**Womens health**

Reduces inadequate smears to 1-2%.
Cells from the sample brush are washed off in the vial.
The fluid is then spun down and the cells are filtered out under pressure onto a slide to be read

Management of abnormal smears
Negative	Inform patient, routine recall
Inadequate	Repeat as soon as possible (definitely within 3 months) Refer colposcopy if three consecutive inadequate smears
Borderline	Endocervical cells: refer colposcopy
Squamous cells	repeat within 6 months three consecutive negatives 6 months apart before routine recall
Mild dyskaryosis	Ideally refer colposcopy Can repeat in 6 months if negative, need three negatives 6 months apart before routine recall
Moderate/severe dyskaryosis	Refer colposcop

Colposcopy

Direct visualisiation of magnified cervix using colposcope. Abdormal areas show up when cervix painted with acetic acid and can be treated directly with cryotherapy, laser treatment, loop diathermy (+/- biopsy)

Criteria for colposcopy referral
Three inadequate smears
Three borderline smears (these women have up to a 30% risk of having high-grade cervical intraepithelial neoplasia (CIN))
One borderline glandular smear
Two smears showing mild dyskaryosis
One smear showing moderate or severe dyskaryosis or any abnormal glandular smear
Abnormal cervical appearance: common benign causes of abnormal cervical appearance are ectropions (always benign), polyps and nabothian cysts (white/yellow cysts on cervix).

Obstetric outcomes after CIN

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02460.x/full

http://journals.lww.com/greenjournal/Fulltext/2009/10000/Intrauterine_Exposure_to_Preeclampsia_and.5.aspx

http://emedicine.medscape.com/article/269982-overview

Cervical erosion

Cervical erosion @ www.2womenshealth.com

Military OBGYN cervical disease and neoplasia

Cervicitis

Cervicitis @ emedicine

http://youtu.be/BhMyxGQys5E

Premenstrual syndrome PMS

PMS Medscape/a>

Premenstrual disorders BMJ 2011

Management of premenstrual syndrome Royal College of Obstetricians and Gynaecologists

http://www.rcog.org.uk/managing-premenstrual-syndrome-pms-information-you

Symptoms include depression, irritability, headache, bloatedness, mastalgia.

Management
1. Sympathy, reassurance and support
2. Progestogens orally (Dydrogesterone 10 mg bd from day 12 to 26) or by pessaries/suppositories (Cyclogest 200 mg or 400 mg from the 12th or 14th day until menstruation)
3. Pyridoxine 50 mg bd from 14th day of the cycle to menses
4. Diuretics for the premenstrual week often unhelpful
5. For younger patients, consider the oral contraceptive pill
6. If all else fails, consider trying danazol (Danol)

COCP; this should be taken back to back without a pill free interval if possible. If this is unacceptable, the woman should be advised to bicycle or tricycle packets of pills. Third generation pills or Yasmin are preferable, since they have fewer progestogenic side effects

Transdermal oestradiol; continuous 100 flg oestradiol patches with cyclical progestogen for 12 days of each cycle appear to be effective

SSRls; although not licensed, treatment with an SSRI from day 15 to day 28 of each cycle is effective for some women. Half cycle treatment appears to be at least as good as continuous treatment

Herbal remedies; eg agnus castus and red clover.

Notes
1. Exclude a true depression (better treated by antidepressants, etc)
2. Menstrual diary useful in diagnosis and monitoring.

Menstrual problems

Normal cycle occs every 21-35 days lasting 2-7 days with blood loss of around 40ml. Anaemia is common (2/3) if blood loss exceeds 80ml ( or less)

youtu.be/WGJsrGmWeKE

youtu.be/TExPlAh1tCA

Menstrual problems Medscape

Anovulatory Cycles
Occur particulatly in the early years post menarche and then peri-menopausally.
Periods may be irregular, heavy and painful.

Irregular periods

Menstrual disorders Medscape

Low dose COC – will produce an artificial cycle and regular shedding of the endometrium.

Progestogen (medroxyprogesterone acetate or dydrogesterone) for 12 days every 1–3 months will induce a withdrawal bleed

Amenorrhoea

initial investigation of amenorrhoea BMJ 2009

amenorrhoea studenthealth.co.uk

amenorrhoea labtestsonline.org.uk

CKS amenorrhoea

Oligomenorrhoea and amenorrhoea

Amenorrhoea = absence of periods for >6 months in a previously menstruating woman.

Causes: hypothalamic, pituitary or gonadal
Ask about large fluctuations in weight and stress.
Hirsutism and acne might suggest pcas or an androgen-secreting tumour.

Investigations
FSH and LH: a high FSH (>30 U/I on two separate occasions) = menopause or premature ovarian failure.

Inverted LH:FSH ratio occurs in PCOS

Low levels of FSH and LH in conjunction with low oestradiol or testosterone may indicate pituitary failure.

Prolactin: mildly raised prolactin is very common, particularly in PCOS. Prolactin >3000 mu/L is almost always pathological.

Oestradiol and testosterone
oestradiol levels range from 17 pmol/l in the follicular phase to mid-cycle values of 370-1450 pmol/l. Testosterone levels are usually <2.5 nmol/l in women and between 9 and 42 nmol/l in men
testosterone should ideally be measured at 9 am as it displays diurnal variation

Sex hormone-binding globulin (SHBG): low levels are found in PCOS. Free testosterone levels tend to be higher if SHBG is low.

Thyroid function: being hypo or hyperthyroidism can cause menstrual irregularity.

Pelvic ultrasound.

GPGSG

Heavy periods menorrhagia

http://www.bmj.com/content/341/bmj.c3929.full

Treatments @ Ethicon

womenshealthsolutions.co.uk heavy periods

NICE CG44 Heavy menstrual bleeding Jan 2007

Causes

DUB – excessive menstrual loss in the abscence of identified gynaecological cause. May be anovulatory – (failure of corpus luteum and progesterone production results in continuous unopposed oestradiol production with and endometrial proliferation until it outgrows its blood supply and necroses) or ovulatory – prolonged progesterone secretion causing irregular endometrial shedding
Fibroids
Polyps
Endometriosis /Adenomyosis
Endometrial hyperplasia
IUCD
HRT
Pregnancy, miscarriage, retained products of conception
Thyroid disease
Clotting disorders

Investigations

FBC
Pelvic ultrasound,
Endometrial biopsy
Hysteroscopy (GA or LA)

Treatments
Tranexamic acid	oral antifibrinolytic 1-1.5 g tds-qds at start of heavy bleeding for 5 days
NSAIDS	eg mefanamic acid for pain
Norethisterone	10mg tds stops bleeds after 2 days, then 5 mg bd for 12 days
COCP	stops ovulation and endometrial proliferation
LNG-IUS (Mirena)	prevents endometrial proliferation
GNRH analogues	prior to fibroid surgery or perimenopausally

Menorrhagia – surgical Rx

Transcervical resection of endometrium, endometrial laser abalation, hysterectomy

youtu.be/lMGkkh4fT1c

youtu.be/e-G9kFl6YJM

youtu.be/E255wpX-aMc

Painful periods dysmenorrhoea

Mefenamic acid (Ponstan) 500 mg tds from the onset of menstrual pain
Dydrogesterone (Duphaston) 10 mg bd from day 5 to 25
COCP

