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Practice Nurse

Women's Health

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This module includes 10 assessment questions, covering the management of common clinical conditionspresenting in women.Conditions commonly presenting in primary care such as cadida,menopause, polycystic ovarian syndrome and incontinence are covered in this module. All questionsare written as typical clinical scenarios of which will help you to recognise these conditions and appropriate management as a healthcare worker.On completion of the resource you will be able to claim 1 hour of continuousprofessional development and include the certificate as a record of youractivity in your portfolio

On successful completion of this resource the user should be able to:

Have a better understanding of the Diagnosis of the common disordersaffecting women

Have an understanding of the management of common conditionssuch as vaginal thrush, menopause and incontinence

Be better equipped in the interpretation of commonly usedinvestigations for women

Have a better understanding of the basic issues relating to femalehirustism and polycystic ovarian syndrome (PCOS).

NICE Urinary Incontinence Guidelines CG40

The issues concerning the management of common clinical conditions presenting in women is covered in this module of 10 assessment questions. Conditions commonly presenting in primary care are covered such as cadida, menopause, polycystic ovarian syndrome and incontinence. All questions are posed as typical clinical scenarios with which the user will be familiar. On completion of the resource you will be able to claim 1 hour of continuous professional development and include the certificate as a record of your activity in your portfolio.

Diagnose the common disorders affecting women

Understand the management of common conditions such as vaginal thrush, menopause and incontinence

Interpret commonly used investigations for women

Understand basics of female hirustism and polycystic ovarian syndrome

Primary Care

A 55 year old female attends clinic complaining of vaginal itch with a whitish discharge. She has a one year history of diabetes for which she takes metformin 500 mg bd. You diagnose candidal infection (Thrush). Which of the following would be the most appropriate treatment for this woman?

, thrush. This is caused by Candida, a yeast which is found in the vagina and is normally harmless, but when it multiplies it can cause the symptoms of thrush.
The most common symptoms of thrush include:


vaginal discharge which is usually odourless, can be thick and white like cottage cheese


The most mostappropriate treatment for this lady would be a cream or pessary of fluconazole

http://www.nhs.uk/Conditions/Thrush/Pages/Introduction.aspx

Question 1

A 51 year old female presents with menopausal symptoms of flushing and sweats which have been problematic over the last six to twelve months. Her last period was over 12 months ago. Her life has been quite affected by this problem and she is desperate to improve these symptoms. She is otherwise well and has no medical history of note. There is no other family history of note. Her BMI is 28.8 kg/m

 and her blood pressure is 122/76 mmHg. Which of the following would be the most ap-correctpropriate approach to managing this patient

This post menopausal woman complains of disabling sweats and the most appropriate approach to the management of this would be use of 

 containing oestrogen and progestogens. After the menopause, women stop producing the hormones oestrogen and progesterone, and this is what causes the symptoms that she is experiencing. Therefore, replacing these hormones with HRT would be beneficial for her. There appears to be no contra-indication to HRT and so commencing a low dose combined HRT (oestrogen with progestogen) to begin with would be appropriate, which can be titrated according to her symptoms.
Some contraindications for HRT include a history of breast, ovarian or endometrial cancer, previous clots such as a DVT or strokes, untreated high blood pressure, and liver disease.

http://www.nhs.uk/Conditions/Hormone-replacement-therapy/Pages/Introduction.aspx

Question 2

A 45 year old female complains of inability to control her bladder having problems with incontinence on physical activities which involves jumping exercises, coughing or sneezing. Typically only small amounts of urine are lost at any time but she has resorted to using pads. This has been a problem for her over the last 6-7 years since the birth of her 3 children. She is keen to have something done about this embarrassing problem. What is the likely diagnosis?

This patient displays typical symptoms of 

. This is the most common form of incontinence which happens when the muscles that surround and support the bladder are weakened. Childbirth is a very common cause of this. Patient with stress incontinence experience a leakage of small volume of urine with raised abdominal pressure, such as during coughing, sneezing or exercise. The patient should be referred to a gynaecologist with an interest in uro-gynaecology and consideration given for surgical correction. Also pelvic floor exercises may help, and patients should be taught how to do this.

http://www.patient.co.uk/health/Stress-Incontinence.htm

http://www.netdoctor.co.uk/womenshealth/sui/pelvicfloor_005167.htm

Question 3

A 62 year old female attends clinic complaining of some vaginal bleeding. She has noticed some spotting from the vagina over the last two to three months which is painless and otherwise she has been well. Her only history is that of hypertension for which she takes atenolol 50mg daily as well as amlodipine 10mg daily. Her menopause was at least 10 years ago and she went through this uneventfully. Urinalysis reveals blood ++.
Which of the following would be the most appropriate approach to the management of this patient?

This patient presents with post-menopausal bleeding (bleeding after 12 months after the menopause). This is a sinister symptom meriting urgent investigation as it may signify endometrial malignancy. The patient should therefore be referred to gynaecology with the recommendation of an urgent review due to the potential for malignancy. Other, less serious causes for post menopausal bleeding include :


However it's important to have a low index of suspicion for this presentation, and ensure investigations are carried out to rule out malignancy.

