Long term genitourinary and gynaecological conditions Flashcards
Menorrhagia
Ask about menstrual history - Age of menarche, Gravidity and parity, Normal menstrual cycle and any variation (regularity, duration, and number of pads/tampons per day), Last menstrual period (the start date of the most recent menstrual period).
Cervical screening history, if they want to conceive.
If the woman has a history of menorrhagia without other related symptoms, consider starting pharmacological treatment without carrying out a physical examination (unless the treatment chosen is [LNG-IUS] - then do vaginal exam and swabs).
For women with menorrhagia and no identified pathology:
Consider a levonorgestrel intrauterine system as first-line treatment. Advise that she should wait for at least 6 cycles to see benefits.
The non-hormonal treatment options are tranexamic acid (4 days) or a NSAID.
The hormonal treatment options are combined hormonal contraception (triple cycling - taking without break) or cyclical oral progestogen (norethisterone - stop periods but strong withdrawal bleeds - when going on holiday).
If the woman has a history of menorrhagia with other related symptoms, offer a physical examination to exclude an underlying cause. Can do BP - if lots of blood loss.
Perform an abdominal examination — to assess for large fibroids and other masses.
Perform a bimanual pelvic examination, including a speculum examination of the cervix (abnormality of os - 2 week wait) — to exclude an underlying cause, such as ascites, fibroids, or cancer.
Look for features of an underlying systemic disease, for example:
Hypothyroidism — goitre.
Coagulation disorders — bruises or petechiae.
Polycystic ovary syndrome — acne, hirsutism.
Arrange investigations as appropriate to exclude an underlying cause:
Arrange a full blood count in all women — to rule out iron deficiency anaemia (which is a strong indicator of excessive menstrual bleeding).
A pregnancy test — in all women of reproductive age who have any deviation from their normal pattern of menstrual bleeding.
A vaginal or cervical swab — if an infection is suspected.
Thyroid function tests — if there are features of hypothyroidism.
Tests for coagulation disorders — in women who have had heavy menstrual bleeding since menarche and a personal or a family history of a coagulation disorder.
Do not:
Routinely carry out a serum ferritin test
Carry out female hormone testing
Measure blood loss
LUTS symptoms history and exam and differentials
Type of LUTS:
Storage — urgency, frequency, nocturia, urinary incontinence, and feeling the need to urinate again just after passing urine. FUN symptoms.
Voiding — hesitancy, weak or intermittent urinary stream, straining, incomplete emptying, and terminal dribbling.
Post-micturition symptoms — post-micturition dribble and the sensation of incomplete emptying.
Ask about:
What protection they need to cope with leakage.
How they manage diet and fluid intake to try to control leakage.
If they have any pain when passing urine. Flank pain.
Underlying causes and comorbidities (such as diabetes and MS).
Sexual function using a symptom questionnaire - the International Index of Erectile Function.
Haematuria
Physical examination:
Examine the abdomen for signs of a distended, tender, palpable/percussible bladder.
Examine the external genitalia to identify conditions that may cause or contribute to LUTS (for example, phimosis, meatal stenosis, or penile cancer).
Perform a DRE to assess the prostate’s size, surface smoothness etc. - can only take PSA after 1 week.
Examine the perineum and/or lower limbs (to evaluate motor and sensory function).
Differentials:
Urological cancer — may present with unexplained haematuria, lower back pain, bone pain, and weight loss. Rectal examination may show a prostate that is hard and irregular.
Urological infection — may present with pain when urinating, pelvic pain, loin pain, fever, and abnormal urine dipstick test findings.
Sciatica — may present with weakness, numbness, or tingling in the leg and can cause or aggravate LUTS.
Cauda equina syndrome
Renal cancer
Renal stones
Bladder cancer
Pelvic organ prolapse in women
Diabetes, neurological conditions
LUTS investigations
Investigations:
Urine dipstick to check for blood, glucose, protein, leucocytes, and nitrites. MSU.
A serum creatinine test and calculation of eGFR - if renal impairment is suspected - palpable bladder, nocturnal enuresis, recurrent UTI, history of renal stones.
PSA testing if:
Their LUTS is suggestive of bladder obstruction secondary to benign prostatic enlargement.
Their prostate feels abnormal on digital rectal examination
They are concerned about prostate cancer.
International Prostate Symptom Score (IPSS)
Urinary frequency-volume chart for at least 3 days - indication of the voiding pattern, the severity of symptoms, and the impact on the person’s daily life. They can help distinguish the following:
Frequency, Polyuria (up to 3 L in 24 hours is normal), Nocturia,
Nocturnal polyuria (passing, at night, more than 35% of the 24-hour urine production).