Intermenstrual bleeding
Normal variation	ovulatory bleeding may occur due to mid-cycle drop in oestrogenspotting just before the start of menstruation.
COCP	Women on the COCP often get ‘breakthrough bleeding’; in this case, if the problem persists for more than two to three cycles, it is helpful to change the pill to one containing a different progesterone (gestodene and desogestrel may be associated with better cycle control) or a higher dose of the same progesterone. Running pill packets together and omitting the pill-free interval may also help. Up to 50% of women on the COCP have ectropions, so exclude this as a possible cause.
Structural causes	eg cervical ectropion, cervical polyp or endometrial polyp. Endometrial polyps can be identified on ultrasound examination. If the woman is >30 or the polyp is causing problematic intermenstrual bleeding, she should be referred for biopsy/excision. Cervical ectropions are always benign and may be associated with the combined oral contraceptive pill (COCP) or pregnancy. Cervical polyps are almost always benign, but ideally should be twisted off and sent for histology (providing the pedicle is not too thick).
PCOS	failure to ovulate results in prolonged endometrial stimulation, with incomplete, irregular and often heavy bleeding; the usual cycle regulator is the progesterone secreting corpus luteum, which is only formed as a result of ovulation
Endometrial or cervical ca	refer patients at high risk of endometrial cancer (>40, obese, diabetic, PCOS, other unopposed oestrogen states) for ultrasound ± Pipelle biopsy
Infection	swab/test for STDS esp chlamydia
IUD	take swabs for infection and remove the IUD.Mirena often produces irregular bleeding; this may settle with time and does not necessarily indicate infection

Postcoital bleeding
Non menstrual bleeding after sex
Trauma during intercourse
Atrophic Vaginitis
Infections especially Chlamydia/Gonorrhoea/Trichomonas vaginalis
Cervical ectropion
Cervical polyps
Endometrial polyps
Cervical malignancy
10

Before referral to colposcopy perform
Full sexual / medical history/careful speculum examination.

In all patients:
Screen for infection
Check cervical smear history – if 25 years or older, and not had a smear within normal screening interval do one but not if smear not due
Ruling out trauma as a cause for bleeding…. ?piercings, sex toys.
Atrophy – treat with topical HRT/other lubricants inc SYLK
Clotting disorders (other h/o bruising/bleeding) – refer to haematology or test as appropriate –

Infection
If <25 triple swabs:
Endocervical sample for chlamydia using Chlamydia Screening Programme form and add note on request form for result to be returned to practice

endocervical swab for GC
high vaginal swab for MC&S + TV

If ?25 triple swabs (inc TV) to labs following usual procedure
Treat as appropriate, including contact tracing. Refer to GUM if necessary.

Cervical warts – if only cervical warts refer colposcopy but if coexistent vulval/vaginal warts refer GUM

Cervical ectropion – will nearly always have some contact bleeding

Exclude infection first – bleeding from ectropion aggravated by Chlamydia etc

If normal looking ectropion
If applicable try change of oral contraceptive from oestrogen containing to progesterone only
+/-Refer to colposcopy for treatment with cryocautery/diathermy

If abnormal appearance (eg marked contact bleeding or abnormally vascular looking ectropion) refer on fast track form to colposcopy – do not wait for the results of smear if one has been sent

Polyps. These can be avulsed at the surgery if on a ‘stalk’.
Haemostasis usually easily achieved with silver nitrate. Send for histology.
Broad base polyps, may need removing using loop diathermy at colposcopy

Remember endometrial bleeding can present with PCB.
If cervix is clinically normal consider hysteroscopy referral, especially in older women with IMB or menstrual abnormality.
Fast-track post-menopausal bleeding (>12/12 after last menstrual bleed in women NOT using hormonal treatments)

Suspected cervical malignancy
Abnormal appearance of cervix, irregular bleeding, offensive discharge.
Refer as fast-track to colposcopy do not wait for the results of smear if one has been sent

HIV positive patients require annual smears – have lower threshold for referral for colposcopy if abnormal cervical appearances

Post Menopausal Bleeding
Bleeding > 12 after last normal period.
Endometrial Ca
Atrophic vaginitis
Cervical polyp
Cervical cancer
Drugs – HRT, tamoxifen
Chlamydia

Investigations
Transvaginal ultrasound
Endometrial biopsy
Hysteroscopy

Post Menopausal Bleeding SIGN 61

Postponing menses

For weddings, holidays etc
Norethisterone 5 mg tds, starting 3 days before the anticipated onset of menstruation.
Bleeding will usually start 2-3 days after stopping the norethisterone.

Bicycling the pill (ie taking two packets back-to-back) can also be tried, but some women may get breakthrough bleeding, especially at first.

Stopping a heavy bleed

uncontrollable menorrhagia, eg from an endometrial polyp

high-dose progesterone eg norethisterone 10 mg tds for 1 week, decreasing to 10 mg bd for a further week. Once the progesterones are stopped, bleeding will probably occur within 2 or 3 days and may be like a normal period.

Tranexamic acid (1 g tds or qds for up to 4 days) ± mefenamic acid is also very effective, and can be better than
progesterones at stopping a bleed.

If medical measures fail, the patient may need a dilation and curettage (D&C) under general anaesthetic.

GPCSG

Endometriosis

Very painful incapacitating periods plus pain present throughout and on post-menstrual days.
Painful Intercourse and pelvic pain throughout the cycle.
Funny symptoms may include heterotopic menstruation, low back bladder or bowel pain and infertility.

RCOG endometriosis

Endometriosis-uk.org/

http://www.nejm.org/doi/full/10.1056/NEJMcp1000274

youtu.be/TUNKyz5X1l8

youtu.be/hS-9rejd9jg

Fibroids

Heavy prolonged painful periods.
Pain may be colicky cf pregnancy pains or a sensation of bloating or heaviness.
Uterus may be enlarged on examination.

PCOD PCOS

RCOG Guidelines 33 May 2005

pcos-uk.org.uk

cos-uk.org.uk/resources

PCOS and pregnancy outcomes

http://www.bmj.com/content/343/bmj.d6407.full

PCOS PUK

verity pcos.org.uk

The appearance on ultrasound of multiple ovarian cysts is very common,occurring in approximately 20% of women and is not significant in the absence of hormonal changes. PCOS is commonly defined as the existence of polycystic ovaries as demonstrated by ultrasound, in combination with irregular or absent periods, obesity and symptoms of raised testosterone levels such as acne and hirsutism. However, the underlying cause is insulin resistance hyperinsulinaemia in the presence of normoglycaemia. Elevated insulin concentrations stimulate the ovaries to produce more testosterone and reduce SHBG production by the liver.

youtu.be/caeNL4nprnQ

youtu.be/XjdbPRrplQ4

PCOS UK Guidelines Diagnosis and management of polycystic ovary syndrome

Diagnosis
Polycystic ovary syndrome (PCOS), defined as occurring when two of the following are present:
oligo or anovulation
clinical and/or biochemical signs of hyperandrogenism
polycystic ovaries, with the exclusion of other aetiologies

Clinical manifestations of PCOS
Symptoms
obesity
menstrual disturbance
infertility
hyperandrogenism
asymptomatic, with polycystic ovaries on ultrasound scan

Serum endocrinology
increase in fasting insulin (not routinely measured; insulin resistance assessed by glucose tolerance testing)
increase in androgens (testosterone and androstenedione)
increase in luteinising hormone (LH), normal follicle stimulating hormone (FSH)
decrease in sex hormone binding globulin (SHBG), results in elevated “free androgen index”
increase in oestradiol, oestrone

Possible late sequelae
diabetes mellitus dyslipidaemia
hypertension
cardiovascular disease
endometrial carcinoma

Glucose tolerance
Women who are obese, and also many slim women with PCOS, will have insulin resistance and elevated serum concentrations of insulin (usually < 30 mU/l fasting)
We suggest that a 75 g oral glucose tolerance test (GTT) be performed in women with PCOS and a BMI >30 kg/m2, with an assessment of the fasting and two hour glucose concentration
It has been suggested that South Asian women should have an assessment of glucose tolerance if their BMI is greater than 25 kg/m2 because of the greater risk of insulin resistance at a lower BMI than seen in the Caucasian population

Investigations for PCOS
Pelvic ultrasound to assess ovarian morphology and endometrial thickness
Transadominal scan not optional but an alternative in women who are not sexually active

