Primary Care Gynaecology Service: Advice and Guidance Case ...



North and West Primary Care Gynaecology Service: Advice and Guidance Case StudiesQuestion 1: A 32 year old patient had the mirena inserted 2 years ago and in the first 18 months had 1-2 light bleeds in total.She went on sabbatical for 6m from Oct 2013 to March 2014. She did not have sex for this 6 month period but had the same partner throughout the whole time. Since returning, she has had post coital bleeding 90% of the time with spotting necessitating a panty liner for 24 hours. She is also having unpredictable spotting lasting around 12 hours every 1-2 weeks. For the first 2-3 months she had occasional cramp-like abdominal pains but these have now entirely resolved.She has no fever or unusual discharge. She has deep dyspareunia around 30% of the time but this has been true for her entire sex life, now no better or worse.NAAT and LVS: negativeSmear: negative (February 2012)TVUSS: correctly sited IUS, endometrium normal and 3mm. Ovaries and uterus normal.Examination: no adnexal masses/tenderness, no true cervical excitation but some pain when moving the uterus, cervix had bloody discharge at the os, some slight signs of ectropion but no contact bleeding and certainly not prominent or angry.She takes no regular medications. She had Pelvic Inflammatory Disease (PID) 10 years ago treated with antibiotics.If we can fully reassure her, she is happy to put up with the bleeding and leave the mirena in. Advice: This lady is still young at 32 and so our worries re endometrial abnormalities are very low (unless of course has any high risk features, e.g. obese/polycystic ovary syndrome (PCOS)/family history of endometrial cancer/diabetes). She has had smear and cervix looks normal. Swabs and scan are normal, and particularly reassuring is the 3mm thin endometrium and good IUS position. This is likely just dysfunctional bleeding (DUB). The key investigations in any lady with persistent abnormal bleeding e.g. Intermenstrual/Postcoital bleeding is:A comprehensive examination including speculum and vaginal examination. Looking for example for tenderness/masses or abnormalities to vulva/vagina/cervixCheck smear history is up to date i.e. had within the last 3/5 years appropriate to ageDo swabs unless sure inappropriate e.g. HVS/NAATSOrder Transvaginal Scan (TVS) to assess uterus/endometrium/ovaries/free fluid etc.If all the above is normal and the lady is <40 years and without higher risks (see above) then you can be very confident this is just dysfunctional bleeding either unexplained or often related to the contraceptive method. If above 40 years this is still reassuring but if the bleeding is persistent or worsens or doesn’t settle then she warrants a referral to our PCGS service for consideration of endometrial pipelle biopsy or a Saline Infusion Sonography/SIS examination (similar to hysteroscopy but using ultrasound). Clearly if postmenopausal then refer via 2WW pathway.A good test could be to put her on either the combined pill for 1-2 months or Provera 2-3 weeks to see if bleeding all settles. If Provera, 5-10mg twice a day would be appropriate. A lower dose makes side effects less likely, but is also less likely to stop the bleeding. You could start with 5mg twice daily and increase to 10mg twice daily if bleeding continues. If still not stopping, please refer on. You can use Provera for as long as needed, but ideally the patient should have a break after 3 weeks. It is high dose progesterones so I try to use long term Provera as last resort. Remember that one strategy for problematic menorrhagia is to use norethisterone or Provera from days 5-25 of cycle in the theory that the period in the gap will be lighter. So I would advise that you put the patient on Provera for 2-3 weeks and then review. If DUB you would expect the bleeding to stop on the pills and then have a withdrawal bleed afterwards. It’s a bit like an extended provera challengeIf this was a worrying cause the likelihood is that the bleeding would continue. If it stops on these tablets it would make it likely DUB probably related to the mirena. As long as you have ruled out worrying causes you can just leave it with the patient to decide if they want to continue the method i.e. mirena. Often, once reassured, the patient can live with the symptoms. If you watch and wait here things may just settleAlways though remind the patient to return if the symptoms are worsening or if new symptoms develop. If this happens just reinvestigate as you did this time i.e. start afresh.Question 2: Patient is a 43 year old lady with dysmenorrhoea, menorrhagia and an abnormal ultrasound scan. Patient attended the surgery in October 2013 reporting that over the