Download Minutes of the Exeter Sessional GPs Group

Minutes of the Exeter Sessional GPs Group Study
Day - Gynaecology afternoon
at Darts Farm – 10 October 2012
Attendance: 30 members
The meeting was kindly funded via the PCT.
Welcome:
Hamish opened the meeting and thanked everybody including the speakers for
attending. He reminded members to sign the register
Speakers:
Chronic Pelvic Pain (Female)
Mr Neil Liversedge – Consultant Obstetrician and Gynaecologist – RDE Exeter
Exeter chronic pelvic pain clinic developed from a pain clinic run by Dr Conn
(anaesthetist) who noticed that he had referrals for these complex patients with
multiple symptoms and previous operations but his gynae knowledge was limited. He
joined with Miss Dalton (gynaecologist) who retired in 2010. Neil replaced her as the
gynaecologist. The aim of the clinic is to improve care, reduce waiting time and
reduce unnecessary treatments and surgery on affected women.
Chronic pelvic pain is nearly always multi-factorial.
Gynae reason – usually fluctuates with menstrual cycle – worse mid cycle or with
period..
May include irritable bowel and bladder pain.
Can get “red herrings” as there is common neural pathway involving bladder, uterus
and bowel.
Remember constipation – even if bowel open daily take history carefully – may be
long transit time.
Adhesions - commonly used as diagnosis. If adhesions recur then it will be within
the first week after surgery. Little evidence that adhesiolysis relieves pain – although
some evidence that dense vascular adhesions can result in trapped ovaries.
If residual ovarian tissue suspected as a cause for pain then trial of gonadorelin
analogue may help by inducing temporary menopause and aiding the decision as to
whether future surgery may help.
There is central sensitisation resulting in pain with a common neural pathway.
50% of women referred to gynae out patients compared with 28% referred to ENT out
patients have symptoms of irritable bowel. 38-84% of women with chronic pelvic
pain have symptoms of interstitial cystitis.
Constipation, often longstanding, is common in chronic pelvic pain clinic – opiates,
poor diet, low exercise levels.
Need availability of psychological assessment – is low mood cause or effect?
History and examination:
 Pain history
 Gynae and obstetric history
 General physical examination – back, sacro iliac and hips, abdominal wall
triggers (trial of injection depo medrone / bupivicaine which may need
repeating in 3-8 weeks can help with abdominal wall triggers).
 Gynae examination – superficial pain or tenderness, deep pain, pain over
ischial spines, pain over pelvic floor muscles (e.g. levator spasm – relaxation
techniques can help).
Investigation:
Almost all have already had swabs, ultra sound scan, laparoscopy, cystoscopy,
colonoscopy, urodynamics.
Current diagnosis depends who has seen them first – e.g. bladder pain syndrome /
interstitial cystitis, irritable bowel syndrome, pelvic floor dysfunction, neuralgia –
pudendal, vulvodynia, vestibulodynia, clitorodynia –
www.vulvalpainsociety.org/vps/index.php/vulval-conditions may help.
Pelvic floor dysfunction – the pelvic floor has three functions – to support, contract
and relax – can be over or under active. Manage by pelvic floor exercises – physio.
Pudendal neuralgia – common and under diagnosed – pain, over or under sensitive,
incontinence urine or faeces, dyspareunia. Usually involves the perineum and usually
worse on one side. Relief by standing or lying and worse with sitting but ok on toilet
seat due to no pressure on area, commoner in women than men, onset usually after
menopause but can be soon after childbirth and then it is often confused with perineal
trauma, other causes – fall on to perineum, cycling, traction on pelvis after
orthopaedic surgery.
Signs – asymmetry, pain level pudendal nerve.
Tests – nerve conduction studies, pudendal nerve block using local anaesthetic.
May need to exclude other causes – e.g. tumour in pelvis – with MRI.
Treatment – sit on tuberosities with perineum free, avoid cycling, anti neuropathic
drugs (amitriptyline 10-60mg, gabapentin, pregabalin), local anaesthetic and steroid
injection, pelvic floor physio, surgery – but success rate poor, neuromodulation.
Empirical approach:
 Use as little opiate as possible
 Ensure bowel working
 Manage irritable bowel
 “There is no pain so terrible that it can’t be made worse by an operation”
Infertility
Lisa Joels - Consultant Obstetrician and Gynaecologist – RDE Exeter
Involuntary failure to conceive
Causes:
 Unexplained – 25%
 Ovulatory – 25%
 Tubal 20%
 Sperm dysfunction 30%
 Uterine abnormalities and endometriosis – a few

Coital and cervical mucous abnormalities – a few
NICE 2012:
Over 80% of couples conceive in the first year if woman is less than 40, they do not
use contraception and they have regular intercourse. Another 10% conceive in the
second year.
Chances of conception – 33% in the first cycle,. In young couples where woman age
under 25 rate of conception is 20-25% per cycle – 60% by 6 months, 85% by 12
months and 95% by 24 months.
Chance of conception decreases with increasing age.
NICE emphasises lifestyle issues important:
 Weight – BMI 19-29.9 as more chance of ovulation
 Smoking – toxic to egg and sperm and increases miscarriage risk
 Alcohol – woman 2-4 units per week allowed, man 3-4 units per day allowed
 Folic acid
 Frequency of intercourse weekly has 10% less chance than 2-3 times per week
– conceive better if sperm are in upper GU tract at ovulation.
