously handicapped.

95% of terminations of pregnancy are carried out under clause C ((3) above). Two doctors are required to agree that the pregnancy should be terminated.

Counselling before termination

Counselling process can help to identify women who will have coping problems and distress and can help identify what went wrong and led to the pregnancy.

Timely referral to a social worker should be available.

Pre-termination investigations

• Blood tests: Hb, ABO and Rh blood grouping. Rh –ve women need anti-D injection after the abortion. HIV, haemoglobinopathy and other tests can be performed as indicated.
• Estimation of gestation: performed by either clinical examination or ultrasound.
• Prevention of infection: infection can occur in about 10% of women after abortion, reduced with use of antibiotics. Some clinics give everyone prophylactic metronidazole and azithromycin.
• Cervical cytology required if a woman is due a smear.
• Provision of information: types available, risks and complications, who to contact if there are any problems.

Methods of termination

1. Medical abortion – if less than 12 weeks, give mifepristone (blocks action of progesterone), allow woman home, returns in 48 hours, admitted for prostaglandin pv. Bleeding starts within a few hours and usually continues for 10 days. Mid-trimester medical abortion (13-24 weeks) requires mifepristone + multiple misopristol doses +/- feticide intervention if >22w.
2. Early surgical abortion – below 7 weeks, use a narrow suction curette of 4-5mm, inserted into uterus under local paracervical block. 50ml syringe used to aspirate the pregnancy.
3. Surgical abortion between 7-14 weeks use suction or vacuum aspiration – flexible suction curette and a mechanical/electrical pump. Curette inserted into uterus after cervical dilatation and contents are aspirated. Usually under general anaesthesia. Misoprostol 400ug vaginally is often given 3 hours before surgery. Complications increase with increased gestation – some doctors do not offer surgical termination after 12 weeks.
4. Late surgical abortion (15-24 weeks) – cervical prep followed by dilatation and evacuation (D&E). Offered by limited amount of doctors in the UK. May be necessary to dilate cervix up to 20mm. Advantage is that women are unaware of procedure – however many medical personnel find the process disturbing.

Complications

• Retained products of conception (5%) more common after medical abortion.
• Failure of abortion 2.3/1000 in surgical abortion and 1-14/1000 women having medical termination, therefore it is critical to advise women of importance of follow-up.
• Post-abortion infection: pelvic infection can occur in up to 10% after termination – halved with pre-abortion STI screening and prophylactic antibiotics.
• Haemorrhage – 1/1000 cases of significant bleeding at time of termination.
• Trauma to genital tract – perforated uterus 1/1000, cervical trauma 1/100, small risk of uterine rupture.
• Future fertility – may be a slight increase in subsequent miscarriage and preterm delivery with later abortion
• Psychological sequelae – no evidence of lasting psychological harm to women undergoing abortion.

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• Oral sex can result in pharyngeal infection, which can cause a sore throat and fever.

• Resistance to first line treatments is starting to become a problem

Epidemiology

• A relatively common STD, but less common than chlamydia and genital warts
• Most commonly affects 16-24 year olds
  • This age group accounts for about 50% of new diagnoses
• Incidence has declined in recent years

Aetiology

High number of sexual partners
Non-practice of safe sex
Sharing sex toys
Associated with other STI’s

• 20% of affected men also have chlamydia
• 40% of affected women also have chlamydia

Clinical features

50% of women and 10% of men are asymptomatic
It has an incubation period of 2-14 days. Most people get symptoms about 2-5 days after infection.  
Symptoms consistent with Urethritis:

• Pain and frequency of micturition
• Discharge – usually white and purulent

Gonorrhoea of the rectum – sometimes seen in MSM. Can vary from being symptom free, to causing a discharge of painful bloody pus from the rectum (proctitis)
Extra symptoms in women – inter-menstrual bleeding, pelvic pain (with an ascending infection)

• The most common site of infection in women is the endocervical canal. This is the canal between the external os and the uterine cavity.
• Sometimes it can spread to the anus from the vagina
• Dyspareunia is common

Complications

Men – the infection can ascend the urinary tract, and cause epididymitis or prostatitis. These can be acute or chronic.

