Summary

Women make up about half of our population. Gynaecological symptoms are common in general practice. With this article, we would like to focus on the management of a number of common gynaecological problems, namely: abnormal cervical smear, hormonal replacement therapy, dysmenorrhoea, abnormal menstrual bleeding and vulvovaginitis.

摘要

女性約佔本地人口的一半。在普通科門診，各種婦科病狀是常見的女性病狀。本文著眼於各種常見婦科疾病的診療，如子宮頸抹片異常、荷爾蒙替補療法、經痛、異常經期出血和外陰陰道炎。

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Introduction

Woman's health care is an all-encompassing discipline that crosses many fields of medicine. Virtually, every physician is somehow involved regardless of his/her practising specialty. General practitioners (GPs) are therefore frequently involved in the management of gynaecological problems in their daily practice. Unfortunately, exposure to gynaecological care in medical school and residency is almost exclusively orientated to an in-patient setting. This paper is designed to help the GPs understand the out-patient management of a number of common gynaecological problems which they might face in their daily practice. This paper will discuss the management of abnormal cervical smear, peri- and postmenopausal problems, hormonal replacement therapy (HRT), abnormal menstrual bleeding, dysmenorrhoea and vulvovaginitis.

Abnormal cervical smear

Cervical cancer is virtually a preventable disease, with an effective screening programme. The incidence in Hong Kong is about 500 new cases every year. It is the 4th commonest malignancy¹ in our female population indicating that a well-organized screening programme is mandatory in Hong Kong.

In recent years, most pathologists use the Bethesda system² (Figure 1) to report cervical smear results. According to the Hong Kong College of Obstetricians and Gynaecologists guideline³ (Figure 2), ladies with a normal smear (inflammatory changes) should follow the normal screening programme.

Ladies with "ASCUS" results (see Figure 1 and 2 from here onwards) need to have their smear repeated at 4-6 months intervals or undergo high risk HPV testing. If the 2nd smear is still ASCUS (or more) or the HPV test is positive, the patient will then need to be referred to a colposcopist as these findings are associated with a high incidence of CIN lesions. Patients with ASC-H, LSIL, HSIL or invasive lesions should all be referred to a colposcopist.

Another category of reports we should pay attention to is the abnormal glandular cell (AGC) which may come from the cervical canal or higher up from the uterine cavity. These patients will need to be referred immediately for further investigations since it is associated with high grade lesions or carcinoma of the cervix or the endometrium.⁴ Finally, we come to endometrial cells being found on a smear. If it is seen in postmenopausal women, they should be referred for further investigations because 12% of them may have significant pathology of the endometrium such as hyperplasia or carcinoma.⁵ However if it is seen in menstruating women over the age of 40, management will depend on the clinical finding and woman with risk factors or abnormal vaginal bleeding should be referred for further management. On the other hand, if it is seen in woman less than 40 years old, no further investigation is needed, unless there are persistent menstrual problem or other significant abnormality found.

Hormonal replacement therapy

HRT may be offered to women with problems in the peri- and postmenopausal period as a result of oestrogen deficiency. The usual indications are climacteric symptoms, prevention and treatment of osteoporosis, prevention of cardiovascular disease, improvement of cognitive function and perhaps prevention of cancer of the colon.

Climacteric symptoms

Climacteric symptoms, like hot flushes and sweating, are very effectively controlled by HRT and are probably the most frequent indications. The duration of treatment is usually short-term.

Osteoporosis

Oestrogen therapy can also protect the bone against fracture. However, in the recent Woman Health Initiative (WHI) Trial, women who were randomised to receive Premarin 0.625mg and Provera 2.5mg daily were found to have an increased risk of breast cancer and cardiovascular disease. The author concluded that these risks out-weighed the beneficial effects on the bone.⁶ The rationale of HRT in the management of osteoporosis should therefore be clearly explained to the patient, especially when there are alternative treatments available such as the bisphosphonates and selective oestrogen receptor modulators (SERM).

Cardiovascular disease

There was an increased risk of cardiovascular problems found in the WHI Trial. Though epidemiological studies suggest oestrogen reduced the risk of cardiovascular disease in healthy postmenopausal women,⁷ the consensus now is that HRT should not be given to women with established heart disease as this may precipitate a cardiac event. One should also explain carefully to patients that it is still uncertain whether oestrogen alone or in combination is beneficial for the cardiovascular system in primary prevention. The evidence in the recent WHI study indicated that there is no increase or decrease in the overall risk. Furthermore, there was also a significant increase in the risk of stroke and venous thrombosis in the treatment group of the study.⁶

Breast cancer

Another issue which must be addressed here is the risk of breast cancer. In the studies which have identified an increased risk, it does not appear to be significant until after 5 years of use.⁸

The prescription of HRT requires detailed discussion of the pros and cons with the patients. The duration of treatment is usually short for climacteric symptoms because these symptoms only last for a few years. For the management of osteoporosis, the duration is usually much longer as the protective effect will be rapidly lost once the treatment is stopped.

