Symposium: Women's health

Symptom recognition key to diagnosing endometriosis

22 Mar 2018Registered users

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.

Managing osteoporosis in postmenopausal women

22 Mar 2018Paid-up subscribers

Most patients with osteoporosis are asymptomatic unless they suffer a fragility fracture. A fragility fracture is a type of pathological fracture that occurs as a result of normal activities, such as lifting, bending, or a fall from standing height or less. There are three fracture sites said to be typical of fragility fractures: vertebral fractures; fractures of the neck of the femur; and Colles' fracture of the wrist. Following fracture risk assessment a dual energy X-ray absorptiometry (DXA) scan may be recommended.

Tailor management to the patient with fibroids

22 Mar 2017Paid-up subscribers

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.

Preventing stroke and assessing risk in women

22 Mar 2017Paid-up subscribers

Ischaemic stroke is rare in premenopausal women but risk increases with advancing age and doubles in the ten years following the menopause. Up to the age of 75 years men have a 25% higher risk of suffering a stroke compared with women. However, the increased life expectancy of women ultimately results in a higher overall incidence. Twice as many women die from stroke compared with breast cancer. Women with cerebrovascular disease are more likely to present with atypical symptoms than men. Atrial fibrillation and hypertension, although less common than in men, are more potent risk factors for stroke in women.

Managing debilitating menopausal symptoms

21 Mar 2016Paid-up subscribers

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.

Be vigilant for perinatal mental health problems

23 Mar 2015Paid-up subscribers

The postnatal period appears to be associated with higher rates of adjustment disorder, generalised anxiety disorder, and depression. Women who have a history of serious mental illness are at higher risk of developing a postpartum relapse, even if they have been well during pregnancy. Postnatal depression is more severe than baby blues, follows a chronic course and may relapse outside the perinatal period. Bipolar disorder may present as a first depressive episode in pregnancy or the postnatal period. In the postpartum period women have a high risk of severe relapse.

GPs have key role in early diagnosis of endometriosis

23 Mar 2015Registered users

Risk factors for endometriosis include early menarche, late menopause, delayed childbearing, vaginal outflow obstruction and a first-degree relative affected. Women commonly present to their GP with pelvic pain, painful intercourse or subfertility. Referral should be considered if pain is not controlled with simple analgesia or the diagnosis is suspected in a woman who is actively trying to conceive. Early referral should be considered in women with abnormal examination findings, or an abnormal ultrasound result.


Clinical reviews: Obstetrics and gynaecology

Labour induction vs expectant management in nulliparous women

24 Sep 2018Registered users

Induction at term significantly reduced the Caesarean section rate, compared with expectant management, in low-risk nulliparous women in a large multicentre trial from the US. However, it did not confer any benefits in terms of perinatal outcomes.

Active surveillance vs immediate treatment for CIN2

25 Jun 2018Registered users

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

Bicarbonate for dystocia improves maternal and fetal outcomes

23 Apr 2018Registered users

Administering a drink of sodium bicarbonate dissolved in water to women with dystocia an hour before oxytocin treatment resulted in better outcomes for both mother and child, compared with standard oxytocin treatment alone, a small trial from Sweden has found.

Women with endometriosis at raised risk of ovarian cancer

22 Mar 2018Registered users

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.

Maternal sleeping position may raise the risk of late stillbirth

22 Feb 2018Registered users

Pregnant women who went to sleep in a supine position had a two-fold increased risk of late stillbirth, a UK study has shown.

Position during second stage of labour may influence spontaneous vaginal delivery rates

20 Dec 2017Paid-up subscribers

Nulliparous women, undergoing epidural analgesia, who adopted a lying down position were more likely to achieve a spontaneous vaginal delivery than those in an upright position during the second stage of labour, a UK study has found.


