Adolescent Gynaecology – what you need to know in primary care
- Menorrhagia presentation
- Polycystic Ovarian Syndrome (PCOS)
- Vulval Concerns
- Ovarian Cysts
This is a charity dedicated to the education and support of healthcare professionals across the UK caring for female patients. The charity promotes best practice through supportive materials, educational meetings and informative webinars. There are a number of useful publications on their website such as NICE Guidance on the Menopause, Tips for Safe Practice with Nexplanon Insertions, Top 10 Tips for Premenstrual Syndrome, etc
5) The following CASES gynaecology presentation was given by Dr Joshi and Dr Reynolds at the HASL Clinical Council Meeting on 11/05/2017.
6) The following presentation on Adolescent Healthcare was given by Dr Emma Park.
Top hints: Gynaecology
1. Do a smear if due, even if concerns about cervical appearance, as most ‘abnormal ‘cervices will not be Ca and the HPV result/cytology if positive can be useful.
2. PCB – refer only if on-going for 3 or more cycles; if there is an ectropion it can be cryo-cauterised in clinic if symptoms of bleeding troublesome.
3. HMB– treat as per NICE guidelines, ensure FBC checked and only needs referral if failed medical treatment for 3mo or Mirena for 6mo – see secondary care HMB referral form and other info on the Portal.
Pipelle only needed if higher risk factors such as PCOS or BMI >30. (see PCS referral form if no access via practice or network)
IMB – refer on for hysteroscopy if ongoing for 3 or more cycles
4. Small <3cm fibroids, unless in the endometrial cavity/submucosal and/or causing fertility concerns, are not usually troublesome or a barrier to Mirena effectiveness and can be managed medically.
5. Pre-menopausal simple ovarian cysts
- 5cm or less need no further action
- 5-7cm can be monitored with annual ultrasound to check and no action is needed if not increasing in size or causing symptoms
- Refer if >7cm (RCOG guidelines) – no need for CA125 in premenopausal simple cysts.
CA125 needed for secondary care if referred as 2WW due to complex nature, so available when seen, on the fast track form. Coincidental/asymptomatic dermoids less than 3cm (if isolated or few) don’t need additional monitoring – refer if larger
6. PCOS – most cases can be managed in primary care unless fertility concerns, with hormonal treatment to ensure at least 4 bleeds per year, and advice re weight loss if needed and the link with insulin resistance (also see soundbite for more detail)
7. Painful periods – try to treat with COCP for 3 months, if not effective and suspected endometriosis then refer. If adenomyosis on scan, then Mirena is the best first line option for treatment
8. Prolapse – helpful when referring to mention the options discussed with patients regarding pessaries or surgery and any preference; consider referral to the continence service for patients who haven’t tried PFEs, mild prolapse or other urinary/bowel symptoms or if family not complete.
9. Sterilisation – helpful when referring to mention if Mirena been discussed as an option, equivalent or better effectiveness and added benefit on menstrual loss.
10. Urogenital symptoms –(vulval soreness/urgency and urge incontinence/recurrent UTI)
Need to use vaginal oestrogen for up to 3 months before evaluating effectiveness and continue if helping long term – using vaginal E2 all year (every night for 2 weeks then twice weekly) is the equivalent of taking one oral HRT tablet per year. Sometimes women may need higher doses eg two twice weekly and this is ok.
Remember moisturising washes eg Aqueous cream/hydromol etc, and vaginal moisturisers e.g. Replens and lubricants eg Sylk/Yes
11. Lichen sclerosis – if typical loss of architecture/‘figure of 8’ distribution around the vulva and anus/pallor or erythema/ecchymosis/itch – can treat without necessarily needing a biopsy (see BASHH guidelines) – use clobetasol ointment every night for 1 month then review and can then reduce to maintain –if not effective consider referral at this stage.
12. Lost coil threads – a handy tool for retrieving lost coil threads is the Hartmann’s crocodile forceps – (long type) or urethral forceps- these can be inserted gently through the os to grip non visible threads. If unable to locate, scan to check coil in situ and refer to Sexual Health services if coil used for contraception.
13. Endometrial thickness- Post
menopausal – if NO bleeding and coincidental scan finding 10mm or less is acceptable (low risk of endometrial pathology) Traces of fluid in the cavity with no other symptoms is not usually significant