Special Interest: Women's health

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.

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

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.

The risk of ovarian cancer is increased in women with endometriosis, a large cohort study from Scotland has shown. The study also found that women with endometriosis are likely to undergo more surgical procedures compared with women who do not have the condition.

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]

Babies of women with bipolar disorder are more likely to be born preterm, irrespective of whether the mother had received mood stabilising drugs, a Swedish cohort study has found. Infants whose mothers had untreated bipolar disorder had an increased risk of microcephaly and neonatal hypoglycaemia.

A population-based cohort study from the Nordic countries has found that women who take SSRIs during the second half of pregnancy are more than twice as likely to give birth to children with persistent pulmonary hypertension of the newborn (PPHN). However, the absolute risk remains very low. Data were obtained from national registers of births, deaths and dispensed prescriptions. Exclusion criteria were multiple births and a gestational age of less than 33 weeks. More than 1.6 million infants, born between 1996 and 2007, were included in the study.

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

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.

In perinatal mental illness not only does the patient suffer, but obstetric outcomes, mother-baby interactions and hence longer term emotional and cognitive development of the child are also affected. Perinatal mental illness also has an impact on other family members. The UK Confidential Enquiry into Maternal and Child Health has consistently found psychiatric disorders to be one of the leading causes of maternal death, often through suicide. Postnatal depression and puerperal psychosis are two disorders most commonly associated with the perinatal period: the first, because of its high prevalence, 13% in the first few months following birth, the second because of its potentially disastrous consequences, including suicide, neglect of the baby and infanticide. [With external links to the current evidence base]