1. Common Gynaecological
Disorders
Dr. Lee Chin Peng
Honorary Clinical Associate Professor
Department of Obstetrics and Gynaecology
University of Hong Hong

2. Outline
General approach to gynaecological
problems
Management and recent advances:
vaginal discharge
abnormal vaginal bleeding
dysmenorrhoea
uterine fibroid
Useful resources

3. History and physical examination
Menstrual history, LMP
Contraception
Cervical smear history
Can the patient be pregnant?
Obstetric history
Patient’s concerns
Is pelvic examination necessary?

4. Investigations
Pregnancy test
Swabs for culture
Cervical smear
Endometrial aspiration
Ultrasound pelvis

5. Need referral?
Reasons for referral:
1. Unsure diagnosis
2. Special diagnostic tests
3. Treatment
4. Second opinion
Many common gynaecological problems can
be managed by GP

6. Should investigations be done
before referral ?
1. Affect decision to refer?
2. Delay the referral?
3. Reliable laboratory?

7. Referral letter
Name and age of the patient
Reason for referral
Any investigations and treatment before the
referral
Wish to continue post-referral care
Ix reports, copies of X-ray, ultrasound images
are very helpful

8. Reply from hospital specialist,
follow up
1. Confirm with patient: diagnosis, treatment
and plan of management
2. Clarify with specialist if needed
3. Your feedback is welcomed

9. Vaginal Discharge
Physiological:
midcycle, premenstrual
Pathological:
odour, itchiness
blood stained
Postmenopausal: atrophic vaginitis
May need to explore hidden anxiety,
especially anxiety about STD

10. Vaginal Discharge
Speculum examination is necessary and
digital examination preferred
Need to take culture swab?
Typical moniliasis: treat without culture, take
swab if treatment fails
Need to screen for STD?

11. Vaginal Discharge
Need to refer?
Recurrent
Blood stained and not midcycle
Fail to response to treatment
Uterine or cervical pathology suspected
Postmenopausal and fails to respond to HRT

12. Vaginal Discharge
In children:
Think of foreign body and
? Sexual abuse
May need referral

13. Abnormal vaginal bleeding
Postmenopausal bleeding (PMB)
Reproductive age group:
irregular
inter-, pre- or post-menstrual spotting
heavy bleeding (menorrhagia)

14. Abnormal vaginal bleeding
Malignancies?
Carcinoma of corpus
Carcinoma of cervix
Oestrogen producing ovarian tumour
Premaligant conditions?
Atypical endometrial hyperplasia
CIN (usually do not present with bleeding)

15. Abnormal vaginal bleeding
Benign conditions
Polyps: endometrial, cervical
Fibroid
IUCD?
Drug effect?
Systemic diseases
DYSFUNCTIONAL UTERINE BLEEDING
IS THE MOST COMMOM

16. Abnormal vaginal bleeding
Assessment of the endometrium (not needed for
women with very low risk of Ca endometrium)
endometrial aspirate
ultrasound pelvis (transvaginal) to assess
endometrial thickness
hysteroscopy

17. Abnormal vaginal bleeding
When to refer:
over the age of 40
high risk of endometrial Ca (obesity, DM,
PCOD)
uterus > 10 week size or irregular
cervical pathology suspected
no response to medical treatment

18. Abnormal vaginal bleeding:
a practical approach (1)
History:
age
pattern of bleeding
risk factors for endometrial Ca
pregnant?
drug
previous treatment
last cervical smear

19. Abnormal vaginal bleeding:
a practical approach (2)
Physical examination
general: obesity? thyroid? pallor? pulse?
abdomen: palpable mass?
pelvis: cervical or vaginal lesion? uterine
size

20. Abnormal vaginal bleeding:
a practical approach (3)
Over 40
or high risk of endometrial Ca
or genital tract lesion suspected (except
cervical polyp), including uterus big
or previous medical treatment fail
REFER (or endometrial aspiration and TV USG)

21. Abnormal vaginal bleeding:
a practical approach (4)
None of the above factors
consider investigations
cervical smear if sexually active and last smear
more than 1 year ago
CBP if menorrhagia
ultrasound pelvis if PV not possible
thyroid function, coagulation only when history
suggestive

22. Abnormal vaginal bleeding:
a practical approach (5)
Medical treatment (for women under 40 with
no suspicion of organic lesions)
Hormonal (for irregular bleeding as well as
menorrhagia)
combined OC
progestogen only (21 days needed)
Non-hormonal (for menorrhagia)
NSAID
antifibrinolytic agent