Testosterone 0.50–3.5 nmol/l
Sex hormone binding globulin It is unnecessary to measure other androgens unless total testosterone is >5 nmol/l, in which case referral is indicated
Free androgen index (FAI): T × 100 / SHBG <5 Insulin supresses SHBG, resulting in a high FAI in the presence of a normal total T
Oestradiol
Measurement is unhelpful to diagnosis Oestrogenisation may be confirmed by endometrial assessment
Luteinising hormone (LH)
Follicle stimulating hormone (FSH)
2–10 IU/l
2–8 IU/l FSH and LH best measured during days 1–3 of a menstrual bleed. If oligo-/amenorrhoeic then random samples are taken
Prolactin,
thyroid function, thyroid-stimulating hormone <500 mU/l 0.5–5 IU/l Measure if oligo /amenorrhoeic
Fasting insulin (not routinely measured) <30 mU/l
Fasting glucose <5.5 mmol/l Fasting level below 5.5 mmol/l makes impaired glucose tolerance very unlikely

Management
Clinical management of a woman with PCOS should be focused on her individual problems
Obesity
Obesity worsens both symptomatology and the endocrine profile and so obese women (BMI >30kg/m2) should therefore be encouraged to lose weight
Weight loss improves the endocrine profile, the likelihood of ovulation and a healthy pregnancy
The right diet for an individual is one that is practical, sustainable and compatible with her lifestyle. It is sensible to reduce glycaemic load by lowering sugar content in favour of more complex carbohydrates and to avoid fatty foods; it is often helpful to refer to a dietitian, if available
An increase in physical activity is essential, preferably as part of the daily routine. 30 minutes per day of brisk exercise is encouraged to maintain health, but to lose weight, or sustain weight loss, 60 to 90 minutes per day is advised
Concurrent behavioural therapy improves the chances of success of any method of weight loss
Anti-obesity drugs may help with weight loss and both orlistat and sibutramine have been shown to be effective in PCOS in small studies:
orlistat is a pancreatic lipase inhibitor which prevents absorption of around 30% of dietary fat, whereas

16–119 nmol/lsibutramine is a centrally acting serotonin and noradrenaline reuptake inhibitor, which enhances satiety
both agents can also improve insulin sensitivity and are currently licensed for individuals with a BMI of 30 kg/m2 or lower if comorbidities such as type 2 diabetes are present
both agents have been shown to improve insulin resistance, lipid profile and glycaemic control and orlistat has been shown to reduce blood pressure and testosterone. Orlistat and sibutramine are increasingly being used in primary care as an adjunct to diet and lifestyle advice; both require monitoring for efficacy and sibutramine for possible increases in blood pressure and pulse rate
new agents in development for obesity and the metabolic syndrome may also have a role to play in PCOS, such as rimonabant, but data is lacking at present. Metformin can also improve insulin resistance and may aid some women with modest weight loss, though this has not been confirmed by randomised trials. The combination of metformin and an anti-obesity agent may be ideal and while metformin combined with orlistat is not contraindicated, their combination is still unproven and clinical trials to formally evaluate this approach are required

Infopoems Pregnancy Risks in PCOS Aug 2011

RCOG PCOS long term consequences

Infertility

Failure to concieve after 1 tear of regular unprotected sex.

Primary – if no previous pregnancies

Secondary if there have been pregnancies including miscarriage or TOP.
womenshealth.gov infertility

http://www.acog.org/publications/patient_education/bp136.cf

Infertility Medscape

* Ovulation can be induced with the antioestrogens, clomiphene citrate (50–100 mg) or tamoxifen (20–40mg), days 2–6 of a natural or artificially induced bleed. While clomiphene is successful in inducing ovulation in over 80% of women, pregnancy only occurs in about 40%. Clomiphene citrate should only be prescribed in a setting where ultrasound monitoring is available (and performed) in order to minimise the 10% risk of multiple pregnancy and to ensure that ovulation is taking place

A daily dose of more than 100 mg rarely confers any benefit. Once an ovulatory dose has been reached, the cumulative conception rate continues to increase for up to ten to twelve cycles. Clomiphene is only licensed for six months use in the UK, and so we would advise careful counselling of patients if clomiphene citrate therapy is continued beyond six months
Hyperandrogenism

* Hyperandrogenism is usually managed with ethinyloestradiol (35 ?g) in combination with cyproterone (2 mg). Rospirenone (3 mg) and ethinylestradiol (0.030 mg) may also be of benefit
* Alternatives include spironolactone, flutamide and finasteride (all unlicenced) are not routinely prescribed because of potential adverse effects. Reliable contraception is required

Indications for referral
* Serum testosterone > 5 nmol/l (to exclude other causes of androgen excess, e.g. tumours, late onset congenital adrenal hyperplasia, Cushing’s syndrome)
* Infertility
* Rapid onset hirsutism (to exclude androgen secreting tumours)
* Glucose intolerance / diabetes
* Amenorrhoea of more than 6 months – for pelvic ultrasound scan to exclude endometrial hyperplasia
* Refractory symptoms

Infertility investigation

NICE CG11 Fertility Feb 2004

Sperm count

http://www.nlm.nih.gov/medlineplus/ency/article/003627.htm

sperm count 20 2 4 6
20 million
2ml
40% motile
60% normal morphology

Vaginal thrush

1. First attack or infrequent attacks
use pessaries and cream (e.g. Canesten) or tampons (GynoDaktarin).
Treat partner with cream

2. Recurrent attacks
(i) Exclude diabetes mellitus
(ii) Advice-avoid tights, wear cotton pants, wash with plain soap and water daily, avoid vaginal deodorants
(iii) Make sure partner has been treated
(iv) Intermittent use of tampons or pessaries or longer courses, remembering not to stop around the time of the period, e.g. use of Canesten 1 (single clotrimazole pessary with applicator) once a week for 4-5 weeks or monthly just after a period for a few months
(v) Oral therapy with nystatin to eradicate the bowel reservoir
(vi) Use of natural yoghurt (or lactic acid pessaries) put into the vagina at the first indication of an attack or prior to menstruation may be useful in aborting some episodes
(vii) Use of single capsule therapy with fluconazole (Diflucan).
Consider referral for recurrent infection eg to Sexual Health Clinic.

Clotrimazole 1 x 500mg pessary at night as a single dose
10% vaginal cream 10%, insert 5g at night as a single dose
1% cream, apply to anogenital area 2 to 3 times daily.
Fluconazole 1 x 150mg capsule po
Itraconazole2 x 100mg capsules po bd for 1 day

A single dose of a clotrimazole 500mg pessary is at least as effective as the oral imidazoles (which are contraindicated in pregnancy or risk of pregnancy)

Recurrent thrush

Recurring Vaginal Thrush PUK

Recurrent candidiasis is defined as at least four proven attacks within 12 months. There is often associated vulval eczema, or one of the other conditions listed above. Candida found incidentally in an asymptomatic woman does not necessarily need to be treated.

Take vaginal swabs and ask the lab to determine the species and sensitivities of the Candida.

Candida albicans is the most common species, but non-albicans species (eg Candida glabrata) do occur in
10% of cases and can be resistant to azole antifungals (such as clotrimazole). They can therefore result in chronic infection. Nonalbicans species can be eradicated, but this sometimes requires
intensive treatment with antifungals (eg 14 days of nystatin pessaries or two doses of itraconazole in the same day). Nystatin pessaries can stain clothing.

Exclude diabetes mellitus.
Exclude the co-existence of another cause of pruritus (as listed above).

Treatment Recurrent Thrush
Initial management usually consists of treatment with an azole pessary or oral tablet. Two doses of fluconazole, separated by 3 days may be more effective than a single dose in severe attacks.

