Brief advice for family physicians.

Ø      Family physicians should play their primary role in motivation for family planning.

Ø      During antenatal care blood pressure should be monitored by family physicians.

Ø      Use of drugs should be monitored during pregnancy.

Ø      GPs should be watchful about problems of perimenopausal age.

Ø      Menstrual abnormalities should be interpreted according to age period of the patient.

 

Menstrual Disorders and Abnormal Vaginal Bleeding

 

In Neonates

¨      During first 4-5 days there may be vaginal bleeding in the neonate. It is due to oesterogen withdrawl (of the mother) effect. It does not carry any significance or prognosis. Nothing needs to be done other than reassurance.

 

In Children

¨      Foreign body should be excluded by local examination.

¨      Sexual assault should be kept in mind.

¨      Rarely malignancy may be the cause.

 

Imperforate hymen

In girls of 14-16 yrs of age presenting with primary amenorrhoea, swelling in the lower abdomen and cyclic, monthly pain one should think of this condition. Sometimes these patients present with acute urinary retention. Inspection of external genitalia will show a bulging bluish membrane, which is imperforate hymen. Ultrasound confirms the diagnosis. Simple incision under general anaesthesia is good enough.

 

Menarche, Adolescence and Puberty

 

v     Average age for menarche is 12-14 years but it may be delayed uptil 16 years.

v     If there is no onset of menses even at the age of 16 years, it needs to be investigated starting with ultrasound to confirm the presence of uterus and ovaries. It should also rule out any mass.

v     Menstrual cycle may be irregular and the blood loss can be heavy or small in amount for the first few cycles. Nothing more than reassurance is needed.

v      If bleeding is heavy and prolonged then a progestogen like Tab. Primolut-N twice a day for 10 days can be given. It will stop the bleeding to be followed by withdrawal bleeding and normal pattern of menstrual cycles. In case the problem persists the cycle can be regularized with the help of contraceptive pills given cyclically for three months.

v     Menstrual disorders upto 20 years of age should generally be regarded as functional in the sense that the system is finding its rhythm. Therefore, conservative approach should be adopted. Ultrasound should rule out any organic lesion and then simple contraceptive pills can be given to regularize the cycle. Reservations about the use of contraceptive pills in young girls are unfounded. In about 1% of girls treated with contraceptive pill there may be post pill amenorrhoea. These girls would have had amenorrhoea anyway and it was the use of pill, which was bringing about withdrawal bleeding.

In 20-40 years age

v     Always rule out early pregnancy problems.

v     Ultrasound should always be ordered to rule out pregnancy, missed abortion, ectopic pregnancy or fibroid / polyp, etc.

v     Simple progesterone (like Primolut N) tid can be used to stop bleeding. Bleeding should stop within two or three days. Otherwise patient should be referred to a specilist. If bleeding stops Primolut N should be continued for 10 days and then stopped. There will be withdrawal bleeding after this. Patient should be placed on contraceptive pills to regularize the cycle.

v     Usually unnoticed or undiagnosed incomplete abortion is the case that can be diagnosed on D & C, which proves to be therapeutic as well.

In more than 40 years age

¨      A major concern in this age group is malignancy. The physician should be alert to this possibility without arousing undue concern and alarm in the patient.

¨      The problem usually referred to as DUB (Dysfunctional Uterine Bleeding) is the common diagnosis. But this diagnosis is reached only after excluding organic pathology by examination and relevant investigations.

¨      At general practice level ultrasound and pap smear are the initial investigations. For further workup the patient should be referred to the specialist.

Use of progestogens in pregnancy

 

Bleeding in pregnancy is always abnormal. Use of progestogens for early pregnancy bleeding is not of much benefit. First trimester miscarriages usually are due to an abnormal conceptus and as such progestogens will not have any effect.

 

Oligomenorrhoea

 

Oligomenorrhoea is infrequent menstruation, i.e., the duration of menstrual cycle is longer than normal, which is 21 to 35 days. It may be routine matter for any single patient.

Hirsutism and obesity usually accompany oligomenorrhoea in polycystic ovaries. The condition of polycystic ovaries (PCO) is fairly common, the incidence being 22%. Ultrasound examination demonstrates the typical appearance of these ovaries.

Hyperprolactinaemia can be a cause in which case galactorrhoea may be present.