History:
Duration >1yr – refer fertility clinic
Early referral if:
 Not ovulating
 Sperm dysfunction
 Tubal disease
 Endometriosis
 Older women
Investigation:
Check rubella status before referral – even if confirmed immunity in the past, it can
wane with time.
The precise diagnosis has impact on conception rates – tubal and sperm dysfunctions
have very low natural conception rates.
Ovulation generally only if regular menstrual cycle with cycle length 21-42 days and
less than 5 days variation in cycle length from cycle to cycle.
Hormone profile:
 FSH / LH day 3 of cycle to assess ovarian reserve – FSH over 10 suggests
there will be poor response to ovulation induction and if less than 4 then
higher risk of ovarian hyperstimulation
 Progesterone – 7 days before predicted menses – if periods very irregular can
assume they are not or only rarely ovulating.
 TFT and prolactin
 Anti Mullerian hormone better than FSH to assess ovarian reserve but is
expensive so not generally available.
 Some women may go privately and undergo antral follicle count – by ultra
sound scan on day 5 of cycle – if less than two follicles then response to
ovulation induction likely to be poor and if more than sixteen follicles then
higher risk of ovarian hyperstimulation.
PCOS – two out of the three criteria – PCO on scan, oligo- or an-ovulation,
biochemical or clinical high androgen levels.
Management of an-ovulation
 Normalise weight – BMI 19-30
 Oestrogen antagonists – clomifene or tamoxifen with mid cycle ultrasound
scan to check no hyperstimulation
 Gonadotrophins
Sperm dysfunction
Check semen even if history of having fathered a child.
Complete sample after 2-7 days abstinence.
Volume >1.5ml, pH 7.2, conc >15x106/ml, total sperm > 39x106, motility > 40%,
normal forms > 4%
Repeat after at least six week interval if abnormal.
Treatment of sperm dysfunction
 Mild – IUI
 Moderate or severe – IVF + ICSI
 Azoospermia – obstructive – surgical sperm recovery, testicular failure –
donor sperm.
Tubal disease:
History of STI, PID, surgery
Get chlamydia serology to screen previously asymptomatic women for infection.
If the chlamydia titre is higher then the chance of severe tubal damage is greater
Investigation of tubal disease:
 HVS and endocervical swabs
 Chlamydia serology - if titre <1/16 then assume normal tubes, treat
presumptively, consider hysterosalpingogram, if titre > 1/512 then assume
tubal damage and get lap and dye.
Tubal surgery:
 Laparoscopic adhesiolysis
 Laparoscopic cuff salpingostomy
 Hysteroscopic fallopian tube cannulation
 Bilateral salpingectomy if hydrosalpinges and then will need IVF
Peritoneal disease:
Endometriosis – symptoms, signs, chocolate cysts on USS. If mild then surgical
treatment increases pregnancy rates. If moderate to severe then need to excise
endometrioma and proceed to IVF.
Referral – look at age, risks – irregular periods or previous PID, assess ovulation then
? refer.
Disadvantages of referral – cost - £138 tariff, possibility of over investigation,
possibility of over treatment, risks of multiple pregnancy.
Benefits of IVF – has improved rates of pregnancy.
Risks of IVF – multiple pregnancy, ovarian hyperstimulation, bleeding, infection,
torsion and anaesthetic risks, risks in pregnancy, congenital abnormalities, borderline
ovarian tumours.
IVF pregnancies carry higher risks of IUGR, still birth, PET, caesarean section,
congenital abnormalities – 2-3% with spontaneous or IVF, 4-5% with ICSI.
Obesity
Above BMI 35 the drugs don’t work
Maternal risks of obesity – miscarriage, PET, DM, VTE, induced labour, C section,
death
Fetal risks of maternal obesity – stillbirth, congenital abnormalities, macrosomia,
birth trauma, neonatal death, obesity in later life
Take home messages:
 Lifestyle advice is important.
 Fast track appropriate cases
Advances in ambulatory gynaecology and female sterilisation
Jim Clark Consultant Obstetrician and Gynaecologist – RDE Exeter
Methods to enable major surgery with rapid recovery and return to normal activity.
1. Real time vaginal ultrasound scanning in out patients instead of laparoscopy.
2. Novasure endometrial ablation – under local anaesthetic, no LHRH prep
needed, 90 second treatment, 70% likelihood of amenorrhoea instead of trans
cervical endometrial ablation.
3. Fibroid resection under local anaesthetic – can certainly do fibroids up to 3cm
diameter.
4. Hysteroscopy and polypectomy using a small scope not needing speculum,
anaesthetic or dilatation.
5. Hysteroscopic sterilisation using Essure method – a 4cm spiral device inserted
into tubes. Currently patient needs to use contraception until had HSG or X
ray but this restriction liable to be lifted. Use NSAID before to decrease tubal
spasm. It is very effective (0.1% risk of pregnancy).
6. ERPC for miscarriage – local anaesthetic in clinic room.
Housekeeping.
Future ESGPG Meetings
November 6th – Menopause Dr C Seamark GP with interest in women’s health
December 4th – Haematology Update Dr P Kerr Consultant haematologist
January 8th – A-Z of knee orthopaedics Mr V Mandalia Consultant orthopaedic
surgeon
February 5th – Osteoporosis and Vitamin D Dr M Brown Consultant rheumatologist
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Hamish Duncan (chairman and LMC link)
Dr Diane Baker (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
Dr Katherine Wood (funding co-ordinator)
Dr Megan James (treasurer)
Dr Kathryn Shore (minutes secretary)
Dr Clair Homeyard (social secretary)
Dr Francesca Vasquez (social secretary)
Dr Megan James (LMC link)
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