If a woman is very distressed by her symptoms, prophylactic treatment may be considered (see below), but general advice should always be given first; although candidiasis is not asexually transmitted infection, sexual intercourse can trigger it and couples should be advised to use a lubricant such as KY jelly®.

Avoiding soap and perfumed products and wearing loose, cotton underwear can help,particularly if there is co-existent eczema. It can be helpful to prescribe a soap alternative such as aqueous cream.

If these general measures fail and the woman is still suffering from recurrent thrush, prophylactic medication can be tried. Flare-ups are more common premenstrually and in this case pessaries (either clotrimazole 500 mg or econazole 150 mg) may be prescribed on days 8 and 18 of the cycle. If this does not work, the woman could try weekly pessaries. Oral fluconazole is an alternative, but has more potential side-effects.

Another strategy is to take daily itraconazole (100 mg od) for a week before the anticipated onset of menstruation and use a pessary after intercourse.

There is limited evidence to suggest that using a POP containing desogestrel may be of benefit, although the COCP may make matters worse.

Prophylactic treatment should be continued for 6 months in the first instance and then stopped, to assess the need for further treatment. Some specialists advise treating the partner, although there is not much evidence behind this.

Vulval ulceration and sores

http://emedicine.medscape.com/article/264648-overview

http://www.ccspublishing.com/journals3a/vulva.htm

Genital lichen sclerosis

http://hacking-medschool.com/lichen-sclerosis

lichen sclerosis Medscape

lichen sclerosus.org

lichen sclerosus.net

Flat, atrophic, paperthin lesions.
Topical corticosteroids can be helpful; eg 2 weeks of a high-potency steroid cream used twice a day, followed by 2 weeks of a lower potency cream used once a day.
If there is no improvement, the diagnosis should be reconsidered.

Uncommon and poorly recognised, chronic inflammatory autoimmune skin disease.
Strong links with other autoimmune related conditions such as thyroid, vitiligo and pernicious anaemia.
Most commonly affects anogenital area less commonly extragenital sites
Affects mainly older women – less commonly men and young children.
It is estimated that one in 300 people may be affected or 10,000 new cases each year in the UK.
Recent unpublished studies suggest that there may be as many as
LS is not contagious and cannot be transmitted by sexual intercourse.
There is some speculation, that LS may be genetic.
There is a small risk of cancer of the vulva (and penile cancer)
LS tends to be relapsing and remitting condition, and symptoms may disappear for long periods of time and then flare up again

Vulval lichen planus

hacking-medschool/lichen-planus

Vulval Lichen Planus @ McMillan.org.uk

Atrophic vaginitis

youtu.be/s4-OB0aC9II

youtu.be/k_-iraALYPU

Persistant Vaginitis BMJ Dec 2011

Estriol cream 0.01% (Ortho-Gynest®)
Insert 1 applicatorful daily, preferably in evening for 2 weeks; reduced to 1 applicatorful twice a week. Attempts to reduce or discontinue should be made at 3 to 6 month intervals with re-examination.

Estradiol vaginal tablets 25micrograms (Vagifem®)
Insert one tablet daily for 2 weeks then reduce to a maintenance dose of 1 tablet twice weekly.
May be used in women with or without an intact uterus.

Topical estrogens should be used at the lowest possible effective dose and discontinued every 3-6 months for review.
The vaginal tablet applicator is narrower and may be easier for some to use than a cream applicator.

Pruritis vulvae and vulvovaginitis

Causes
Infection: Candida, bacterial vaginosis, Trichomonas, pubic lice and threadworms.
In prepubertal girls, thrush is quite rare and the most common cause is group A Streptococcus
Skin problems; eg eczema, psoriasis, contact dermatitis, lichen simplex (a localised area of lichenified, excoriated eczema) or lichen planus (presents as purple or white shiny spots)
Lichen sclerosus and leukoplakia
Urinary incontinence
Hypo-oestrogenism in postmenopausal women
Vulvodynia (a chronic idiopathic pain syndrome)
Vulvo-vestibulitis (pain around the introitus).

youtu.be/dsFFadRTwLI

Vulval swelling

female health made simple vulva

rightdiagnosis.com vulval swelling

Urethral caruncle

Bright red soft, fleshy protrusion of the urethral lining from the urethral opening.

It is most often found in young girls before puberty and in postmenopausal women.

Sometimes it can cause painful urination (dysuria), blood in the urine, and tenderness or irritation around the opening of the urethra. Although the exact cause of urethral caruncles isn’t known, they may be associated with low estrogen levels.

If a urethral caruncle is causing pain or irritation, treatment may include:

* Soaking in a warm bath
* Topical estrogen creams or anti-inflammatory creams applied directly to the caruncle
* Removal of the caruncle

Although urethral caruncles are usually noncancerous (benign), a final diagnosis should be made by a urologist.

Vulvodynia

Vulvodynia PUK

Vulval Pain Society

http://www.bad.org.uk/site/884/Default.aspx

vulvodynia.com

RCOG vulvodynia-tips-and-tricks

nva.org

Dyspareunia

http://www.aafp.org/afp/2001/0415/p1535.html

http://www.bmj.com/content/338/bmj.b2284.full

vaginismus awareness network.org

Vaginal and uterine prolapse

http://emedicine.medscape.com/article/797295-overview

youtu.be/Irj3i-OBJ5Q

youtu.be/STdZa5Fwzyk

Bladder physiology and continence

Anal and Urethral Sphincter innervation
S2 3 and 4 keep piss and faeces off the floor

youtu.be/tZg-Q4w-flc

youtu.be/v3PRC5H3_mw

youtu.be/JCOSVIGR77s

Incontinence

Involuntary loss of urine.

Incontinence may be divided into the following categories:
1 Incontinence associated with physical activity (stress incontinence)
2 Incontinence associated with urgency and/or frequency (urge incontinence)
3 A mixed picture of stress and urge incontinence
4 Overflow incontinence
5 Incontinence with a complex history (eg surgery, haematuria, pain, recurrent infections).
The latter two types often require specialist management but the first three may be managed (at least initially) in the primary care setting, especially with
the support of community-based continence advisors.

Initial assessment should involve:
History: voiding diaries are a useful adjunct (ie how frequently the patient urinates, and how long they spend urinating each time)

Bladder Chart PUK

Physical examination: the bladder should be palpated and the patient asked to cough, in order to demonstrate stress incontinence.
Urinalysis ± MSU.

Further assessment with an ultrasound of the kidneys and bladder is often useful and allows the residual volume to be calculated. Patients with significant residual volumes (more than 10% of their bladder capacity, usually >100 ml) require specialist referral to determine the cause. The underlying aetiology is generally obstruction (eg from a large prostate or a urethral stricture) or bladder failure, or a combination of these.

Uncomplicated stress incontinence should initially be managed with lifestylechanges, pelvic floor exercises and bladder retraining Further therapies include specialised physical equipment such as vaginal cones and medical treatment with duloxetine. Surgery is indicated if these measures fail.

Urge incontinence is initially managed with lifestyle modifications, bladder retraining and antimuscarinics. If a mixed picture exists, then the most bothersome aspect should be treated first.
Lifestyle changes include: cessation of smoking, reduction in caffeine and alcohol intake, avoidance of fizzy drinks, and weight loss in the obese.

hacking-medschool/faecal-incontinence

Continence in women

NICE CG40 Urinary incontinence Oct 2006

NHS Choices Incontinence

rcog.org.uk surgery for stress incontinence

Oxybutinin 2.5-5 mg bd
Tolterodine 1-2 mg bd

All Party Parliamentary Group For Continence Care Report A guide for commissioners written by continence care professionals

Drugs for urinary frequency (in the absence of outflow obstruction)
Conservative measures and simple lifestyle changes can help considerably and should be considered before resorting to pharmacotherapy. See Tayside Urology Guidance – Urinary Incontinence for further advice.