Special report 2014

Diagnosis and management of miscarriage

22 May 2014Paid-up subscribers

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]


Urinary incontinence

Improving the management of urinary incontinence

20 Mar 2014Paid-up subscribers

Urinary incontinence is a common condition that is likely to be under-reported. Its frequency increases with age, parity, high BMI, and associated comorbidities. The history should include the circumstances in which the incontinence occurs, the duration and how it affects the patient’s quality of life. The initial assessment should include enquiring for symptoms of urinary tract infection and carrying out a urine dipstick test. [With external links to the current evidence base]

Overactive bladder and irritable bowel syndrome often co-exist

24 Jun 2013Registered users

The link between overactive bladder (OAB) and irritable bowel syndrome (IBS) suggests that it is worth GPs asking about bowel symptoms when assessing patients with symptoms suggestive of OAB, a study from Japan concludes. The researchers investigated the prevalence of OAB and IBS using a large-scale internet-based survey. Questionnaires were sent to 10,000 patients, 5,000 men and 5,000 women, with 1,000 of each gender represented from each decade from 20-29 through to 60 and over. [With external links to the current evidence base]

Urinary incontinence in women: diagnosis and management

21 Mar 2010Registered users

Urinary incontinence can affect women of all ages. Incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals, and the impact on the families and carers may also be profound. There are more than 3.5 million sufferers in the UK. [With external links to the current evidence base]

Improving compliance in overactive bladder syndrome

16 Feb 2010Registered users

Having a full discussion with patients, before commencing treatment, about the pros and cons of medications for overactive bladder (OAB) syndrome and the role of lifestyle measures could improve adherence to therapy. This was the conclusion of a survey conducted in the United States used families participating in a large nationwide market research panel of 600,000 households. [With external links to the current evidence base]

Anticholinergics can help improve bothersome overactive bladder symptoms

01 Oct 2009Registered users

This study is directly applicable to patients seen in primary care. It would suggest a safe strategy of initiating an alpha-blocker in patients with mixed storage and voiding symptoms, reviewing at 4-6 weeks, and adding an anticholinergic for those patients whose storage symptoms remain bothersome. It is always possible to trial removing the anticholinergic after a few months of bladder retraining, particularly to see if a placebo effect had a significant role, with therapy reintroduced if storage symptoms relapse. [With external links to the current evidence base]


Clinical reviews relating to women's health

Bipolar disorder associated with adverse outcomes in pregnancy

21 Feb 2013Paid-up subscribers

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.

Statins are as beneficial in women as men

21 Mar 2012Paid-up subscribers

A large meta-analysis has shown that statins are just as effective in women as in men for reducing cardiovascular events and all-cause mortality. The analysis included 141,235 patients, 40,275 of whom were women, from studies such as JUPITER, ALLHAT-LLT, ASCOT-LLA, the Heart Protection Study, PROVE-IT and TNT.

Use of SSRIs in pregnancy increases risk of persistent pulmonary hypertension in the newborn

21 Mar 2012Paid-up subscribers

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.

Which women with GDM are at risk of future diabetes?

24 Jan 2012Paid-up subscribers

Impaired glucose tolerance, low HDL cholesterol and age > 35 were the strongest predictors of developing diabetes in women with gestational diabetes mellitus (GDM), a study from Vienna has found. Commenting on the study, Dr Chris Barclay, GP with an interest in O&G, Suffolk, writes: ' The development of type 2 diabetes appears to be a continuously progressive process which can last for years or even decades. The metabolic stress of pregnancy appears to unmask this tendency temporarily, even though most women will become euglycaemic after delivery. The underlying metabolic disorder for many of these women will however continue to progress. GDM is an independent risk factor for diabetes. The opportunities for timely intervention and prevention here are obvious. Primary care is best placed to offer this help.'


