Special Interest: Women's health

Hypertension is the most common medical complication of pregnancy, affecting 8-10% of pregnancies in the UK. It is associated with risks to both the woman and the fetus, with increased risks of pre-eclampsia, preterm delivery, fetal growth restriction, placental abruption and perinatal death. Any new onset of hypertension after 20 weeks or symptoms or signs suspicious of pre-eclampsia should be referred for same day assessment at a secondary care antenatal assessment unit.

A detailed patient history is key to the assessment of patients with urinary incontinence and to guiding initial investigation and management. Clinical examination should include abdominal palpation to assess for masses, including an enlarged bladder. Visual inspection of the perineum and vagina helps determine whether the patient may be hypo-oestrogenic and can confirm the presence and grading of pelvic organ prolapse. Digital vaginal examination enables detection of masses, and an assessment of pelvic floor muscle strength. Urinalysis should also be carried out. Most patients will have either stress, urgency, or mixed urinary incontinence.

Pelvic inflammatory disease (PID) is caused by infection ascending from the cervix. It can affect the uterus, fallopian tubes, ovaries, and peritoneum. Important sequelae include infertility, ectopic pregnancy and tubo-ovarian abscess. PID is associated with sexually transmitted infections. These are more prevalent in younger women. A diagnosis of PID should be considered in any sexually active woman with recent onset pelvic pain associated with tenderness on bimanual examination where other differentials have been excluded. Delay in commencing treatment for PID has been shown to increase the risk of long-term complications.

Polycystic ovary syndrome is a condition characterised by hyperandrogenism, multifollicular ovaries and ovulatory dysfunction. It affects 8-13% of women of reproductive age and is associated with insulin resistance, hyperlipidaemia and obesity. Baseline measurements should include blood pressure and BMI. Clinical signs of hyperandrogenism including hirsutism, acne and androgenic alopecia should be assessed. A hormone profile should be done during days 1-5 of the menstrual cycle or as a random sample when there is amenorrhoea.

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

Fibroids are benign, hormone-dependent tumours of uterine smooth muscle and connective tissue. They are commonly asymptomatic, but can cause symptoms such as heavy menstrual bleeding and pelvic pressure symptoms. Around 20 to 30% of women with heavy menstrual bleeding have fibroids. Fibroids are most prevalent in women aged 30-50 years and there may be a genetic predisposition. They are more common in black women than white women. Other risk factors include obesity and nulliparity. Asymptomatic women should only be referred if their uterus is palpable abdominally, if fibroids distort the uterine cavity or the uterus is larger than 12 cm in length.

Intrauterine exposure to maternal smoking is associated with an increased risk of fractures in the first year of life, a national cohort study from Sweden has found. The study cohort comprised 1,680,307 live born singletons in Sweden, born between 1 January 1983 and 31 December 2000, followed up until 31 December 2014.

Urinary stress incontinence is more likely following vaginal than caesarean section (CS) delivery of twins, a multinational randomised controlled trial has shown.

Active surveillance may be a suitable option in selected, particularly younger, women with CIN2, a systematic review and meta-analysis has concluded.

Miscarriage is the most common complication of pregnancy. It is defined as a pregnancy failure occurring before the completion of 24 weeks of gestation. It has been estimated that 10 to 15% of all pregnancies end in early spontaneous first trimester miscarriage i.e. before the end of the completed twelfth week of pregnancy. The risk of miscarriage decreases with increasing gestational age, and late miscarriages, from 12 to 24 weeks’ gestation, occur in only 1-4% of cases. While miscarriage is rarely associated with significant health problems, it can cause significant psychological distress to the woman and her partner. [With external links to the current evidence base]

The children of mothers who experience perinatal depression are more likely to report psychotic experiences at the age of 18, a UK prospective cohort study has found. A joint analysis found an association between maternal antenatal depression symptoms and both offspring psychotic experiences and depression at age 18. Most of those with psychotic symptoms will not go on to develop psychosis or schizophrenia. However, they are still at increased risk of low educational and occupational achievement, social impairment, harmful drinking and substance misuse.

Male doctors have a lower suicide risk than the general male population, an analysis of English death registrations from 2011 to 2015 has found. However, the risk for female doctors is comparable with that of the general female population, although the male preponderance of suicide meant that there were in fact more than twice as many male as female doctor suicides. There are differences between specialties: compared with physicians, GPs are more than three times as likely to commit suicide.

A landmark study from Scotland has shown that bivalent HPV vaccine confers significant protection against cervical epithelial dyskaryosis and dysplasia, both precursors of invasive cervical cancer. This study reports statistically significant reductions in all grades of CIN, equating to vaccine effectiveness estimates of 80% or greater after routine immunisation of girls at age 12-13 years.

Women who use the combined oral contraceptive pill (COCP) are at reduced risk of developing ovarian cancer, a benefit that persists for several years after cessation, a nationwide cohort study from Denmark has found.

• Superficial thrombophlebitis
• Polymorphic eruption of pregnancy
• Chloasma
• Naevi
• Jaundice