last six years her periods had become heavier. She bleeds for several days every twenty eight days and these are very painful and heavy. She wanted to re-start the combined pill but has a history of migraine with aura. She was sent for a full blood count which was normal and was started on some Mefenamic acid which she did find helpful. I arranged for her to have a transvaginal ultrasound scan given her new symptoms and we started her on some Cerazette to control her bleeding. Her transvaginal scan shows a bulky uterus with coarse echo texture but no fibroid and the appearance of the myometrium on the scan raising the possibility of adenomyosis. On review, the patient reports that her symptoms are well controlled on Cerazette. She is not having regular periods and they are therefore less heavy and painful. She is going to continue with this. Given the diagnosis of possible adenomyosis, I would be grateful for your advice on whether she would warrant any further investigation or benefit from any other treatment. I suspect this is unlikely given her symptoms are managed with her current treatment, but I would be grateful for your advice. She is not keen for the Mirena coil.Advice: Adenomyosis is ectopic endometrium within the myometrium. It is therefore similar to endometriosis really. It is also managed in a similar way. Ultrasound can give you a guide as to the diagnosis but the only definitive way to diagnose is after hysterectomy, although this is usually not needed.The best methods of treatment are the combined oral contraceptive pill (COCP) or mirena (or a combination of the two) but cerazette is another good option as it in most women suppresses the natural cycle. You are right that if she is happy on the current treatment that this is fine long term.One significant difference if adenomyosis is suspected is that endometrial ablation doesn’t perform well at managing menorrhagia (due to the problem being below the endometrium). If needing referral and COCP/mirena/cerazette all failed then hysterectomy are more likely to be needed.Question 3: I sent a 51 year old patient with one episode of post-menopausal bleeding (PMB) (like a period) for an ultrasound. The rest of the work up was normal. The scan reported as follows: US Pelvis Trans abdominal: Uterus: poor views were obtained transabdominally but on the transvaginal scan it appears normal size and anteverted measuring approximately 6.5 x 3 x 4cm.The endometrium measures approximately 4.5mm which is very minimally thickened. There is a tiny cyst within which measures approximately 3mm. No other obvious pathology seen. Ovaries: neither ovary was confidently demonstrated on either scan although there are no obvious pelvic masses or free fluid noted in the adnexae or iliac fossae. SUMMARY:The endometrium is very mildly thickened measuring 4.5mm. Gynaecology referral is suggested. I thought 5mm was considered within normal range? Advice: You are correct. The clinics at St. Mikes use a cut off of 5mm. As long as checked exam/smear history/swabs etc. and bleeding settled, then reassure her. If the bleeding is persistent, then you can send to PMB 2ww if the patient is postmenopausal.Question 4: I have a 37 year old lady who has premature ovarian failure (FSH >50). She has been seen in the gynae-endocrine clinic already about this. She is on cyclical combined HRT. She is finding it very difficult to come to terms with this and would still desperately like to conceive a second child. I have emphasised to her that her chances of pregnancy are now extremely low, but I just want to check I am giving the correct advice. Is it still technically possible, although rare, to conceive up to 2 years after her last period? How will being on HRT affect her fertility? I understand HRT is not a contraceptive, but will it increase/decrease her fertility? She is reluctant to take HRT because she is concerned it will reduce her fertility.Advice: There is thought to be about a 5% chance of spontaneous ovulation and therefore possible pregnancy in women affected by this condition. HRT technically is not a 'contraceptive' but of course could affect fertility. Regular HRT is about the strength equivalent of a 5-10 mcg combined pill (if there was one).This is a difficult one but you can only counsel the patient. A patient of mine in a similar position recently conceived; she had decided not to take HRT in order to give herself any chance of conceiving. The patient doesn’t have to take HRT and it probably will not harm her in short/medium term although technically it is advisable. Your patient could always take HRT once she is ready to stop trying for another baby, e.g. when she reaches 40+ years. Ultimately it is up to the patient as the