Gynaecology

Gynaecology and GP Communication

  • Warning features

 

Warning features of disease for Jane are that she has very irregular bleeding for one or two days between periods. These symptoms would probably lead to a western medicine diagnosis of metrorrhagia. Rosevear (2002) describes metrorrhagia as irregular uterine bleeding at frequent intervals that is variable

She has been receiving treatment for four months which has been effective at making her periods less heavy, but her inter-menstrual bleeding has not changed during this period. Stephenson (2012) says that there should be referral for further investigation if inter-menstrual bleeding occurs on more than three occasions and which seems to fall outside the normal confines of a 2-5 day menstrual bleed might rarely signify a uterine or cervical tumour. Given the four months that Jane has been having treatment this does apply.

CICM (2010) caution that metrorrhagia should be investigated seriously as it may indicate a serious structural problem of the endometrium or cervix, and in particular cancer. Red Flags of cancer are unexplained bleeding: either from surface of skin, or emerging from an internal organ such as bowel, bladder or uterus.

 

Jane also has just informed you that last week she also had bleeding after intercourse. Impey and Child (2012) say that except for first intercourse, post-coital bleeding is always abnormal and cervical carcinoma must be excluded.  However Shapley and Jordan (2006) statethat evidence for the predictive value of post-coital bleeding for cervical cancer is poor

  • Underlying diseases

 

There are many causes of metrorrhagia such as hormonal imbalance, fibroids, cysts, polyps or cancer.

Impey and Child (2012) explain that non-malignant causes include

  • fibroids
  • uterine and cervical polyps
  • adenomyosis (ectopic endometrial tissue)

However they caution that as women get into their 40s and older the chances of malignancy especially endometrial, are slightly increased – particularly if there has been a recent change,

Hollingworth (2008) lists the causes of irregular bleeding during menstrual life:

Malignant growths

  • Carcinoma of the cervix
  • Carcinoma of the uterus
  • Sarcoma
  • Carcinoma of the Fallopian tube
  • Carcinoma of the ovary

Benign growths

  • Submucous fibroids
  • Endometrial and endocervical polyps

 

Other

  • Endometriosis
  • Cervical ectropion (cervical erosion or abrasion)
  • Ectopic pregnancy
  • Pathophysiology

 

As Oriel and Schrager (1999) explain the specific diagnostic approach depends on whether the patient is premenopausal, perimenopausal or postmenopausal. The likelihood of ovarian cancer, for example, is greater in an older woman than a teenager.

Fibroids

Waugh (2010) explains that uterine fibroids or leiomyomas are common in women of Jane’s age. They arebenign or non-cancerous tumours found in the muscular wall of the uterus. They vary greatly in size and develop during the reproductive period and may be hormone dependent. enlarging during pregnancy and when oral contraceptives are used. Hollingworth (2008) says that irregular bleeding tends to occur when they develop in the submucosal layer – the inner side of the uterus and explains that submucosal leiomyomas can cause bleeding, even when small.

Polyps

Hollingworth (2008) describes polyps as small, usually benign tumours which can occur within the cervix and endometrium. If the tip becomes inflamed, then it can give rise to vaginal bleeding or post-coital bleeding. Polyps within the endometrial cavity, whether fibroid or mucous, are common causes of inter-menstrual bleeding. They are common in women aged 40–50 years (exactly Jane’s age group).

Endometriosis/Adenomyosis

Rosevear (2002) defines endometriosis as the presence of ectopic tissue outside the uterus with the histological structure and function of the uterine mucosa i.e. uterine lining tissue growing outside of the uterus. Stephenson (2011) clarifies that adenomyosis is when these endometrium cysts are attached to the uterine muscular wall. These misplaced patches are still responsive to the female reproductive cycle and will build up and break down throughout the menstrual cycle. It is one of the commonest benign gynaecological conditions. Waugh (2010) explains the lesions may cause dysmenorrhoea and irregular excessive bleeding, usually beginning between 40 and 50 years of age. Pearce et al (2012) have suggested a link between endometriosis and certain ovarian cancer sub-types.

Cervical cancer

The cervix is the inferior part of the uterus and is characterized by two types of epithelium: the endocervical epithelium lines the uterus and superior part of the cervix, while the squamous epithelium is located distal to the endocervical epithelium. Rosevear (2002) explains the majority of cervical cancers are squamous in type and says that of those over 85 per cent of cervical squamous cancers and precursor lesions contain DNA of the sexually transmitted virus human papillomavirus (HPV). However because in most case HPV will not lead to cancer it is thought that there must be additional factors. NHS (2012) state that now all girls aged 12 to 13 are offered HPV vaccination as part of the NHS childhood vaccination program.