Antimuscarinic drugs
FIRST CHOICE: OXYBUTYNIN
Oxybutynin tablets 2.5mg, 3mg, 5mg, elixir 2.5mg/5ml, m/r tablets 5mg, 10mg
Dose: initially 5mg 2-3 times daily, increased if necessary to max. 5mg 4 times daily, elderly: initially 2.5mg-3mg twice daily, increased to 5mg twice daily according to response and tolerance, m/r tablets, 5mg m/r once daily, adjusted if necessary in 5mg steps weekly to a max. of 20mg daily taken as a single dose

Oxybutynin standard release preparations may be associated with a higher incidence of side effects compared to modified release preparations. Oxybutynin is also available as a transdermal patch for patients who experience intolerable side effects with oral oxybutynin preparations. Specialists may use or recommend doses of up to 30mg daily of oxybutynin (unlicensed dose).

Solifenacin tablets 5mg, 10mg
Dose: 5mg daily, increased if necessary to 10mg once daily

Tolterodine m/r capsules 4mg
Dose: 4mg m/r once daily.

Oxybutynin and tolterodine are well-established antimuscarinic agents for the management of urinary incontinence. All the above medicines produce antimuscarinic side-effects (eg dry mouth, blurred vision) to a greater or lesser degree. Choice of therapy should be made on the basis of patient tolerability and cost, as there are significant cost differences between preparations. Caution should be used in the elderly with all these preparations due to central nervous system adverse effects, however solifenacin may be better tolerated. The need for continuing antimuscarinic drug therapy should be reviewed after 6 months.

Stress
Detrusor Overactivity
BOA
Detrusor failure
(coles)

CONTINENCE
Always exclude urinary tract infection (UTI) and ask the patient to reduce
their consumption of alcohol, caffeine and cigarettes, all of which can
exacerbate the problem.

STRESS INCONTINENCE
The pelvic floor muscles play an important role in maintaining continence
and supporting the female genital tract. Pelvic floor exercises can be very
effective in helping women with incontinence problems, particularly genuine
stress incontinence. Genuine stress incontinence is extremely common,
affecting up to 10% of parous women; it occurs as a result of the upper
urethra descending through the pelvic floor, so that when intra-abdominal
pressure rises (eg when laughing or sneezing), the urethra is no longer
compressed by the pelvic floor muscles. There is often an associated
cystocoele. Surgical treatment with colposuspension or tension-free vaginal
taping (TVT) is usually very effective for isolated genuine stress incontinence,
but first the woman should be encouraged to try pelvic floor exercises; when
done correctly, these are often sufficient to alleviate symptoms. Another
alternative if there is associated utero-vaginal prolapse, especially for elderly
or infirm patients, is a ring pessary. This is fitted in the same way as a
diaphragm (with the same sizing system) and needs to be replaced every
3-4 months. Women who are still sexually active can remove it prior to
intercourse.
Duloxetine is a serotonin and noradrenaline reuptake inhibitor that has
recently been Iicensed for the treatment of moderate to severe stress
incontinence. Results so far have been promising.

PELVIC FLOOR EXERCISES
Ask the woman to imagine that she is trying to stop herself from passing
urine and to tense the muscles at the front of her vagina. Similarly, she
should tense the muscles around her anus, as if she were trying to prevent
herself from opening her bowels. She should draw her pelvic floor inwards
and upwards (it is important not to tense other parts of the body such as the
buttocks, legs or abdomen) for up to 10 seconds at a time, and repeat these
contractions several times in a row; this routine should be performed as many
times as possible every day.

GYNAECOLOGY
Vaginal cones are small weights, which are placed in the vagina and held in
position by the woman as part of her pelvic exercise routine; she should be
asked to hold the cone in place for 15-20 minutes at a time, eg when going
out for a walk or doing housework. Cones are available from large
pharmacists and cost about £15. They are available in sets of different weight
cones; women should start with the lightest and then increase gradually.
URGE INCONTINENCE
Most women with incontinence have a mixed picture of urge and stress
incontinence. Urge incontinence is also known as ‘detrusor instability’.
Anticholinergics (eg oxybutynin, tolterodine) can help with urgency, as can
bladder ‘retraining’. Pelvic floor exercises are beneficial if there is a mixed
picture of urge and stress incontinence, but surgery is rarely helpful. If
surgery is being planned for stress incontinence, it is important to first
eliminate any element of detrusor instability and so urodynamic testing is
essential.

BLADDER TRAINING
The aim is to achieve:
Voiding intervals of 3-4 hours (no more than six to eight times a day)
Urine volumes of 300-400 ml
Dryness.
The woman should be asked to keep a ‘voiding diary’ for a week before she
starts the bladder training, and then at least once a week during the training.
She should record:
when she urinates
the quantities passed (either by using a measuring jug or counting
out how many seconds she urinates for)
whether there has been any incontinence.
The idea is to gradually increase the intervals between voiding (for example
by half an hour a week), thus stretching the bladder and increasing its
capacity, so that she is passing larger volumes of urine. For the same reason,
the woman should be asked not to restrict the quantity of fluid she drinks to
less than about 1.5 litres per day, as many of these patients do; patients who
persistently restrict their fluid intake inappropriately may be left with a
reduced functional bladder capacity. When she feels the ‘urge’ to urinate, the
patient should contract her pelvic floor muscles until the bladder spasm
passes. Strategies that can help to increase bladder capacity include the
following:
Asking the woman to sit down when she gets the urge to urinate
Drinking a reasonable quantity of fluid (about 1.5 litres per day)
while avoiding alcohol and caffeine
Practising pelvic floor exercises so that she is able to ‘hold on’ when
the urge to pass urine occurs
Avoiding constipation
Avoiding going to the toilet ‘just in case’.
Bladder training usually has a positive effect by about 4-6 weeks after
starting

Stress and urge incontinence

youtu.be/kXBeBFfP6GQ

youtu.be/pqcNDndQI8k

Urinary Incontinence PUK

Urge Incontinence PUK

StressIncontinence PUK

Pelvic floor exercises

Pelvic Floor Exercises PUK

youtu.be/5IbliBiRzOw

Surgery for incontinence and prolapse

Neurogenic bladder

Neurogenic bladder Medscape

youtu.be/at2zG2T5Gj0

Cystitis LUTS UTI women

UTi women Patient UK

Should we treat lower urinary tract symptoms without a definitive diagnosis? BMJ Dec 2011

Symptoms & dipstick as predictors of UTIs BJGP 2010

Females are more prone to UTI infections due to the length of the females’ urethra and its proximity to the anus. Sexually activity also increases risk of developing a UTI, as does pregnancy (due to hormonal changes and urinary stasis that results from urethral dilation).

Other risk factors include trauma or invasive procedures, urinary tract obstruction such as a narrowed ureter or calculi lodged in the ureters or bladder, vesicourethral and vesicoureteral reflux, and urinary stasis.

Female with symptoms of an uncomplicated urinary tract infection (cystitis)
No need to dipstick or send sample to microbiology
1st line Rx Trimethoprim 200mg tablets bd for three days (unless pregnant then cephalexin)
or nitrofurantoin (Macrobid) m/r capsules 100mg bd or 50mg qds for three days.

Treatment failure
Sample essential
2nd line treatment as per sensitivities. Community multi-resistant E.coli with Extended-spectrum Beta-lactamase enzymes are increasing so perform culture in all treatment failures.

Prophylaxis of recurrent UTI (> 2/month or > 3/year)
Treat for 6 months then review.
Trimethoprim 100mg at night or post coital OR
Nitrofurantoin 50-100mg at night or post coital.