chances are slim but possible. Do advise her that it is important to take HRT as soon as she can.Question 5: I would be really grateful for your advice on this 30 year old lady who is requesting clomid having been trying to conceive for the past six months. Her new partner has had a reversal vasectomy and has had a good semen analysis result in January. She has confirmed PCOS (FSH 6 and LH 10 on day 3 of cycle in May 2014) and has been on metformin 400mg three times a day for the past 6 months which is giving her 31-35 day cycles for the past 4 months. She did ovulate in May with progesterone of 66. She was given clomifene in 2008 by the fertility clinic but did not use it as she conceived without needing it but is keen to have it now. She has one child.I am slightly reluctant to give clomid after only 6 months and with positive progesterone. What do you think?Advice: Clomifene queries like this are very common. In the past, some GPs would rightly or wrongly give clomifene to patients with often minimal skill. As time has gone by, the new NICE fertility guidance has been released and so it has now become difficult to recommend GPs to do this. In general some review articles suggest safe and ok in primary care. Other suggest should be secondary care. NICE now suggest that the first cycle of clomifene should be ultrasound monitored to reduce the risk of overstimulation (even used correctly, it has a 10% risk of multiple pregnancies). Unfortunately these scans are not done in routine ultrasound departments at St Mike’s/Southmead. These scans are available either in my service or in secondary care. Unfortunately, however, both of our services require NHS fertility criteria to be met before referral. As this patient has already had a child, she will not meet these criteria.Aside from the ultrasound monitoring in the first cycle it is also good practice to check day 21 progesterones to check the clomifene is effecting ovulation. Sometimes the dose needs to be increased - there is little point in giving 6 months of an inadequate dose. There are a finite number of doses of clomifene that a woman can have (6-12) as there is a possible link with ovarian malignancy that has never been totally proved in long term use. Therefore you don't want to waste treatments with an inadequate dosing regime or potentially put a woman at risk unnecessarily.In short, even without the NICE guidance I wouldn't recommend using clomifene as a GP unless you are very confident and able to commit the time and resource to manage optimally. Whilst NICE guidance is of course only guidance, you would have to justify why you didn't follow it if things went wrong, e.g. multiple pregnancies.Separate to this I fully agree with you that considering the patient is only 30, had a previous natural conception, is having regular periods (and hence likely ovulation which you have also proved), and has only been trying to conceive for 6 months, it is very early to consider clomifene. The guideline is 2 years of trying before fertility referral.In summary, I would encourage the patient to continue trying until the 2 year mark. If she wants clomifene either at that point or earlier the only option is to go privately as she has a child and doesn't fit fertility criteria. I would suggest referring the patient to someone like Uma Gordon at Spire.I am going to look into discussing with the fertility consultants whether we could advise GP’s to give the lowest doses of clomifene safely without monitoring for a short period of time. I will feedback in the future. The long and short of it is that the lower doses are nearly always safe but guidelines these days are becoming more tight.Question 6: My 43 year old patient has a longstanding and severe mental health problem with psychotic elements. She is a homosexual and hates having periods, so has been on depo. Over the last 4 months she has started having erratic bleeding which distresses her, and hot sweats. Her mother had an early menopause.The bleeding is controlled with norethisterone. A scan (which she found difficult) showed an endometrium 2mm thick, no other abnormalities (FSH is 28.4, LH 8.3, but I am not sure what effect the depot will be exerting here). The examination, swabs and smear history are all normal.Her mental health is detrimentally affected by the bleeding. She’s a smoker.She would like a surgical solution to stop her bleeding. Is there a case for this?Advice: With new onset irregular bleeding the first response is to rule out pathology. I agree it is difficult to assess the hormone profile on depo but it may give an indication of early menopause putting it all together. If the bleeding is persistent, then an endometrial biopsy must be considered as she