IPP: Women's Sexual Health Flashcards
What is dysmenorrhoea?
Dysmenorrhea aka as period pain is painful cramping usually in the lower abdomen occurring shortly before or during menstruation or both. Dysmenorrhoea is the most common gynecological symptom reported by women.
What types of dysmenorrhoea are there?
Why is it important to distuingish?
There are two types: Primary and secondary. It is important to distinguish between the two to determine If management OTC is suitable:
- Primary: Absence of any underlying pelvic pathology. Assumed cause is production of uterine prostaglandins during menstruation, which causes uterine contractions and pain
- Secondary: Underlying pelvic pathology (Endometriosis, fibroids, PID, IUD insertion)
Secondary causes must be excluded before a diagnosis of primary dysmenorrhoea.
What are risk factors for primary dysmenorrhoea?
For primary dysmenorrhoea: early menarche, heavy menstrual flow, nulliparity and family history of dysmenorrhoea.
When is the onset of primary dysmenorrhoea symptoms and what are the associated symptoms?
Primary dysmenorrhoea usually starts 6–12 months after the menarche, once cycles are regular:
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
The pain is usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain. Pelvic examination is normal.
Secondary dysmenorrhea symptoms
Often starts after several years of painless periods. The pain is no consistently related to menstruation alone but may persist after menstruation finishes or present during but is exacerbated by menstruation.
Other gynecological symptoms are often present (e.g. dyspareunia). Pelvic examination may be abnormal but the absence of abnormal findings does not necessarily exclude secondary dysmenorrhoea.
What are clinical features of secondary dysmenorrhoea?
Clinical features indicating a serious secondary cause of dysmenorrhoea include:
- Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids).
- Abnormal cervix on examination.
- Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge.
What is management of primary dysmenorrhoea?
NSAID (e.g. ibuprofen) and/or paracetamol for pain relief
For women who do not wish to conceive, hormonal contraception is an alternative first-line treatment and has the additional advantage of providing contraception.
Local application of heat (e.g. hot water bottle or heat patch) and transcutaneous electrical stimulation (TENS) may also help reduce pain
If symptoms are severe and have not responded to initial treatment within 3–6 months or there is doubt about the diagnosis, referral to a gynecologist should be arranged.
Management for secondary dysmenorrhoea
Refer to secondary care for further investigation and management.
What is cystitis?
Cystitis is inflammation of the bladder characterized by urgent and frequent need to urinate and pain when passing urine.
What is cystitis usually cause by?
It is usually the result of an infection in the bladder (UTI) but can also be caused by irritation or damage.
Can cysitis be treated in the pharmacy?
Acute cystitis can be managed in the pharmacy but there are a number of alarm symptoms that would indicate referral.
Acute cysitis typically resolves in a few days
What risk factros for complicated UTIs?
Risk factors for complicated UTI include:
Structural or neurological abnormalities, pregnancy, urinary catheterization, atypical or resistant infecting organisms, co-morbidities such as immunosuppression.
What are clinical features of lower UTIs?
Clinical features of lower UTIs: dysuria, frequency, urgency, change in urine appearance, nocturia and suprapubic discomfort
In those with underlying cognitive impairment typical features may be absent and UTI may be present with delirium and reduced functional ability.
Urinary symptoms can be caused by other genitourinary conditions such as STI and vaginal atrophy.
What does diagnosis of lower UTI involve?
Urine dipsticks can be used to aid diagnosis of UTI in women U65 who do not have risk factors of complicated UTI and not catheterized:
- If +ve for nitrite or leukocyte AND RBC = UTI likely
- If –ve nitrite and +ve leukocyte = UTI equally likely to other diagnoses
- If –ve nitrite, leukocyte and RBC = UTI less likely
A Urine sample should be sent for culture in all women with suspected UTI who:
- Pregnant — a repeat sample following treatment should be sent to confirm cure.
- Older than 65 years.
- Have persistent symptoms or if treatment fails.
- Have recurrent UTI.
- Catheterized
- Have risk factors for resistant or complicated UTI.
- Have visible or non-visible haematuria.
Management of cystitis
- Advice on self-care measures (hydration and analgesia)
- Treatment with AB (in most cases) – potentially a delayed script in non-pregn women with mild symptoms and no risk factors for complicated infection.
- Advice on when to seek medical review
- Reviewing choice of AB when results available.
Pregnant women:
- In pregnancy:
- Women with asymptomatic bacteriuria and suspected or proven UTI should be treated promptly with a 7-day course of antibiotics and followed up.
- Urgent specialist advice should be sought for recurrent UTI, catheter associated UTI, atypical pathogens or if an underlying cause is suspected.