The menopause and HRT

Postmenopausal bleeding should be referred urgently

21 Mar 2012

All women with postmenopausal bleeding should be referred urgently. Endometrial cancer is present in approximately 10% of cases. First-line investigation is a transvaginal ultrasound scan. A normal TVUS is reassuring, and if examination is normal further investigation is not required, providing the bleeding has stopped. There is no evidence to indicate whether different patterns of postmenopausal bleeding such as one-off bleeding or more frequent bleeds are more likely to be associated with malignancy. [With external links to current evidence and summaries]

Management of fibroids should be tailored to the patient

22 Mar 2011Paid-up subscribers

At least one in four women will develop one or more fibroids during their lifetime. They are most common in women aged 30-50 years and can run in families. Patients often have multiple fibroids, although some women have just one. Fibroids are three times more common in women of Afro-Caribbean descent than Caucasian women. Risk factors for the development of fibroids are:age; nulliparity; race; family history; obesity. There appears to be a decreased risk in smokers. Fibroids may be found during a routine examination or by chance during a scan for some other reason. On bimanual examination the uterus appears irregular in outline. An ultrasound scan can confirm the diagnosis. Women with menorrhagia and fibroids >12 cm and/or a palpable uterus should be referred to a specialist for further opinion. [With external links to current evidence and summaries]

Weighing up the benefits and risks of HRT

21 Feb 2011Registered users

An observational study from Canada has shown that a decline in the use of HRT over the past decade was followed by a reduction in the incidence of breast cancer. Data on HRT prescriptions dispensed for women aged 50-69, during the years 2001-2006, was collated from a national registry. Information about current HRT use was obtained by telephone from a sample of 1,200 women in this age group already enrolled in the National Population Health Survey. However, the data are observations of association only, and are not controlled for other risk factors for breast cancer such as parity and alcohol intake. The absolute risk of breast cancer to an individual user of HRT is small (and smaller still in oestrogen-only formulation users). The potential benefits need to be weighed up against the risks for each individual patient. [With external links to current evidence and summaries]

Do HRT patches increase the risk of stroke?

20 Oct 2010Registered users

Low-dose transdermal oestrogen patches do not appear to raise the risk of stroke. However, high-dose patches, oral HRT using oestrogen alone or combined with a progestagen, are associated with an increased risk. A total of 15,710 cases of stroke were identified, from a cohort of nearly 900,000 women aged 50-79, on the General Practice Research Database; giving an incidence of 2.85 per 1,000 woman-years. The average age at stroke was 70 years. Four matched controls were selected for each case. [With external links to current evidence and summaries]

Premature menopause linked to CVD and osteoporosis

22 Mar 2010Paid-up subscribers

Premature menopause can mean the end of fertility. The condition affects 1% of women under the age of 40, one in 1,000 under the age of 30 and one in 10,000 under the age of 20. In the UK, each year, 110,000 women will experience premature menopause between the ages of 12 and 40. [With external links to current evidence and summaries]

HRT increases cardiovascular risk in older women

01 Oct 2007Paid-up subscribers

There has been much discussion over the years about the effects of hormone replacement therapy (HRT) on cardiovascular disease. Results have recently been published from the WISDOM trial, a multicentre, randomised, placebo-controlled, double-blind trial recruiting from primary care centres in the UK, Australia and New Zealand. The trial was stopped early following adverse cardiovascular outcomes in the HRT arm of the American Women's Health Initiative (WHI) trial. By this time the WISDOM trial had screened more than 56,000 postmenopausal women aged 50-69 years (mean age 63), and 5,692 had started treatment. Although WISDOM never reached its full potential, its message is broadly similar to the WHI trial: HRT increases cardiovascular and thromboembolic risk when started in older postmenopausal women. [With external links to current evidence and summaries]

Balancing the risks and benefits of HRT

27 Jul 2007Paid-up subscribers

A paper from the influential Million Women Study has shown that the risk of developing ovarian cancer is increased by HRT use. The question is: how should these data be incorporated into HRT consultations in primary care? A total of 1.3 million women were originally recruited to the study, beginning in 1996. Data were collected over an average of 5.3 years from nearly 950,000 women. Half the women had used HRT, 30% of whom were current users. [With external links to current evidence and summaries]