is >40 years despite the normal endometrium on scan (although that is very reassuring). The best option here would be a mirena as this would be lower risk than any surgical options. If the patient will not consider this, the next step would be consideration of ablation, assuming that the patient has completed her family.Question 7: I would like to know whether my 31 year old patient would be considered for clomifene.The patient was diagnosed roughly 10 years ago (by a different practice) with PCOS. She has never been pregnant and has now been trying unsuccessfully for 18 months. She was having 7-8 day bleeds roughly every 3 months (and before this was on the combined oral contraceptive). The patient is a non-smoker, she exercises regularly and has a BMI of 25.3. Her husband is fit and well and a non-smoker, but has not had a sperm check. I saw her first 10 weeks ago when she was asking for referral. I started her on metformin 500mg MR, 1 tablet daily for 2 weeks and then increased to 2 tablets daily. She has tolerated this well and had a good response with a 36 day and then 33 day cycle since then. She has returned today still not pregnant, 10 weeks after starting metformin and she is keen to pursue clomifene, despite being advised of increased risk of twin pregnancies, possible risks to her ovaries re future cancers, and the need to medicalise the process (e.g. regular scans). Would you be happy to see this lady to discuss ongoing treatment? If so, would you want her husband to have a sperm check before/alongside the referral?Advice: The patient needs to fulfil NHS fertility criteria before referral (please always attach a completed form with each referral). She would need to have been trying for at least 2 years to fulfil this (unless severe oligomenorrhoea i.e. 1-2 periods yearly). Even with severe oligomenorrhoea, you would need prior approval from exceptional funding before referring.We would also expect a sperm test prior to referral as we can only see patients in community if sperm test normal. The fact her periods have regulated on metformin is a great sign and with these regular periods she is likely ovulating. Reassure her to persist especially as so young. If the patient is still not pregnant at 2 years of trying, please refer her with a completed criteria sheet and all completed tests (i.e. hep b/HIV/sperm test/hormone profile etc.). We can then consider clomifene and tubal latency test in the community PCGS clinic.Question 8: One of my ladies was seen by secondary care for dysfunctional uterine bleeding. She has used TA/MA/Implant/COCP/Progesterone and has had anaemia.The secondary care team have suggested a Skyla IUS. They have told the patient that she should have this in preference to a mirena, and that we can fit this in primary care. Do you know anyone who is trained as I would be uncomfortable doing so? Do we need to feed this back to secondary care?Advice: Skyla is the American name for Jaydess i.e. the new 3 year IUS. This is made by the same company as Mirena with a third of the hormone of Mirena. It is smaller in itself as is its introducer. It is mainly aimed at younger women as a contraceptive. There is no long term data on effect on bleeding pattern but it is thought will reduce heaviness of periods.In general I feel it will have small market as it makes sense to fit a Mirena where possible as it lasts longer and has more hormone to exert reduced bleeding. However, it will be useful in women with small uterus (e.g. young primips if difficulty fitting Mirena) and women who have had possible hormone effects with Mirena who may benefit from a lower hormonal load. It is possible that the secondary care team have suggested this if the patient is very young or would not like to use hormones.There really is no need for further training as the introducer is almost identical to the Mirena one (apart from pink instead of green) and the insertion tube and coil are smaller (think of T Safe cu380QL vs TT slimline copper IUCDs). I would suggest just ordering and fitting. If you want to pop over, I would be happy to show/teach you on my “dummy” Jaydess device.Question 9: A 33 year old patient has attended with oligomenorrhoea (cycle 45-60days). Her USS showed polycystic follicles and I have gone through PCOS with her.However, the scan also reported "adjacent to the right ovary there is a tubular echopoor structure. This may represent hydrosalpinx".She has a stable partner and has never been pregnant with no plans to conceive. She has no pelvic pain other than mild period pains. The chlamydia NAAT is negative and serology negative at <64.Should I do anything further? Advice: The first thing I would do is rescan at about 4-6 months to see if this echo