Refer if they have LUTS complicated by recurrent UTI, retention, renal impairment, or suspected urological cancer.
LUTS voiding symptoms management
Offer drug treatment to men with bothersome LUTS if conservative management options have been unsuccessful or are not appropriate.
Offer an alpha blocker (doxazosin, tamsulosin) to men with moderate to severe LUTS (an International Prostate Symptom Score [IPSS] of 8 or more).
Review men taking alpha-blockers at 4 to 6 weeks and then every 6 to 12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment.
If the man has symptoms that persist after treatment with an alpha-blocker alone, consider adding an antimuscarinic drug, such as oxybutynin (immediate release).
If antimuscarinics are contraindicated, not tolerated, or not effective, offer mirabegron.
Review as above.
Offer a 5-alpha reductase inhibitor (dutasteride or finasteride) to men with LUTS who have enlarged prostate.
Review as above.
Consider offering a combination of an alpha-blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and enlarged prostate.
If treatment fails, refer.
Secondary care treatment options include:
Urethral catheterization (which may be intermittent, indwelling urethral, or indwelling suprapubic).
Prostate surgery (including transurethral resection of the prostate etc).
LUTS general management
Offer lifestyle interventions when LUTS not bothersome.
Offer review if symptoms change.
Provide tailored advice for example:
To reduce fluid intake at specific times to reduce urinary frequency when most inconvenient (for example, at night or when going out in public).
That fluid intake should not be limited excessively as this could increase the risk of complications (such as UTI).
To treat constipation to maintain a healthy lifestyle (reduce weight, stop smoking, and improve diet)
Avoid or moderate caffeine or alcohol intake.
LUTS storage management
Offer men with storage LUTS suggestive of overactive bladder:
Supervised bladder training — urology clinic.
Advice on fluid intake and lifestyle advice.
Containment products (if needed).
Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy — continue the exercises for at least 3 months before considering other options. Refer all other men with stress urinary incontinence for specialist.
Offer an alpha blocker (tamsulosin) to men with moderate to severe LUTS .
Review men taking alpha-blockers at 4 to 6 weeks and then every 6 to 12 months.
Consider offering an antimuscarinic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone.
Offer an antimuscarinic to men to manage the symptoms of overactive bladder — such as oxybutynin (immediate release), tolterodine (immediate release), or darifenacin.
Review as above.
If the first-line drug treatment is not effective or tolerated, offer one of the other drugs.
Consider offering a combination of an alpha-blocker with an antimuscarinic in men who still have storage symptoms after treatment with an alpha-blocker alone.
If antimuscarinics are contraindicated, not tolerated, or not effective, offer mirabegron.
Review as above.
For men with nocturnal polyuria, consider offering:
A late afternoon loop diuretic — for example, furosemide 40 mg
Oral desmopressin (if other medical causes have been excluded and they have not benefited from other treatments). Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.
Menopausal symptoms
Symptoms:
Hot flushes/night sweats (vasomotor symptoms)
Anxiety, mood swings, irritability, sleep disturbance.
There may be low mood
Poor concentration and memory
Urogenital symptoms - vulvovaginal irritation, burning, itching, and/or dryness; dyspareunia; reduced libido
Dysuria, urinary frequency and urgency, and recurrent lower UTI.
Joint and muscle pains.
Investigations:
Do not routinely use blood tests such as (FSH) in otherwise healthy women (who are not using hormonal contraception) aged over 45 years, with typical menopausal symptoms.
Diagnose the following without laboratory testing:
Perimenopause — if the woman has vasomotor symptoms and irregular periods.
Menopause — if the woman has not had a period for at least 12 months (and is not using hormonal contraception) - after 50. Before 50 - 24 months.
Menopause — based on symptoms in a woman without a uterus.
Consider using serum FSH measurements to diagnose menopause provided she is not taking combined hormonal contraception (or HRT), and she is:
Aged over 45 years with atypical symptoms.
Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle.
Younger than 40 years with a suspected diagnosis of premature ovarian insufficiency (POI).
Over 50 years of age using progestogen-only contraception.
If the FSH level is in the premenopausal range, the woman should continue contraception and the FSH level should be rechecked in 1 year.
Check for an elevated FSH level on two blood samples taken 4–6 weeks apart.
Do not routinely perform a pelvic examination to diagnose menopause.
It should only be performed if clinically indicated and to exclude other possible causes of symptoms.