• Proctitis in those that practice anal sex.

Women:

• PID – can be serious, and lead to infertility
• Bartholin’s abscess – a tender, red, fluctuant mass, usually found in the fold between the labia majora and minora, at the 5 or 7 o’clock position. May cause severe unilateral vulvar pain.
• Septic arthritis aka disseminated GC –rare in men, but can occur in untreated women. Tend to be mono- or olioarthritis and asymmetrical. This is associated with a papular or pustular rash, and sometimes fever and malaise.
• Fitz-hugh-Curtis Syndrome – Periphepatitis – rare – can be caused by chlamydia or gonorrhoea, and is the result of infection of the Glisson’s capsule tissue , which surround the liver. This tissue becomes scarred, and will cause acute onset URQ pain and tenderness. Symptoms will be aggravated by coughing, laughing or heavy breathing. Sometimes pain is referred to the right shoulder tip. Laparoscopy may show violin string tip adhesions, which can be removed surgically.

Diagnosis

Testing can either be performed by swab for culture, or swab for NAAT (nucleic acid amplification testing – I.e. PCR)

Smear testing – a swab from the urethra, cervix, throat or rectum can be used for diagnosis.

• Culture – The sample is cultured with a sensitivity of 95%.
• Microscopy:
  • Men – Urethral Sampling – is 90% sensitive
  • Women – Endocervical sampling – only 50% sensitive
• Taking a swab sample in women – when testing for gonorrhoea, you should use the standard swab (looks like a big cotton wool bud), and, whilst using a speculum, swab where there is most discharge. This is usually on the posterior surface of the vagina.

Nucleic acid amplification testing – (NAAT’s) this uses a urine sample, and is highly sensitive

• NAAT is not validated for non-genital sites, although is often used for this purpose
• False positives are possible
• Culture has the added benefit of testing sensitivities
• If culture not collected at time of diagnosis, collect at time of treatment to determine anti tic susceptibility

Blood culture, and joint aspiration – should be performed if disseminated GC is suspected
Tests for other common STD’s should be performed in light of a positive diagnosis of GC – e.g. syphilis, chlamydia and trichomonas.

• First pass urine for NAAT is recommended in most cases for men
  • If there is penile or ano-rectal discharge, collect a swab for culture
  • In MSM it is routine practice to collect NAAT for first pass urine, as well as swabs for culture from the anus and throat – even if they are symptomatic at these sites
• Ano-rectal swab for either culture or NAAT in symptomatic (ano-rectal symptoms) patients

Women

• Endocervical swab for NAAT and / or culture if symptomatic discharge
• Self-collected low vaginal swab is sufficient if asymptomatic and for screening purposes
• First pass urine is much less reliable in women and only recommended if swab cannot be taken
• Pharyngeal swab if history of oral sex (can be NAAT or culture)
• Ano-rectal swab if history of anal sex (can be NAAT or culture)

Treatment

Agents – about 10% of GC is resistant to penicillin and ciprofloxacin, and about 40% is resistant to tetracyclines.

As a result of increasing resistance, dual therapy is now usually recommended, with azithromycin and ceftriaxone. Anogenital infection and conjunctivitis

• Ceftriaxone 500mg IM STAT
  • Usually given 2mls in 1% lignocaine
• PLUS
• Azithromycin 1g PO stat

Pharyngeal infection

As above, but the dose of azithromycin is doubled:

• Ceftriaxone 500mg IM STAT
  • Usually given 2mls in 1% lignocaine
• PLUS
• Azithromycin 2g PO stat

In areas where resistance is low you could consider the following (in Australia, this only applies to some remote locations or in cases of severe allergic reactions):

• single dose amoxicillin (1g) + probenecid (1g) OR
• Ciprofloxacin (500mg) OR
• Ofloxacin (400mg)

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
• Australian STI guidelines – Gonorrohea

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