- Antenatal services must be informed if group B streptococcal bacteriuria is identified.
In recurrent UTI:
- Referral should be made if cause is unknown, the woman is catheterized or malignancy suspected.
- Preventative measures such as behavior and personal hygiene should be discussed — topical vaginal oestrogen and antibiotic prophylaxis may be appropriate.
Red flag symptoms when analysing suspected UTI
Red flag symptoms: haematuria, loin pain, rigors, nausea, vomiting, and altered mental state — consider the possibility of serious illness such as sepsis.
- Pyelonephritis should be suspected in people with fever, loin pain or rigors.
- Haematuria may present as red/brown discolouration of urine or as frank blood.
- Cancers: abnormal vaginal bleeding, loss of weight, loss of appetite, and fatigue
What information should be taken during a history of UTIs?
- Onset and evolution of clinical features
- Other symptoms such as vaginal or urethral discharge, irritation or skin rash which may indicate a cause other than UTI.
- Red flags such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state — consider the possibility of serious illness such as sepsis.
- Family history of urinary tract disease such as polycystic kidney disease.
- Possibly of pregnancy in women of childbearing age — carry out a pregnancy test if unsure.
- Past medical history including risk factors for recurrent UT such as neurological conditions, diabetes mellitus, immunosuppression, urolithiasis, and bladder catheterisation.
- Medication including recent antibiotics.
Read differnetial diagnosis: UTIS
If there are urinary symptoms associated with fever and/or loin pain suspect pyelonephritis.
If there are urinary symptoms but no evidence of urinary tract infection (UTI) on urine culture consider conditions which can present similarly to UTI such as:
- Other urological or genitourinary conditions such as atrophic vaginitis, lichen sclerosis, lichen planus, urolithiasis, or interstitial cystitis.
- Dermatological conditions such as psoriasis, irritant or contact dermatitis. Spondyloarthropathies such as reactive arthritis or Bechet’s syndrome. Alternative or serious diagnoses such as ectopic pregnancy.
- Malignancy: Gynaecological malignancy (for example ovarian cancer) may present with persistent or frequent increased urinary urgency and/or frequency. Urological malignancy may present with haematuria (visible or non-visible). Other infections such as sexually transmitted infections (for example chlamydia, gonorrhoea, genital herpes simplex), candida, threadworm, tuberculosis and schistosomiasis.
- Trauma due to genitourinary procedures, sexual intercourse, sexual abuse or physical activity (such as cycling).
- Adverse drug effects — some drugs such as cyclophosphamide, opioids, and nifedipine can cause urinary tract symptoms.
SUMMARY DIFFERNETIAL DIAGNOSIS
Red flag symptoms: haematuria, loin pain, rigors, nausea, vomiting, and altered mental state — consider the possibility of serious illness such as sepsis.
- Pyelonephritis should be suspected in people with fever, loin pain or rigors.
- Haematuria may present as red/brown discolouration of urine or as frank blood.
- Cancers: abnormal vaginal bleeding, loss of weight, loss of appetite, and fatigue
- Check medication
What does normal vaginal discharge look like?
Normal physiological vaginal discharge is a white or clear, non-offensive discharge that changes with the menstrual cycle. It is thick and sticky for most of the cycle but becomes clearer, wetter, and stretchy for a short period around the time of ovulation.
What is abnormal vaginal discharge characterized by?
Abnormal discharge is characterized by change of colour, consistency, volume and/or ordour and may be associated with symptoms such as itch, soreness, dysuria, pelvic pain or intermenstrual or post-coital bleeding.
What might causes changes in discharge between people or wihtin the same person which is normal?
The nature and/or volume of normal physiological discharge may also be altered by pregnancy, sexual stimulation, contraceptive use, and age.
What are causes of abnormal discharge?
Most common causes are bacterial vaginosis (BV) and vaginal candidiasis. Others include STIs and non-infectious causes e.g. retained foreign body, inflammation due to allergy or irritation, tumors.
Which patients are at increased risk of STIs?
at increased risk if:
- <25 Years
- New sexual partner or >1 sexual partner in last 12 months
- Had previous STI
Describe vaginal discharge examination and possible results
Examinations and investigations typically recommended unless classical signs of BV of VC or history of physiological discharge:
- BV: fishy-smelling, thin, grey/white discharge
- VC: Odorless, white discharge
- Cervicitis caused by chlamydia or gonorrhoea: inflamed cervix which bleeds easily and may be associated with mucopurulent discharge.
- PID caused by chlamydia or gonorrhoea: lower abdominal pain, with or without fever.