Menopause history
Ask about:
Other potential causes of amenorrhoea, including pregnancy.
The need for ongoing or future contraception.
Smear status and engagement with screening programmes.
Family history including premature menopause or POI, venous thromboembolism, or hormone-dependent cancer including breast cancer.
Co-morbid conditions such as:
Cardiovascular disease, hypertension, diabetes mellitus, venous thromboembolism (give patch rather than pill), or stroke disease, hormone-dependent cancer including breast, endometrial, and ovarian cancer.
Previous medical or surgical treatment, including chemotherapy, radiotherapy, hysterectomy, and/or bilateral oophorectomy.
Bone health and assess risk of osteoporosis.
Examine:
BP and BMI
If there is a sudden change in menstrual pattern, intermenstrual bleeding, postcoital bleeding, or postmenopausal bleeding — assess appropriately and arrange an urgent 2-week referral if a gynaecological cancer is suspected.
Menopause symptoms differentials
Menopausal symptoms may also be caused by other conditions:
Secondary amenorrhoea
Irregular vaginal bleeding - endometrial polyps; uterine fibroids; adenomyosis; endometrial hyperplasia or cancer; and vulval, vaginal, or cervical lesions.
Hot flushes - Endocrine causes such as hyperthyroidism and phaeochromocytoma (typically causes hypertension, flushing, and profuse sweating).
Tumours such as carcinoid syndrome (typically causes flushing without sweating), pancreatic cancer, medullary thyroid cancer, renal cell cancer, lymphoma and mast cell disorders (usually with gi symptoms), and paraneoplastic syndrome.
Excess alcohol, spicy food.
Dumping syndrome (such as post-weight loss surgery).
Anxiety and panic disorders.
Tuberculosis.
Drugs such as opiates, nitrates, SSRIs, calcium-channel blockers, levodopa, gonadotrophin-releasing hormone agonists, anti-oestrogens or selective estrogen receptor modulators (SERMs).
Vaginal atrophy — trauma, infection, or lichen sclerosis
Urinary incontinence — this is more likely to be due to mechanical factors, such as obesity, gynaecological surgery, or multiparity.
Sleep disturbance — may be associated with the normal ageing process.
Cognitive impairment (such as memory problems or difficulty concentrating)
Loss of libido — may be due to androgen deficiency, however other non-hormonal factors, such as insomnia, inadequate sexual stimulation, life stresses, and depression, may also contribute.
Muscle and joint pains — These symptoms have been linked to a decrease in oestrogen levels, but other musculoskeletal causes (such as osteoarthritis and rheumatoid arthritis) are possible.
Skin changes — ageing, smoking, and sun exposure
Weight gain — Body weight in women tends to increase with age (average weight gain is 2.25–4.19 kg).
Menopause management
Lifestyle measures:
Hot flushes and night sweats — regular exercise, weight loss, wearing lighter clothing, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).
Advise to seek occupational health advice if support is needed in the workplace.
Advise on bone health - inc calcium and Vit D.
Advise on the need for contraception - HRT does not provide contraception. Potentially fertile for 2 years after last menstrual period if younger than 50, and for 1 year if over 50. All can stop contraception at 55.
All progestogen-only methods of contraception are safe to use alongside cyclical HRT.
Combined hormonal contraception can be used in in under 50 as an alternative to HRT for relief of menopausal symptoms. Women should be advised to switch to a progestogen-only method of contraception at 50 years of age, if needed.
Hormone replacement therapy:
For vasomotor symptoms:
In women with a uterus, offer combined preparation.
In women without a uterus, offer oestrogen-only preparation.
In eligible women under 50 years of age, offer a choice of HRT or a combined hormonal contraceptive as an alternative option.
For mood disorders, offer a choice of oral or transdermal HRT.
For urogenital symptoms - Offer low-dose vaginal oestrogen first-line and continue treatment for as long as needed to relieve symptoms.
For altered sexual function, seek specialist advice on the appropriateness of testosterone supplementation (off-label indication).
Arrange to review the woman after 3 months if HRT has been started or changed, then at least annually thereafter. At each review:
Assess the efficacy, adverse effects or persistent symptoms, and offer to adjust the dose or preparation. Options include:
Reduce the dose of oestrogen.
Change the dose or type of progestogen.
Alter the route of administration eg from oral to transdermal.
If there is a sudden change in menstrual pattern, intermenstrual bleeding, postcoital bleeding, or postmenopausal bleeding — assess appropriately and arrange an urgent 2-week referral if cancer is suspected.