poor area is still there. It could well be a hydrosalpinx, but sometimes areas of fluid like this do appear and disappear with no explanation. A second scan would hopefully confirm if a hydrosalpinx or not, and if not what this area is.Has the patient had any pelvic operations or episodes of pelvic inflammatory disease unrelated to chlamydia which might put her at risk of a hydrosalpinx? Unfortunately some women just have these for no apparent reason.The good news is that hopefully the other tube will be open. As women only need one tube, there is a very good chance she will get pregnant. If she does try to conceive, she would still need to try for a baby as normal and be referred to fertility using the normal criteria form i.e. try for 2 years etc.I would encourage her to not delay any longer than needed to try for a baby just in case there are other issues. If she doesn't get pregnant then fertility or our service will organise a tubal patency test and manage her further.As the patient has PCOS and a hydrosalpinx (if confirmed) then you could consider applying for exceptional funding after a year of trying as she may be allowed an early referral considering both diagnoses? Otherwise work her up as normal for infertility if it occurs.Question 10: My 37 year old patient, booked in for a scan due to abdominal pain with regular periods, has fallen pregnant. She had the scan done last week, when she was 11 weeks pregnant. Also noted was a 45mm luteal cyst.She has suffered with hyperemesis and we are glad to see that this is improving.Is this cyst normal for pregnancy at this size, or should we be doing something else (e.g. rescan at a later date)?Advice: A luteal cyst is a functional simple cyst left over post-ovulation. The RCOG recommends that simple functional cysts <5cm do not need follow up as they will likely go on their own. Occasionally they can cause pain when they rupture and even more rarely can twist/undergo torsion. You should advise the patient to should seek medical help if she experiences quick onset and severe pelvic pain.For simple cysts of 5-7 cm, the RCOG suggest a rescan at a year. As this cyst is nearing 5cm you could do that.Question 11:I requested an urgent US Pelvis Transvaginal scan as my patient has bloating, full right adnexa and a tender uterus of unknown cause. The patient is on HRT. The returned scan stated that:The uterus is anteverted and of normal appearance.The endometrium is a little indistinct, however, does not appear thickened measuring 5 mm maximally. There are multiple small echogenic foci noted within the endometrium the nature of which is uncertain.No ovarian tissue identified although there is no free fluid or adnexal masses detected. Advice: I have presumed that this patient went through the menopause early. If the scan wasn’t for bleeding (or even if it was) it is reassuring as the endometrium was not thicker than 5mm despite the patient being on HRT. Echogenic foci when looked at in studies are normally calcification or ossification of the tissues and are usually related happily to benign conditions. They are more common in women with previous uterine instrumentation e.g. hysteroscopy/D+C etc. They are also much more common as you get older. Do not worry about these echogenic foci but look instead at the endometrium thickness and appearance in general which in this case was fine, especially if no bleeding. The ovaries were not seen which is usually a good sign, as if abnormal they are usually large and easily seen. Certainly there was nothing worrying on this scan. With regards the uterine tenderness, have you considered STI or PID...still possible at her age? If excluded this by swabs and bimanual, then I would look elsewhere to bowels etc. as a cause of her symptoms.Question 12: Can I ask your advice about a 37 year old patient who has presented 6 times with dyspareunia, no continuity of care (I have not seen her before) and she is rather unhappy not to have been referred earlier. She complains of burning superficial pain on penetration that interferes with intercourse. She is in a long term relationship with no other issues than her reluctance to have SI due to her pain. At one time she was worried about an abnormal lump but one of my colleagues reassured her this was her urethra. Her partner reported an abnormal appearance of her vulva when I saw them but it looked entirely healthy to me (I did not repeat bimanual or speculum examination as this has been documented as normal twice in the last few months).A swab on 8th June showed ++ candida and + b haem strep. She had used OTC clotrimazole and was given fluconazole but no effect (and her symptoms are not typical of thrush). She then had a course of pen V and a few