Abnormal menstrual bleeding

Abnormal menstrual bleeding is a very common problem, and is commonest at the extremes of reproductive age. In adolescent, it is usually related to immaturity of the hypothalamic-pituitary-ovarian axis. In the premenopausal age group, it is usually caused by failing ovarian function. However, in women over the age of 40, the diagnosis of carcinoma of the uterus must be excluded as the first priority. Abnormal menstruation in the reproductive age group is relatively uncommon, and all should be investigated in order to determine the underlying cause. Common causes can be divided into local, pregnancy-related and medical problems, such as thyroid disease, hyperprolactinaemia and polycystic ovarian syndrome.

Management of abnormal menstrual bleeding will depend on the age of the patient. In teenage girls, who are sexually active, a pregnancy test must be performed before prescribing treatment. Combined oral contraceptive (COC) pill is commonly used, as it serves the purposes of controlling menstruation and contraception.

In the reproductive age group, after physical examination and a pregnancy test, complete blood picture with platelet count should be checked. According to the clinical picture, thyroid function, FSH to LH ratio, prolactin level and an ultrasound can be ordered to look for the causes mentioned above. In cases with persistent symptoms despite treatment, Z-sampling or hysteroscopy can be performed.

Lastly, in the premenopausal group, especially those over the age of 40, initial assessment would include physical examination, pregnancy test, complete blood picture with platelet count, as well as endometrial sampling and sometimes, hysteroscopy. As in other age groups, if relevant symptoms and signs are present, TSH level, prolactin level and ultrasound can be included.

In cases where no cause can be found, treatment is mainly symptomatic. Medical treatment includes transamin, progestogen and Mirena (progestogen-secreting IUCD), while surgical treatment involves endometrial ablation and total hysterectomy.

Dysmenorrhoea

Dysmenorrhoea is probably the commonest gynaecological problem. Up to 50% of women suffer from some degree of dysmenorrhoea. Amongst these, 10% of them can be very severe. Primary dysmenorrhoea refers to pain related to menstruation in the absence of demonstrable gynaecological pathology and usually starts early at menarche. Secondary dysmenorrhoea refers to pain related to menstruation in the presence of organic pelvic disease e.g. endometriosis, chronic pelvic infection and uterine fibroid. It occurs most commonly in the thirties.

Management of dysmenorrhoea starts from excluding local causes by pelvic examination and ultrasound scanning. In cases where causes are found, treatment will be directed to the cause. However in cases of primary dysmenorrhoea, treatment will aim at symptomatic relief. Treatment options include NSAID, COC pills and Mirena. NSAID and sometimes COC can also be used to treat cases of secondary dysmenorrhoea refusing surgical intervention. Commonly used NSAID are mefenamic acid, naproxen, diclofenac and celecoxib.

Vulvovaginitis

The normal vagina is a habitat for microbial flora including gram-positive and gram-negative anaerobic species. The predominant flora is Lactobacillus species (Gram positive rods) which exerts a protective effect by the production of H₂O₂ and an acidic pH. These inhibit the growth of various potential pathogens.

In vulvovaginitis, investigations include gram stain or saline microscopy of discharge obtained by a vaginal swab, and sometimes plus an endocervical swab. Candidiasis, caused by candida albicans, is one of the commonest infections. This fungal infection presents with itchiness, soreness, superficial dyspareunia, external dysuria or a discharge. Vaginal discharge typically appears white, curdy and is non-offensive. The fungus changes the vaginal pH to 4-4.5.

Another common infection is bacterial vaginosis and the causative organisms are anaerobes. It typically presents with genital malodour or white to grayish offensive discharge. Trichomonas vaginalis is another organism that can cause vulvovaginitis and has similar presenting symptoms as candidiasis, apart from the vaginal discharge that appears yellowish green and has an offensive odour. In both bacterial vaginosis and trichomonas infection, the vaginal pH is kept above 5 and the treatment of choice is metronidazole. In bacterial vaginosis, clindamycin and amoxicillin can also be used. As the mode of transmission of Trichomonas is almost always sexual contact, there is a need to workup for other sexually transmitted disease.

For candidiasis, treatment can be topical, plus oral antifungal. Commonly used topical creams are clotrimazole 1%, econazole 1% and miconazole 2%. Antifungal can also be given in the form of vaginal pessary as listed below.

Drug		Dosage
Clotrimazole		500mg nocte x 1 or 200mg nocte x 3 or 100mg nocte x 6
Econazole		150mg nocte x 1-3
Miconazole		100mg nocte x 14 or 200mg nocte x 7

In recurrent cases, it is important to look out for any predisposing factors and treat these accordingly. Predisposing factors to consider would be diabetes mellitus, HIV or other immunocompromised conditions, frequent antibiotic treatment, hormonal treatment and tight-fitting clothing.

Conclusion

To conclude, general practitioners play a very important role in the management of common, simple gynaecological problems as well as the screening of high risk groups who may subsequently need further specialist input.

Key messages

1. A good screening programme is the key to the prevention and early detection of cervical cancer.
2. The benefits and side-effects of hormonal replacement therapy are still controversial and under investigation, hence its prescription needs thorough discussion with the patient.
3. Abnormal menstrual bleeding is a very common problem and management varies according to patient's age. Possible causes should be excluded before giving the patient symptomatic treatment.
4. In woman over the age of 40 with abnormal menstrual bleeding, the diagnosis of uterine carcinoma must be excluded.
5. Two common gynaecological problems encountered in the out-patient setting are dysmenorrhoea and vulvovaginitis. All general practitioners should be familiar with their treatment options.

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References