Dysmenorrhoea

Primary dysmenorrhoea is quite common. History can demonstrate that mothers, who had this problem, usually have daughters with the same complaint. Conservative approach with reassurance and explanation is all that may be needed. If pain is severe then simple NSAIDS like Ponstan or Brufen tid for 2-3 days can be good enough.

In persistent cases to rule out organic cause ultrasound as an initial investigation should be done. Endometriosis is an example of the organic causes.

Hyperemesis Gravidarum

Family physicians are often confronted with this problem. Hyperemesis gravidarum is excessive vomiting to the extent that the patient cannot retain any food or water leading to severe depletion. Nothing should be given by mouth for 2-3 days to break the cycle of vomiting. Fluids and electrolytes should be given by I/V route. One litre each of Ringer's lactate, 10 % Dextrose, Dextrose / Normal saline can roughly meet the daily needs. Hospital admission brings change of environment for the patient and should not be delayed as severe condition can affect liver function and patient may develop jaundice

For vomiting frequency of 2-3/day the patient should be reassured. She should be advised to have intervals between taking solid food and liquids. Navidoxine one tablet thrice a day half-hour before meals is quite helpful.

Air hunger / Breathlessness in late pregnancy

It is due to physical effects of pregnancy along with the effects of progesterone. Palpitation and breathlessness when only due to these factors needs only explanation and reassurance.

Hirsutism / PCO

Hirsutism, excessive facial hair, is not an uncommon complaint. It may be familial, therefore, history of the problem in mother or sister should be elicited.

Usually hirsutism is accompanied with menstrual abnormality (oligomenorrhoea or even amenorrhoea) and weight gain. Married women may also present with infertility. As such it is part of polycystic ovarian disease (PCO) for the diagnosis of which ultrasound is quite helpful. Obesity plays an important role in the hormonal disturbance of this condition.

Young unmarried girls:

§         They should be emphasised the need of weight reduction by limiting caloric intake and regular physical activity, like brisk walk.

§         For excessive facial hair, as well as for menstrual irregularity, medical treatment in the form of Diane-35 may be prescribed. It has to be taken cyclically for around nine months to reduce the severity of hirsutism.

§         Additional cosmetic measures like electrolysis may also be required.

For married women:

§         Same general measures as for unmarried girls.

§         Those desirous of pregnancy should have basic workup for infertility. If other causes of infertility are ruled out induction of ovulation is carried out with clomiphene citrate. For unresponsive patients specialist referral would be needed.

Early warning for malignancy in gynaecology

¨      Screening programme for carcinoma of cervix in western countries has considerably reduced the incidence of this malignancy. Previously this was the commonest female genital malignancy and its incidence was double that of carcinoma of body of uterus. Now ovarian cancer is number one followed by malignancy of uterus and then carcinoma cervix.

¨      Any abnormal bleeding after 40 years of age should be viewed with suspicion. Postcoital bleeding is also an early warning sign.

¨      D & C and cervical biopsy are general recommendations for abnormal vaginal bleeding after the age of 40.

¨      Peak age for CA cervix is 45 - 48 years while for CA uterus it is 60 years.

¨      Whereas malignancies of cervix and uterus announce themselves in the form of abnormal vaginal bleeding ovarian cancer remains silent for a longer time. Ovarian abnormalities picked up on ultrasound should be referred to the specialist for further management.

¨      It should be remembered as a general rule that 45% of ovarian tumours at 45 years of age are malignant.

Ovarian Cysts

With the wider use of ultrasound examination, reporting of ovarian cysts has increased tremendously. The fact that the graffian follicle may reach a size of 2.5 cm before releasing the oocyte should be kept in mind. Criteria for management are simple. Cysts of 4-5 cm should be taken as follicles that have failed to rupture giving rise to functional cysts of the ovary. These should be monitored by repeat ultrasound examinations at monthly intervals. If they continue to grow in size, operative management would be required. Most of these gradually become smaller and disappear spontaneously. In good compliance patients, especially of younger age, cysts of even 7-8 cm size may be observed by periodic ultrasound.

 

Lower abdominal pain / Backache

 

¨      The explanation of these common complaints in most patients is obesity and relaxed muscles of abdominal wall. This puts extra burden on back muscles. The solution is simple but difficult to practice. It requires weight management and exercise to strengthen abdominal muscles.