weeks later empirical azithromycin although NAATS subsequently reported as negative. MSUs on 2 occasions have been negative (although she was given empirical trimethoprim and then nitrofurantion as she reported urinary frequency).Her smears are up to date and her cycle is normal. She tolerated superficial vulval and vaginal examination well, i.e. not suggestive of vulvodynia. She has tried lubricants etc., but it is possible that there is now a large element of psychological overlay.Advice: With a normal examination this is likely to be either vulvodynia, recurrent thrush, psychological or possibly contraception related. Perhaps even a combination.Vulvodynia is a diagnosis of exclusion really and is a pain syndrome with unknown exact cause. It is thought to involve hypersensitive nerve responses at the vulva. Biopsies are not useful in diagnosis if a normal examination. The diagnosis is made after excluding others and on the history.I completely agree that there are likely to be significant psychological issues. In all vulval pain conditions there is a psychological side which you can help by counselling re partners working together/mood/lighting etc and by also using vaginal dilators and pelvic floor exercises to try and overcome the pelvic floor dysfunction/ vaginismus which is a side effect (see below). Anaesthetic gels can be used to aid initial use of dilators until more confidence (either lidocaine ointment 5% PRN or Instillagel syringes) and also be used to help with intercourse.To be honest all of the management options for this type of vulval pain can be done in primary care and really as long as the examination is normal there is nothing secondary care can do that you can’t. BUT we are always happy to see though to give a second opinion and aid in what can be a tricky condition to manage.The first thing that must be ruled out is recurrent thrush especially considering the strongly positive thrush swab. I suggest trying a thrush suppression course. I commonly use fluconazole 150mg every 3 days for 3 doses and then once weekly. I usually try a 2/12 trial to see if helps. If not then stop this. You could also use 50mg fluconazole daily.The contraception the patient uses can also have an impact. Combined pills in particular can cause recurrent thrush and all hormonal contraceptives that cause hormonal suppression (i.e. cocp/cerazette/depo/implant) could potentially cause vulval dryness/soreness/problems. With depo we certainly know you can get a hypooestrogenic effect much like postmenopausally. If in doubt you can try 2-3 months ovestin cream twice weekly with daily at night for first 2 weeks particularly if on cerazette/ implant/depo. You could also try this with combined oral contraceptive pills and especially so if second generation which are more androgenic in their action (e.g. microgynon/loestrin /brevinor/ovysmen/norimin).If the patient has any other skin conditions eg eczema you could give 1/12 potent steroid to vulva to rule out an inflammatory disorder, e.g. dermovate, once daily at night for 1/12. It is even worth a trial of this if the vulva is normal to rule out a subclinical inflammatory condition and reassure yourself. In vulvodynia potent steroid usually doesn’t help.Ensure you discuss good vulval care and encourage her to use a soap substitute/ moisturiser e.g. hydromol ointment/diprobase. Also patients with chronic vulval pain often develop secondary vaginismus and fear around sexual activity. Encourage practicing pelvic floor exercises by explaining and giving a patient information leaflet can help. This is so the patient can get used to tightening and then relaxing the pelvic floor on command. Dilators can also be prescribed to allow the patient to get used to increasing sizes of dilation in the vagina. These can be prescribed on FP10 as Amielle comfort dilators. They come as pack of 4/5. Inform that largest one is too big and to aim for second largest. It can be tricky to get the patient to use these but explain the importance of her being able to use these herself before it is likely will have the confidence to relax back into sex with her partner.Remember to advise lubricants with sex and the dilators. Anxiiety/worry/stress along with vaginal tightness can mean pain even without chronic vulval pain.Clearly after all the above treatments have failed you are likely to want a second opinion if only for your own peace of mind before embarking on further vulvodynia management such as amitriptaline/gabapentin/pregabalin. I would certainly try the above measures before referring her onto our service. E mail me if need further advice. Happy for phone calls if needed also. ................
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