Dipstick urinalysis
for blood/protein/nitrites, (if urine readily available)
(to avoid contaminating the whole sample, pour a little urine on to the test strip).
Positive nitrite test is diagnostic, but a negative test does not exclude infection

MSU
essential before starting treatment in:
children. Bag or pad samples may be needed in infants. Older children should be encouraged to pass a sample directly into a sterile container, but if this proves impossible it is reasonable to collect a sample
from a cling-film-lined container or potty
men
pregnant women
persistent/recurrent symptoms
fever/loin pain

ensure adequate fluid intake
OTC remedies such as Cymalon Cystemme or Robinsons Barley Water (1 pint stat) make the urine more alkaline, and are said to relieve the discomfort of cystitis.

children or men: trimethoprim for 7 days (or cefalexin for 7 days if allergic to trimethoprim)
pregnant women: cefalexin for 7 days

children (important urine infections in small children may cause permanent kidney damage)
men (for assessment of prostate and possible further investigation)
women with severe/persistent symptoms
Caution in children and pregnant women, do not wait for the MSU result before starting antibiotics. (UTI in early pregnancy increases the risk of miscarriage)
women sometimes confuse the symptoms of thrush and cystitis
Chlamydia infections may cause dysuria

In adult males and children lower UTI’s may be associated with anatomic or physiologic abnormalities and require close evaluation.

Diagnosing a UTI in the elderly may be problematic, the only complaint may be urinary incontinence or seemingly unrelated symptoms such as altered mental status, anorexia or malaise.

Source MIM

Recurrent UTI in women

kidney.niddk.nih.gov uti adult/

Topical oestrogen cream may be helpful in patients with atrophic vaginitis.

Antibiotic prophylaxis (eg trimethoprim 100 mg nocte, nitrofurantoin 50-100 mg od or ciprofloxacin 125 mg od) should be considered when conservative measures have failed.

For UTls associated with sexual intercourse, a single dose of antibiotic taken postcoitally may be of benefit (eg trimethoprim 200 mg or nitrofurantoin 100 mg).

Recurrent or persistent UTls should be referred for further urological investigation.

Management includes general lifestyle advice:
Ensure fluid intake >2 I/day
Cotton underwear
Void after intercourse (generally within 1 hour)
Avoid adding products to bathwater
Cranberry juice/capsules

http://youtu.be/q6Px3GN0zd4

Cranberry juice in UTIs

Cranberry compared to antibiotics for UTIs July 2011

cranberry juice has previously been recommended, but a systematic review found no evidence that it reduced the symptoms of an acute attack. It should not be taken by patients on anticoagulants

Cranberry extract may be a useful non antibiotic alternative for recurrent UTI.

A chemical in cranberry products is thought to work by preventing certain bacteria from attaching to cells that line the bladder. Therefore this helps to prevent bacteria from infecting the bladder and so helps to prevent (rather than cure) infection.

Pelvic pain

Pelvic Pain PUK

Pelvic mass

pelvic mass medscape

acpmedicine.com/dxrx1615.htm

Ovarian cyst

http://www.acog.org/publications/patient_education/bp075.cfm

njh.u-net.com/cyst.html

http://emedicine.medscape.com/article/255865-overview

http://youtu.be/IbP2k1PraiI

Ovarian cyst rupture and torsion

Ovarian cysts in emergency medicine Medscape

Ovarian torsion medscape

Primary and premature ovarian failure

pof support.org

Daisy Network Premature Meonopause Support Network

POF NEJM 2009;360:606–14

Causes
Idiopathic/Unknown
Chromosomal/Genetic
Turner syndrome
Swyer syndrome
Androgen Insensitivity Syndrome
Premutation of Fragile X
Familial
Enzyme defects/Metabolic
Galactosemia
Thalassemia major treated with multiple blood transfusions
Hemochromatosis
Chemotherapy/Radiation therapy related
Surgical removal of the ovaries, multiple ovarian surgeries
Viral infection
Abnormal gonadotropin (FSH and LH) secretion or action

Autoimmune diseases associated with POF
Thyroid dysfunction
Polyglandular failure I and II
Hypoparathyroidism
Rheumatoid arthritis
Idiopathic thrombocytopenia purpura (ITP)
Diabetes
Pernicious anemia
Adrenal insufficiency
Vitiligo
Systemic lupus erythematosus

Menopause and HRT

Menopause medscape

menopause.org.uk

British Menopause Society

Menopause diagnosis

http://hacking-medschool.com/menopause-lhfsh-testing

No periods for 2 years in patients <50 years or 1 year for patients >50 years.

Blood tests not generally encouraged unless diagnosis in doubt as can be normal perimenopausally.

However LH >30IU/L + amenorrhoea suggests woman is postmenopausal.

If on COCP or HRT stop for 6-12 w before testing.

Contraception is recommended until the ‘official’ diagnosis of menopause as above
However, some women choose to discontinue contraception as soon as their periods stop, if this is in association with vasomotor symptoms and raised FSH.

HRT

Currently indicated for troublesome vasomotor symptoms associated with the menopause.

Still indicated for women with a premature menopause (below the age of 45) until the age of 50.

Royal College of Obstetricians and Gynaecologists
makes the following recommendations:
HRT will continue to be prescribed for women with severe menopausal symptoms.
For women who are not suffering from menopausal symptoms, the risks of taking HRT outweigh the benefits.
Ultimately, women should have the choice of whether or not to take HRT, provided they understand the risks.

Starting HRT
In perimenopausal women, it is better to start a cyclical form of HRT; continuous combined HRT (including tibolone) is likely to cause erratic bleeding, which may then lead to unnecessary investigations. Some women eventually become amenorrhoeic, even on cyclical HRT.

HRT is usually started in the first 5 days of the menstrual cycle if the woman is still menstruating, or at any time if the periods have stopped.
Older women who have been on cyclical treatment for 2-3 years may be switched to continuous combined HRT if they no longer wish to have periods. Amenorrhoea on continuous HRT is likely to occur in women who have only had light withdrawal bleeds or no bleeding at all while on cyclical treatment. Tibolone is also taken continuously and has the advantage of a slightly better risk profile in terms of breast cancer.

A small proportion (5-20%) of women will continue to have erratic bleeding on continuous combined therapy and may be better off with cyclical treatment, so that at least their bleeding patterns are predictable.

Theoretically, older women who have been amenorrhoeic for some time already could be started directly on continuous combinedtreatment.

There is no value in measuring hormone levels while a woman is taking HRT (except in women who are using oestradiol implants; in this case, oestradiol levels can be measured just before the next implant is due); the same advice applies as for the COCP

Stopping HRT
This is best done gradually, to reduce the chances of recurrence of troublesome symptoms such as hot flushes. Patches and tablets can be cut in half and tailed off gradually. Women on cyclical HRT should keep taking their progesterone as usual.

Which preparation to choose?

Women who have had a hysterectomy can be given oestrogen alone, orally, as patches, as a gel or as a nasal spray (Aerodiol®). The nasal spray tends to
achieve high concentrations of oestrogen soon after administration, and the levels then drop quite quickly. Women who still have their uterus intact should use a cyclical progesterone as well, for at least 12 days of the cycle (in the latter half, from day 16 to day 28).

The Mirena® is sometimes used as an alternative to oral progesterone; it releases sufficient progesterone to prevent endometrial hyperplasia but not enough to cause systemic sideeffects. It received a licence for use solely in HRT in 2004. There are also patches available that release progesterone combined with oestrogen (eg Estracombi®, Evorel®, FemSevenconti®).

Topical vaginal oestrogens
There is always a theoretical risk of endometrial hyperplasia and cancer with the use of unopposed oestrogens. The CSM has concluded that the safety oflong-term use of topical vaginal oestrogens is not well known. Therefore, the following precautions should be taken:
Use the lowest effective amount of cream.
Do not use topical oestrogens for more than 1 year at a time; at this point, the patient should have a break from use, to see whether she still requires treatment.
Any breakthrough bleeding or spotting needs to be investigated promptly with an ultrasound and Pipelle biopsy.
Some gynaecologists recommend the use of the ‘natural oestrogens’ listed above, although there is no proof that these are safer.