¨      Vaginal discharge, weakness, backache and leg pains are frequent presentation in women. A common perception is that the vaginal discharge causes this weakness and aches and pains, whereas it is the above-mentioned mechanism that produces these complaints. If on vaginal examination uterus is not fixed and ultrasound examination is normal then the patient should be reassured.

¨      Endometriosis and pelvic inflammatory disease are important organic causes for lower abdominal pain and backache. Their definitive diagnosis requires ultrasound and in some cases laparoscopy.

 

Vaginal discharge

 

First of all it should be decided whether it is normal or abnormal. There is some discharge (secretions) present in the vagina normally to keep it comfortably moist. Sometimes there is excess of this normal discharge and apart from its amount there is no other complaint. This happens in mid cycle, during pregnancy, with contraceptive pills or when there is cervical ectopy (previously called erosion). Cervical ectopy may require cauterisation; in all other cases reassurance is all that is needed.

 

Abnormal vaginal discharge is accompanied with smell and vaginal discomfort or itching. Common varieties are as follows:

1.      Trichomoniasis

The discharge may be watery, frothy and creamy, greyish or greenish in colour and is accompanied with itching. A convenient treatment is single dose of metronidazole 2 gm each for both partners followed by abstinence for one week.

2.      Monilial infection

This is common in pregnancy, in diabetic women or in those who have recently taken broad spectrum antibiotics. The patient complains of itching and whitish curdy discharge. Common treatments are either single dose clotrimazole vaginal pessary or nystatin vaginal pessaries for two weeks. There are many other effective local preparations besides oral single dose preparations like fluconazole.

3.      Bacterial vaginosis

This is a condition in which normal vagina flora is replaced by anaerobes. The resultant discharge produces a fishy smell. Treatment consists of metronidazole with doxycycline or one of the quinolones for five days.

 

Hormone Replacement Therapy

 

Hormone replacement therapy (HRT) is now widely recommended to postmenopausal women not only for alleviation of menopausal symptoms but also for other benefits. These include a general sense of wellbeing, prevention of osteoporosis and cardiovascular benefits. HRT improves quality of life. Concern regarding increased chances of CA breast with HRT use can be put into perspective by the fact that the incidence of CA breast in general population is estimated at 45/1000. After 5 years of use it rises to 47/1000, after 10 years 50/1000, and after 15 years 57/1000. Patient and physician can make an educated decision after going through these figures.

 

Usually HRT is started after the menopause is established, which means six months after the last periods. Some women, due to their symptoms, may require HRT in the peri-menopausal period when their menses have not stopped altogether but are infrequent. If there is any abnormal bleeding that should be investigated first.

 

Following workup should be done before instituting HRT:

1.      Examination of breasts for lumps.

2.      Lipid profile.

3.      Mammography.

¨      The available preparations in the market are either cyclic, three weeks on one week off (Climen, Progyluton) or continuous (Femoston, Livial). The major drawback is their cost.

¨      In women who have had hysterectomy continuous oestrogens are given. The commonly used preparation is Tab. Premarin 0.625 mg daily.

¨      In the presence of uterus continuous oestrogens without progestogens cause high incidence of endometrial carcinoma. In view of this the recommended preparations having oestrogens, both cyclic and continuous, have also a progestogen in them.

If there is irregular spotting during the therapy, Pap smear and specialist consult should be obtained.

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Reproductive Health.

Definition: Care of female gender starting right from female foetus upto the grave. Application of this concept is essential to alleviate all cruelities meted out to women in all fields such as female fetocide.

Background: It is a relatively recent term. Uplift of Society is not possible untill women are fully developed, given equal status in all matters, and are properly educated. They should be economically independent. All human rights must be implemented fully and forcefully as regards women in any society. Prejudices against them should be eliminated. These concerns were raised and policies adopted in very high profile conferences in Cairo in 1994 and later in Beijing.

Contrception use rate increases when literacy rate and income goes up. In Siri Lanka literacy rate is 98 % and number of children is 2.8/women. In India this is 3.4,in Pakistan it is 5.4.Infant and maternal mortality rates also improve with improvements in income, education and granting of more and more rights. Awareness about these things has to be created not only in ladies but in males also.

