Gynaecology in Primary Care

A Practical Guide

Anita Sharma

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000477061
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Gynaecology in Primary Care comes at a time of great change in health service delivery. General practice is facing the challenges of developing Clinical Commissioning Groups, providing an ever greater range of primary care services and implementing NICE guidelines, whilst CCGs through their members will be under a legal duty to innovate. From a provider perspective, the book equips general practitioners with up-to-date knowledge of common gynaecological conditions, suggestions of best practice with regard to management and investigations to be undertaken within primary care, and guidelines for onward referral, where this is appropriate and necessary. From a commissioning perspective it provides an invaluable resource to CCGs, to inform their future pathways for gynaecology care. This highly practical book delivers the main aim of the RCP report - to ensure best care for female patients in the setting of their choice and where possible to develop streamlined one-stop services in primary care so that women do not have to take time off from their work and family commitments. It is ideal for general practitioners needing to be inspired and informed, and is also highly recommended for other healthcare professionals and medical students with an interest in women's health. 'Optimal patient care requires many connected features to synchronise effectively. This book describes how this could be achieved by focusing attention on well-crafted, evidencebased clinical pathways. This book advances our thinking on how we connect clinical, system and patient level perspectives on optimal care management.' Denis Gizzi, in his Foreword 'Written by a highly regarded, experienced and practicing GP, who has taken on the role as Clinical Director on behalf of the CCG for this programme area, this book is a valuable asset for both practicing GPs and developing CCGs to ensure that gynaecology services effectively commission, maximise the health of the population, improve the experience of the patient, and improve value for money.' Kath Wynne-Jones, in her Foreword 'An excellent guide to the management of gynaecological problems in primary care for not only clinicians in training, but for more experienced clinicians who look for straightforward and easily accessible advice to support their clinical management decisions. Look no further than this textbook. Dr Sharma's textbook will be a boon to developing organisations in delivering world-class services.' Dr Ian Wilkinson, in his Foreword

1

Dysmenorrhoea

DEFINITION

Dysmenorrhoea is defined as painful menstruation that interferes with a woman’s physical, emotional and social quality of life.¹ The term dysmenorrhoea is derived from the Greek words dys meaning difficult/painful, meno, meaning month and rrhea, meaning flow.

Dysmenorrhoea is one of the most common gynaecological problems in young women who present to their general practitioner. Menstrual pain is often described as lower abdominal cramp-like pain, sharp/aching pain that comes and goes, or sometimes back pain during the period. Some pain during periods is normal but excessive pain must not be ignored. Premenstrual symptoms are often present including nausea and vomiting.

It is classified as either primary (spasmodic) or secondary (congestive) dysmenorrhoea.

Primary dysmenorrhoea is defined as recurrent, cramp-like pain occurring during menstruation in the absence of any pelvic pathology. It usually begins in adolescence. Current evidence suggests that primary dysmenorrhoea is due to prostaglandin F2 alpha (PGF2 alpha), a potent myometrial stimulant and vasoconstrictor present in the secretory endometrium.² This causes an increased myometrial activity resulting in uterine ischemia and pain. The uterine contractions can last many minutes and may produce uterine pressures greater than 60 mmHg. Elevated levels of prostaglandin were found in the endometrial fluid of women with dysmenorrhoea and the level found correlated with the degree of pain.³

Pathophysiology of primary dysmenorrhoea:

FIGURE 1.1 Pathophysiology of primary dysmenorrhoea

Source: Primary Dysmenorrhoea Consensus Guideline
www.sogc.org/guidelines/public/169E-CPG-December2005.pdf

Secondary dysmenorrhoea is defined as menstrual pain resulting from gynaecological pathology, e.g. fibroids, endometriosis or pelvic inflammatory disease.

Prevalence

Dysmenorrhoea is one of the most common gynaecological problems in young women presenting to clinicians.⁴

Its prevalence is estimated at 25% in women of all age groups. It is most common in adolescents. Ninety per cent of female adolescents tend to suffer with dysmenorrhoea.⁵ Primary dysmenorrhoea affects up to 50% of postpubertal women.⁶ Secondary dysmenorrhoea is most common in women aged 30–45 years. Dysmenorrhoea severe enough to cause absence from work occurs in less than 5% of women.⁷

Risk factors

The following risk factors have been associated with severe episodes of dysmenorrhoea:⁸

• smoking
• early menarche
• heavy menstrual bleed
• prolonged menstrual bleed
• strong family history
• obesity
• age (symptoms are more pronounced in adolescents than in older women)⁷
• lower socioeconomic groups⁴
• frequent lifestyle changes, less social support and stressful relationships.⁹

Obesity and excess alcohol consumption were found to be associated with dysmenorrhoea in some (but not all) studies.^10,11 Physical activity is not thought to be associated with dysmenorrhoea.⁸ There is some evidence that parous women have less severe dysmenorrhoea.^2,10

Primary care management

The optimal management depends on distinguishing between primary and secondary dysmenorrhoea. Although it is not life threatening, it can be debilitating and it is essential that the underlying pathology is identified and treated specifically.

Women suffering from primary dysmenorrhoea do not usually seek medical help and do not make use of available prescription medications. A detailed gynaecological history can easily distinguish between primary and secondary dysmenorrhoea.

History

Menstrual history

Enquire as to the age of menarche, length and duration of bleeding and whether associated with blood clots.

Pain

Enquire about the type, duration, radiation of pain, association with any other symptoms (bladder/bowel), severity and the degree of disability. Ask about all therapies used in the past for pain relief including over-the-counter preparations.

Sexual history

It is important to ask about sexual history, past history of sexually transmitted infections (STIs), vaginal discharge and dyspareunia. Enquire about contraception. Many adolescents use dysmenorrhoea as a pretext to seek contraception.

Family history:

Enquire about any family history of endometriosis. A family history of endometriosis may be an indicator for referral...