Natural alternatives (for vasomotor symptoms)
Black cohosh (8 mg/day): however, there have been some cases of associated hepatotoxicity reported
Kava
Red clover (40-80 mglday): contains phyto-oestrogens, which have 0.01 % of the activity of estradiol.
Sage
SJW
Many of these affect the C450 systems or interact with other drugs.

Other Alternatives
Venlafaxine (37.5mg nocte)
Clonidinine (50-75mg bd)

Risks of HRT
HRT should be used for the shortest period at the lowest dose.
Breast cancer
Thromboembolic disorders
Hypertension.

Starting and choosing HRT

HRT preps Tayside

MIMS Table HRT Preps

HRT selection (Tayside)

Hormone Replacement Therapy (HRT) may be used in women for the short-term treatment of menopausal symptoms. The benefits are considered to outweigh the risks for the majority of women, particularly in those aged less than 60 years. The lowest effective dose should be used for the shortest duration; each decision to start HRT should be made on an individual basis with a fully informed woman and after assessment of overall risk. Treatment should be reviewed at least annually to discuss any new knowledge and any changes in a woman’s risk factors. For the background to this advice and more detailed advice and information on the potential risks of long-term HRT go to the MHRA website

For further information on prescribing HRT including benefits and risks of treatment see the Tayside Menopause Guidelines

HRT: The CSM advises that HRT should not be considered first-line therapy for the long-term prevention of osteoporosis in women who are over 50 years of age and at an increased risk of fractures. HRT remains an option for those who are intolerant of other osteoporosis prevention therapies, for whom these are contra-indicated, or for whom there is evidence of a lack of response to other therapies. In such cases the individual risk:benefit balance should be carefully assessed. HRT may be used in younger women who have experienced a premature menopause (due to ovarian failure, surgery or other causes) for treating their menopausal symptoms and for preventing osteoporosis until the age of 50 years. After this age, therapy for preventing osteoporosis should be reviewed and HRT considered a second-line choice.
Oestrogens and hormone replacement therapy

· Oestrogen may be given orally, transcutaneously as a patch or gel, or as in implant.

· There can be considerable variation in response to different HRT preparations. Each woman should be encouraged to persevere with a preparation for 2-3months (as side-effects may settle in this time) before considering changing. However, often 2 or 3 preparations need to be tried before a suitable one is found.
· HRT is not a method of contraception.

For women without a uterus
Elleste-Solo® tablets estradiol 1mg – 2mg od
Menopausal symptoms, (including second-line osteoporosis prophylaxis in the case of Elleste-Solo® 2mg only), 1-2mg daily.
Evorel® transdermal matrix patches estradiol 25, 50, 75, 100micrograms/24hrs
Dose: Menopausal symptoms (including second-line osteoporosis prophylaxis in the case of Evorel® 50, 75, 100 only), 1 patch to be applied twice weekly on a continuous basis, therapy should be initiated with “50” patch for first month, subsequently adjusted to lowest effective dose.
FemSeven® transdermal matrix patches estradiol 50, 75, 100micrograms/24 hrs
Dose: Menopausal symptoms and second-line osteoporosis prophylaxis, 1 patch to be applied once a week continuously, therapy should be initiated with “50” patch for the first few months, subsequently adjusted according to response.
Estraderm MX® transdermal matrix patches estradiol 25, 50, 75,100 micrograms/24hrs
Dose: Menopausal symptoms, (and second-line osteoporosis prophylaxis in the case of Estraderm MX® 50 and 75 only), as Evorel®.

Women without a uterus, post hysterectomy require only oestrogens. FemSeven® patch may be preferred by some women as it requires to be changed only once weekly.

For women with a uterus
Women with a uterus require progestogen in addition to oestrogen to protect the endometrium. Progestogens can be given cyclically or continuously.
· Women under 54 years or within 12 months of last menstrual period should receive cyclical combined therapy whereas,
· Women over 54 years or one year post menopause (i.e. 12 months since last menstrual period) should receive a continuous combined oestrogen and progestogen preparation.
Prolonged use of cyclical HRT can increase the risk of endometrial cancer. Women should not be kept on cyclical therapy for longer than 2 years, unless it is necessary to change back for a short time if bleeding problems occur.
· If under 54 years, cyclical therapy should be given for 2 years then changed to a continuous combined regimen.

Progestogens can be divided into two groups:
· C19 (testosterone derivatives) e.g. norethisterone, levonorgestrel, norgestrel and
· C21 (progesterone derivatives) e.g. medroxyprogesterone acetate (MPA).
If side-effects experienced with C19 progestogen, change to C21 and vice-versa.

Oestrogen with cyclical progestogen
Elleste-Duet® tablets estradiol 1mg/norethisterone 1mg, estradiol 2mg/norethisterone 1mg
Dose: Elleste-Duet® 1mg, menopausal symptoms, 1 white tablet daily for 16 days, starting on day 1 of menstruation (or any time if cycles have ceased or are infrequent) then 1 green tablet for 12 days; subsequent courses are repeated without interval. Elleste-Duet® 2mg, menopausal symptoms and second-line osteoporosis prophylaxis, see under 1mg dose but taking 1 orange tablet for 16 days then 1 grey tablet for 12 days.

Femoston® tablets estradiol 1mg/dydrogesterone 10mg, estradiol 2mg/dydrogesterone 10mg.
Dose: Femoston® 1/10, menopausal symptoms and second-line osteoporosis prophylaxis, 1 white tablet daily for 14 days, starting within 5 days of onset of menstruation (or any time if cycles have ceased or are infrequent), then 1 grey tablet for 14 days; subsequent courses are repeated without interval. Femoston® 2/10, see under Femoston® 1/10, but taking 1 red tablet for 14 days, then 1 yellow tablet for 14 days.

Evorel Sequi® transdermal matrix patches estradiol 50micrograms/24 hrs, norethisterone 170micrograms/24 hrs
Dose: Menopausal symptoms and second-line osteoporosis prophylaxis, 1 Evorel® 50 patch to be applied twice weekly for 2 weeks followed by 1 Evorel Conti® patch twice weekly for 2 weeks; subsequent courses are repeated without interval.

Oestrogen with continuous progestogen
Kliovance® tablets estradiol 1mg/norethisterone acetate 500micrograms
Dose: Menopausal symptoms and second-line osteoporosis prophylaxis, 1 tablet daily continuously.
Elleste-Duet Conti® tablets estradiol 2mg/norethisterone acetate 1mg
Dose: Menopausal symptoms and second-line osteoporosis prophylaxis, 1 tablet daily on a continuous basis.
Femoston Conti® tablets estradiol 1mg/dydrogesterone 5mg
Dose: Menopausal symptoms and second-line osteoporosis prophylaxis, 1 tablet daily continuously.
Evorel Conti® transdermal matrix patches estradiol 50micrograms/24 hrs, norethisterone acetate 170micrograms/24 hrs.
Dose: 1 patch to be applied twice weekly continuously.
Kliovance® and Femoston Conti® are low dose continuous combined preparations, whereas, Elleste-Duet® preparations are higher dose preparations required if symptoms not fully controlled with lower strength. FemSeven Sequi® and FemSeven Conti® are estradiol HRT patches with sequential and continuous levonorgestrel that require once weekly changes which may be preferred by some women. They are not licensed for osteoporosis. Other
Raloxifene tablets 60mg od
Treatment and prevention of osteoporosis in postmenopausal women, 60mg once daily. Raloxifene does not reduce menopausal vasomotor symptoms.
Tibolone tablets 2.5mg od
Menopausal symptoms and second-line osteoporosis prophylaxis
Tibolone is an alternative to HRT for the treatment of menopausal symptoms and is also indicated as second-line osteoporosis prophylaxis. However in women over approximately 60 years the risks associated with tibolone start to outweigh the benefits because of the increased risk of stroke. This increased risk of stroke with tibolone should be weighed against the increased risk of breast cancer with combined HRT for women with a uterus. See MHRA Drug Safety Update for further information.

