Special Interest: Women's health

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

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.

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.

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.

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.

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.

The risk of major congenital malformations in infants rises with maternal overweight and degree of obesity, a large study from Sweden has shown.

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.

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]

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]

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