23. Abnormal vaginal bleeding:
a practical approach (6)
Choice of medical treatment for irregular
vaginal bleeding:
combined OC gives much better cycle
control (start with a preparation containing 50ug EE)
progestogen only (when oestrogen contraindicated)

24. Abnormal vaginal bleeding:
a practical approach (7)
Choice of medical treatment for menorrhagia
NSAID: 30% decrease in blood loss ,relieve
dysmenorrhoea as well
Antifibrinolytic (transamine): 50% decrease
Combined OC: effective but need to take through out
the month, effective contraception as well
Progestogen only: less effective, need 21 days, not
effective contraception
Haematinics: if anaemic
combinations can be used

25. Abnormal vaginal bleeding:
a practical approach (8)
When to consider medical treatment as
failure?
Failure to relieve patient’s symptoms after 3
months
Remains anaemic after 3 months

26. Abnormal vaginal bleeding:
other modalities of treatment
Levonorgesterol releasing IUCD (Mirena)
Endometrial ablation
pregnancy contraindicated after ablation
Hysterectomy

27. Abnormal vaginal bleeding
Post-referral management
Pathology excluded
Treatment plan suggested, e.g
non-hormonal therapy
hormonal therapy usually for 6 months
just follow the treatment plan
refer back if treatment failure
Follow up after special treatment

28. Dysmenorrhoea
Primary
Secondary:
endometriosis
adenomyosis
chronic pelvic inflammatory disease
pelvic adhesions

29. Primary dysmenorrhoea
Onset a few years after menarche
Regular cycles
Pain for less than 2 days
Cramping pain
Nausea, other GI symptoms
radiation to thigh
relieved after childbirth, but may recur after some years

30. Dysmenorrhoea
History
Physical examination:
Is pelvic examination needed?
Recommended in all cases except in
teenagers who are not sexually active
with typical primary dysmenorrhoea

31. Dysmenorrhoea
Investigations needed?
Ultrasound pelvis if
clinical pelvic examination abnormal
symptoms suggestive of secondary
dysmenorrhoea but PV not conclusive or not
possible
Laparoscopy
seldom needed

32. Dysmenorrhoea: role of laparoscopy
Subfertility
Chronic pelvic pain
Relieve the anxiety of patients
Treatment:
endometriotic cyst
medical treatment fail
subfertility

33. Dysmenorrhoea
Medical treatment for dysmenorrhoea:
Simple analgesics: paracetamol, NSAID
indicated for primary and secondary
dysmenorrhoea without associated subfertility,
or ovarian cysts
Hormonal therapy: as a second line when
simple analgesia fails

34. Dysmenorrhoea
Hormonal therapy:
Primary dysmenorrhoea:
combined OC pills (low EE)
Endometriosis:
progestogen only
combined OC pills (low EE)

35. Uterine fibroids
Common
25-30% of women over 35
Often asymtomatic
Incidentally detected on pelvic ultrasound

36. Uterine fibroids
When to refer:
symptoms related to fibroids
size > 12 weeks (palpable per abdomen)
pain
uncertain diagnosis ?ovarian cyst
subfertility, recurrent miscarriage

37. Uterine fibroids
Symptoms related to fibroids:
menorrhagia
irregular menstruation (only for submucosal
fibroids)
urinary (frequency, retention)
abdominal distention

38. Uterine fibroids
How to follow up asymptomatic fibroids?
Ultrasound?
Usually no needed
Check symptoms and uterine size clinically
every 6 months or ask patient to return if
symptomatic

39. Uterine fibroids: treatment
Surgical treatment remains the mainstay:
myomectomy (laparotomy, laparoscopy,
hysterocopy)
hysterectomy
Medical treatment with GnRH analogue
shrink fibroids before surgery
buy time before menopause
Embolization: inadequate evidence on
effectiveness and safety

40. Uterine fibroids
Post-myomectomy follow up:
fibroids can recur after myomectomy
advice for pregnancy?
When?
Caesarean delivery needed?

41. Useful resources
References used for this presentation:
HKCOG: Guidelines on investigation of women with
abnormal uterine bleeding under the age of 40, HKCOG
Guidelines 5, May 2001
Pretence A: Medical management of menorrhagia, BMJ
1999;319:1343-5
Pretence A: Endometriosis, BMJ 2001;323:93-5

42. Useful resources
Websites:
hhtp://www.bmj.com
hhtp://www.rcog.org.uk/guidelines
hhtp://www.hkcog.org.hk

43. Thanks to:
Schering (Hong Kong) Ltd.
Subsidiary of Schering AG Germany