If there are persistent symptoms despite adjustment consider an alternative cause.
Support the woman on when and how to stop HRT:
HRT should be continued for as long as benefits of symptom control outweigh any risks.
Women with premature menopause or POI should take HRT up to the average age of the natural menopause (51 years), after which the need for ongoing HRT should be reassessed.
HRT may be gradually reduced over 3–6 months, or stopped suddenly (symptoms may recur in short term) depending on preference.
If troublesome symptoms recur, options include restarting HRT at a low dose, or considering alternative non-hormonal treatments.
Vaginal oestrogen - regular attempts to stop treatment, such as annually, can be made.
If bleeding with HRT - ok for 6 months - if still there then refer as worried about endometrial cancer.
Risks of HRT
Venous thromboembolism (VTE)
The risk of VTE associated with HRT is greater for oral than transdermal.
The risk associated with transdermal HRT given at standard therapeutic doses is no greater than baseline risk.
Coronary heart disease (CHD) and stroke
HRT with oestrogen alone is associated with no risk of CHD. Combined HRT is associated with little increase in the risk of CHD.
The baseline risk of stroke in women younger than 60 years is very low.
Oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke.
HRT does not increase CVD risk when started in women younger than 60 years.
Breast cancer
HRT with oestrogen alone is associated with no increase in the risk of breast cancer.
Combined HRT is associated with an increased risk of breast cancer that is dependent on duration of treatment, which reduces after stopping HRT.
Menopause non-hormonal meds
For vasomotor symptoms, consider a trial of:
SSRIs or SNRIs for 2 weeks initially.
Options include fluoxetine (20 mg daily), citalopram (20 mg daily) etc.
CBT
For mood disorders, consider:
Self-help resources and a trial of CBT for low mood and/or anxiety.
Antidepressant treatment for a confirmed diagnosis of depression and/or anxiety, if indicated.
For urogenital symptoms consider a trial of:
Vaginal moisturizers, such as Replens MD®, to be used at least twice weekly.
Vaginal lubricants if there are insufficient vaginal secretions for comfortable sexual activity.
Note: these preparations may be used alone or in addition to vaginal oestrogen preparations.
Arrange to review after 3 months, then at least annually thereafter.
If the woman is symptom free on antidepressant treatment, consider a gradual withdrawal of treatment after 1–2 years. Advise that symptoms may recur once treatment is stopped.
Advise that the use of vaginal moisturizers and lubricants may be continued indefinitely.
Offer to refer the woman to a healthcare professional with expertise in menopause, if treatments do not improve menopausal symptoms.
Menopause women with comorbidities
If there is any uncertainty about appropriate management, seek specialist advice.
Women with or at high risk of breast cancer:
Stop systemic HRT in women who are diagnosed with breast cancer.
Do not offer HRT routinely to women with menopausal symptoms and a history of breast cancer.
Seek specialist advice if a woman wishes to consider the use of hormonal therapy, such as treatment with low-dose vaginal oestrogen.
Advise that women taking tamoxifen should not use fluoxetine or paroxetine, as they may inhibit the effect of tamoxifen.
Do not recommend the use of isoflavones, red clover, black cohosh, vitamin E, or magnetic devices to treat menopausal symptoms in women with breast cancer.
Women with increased risk of venous thromboembolism (VTE):
Consider the use of transdermal rather than oral HRT for women at increased risk of VTE, including women with a BMI over 30 kg/m2.
Consider referring women at high risk of VTE (for example, with a strong family history of VTE or a hereditary thrombophilia) to a haematologist for assessment before considering the use of HRT.
Women with increased risk of CVD:
Manage any cardiovascular risk factors before considering the use of HRT. The presence of cardiovascular risk factors is not a contraindication to taking HRT as long as they are optimally managed.
Consider the use of transdermal rather than oral HRT.
Women with type 2 diabetes:
Consider the use of HRT after taking any other co-morbidities into account.
Women with hypothyroidism:
Advise that TSH levels should be monitored regularly (for example, 6–12 weeks after starting oral HRT), to ensure that levels remain in the acceptable range, as the dose of levothyroxine may need to be increased.
What forms of contraception are most likely to help with regulating heavy or painful periods?
Methods of contraception that can help with heavy periods are:
combined pill
IUS (hormonal coil)
progestogen-only pill
contraceptive implant
contraception injection
The IUS is generally the most effective
What forms of contraception might make periods heavier?
An IUD (copper coil) can make your periods heavier and more painful. This usually gets better within a few months.