Tailor treatment to the patient in endometriosis

01 Mar 2007Paid-up subscribers

Endometriosis is a common gynaecological condition found almost exclusively in women of reproductive age. It is most common in patients aged 25 to 35 years. The signs and symptoms are diverse and the clinical course is highly variable and unpredictable. [With external links to current evidence and summaries]


Sexual health: women and men

GP training programme improves HIV testing rates

22 Nov 2018Registered users

Sexual Health in Practice (SHIP), an educational programme tailored to general practice, increased GPs’ rates of HIV testing.

Intrauterine device use associated with reduced risk of cervical cancer

22 Oct 2018Registered users

Women who had used an intrauterine contraceptive device (IUD) were found to have a lower risk of cancer of the cervix in a systematic review and meta-analysis.

Patients at risk of STIs not attending sexual health services

25 Jul 2018Registered users

More than 80% of women and nearly 90% of men who reported having unsafe sex in the past year did not consult sexual health services, findings from the third National Sexual Attitudes and Lifestyles (Natsal 3) study have shown.

Exploring the barriers to fitting IUCDs in primary care

25 Jun 2018Registered users

A general practice study has revealed a reluctance among GPs and practice nurses to fit intrauterine contraceptive devices (IUCDs). An online survey was sent to 69 practices in the south east of England and 208 individuals responded. More than two-thirds of the respondents were GPs and nearly a third were nurses. When asked about statements relating to potential barriers to providing or recommending IUCDs, respondents who were not trained to fit IUCDs were more likely to identify with more barriers than those who had been trained.

Composition of vaginal microbiota may increase risk of chlamydia infection

22 May 2018Paid-up subscribers

 Lactobacillus iners-dominated vaginal microbiota was associated with increased susceptibility to Chlamydia trachomatis infection in women, in a Dutch nested case-control study.

Self-taken swabs can detect bacterial vaginosis and candidiasis

23 Jan 2018Registered users

Lower vaginal swabs taken by patients are as reliable as high vaginal swabs taken by clinicians for the detection of vulvovaginal candidiasis or bacterial vaginosis, a UK study has shown.

Dyspareunia in women associated with physical and mental health conditions

23 Nov 2017Paid-up subscribers

The third National Survey of Sexual Attitudes and Lifestyles in Britain (Natsal-3) has found a strong association between women reporting painful sex and poor physical health and depressive symptoms.

Chlamydia and HIV testing for young people in primary care

22 Jun 2017Registered users

Young men and women would be happy to be offered chlamydia screening, contraception and HIV tests from GPs, a UK study has shown.

GP vs clinic care for people living with HIV

22 Mar 2017Registered users

Around 60% of people living with HIV would choose GP care in preference to an HIV clinic, a UK study has found.


Special reports

Early treatment vital in pelvic inflammatory disease

23 Apr 2018Registered users

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.

Diagnosis and management of miscarriage

22 May 2014Paid-up subscribers

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]

Identifying patients at risk of perinatal mood disorders

23 May 2012Paid-up subscribers

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]

Improving early detection of ovarian cancer

22 Jun 2011

Ovarian cancer is the fifth most common cancer in women. The incidence has increased over the past 20-25 years, particularly in the 65 and over age group. The outcome for women with ovarian cancer is generally poor, with an overall five-year survival rate of less than 35%. The survival rates for women with ovarian cancer in the UK are significantly lower than the European average. Despite recommendations, published by NICE in 2005, on referral of patients with suspected cancer, the majority of women diagnosed with ovarian cancer are not electively referred via the ovarian cancer two-week pathway. They are often referred to the wrong specialty or present as emergencies. NICE has now published a clinical guideline on the diagnosis and initial management of ovarian cancer.  [With external links to current evidence and summaries]



Pregnancy related conditions

21 Feb 2011Registered users

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