Rosevear (2002) describes the major associated risk factors for cervical cancer as being:

  • Intercourse at an early age;
  • Multiple sexual partners (or a sexual relationship with a man who has had multiple partners);
  • Oral contraceptive use,
  • Cigarette smoking (which unfortunately Jane does)
  • Family history
  • Associated genital infections

Impey and Child (2012) say that often a precursor to cervical cancer is cervical intraepithelial neoplastic (CIN). Stephenson(2011) explains that this is when the nuclei of the epithelial cells of the cervix undergo a characteristic change in shape called dysplasia.If left untreated, about one-third of women with moderate to severe CIN will develop cervical cancer over the next 10 years. Waugh (2010) cautions that not all dysplasias develop into malignant disease and some will regress, unfortunately it is not possible to predict how far development will go, and whether they will remain static or regress

Women who present before the cancer becomes too advanced have the best prognosis.Impey and Child (2012) explain that the rates of cervical cancer have been falling in the UK since smear tests were introduced.  Hollingworth (2008) claims that this testing is so successful that the average GP will see one case of cervical cancer every 7-9 years.

 

Carcinoma of the uterus

Impey and Child (2012) describe primary malignancies of the endometrium as the most common gynaecological malignancy and say they account for 13 per cent of cancers in women. Most patients are over 40 and also postmenopausal, but almost a third are premenopausal.  Endometrial carcinoma presents with irregular bleeding and the risk of malignancy associated with bleeding increases with age.

Rosevear (2002) says there are two subtypes with most cancers of the endometrium being comparatively low-risk adenocarcinomas, arising from the glandular component which causes bleeding symptoms in its early stages and is curable in most cases. Risk factors include obesity (raised BMI), nulliparity (not giving birth) and history of polycystic ovarian disease. However the other subtype which accounts for a minority of endometrial malignancies consists of poorly differentiated tumours which are not associated with increased circulating oestrogens. They mainly affect postmenopausal women without clearly defined risk factors, but are highly malignant with a poor prognosis.

Uterine sarcomas

Impey and Child (2012) say that these are very rare tumours, accounting for only 150 cases per year in the UK.

Carcinoma of the ovary

Hollingworth (2008) remarks that ovarian cancer is unlikely to cause bleeding unless it has invaded the uterus. Rosevear (2002) says the lifetime risk for a woman developing ovarian cancer is 1 in 70 and increases with age. There are a wide range of tumours, (benign, borderline and malignant) which affect the ovaries. The vast majority of these tumours – nearly two thirds of all ovarian tumours, and 90 per cent of the malignancies, are surface epithelial tumours.

Rosevear (2002) explains there is higher risk associated with nulliparity and low parity, whereas reduced risk is found with early age at first pregnancy, early menopause and the use of the oral contraceptive pill which seems to offer protection. The most significant risk factor for ovarian cancer is a positive family history.

Carcinoma of the Fallopian tube

Rosevear (2002) explains that fallopian tube malignancies account for less than 0.3 per cent of gynaecological malignancies.  The mean age of patients is 57 years.  The most common presenting symptoms are abnormal vaginal bleeding and abdominal pain. The carcinomas affecting the tube are similar to those of the ovary.

Ectopic pregnancy

The essential point in diagnosing an ectopic pregnancy says Hollingworth (2008) is to consider that every woman of child-bearing age who complains of irregular bleeding and abdominal pain could have an ectopic pregnancy although they are rare.

Cervical ectropion (cervical erosion or abrasion)/ Cervicitis (inflammation of the cervix

Impey and Child (2012) explain that most post-coital bleeding occurs when the cervix is not covered in healthy squamous epithelium. It is then more likely to bleed after mild trauma.  A typical case is cervical ectropion where the one cell thick epithelium of the endocervix becomes enflamed and is visible as a red area and may result in contact bleeding. Inter-menstrual bleeding would be unusual in such a condition.

d) GP referral

i) Explanation

Well although we’re having success in treating your heavy periods, we’re not being as successful at the moment with your inter-menstrual bleeding. In order for me to be able to exclude any underlying causes, I would like to refer you to your doctor just to get checked over. I want to be cautious here and just be on the safe side. It would be best if you could arrange an appointment within the week, just to keep things moving and try and exclude things as soon as possible.  You should be able to choose whether to see a male or female GP.  Do not delay an appointment because you are bleeding. It may also be helpful to keep a record of your periods and irregular bleeding to take to your appointment.

At your age it’s a time when lots of women are approaching the menopause and there are often changes in the menstrual cycle and so probably there is nothing to be concerned about, but I think it is best to just get you checked over by your Doctor.

ii) Questions

I don’t like Doctors that’s why I’ve come to an acupuncturist. Do I have to go?

The guidelines that I follow as an acupuncturist require me to refer you to a Doctor to get a diagnosis. It’s really in your own interest to find out what is going on. You don’t have to go, it’s really up to you, but I would strongly advise you to go.

Why do you want me to see my Doctor? What do you think might be wrong with me?

There are a wide variety of conditions that cause the symptoms that you have. The answer is that at the moment I really don’t know. This is why I want you to go see your Doctor because she may want to organise various tests or scans. There may be nothing seriously wrong with, however if there is anything serious, the faster you are diagnosed, the sooner treatment can begin.

Serious condition – do you think I’ve got cancer?