HRT MONTHLY BLEED PREPS
WOMB MB +ve WOMB -ve
Tabs Prempak C Tabs Premarin (0.625 – 1.25)
Tabs Kliovance Patch Evorel (25)
Patch Evorel conti Patch Fem Seven (50)
Patch Evorel sequi Patch Estraderm MX
patch Evorel Pak (patch + tab) Patch Fematrix

NO BLEED PREPS
(must not have had a bleed for >2 years ie menopausal > 1 year)
Patch Evorel Conti
Tabs Primque (cc)
Tabs kliofem (cc)
Tabs Tibolone (2.5mg od) (but spotting is common!)
Others : Femostone conti tabs, Climesse, Kliovance

3 – MONTHLY BLEED PREPS
for those who do not satisfy the criteria for NO BLEED PREPS but don’t particularly like the thought of monthly bleeds
Tridestra

MENOPAUSAL DIABETICS Femapak Fematrix

PERIMENOPAUSAL For control of symptoms consider
Nuvelle TS (patch or tablets) Tridestra (3-monthly bleeds)

VAGINAL OESTROGEN CREAMS
For vaginal symptoms in those not wishing to take HRT
Eg vagifem?for short term use only
If you plan on continued use, progesterone tablets must be prescribed too (in a cyclical fashion) ie for 10-14 days of each month

IMB
Common during early phase of HRT (first 3m)
Exclude sinister pathology
Duphaston rather than norethisterone
If already on cc HRT, consider pushing up the dose or switch to a cyclical prep

WEIGHT Review in 6m Patches rather than tabs

HEADACHES Switch to Prempak C 1.25mg tabs
If headaches resolve, then it is likely to be progesterone related

HRT switching preps

HRT follow-up PUK

HRT problems wdxcyber.com

Menopause other treatments

Alternatives to HRT PUK

Hot flushes in women

Sudden feelings of heat and perspiration, accompanied by an increasing reddening of the face, neck and front of the upper body, lasting 1-3 minutes.

Gynaecological cancers

cancerindex.org Gynaecological cancers

cancer research uk.org Womens cancers

http://www.eveappeal.org.uk/gynaecological-cancers.aspx

Vulval cancer

cancer.gov vulval ca

http://www.ucsfhealth.org/conditions/vulvar_cancer/

aafp.org Vulval Cancer

Cervical cancer

SIGN qrg 99 Cervical Cancer Jan 08

bupa.co.uk cervical cancer

Genital warts HPA

Around 95% of cervical cancers are squamous cell, 5% are adenocarcinomas.
The most important risk factor is human papillomavirus (HPV); at least 50% of sexually active people will get HPV (type 16, 18, 31, 33 or 35). Smoking
and the age at first intercourse are also important factors.

HPV vaccination

HPV vaccination Patient UK

HPV vaccination NHS Choices

HPV Vaccine Controversy ISIS.org

NelM CAS communication: HPV immunisation programme – change of supply to Gardasil® from September 2012

HPV serotypes (source ?netter)
HPV1 deep verrucae and common warts
HPV2 common warts mosaic verucae
HPV3 Plane warts
HPV4 Common warts and verrucae
HPV 6 11 Genital Warts
HPV 16, 18 penile cancer, vulval cancer cervical cancer bowens

Endometrial cancer

AAFP endometrial ca

Ovarian tumours and ovarian cancer

NICE CG122 Ovarian Ca Apr 11

RCOG raised Ca 125

Familial ovarian cancer

hacking-medschool/familial-breast-cancer

macmillan.org.uk Cancer genetics OPERA

http://www.ovacome.org.uk/about-ovarian-cancer/familial-ovarian-cancer.aspx

http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/HealthProfessional/page1

ovariancancer.com

gyncancer.com ovarian cancer

Ovarian teratoma

ovarian cancer facts.com ovarian-teratoma

bioscience.org/atlases/tumpath/freprod/ovary/25/synposis.htm

Ovarian teratoma medscape

Ovarian cystadenoma

http://youtu.be/eoGbylFV9BI

Breast Disorders

Medscape/emedicine

Breast history checklist LMNOP
Lump
Mammary changes
Nipple changes
Other symptoms
Patient risk factors

Breast lumps
3Ss	Site Sixe Shape
3Cs	Colour Contour Consistancy
3Ts	Tethering Temp Transillumination

5 ‘D’s of the nipple
discharge
discolouration
dermatological change eg eczematous changes around the nipple in Paget’s disease of the breast
depression or indrawing
deviation

Royal Cornwall Hospitals Trust Breast Referrals

Breast self examination BSE

youtu.be/Po2lGo7LIPM

Fibroadenoma

vashisht surgical services.co.uk fibroadenoma gp

Fibroadenosis

Breast lumps/symptoms NHS choices

Breast Pain

GPCSG

May be cyclical (both breasts, premenstrually) or non-cyclical (one breast)

Previous trauma or infection, or the presence of a (fibro)adenoma or cyst may provide the explanation.

The presence of a discrete lump necessitates referral

Patients who have clear cycle-dependent symptoms, in whom the examination findings (tendel; nodular, irregular) reinforce the diagnosis of mastopathy, should be reassured with a clear explanation and advice about analgesia.

A variety of treatments (e.g. tamoxifen, danazol, bromocriptine, progestogens, evening primrose oil, diuretics and vitamin E or B6 have been tried for mastopathy, but no beneficial effect has been scientifically proven.

Mild non-cyclical pain also requires only reassurance. Severe, diffuse non-cyclical pain may require treatment such as non-steroidal anti-inflammatory drugs or danazol.

Severe localized non-cyclical pain warrants referral, although pain is only very rarely a presenting symptom of breast cancer.

PREVENTION AND ADDITIONAL INFORMATION
An explanation and reassurance are important if the symptoms are clearly cycle related and bilateral, and if no palpable abnormalities
are found in the examination. Pain in the breast is only rarely a pointer towards malignancy.

Key points
Mastopathy can be divided into cyclical symptoms, non-cyclical symptoms and pain in the chest wall.
In some cases, fear of breast cancer may be significant and should be addressed.
The prevalence of mastopathy is age-dependent: the highest prevalence is found in the age group 45-54 years.
The presence of a discrete lump necessitates referral.
Severe localized non-cyclical pain warrants referral, although pain is only very rarely an initial symptom of breast cancer.

Austoker, Mansel. Guidelines for referral of patients with breast problems. Department of Health Advisory Committee on Breast Cancer Screening. London: Department of Health.
Mastitis
Mastitis in a lactating woma MIM
History
Examination
fever
pain
redness of breast
record area of redness
any suggestion of an abscess
Action advise to continue breastfeeding (unless pus from nipple)
offer affected breast to baby first, to ensure good drainage
flucloxacillin for 7 days (cefalexin if the patient is allergic to penicillin)
Refer to doctor if abscess formation

numerous other support agencies. Using chlorhexidine to prevent
cracked nipples has not been shown to be more effective than normal
washing with water.
Key points
The most important aetiological factor is incorrect positioning of
the nipple in the baby’s mouth, and this relates to how the baby is
held to the breast.
Fungal infection, as a cause, is rare.
It is better to breast-feed more often, and to begin with the least
painful breast, than to postpone feeding.

Nipple discharge

Nipple discharge mayoclinic.com

Nipple discharge vashishtsurgicalservices.co.uk

embarrassingproblems.com nipple discharge

imaginis.com nipple discharge

Complication of breast feeding particularly with poor technique – head and mouth should be directly on a level with nipple. Not usually due to fungal infections.