Post-menopausal bleeding referral criteria

http://www.patient.co.uk/doctor/Post-Menopausal-Bleeding.htm

Question 4

A 28 year old female attends clinic complaining of a six month history of reduced frequency of periods and weight gain. She has also noticed a worsening in facial hirsutism with some hair around the jaw-line. She has otherwise been well and her menarche was at the age of 13 and her periods were regular until she began taking the oral contraceptive at the age of 20. She is stressed as she recently broke up with her boyfriend and is also unemployed. She smokes 10 cigarettes daily and drinks 12 units of alcohol weekly. She stopped taking the oral contraceptive 3 years ago and her periods have been generally variable since. Her weight is 76kg and her BMI is 30.6 kg/m

. She has a dark complexion and a few scanty hairs on the jaw line only. Which of the following is the most likely cause for her presentation?

The most likely cause for this young woman's presentation of mild hirsutism associated with oligomenorrhoea (menstrual irregularity) and weight gain is polycystic ovarian syndrome. In this condition, numerous cysts are seen on the ovaries, which remain immature, and do not ovulate. This explains the irregular periods and fertility problems seen in this condition. PCOS is also associated with hirsutism, acne, and weight gain due to hyperandrogenism (an excess of testosterone). Maintaining a normal BMI is particularly important for the management of the condition to improve the symptoms.

http://www.netdoctor.co.uk/womenshealth/facts/pcos.htm

Question 5

A 22 year old woman is suspected of having polycystic ovarian syndrome as she presents with infrequency of periods, weight gain and some facial hirsutism. She is keen on having some treatment for her hirsutism. Which of the following topical treatments would be an appropriate for her facial hirsutism?

Facial hirsutism is a common and often distressing problem associated with polycystic ovarian syndrome. Vaniqa is a recognised treatment for facial hirsutes. It works by blocking the enzyme ornithine decarboxylase, which is an enzyme found in hair follicles and is needed for hair to grow. Vaniqua therefore helps to slow down the growth of the hair, however it does not stop the hair from growing completely. If it is not effective in the initial 6 months of treatment then it can be stopped. Generally one would also recommend additional cosmetic approaches such as electrolysis, bleaching etc. Immac, a depilatory cream should not generally be used on the face as it can be quite irritating.

NHS evidence for Eflornithine in Hirsutism

http://www.netdoctor.co.uk/skin-and-hair/medicines/vaniqa-cream.html

Question 6

You see a 28 year old female in clinic who has been seen by the gynaecology department in the local hospital for polycystic ovarian syndrome. She has had difficulty conceiving, irregular periods and weight gain. They have commenced her on treatment for her polycystic ovarian syndrome. Which of the following treatments is prescribed for polycystic ovarian syndrome?

It is well recognised that insulin resistance is a problem in polycystic ovarian syndrome. Raised insulin levels causes the ovaries to produce too much testosterone causing hirsutism, weight gain and acne. Metformin, the drug used in diabetes, is also a commonly used treatment in 

 It is associated with an improved menstrual cycle and also improved rates of conception. There is evidence that metformin may reduce androgen levels by around 11%. However, normal weight women respond better to metformin therapy than obese women, so weight loss remains to have a big importance in successfully treating PCOS.

http://www.patient.co.uk/health/Polycystic-Ovary-Syndrome.htm

Question 7

A 35 year old female attends clinic as she has noticed that she has not had any periods over the last three months and has also been aware of some breast milk production. Her GP has checked the following results:

Which of the following is the likely cause for her presentation?

This young woman has amenorrhoea and galactorrhoea - together with a raised prolactin concentration and low oestrogen, this would suggest a 

. This is a benign prolactin secreting tumour of the pituitary gland. Prolactin is a hormone that stimulates the breast to produce milk. Prolacinomas most commonly occur in women under the age of 40, and are five times more common in women than in men. They are treatable with a dopamine agonist drug, such as cabergoline or bromocriptine, which work to reduce the amount of prolactin produced. Most people respond well to these drugs.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001377/

Question 8

A 45 year old woman attends clinic as she has been aware of troublesome flushes. Her last period was six months ago. Which of the following blood tests results would you expect to find in this patient if the diagnosis were the menopause?

The menopause is due to a failure of the ovaries with complete loss of oocytes. Therefore you would expect to see a high LH/FSH (these are produced in the pituitary, they are increased in an attempt to drive the ovaries that are failing). There is a a low oestradiol (because there are no oocytes remaining) but the prolactin is normal. If the prolactin were high and LH/FSH and oestradiol low then this suggests a prolactinoma. If the LH/FSH and oestradiol is low with a normal prolactin this suggests a pituitary problem ? hypogonadotrophic hypogonadism.
As well as flushes, other common symptoms of the menopause include:

http://www.patient.co.uk/doctor/Menopause-and-its-Management.htm

Question 9

A 55 year old female attends clinic complaining of frequency of urination. She has noticed this problem over the last 2 years and it has deteriorated over the last few months. She goes to the toilet frequently and passes small amounts of urine. What is the most likely diagnosis?

In urge incontinence, patients feel the need to urgently pass urine otherwise they might wet themselves. It is caused by uncontrolled contraction of the bladder wall, producing urgency, urinary frequency, and sometimes leakage. This is the second commonest cause of incontinence in women (following stress incontinence). Treatment options include bladder retraining as well as the use of bladderrelaxing drugs (anticholinergics) such as Oxybutinin and Solifenacin, which reduce these involuntary detrusor contractions.
It is important that patients drink enough water during the day (about 2 litres), as concentrated urine can irritate the bladder, making symptoms worse. However, tea and coffee should be avoided.
Urge incontinence causes severe social difficulties, in situations such as shopping, meetings, and therefore it could lead to social isolation and have a psychological impact on these patients.

Women's Health

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