(Following on from NHS (2005) Being referred to your doctor or a specialist does not necessarily mean you have cancer; in fact, most people referred don’t have cancer (Shapley and Jordan (2004)). It’s simply better to find out exactly what you have as soon as possible.  If it is the worst case then the sooner you are diagnosed then the better the outcome is. However as I said initially, just because I’m referring you to your Doctor doesn’t mean that you have cancer. It could be just that you are getting near to the menopause or something equally benign. I’m referring you because I don’t know and want to get you checked over as soon as possible.

e) Communication with GP

I think the best way of communicating with Jane’s GP is for Jane to make an appointment within the week and take the letter with her.  Another alternative would be to post the letter, but if Jane is able to get an early appointment then a letter might not arrive in time and so a hand delivered letter would be the best option.

 

 

 

 

 

f) Referral letter

 

 

The Basingstoke Acupuncture Centre

Lordsfield Gardens, Basingstoke. RG25 3EW  Tel: 01256 222222

Practitioner:  Ian Dale Bsc. BA  Lic Ac  MBAcC

e-mail ian@ BasingstokeAcupuncture.co.uk

www.BasingstokeAcupuncture.co.uk

 

Dr Lorgie

Basingstoke Health Centre

Home Gardens

Basingstoke

RG25 2AA

 

10 April 2013

Re:Jane Harris, 21 Any Road, Basingstoke, RG25 1PP DOB: 7/7/65

Dear Dr Lorgie,

I would be grateful if you could see Jane Harris as in view of her symptoms, I believe she needs further investigations to exclude an underlying cause which might require additional medical treatment.

Jane has been coming for acupuncture treatment for menorrhagia for the last four months. This has responded well to acupuncture treatment, however she is continuing to experience a slight bleed between periods which is irregular both in timing and in character.  Last week Jane also experienced an episode of post-coital bleeding.

Health history – Jan is a smoker.

Yours sincerely

Ian Dale

 

 

 

 

References

CICM (2010), CMS Disk Stage 5 Conventional Medical Sciences: Course Manual v2.1 Reading: CICM

Hollingworth, T. 2008 Differential Diagnosis in Obstetrics and Gynaecology an A-Z,  Hodder Arnold

Impey, L and Child, T. 2012 Obstetrics & Gynaecology 4th edition Wiley-Blackwell  Oxford

NHS 2005 NICE Clinical Guideline 27 National Institute for Health and Clinical Excellence Referral guidelines for suspected cancer June 2005

NHS 2012http://www.nhs.uk/Conditions/vaccinations/Pages/hpv-human-papillomavirus-vaccine.aspxLast reviewed: 13/08/2012accessed 13/4/13

Oriel, K. And Schrager, S.1995  Abnormal Uterine Bleeding. Am Fam Physician. 1999 Oct 1;60(5):1371-1380.

Pearce et al. 2012 Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case–control studies. The Lancet, Volume 13, Issue 4, April 2012, Pages 385–394

Rosevear Sylvia K. 2002. Handbook of Gynaecology Management Blackwell Science Ltd, Oxford

Shapley M, Jordan J, Croft PR. 2006 A systematic review of postcoital bleeding and risk of cervical cancer. Br J Gen Pract. 2006;56(527):453–460

Shapley M, Jordan K, Croft PR; 2004 An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004 May;54(502):359-63.

Stephenson, C. (2011) The Complementary Therapist’s Guide to Conventional Medicine, 1st Edition, Oxford: Churchill Livingstone

Waugh, A.(2010) Ross and Wilson Anatomy and Physiology in Health and Illness, 11th Edition. Oxford: Churchill Livingstone Elsevier

 

 

 

 

 

 

Bibliography

American Congress of Obstetricians and Gynecologists. Abnormal Uterine Bleeding (FAQ095) . accessed 4/4/13 http://www.acog.org/~/media/For%20Patients/faq095.pdf?dmc=1&ts=20130421T0348165935

American Congress of Obstetricians and Gynecologists. Perimenopausal Bleeding and Bleeding After Menopause (FAQ162) accessed 4/4/13 http://www.acog.org/~/media/For%20Patients/faq162.pdf?dmc=1&ts=20130421T0333265134

Bradley L.D. Abnormal uterine bleeding: A Quick Guide To Evaluation And Treatment Journal of family practice April 2002 • Vol. 14, No. 4

De Vries CJ, Wieringa-de Waard M, Vervoort CL, et al. Abnormal vaginal bleeding in women of reproductive age: a descriptive study of initial management in general practice. BMC Women’s Health. 2008;8:7.

Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal Uterine Bleeding: A Management Algorithm J Am Board Fam Med. 2006;19(6):590-602.

National Collaborating Centre for Cancer Ovarian cancer: The recognition and initial management of ovarian cancer. Evidence review. April 2011

NHS NICE clinical guideline 122  NHS National Institute for Health and Clinical Excellence Ovarian cancer April 2011

Telner DE, Jakubovicz D. Approach to diagnosis and management of abnormal uterine bleeding. Can Fam Physician. 2007 Jan;53(1):58-64.