Expenditure on such essential sector is appauling low. One week’s expenditure on armaments worldwide is more than what is being spent on contraception in whole of the world.

Role of Family Physicians:

They should lead the crusade

§         for uplifting the nutritional, educational and all social indicators.

§         Awareness about the hazards of early age marriages.

§         Advice right after marriage about birth spacing.

§         To advocate and propagate about all human rights of women in the society.Especially to prepare the society to grant decision making power to the wives in the affairs of the family.To assist her to acquire the decisions about fertility matters

Sexually Transmitted Diseases, STDs:

§         Incidence is probably coming down. May be due to use of antibiotics.

§         Still vigilance about AIDS and Herpes Simplex is needed. There are cases of these infections. We need strong awareness in public and physicians about these.

§         Chlamydial infections are most common cause of tubal blockage.These are asymptomatic. Difficult to diagnose.

§         Use of codoms is much more desirable to avoid these STDs.An awareness compaign is much needed at this stage. Some users complain that they have allergy with condoms. A doctor must confirm allergy. If it is so low allegen condoms are also availabe or brand can be changed.

Prolapse of Uterus.

·        In the etiology one important factor is inappropriate handling and effort to deliver and asking the mother to bear down baby in the phase of undilated cervix.

·        Multiparity and chronic ill health are other factors.

·        Main symptoms are feeling of pressure and something coming out.

·        Pessaries can be used if family is not complete. Once Family is complete then surgical treatment is the only answer.

·        Prior to surgery treatment of any local ulcers is mandatory.

Vaginal Discharge.

q       This is most frequent complaint in our outdoors. Excessive but normal discharge needs only careful listening and giving due weight to the complaints of patients. Explanation of association with menstrual cycle and education may help the women to accept it as normal variant.

q       Leucorrhoea, which is though inflammatory and pathological but it, is not due to any infection. Speculam examination is essential. Cervical erosions (ectopy) are usually there. These need cautery.

q       Vaginal discharge associated with candida, trichomonas or anaerobes needs local treatment. First local treatment should be tried. If there is no response after 2 local courses then systemic therapy can be given.

q       Neither there is routine nor there are facilities available for culture and sensitivity of vaginal discharge. For anaerobes culture has to be inoculated and transmitted to the laboratory. Logistics involved are not feasible.

Urinary Incontinence

Mainly of 3 types. Urge, Stress and Detrusor instability.

q       Urge incontinence: Rule out U T I .It requires psychological management.

q       Stress incontinence/Detruser Instability.Whenever there is sudden rise in abdominal pressure ,some urine leaks.Pelvic floor excercises are quite useful to strengthen.Here patient should be educated that she should contract her muscles as she would do when she is having urge to pass urine but can not pass due to any reason and she is trying to control the leaking of urine. After contracting the muscles she should keep these muscles contracted till she counts upto 10.Then she should release the pressure. It should be repeated 10-20 times at one time.Drugs like oxybutanil may be helpful.

Abortions

Diagnosis.Ultrasound examination is single most important investigation to diagnose the status.

At 6 weeks foetal pole should be visible. As long as it is visible at this time abortion should be labelled as threatened only. At 7-week gestation cardiac activity should be seen. If in doubt USG can be repeated after another one week. Again as long as cardiac activity is visible, abortion is not there.Urine pregnancy test can also be of help to diagnose pregnancy.

Repeated Abortions.

Some figures. In the same patient

Chance of first abortion = 5 %

//          // Second abortion        = 20 %

//          Third abortion   = 23-25 %

//          Fourth abortion =30 %

So in the same patient even after 4 abortions chances of normal pregnancy are still 60-70 %.

Investigations.

Investigations like CBC, ESR, Urine, Blood Sugar, USG are in order.

Proper history should be taken. Complete pelvic examination by gynaecologist is essential.

Following investigations may be ordered for antithrombophilic syndrome.

·        Anti phospholipid antibodies.

·        Lupus antibodies.

·        Anti cardiolipin antibodies.

Chances of normal pregnancy are only 10 %. With use of low dosage aspirin this rises to 40 %. Still further it can go upto 70 % with low molecular wieght heparin.

Karyotyping can be ordered from AFIP Rawalpindi, if patient can afford after 3^rd abortion.