300 \200 y g o o c e a n y G l 1 ukmec4 category denotes that use poses unacceptable health risk: ukmec3=risk from use out weighs advantage; ukmec2=advantage of use outweighs risk; ukmec1=no restriction to use. ukm ec 2009 154 2 If family history of thromboembolism, avoid Pills with desogestrel or gestode ne (or if prothrombotic coagulation abnormality, eg factor V Leiden or antiphospholipid ant ibodies, incl. lupus anticoagulant). 3 Eg: carbamazepine, esli/ox/carbazepine, phenobarbita l, phenytoin, primidone, ru \201 namide,topiramate. 301 Migraine, ischaemic stroke, and the Pill The problem is ischaemic stroke. The background an nual incidence is 2 per 100,000 women aged 20, and 20 per 100,000 for those aged 40. Migrai ne itself is a risk factor. For those with migraine and CoC use, incidence of ischaemic str oke becomes 8 : 100,000 if aged 20; and 80 : 100,000 in those aged 40. Low- dose CoCs only should be used. Those with migraine with aura are known to be at special risk precluding us e of combined Pills in these women (how- ever, there is no problem with them using progeste rone only or nonhormonal contraception). Other risk factors for ischaemic stroke include sm oking, age >35yrs, \200\200BP, obesity (body mass index >30), diabetes mellitus, dyslipida emia and family history of arterial disease <45yrs. Women known to have mi- graine should b e warned to stop Pills immediately if they develop aura or worsening of migraine. If a woma n has 1st migraine attack on CoC, stop it, ob- serve closely: restart cautiously only if th ere are no sequelae and if migraine attack was without aura and there are no other risk fac tors (above). 157 Diagnosing migraine with aura (formerly called classical/focal migraine) 1 Slow evolution of symptoms (see below) over several minutes. 2 Duration of aura usually 1 0 \200\22330min, resolving within 1h, and typically before y g o o c e a n y G l onset of headache. 3 Visual symptoms (99% of auras), eg: \200 Bilateral homonymous hemianopia. \200 Teichops ia and forti \201 cation spectra, eg a gradually enlarging C scintillating edges. \200 Po sitive (bright) scotomata. with 4 Sensory disturbance (31% of auras). Usually associated with visual symptoms. \200 Usually in one arm spreading from \201 nge rs to face (leg rarely aff ected). 5 Speech disturbance (18% of auras): dysphasia; dysarthria; paraphasia. 6 Motor disturbance s (6% of auras). Both motor and speech disturbances are usually accompanied by visual and/ or sensory disturbances. Migraine without aura: (formerly called simple or common migraine) in- cludes symptoms of blurred vision, photophobia, phonophobia, generalized \202 ashing lights aff ecting the whole visual \201 eld in both eyes, associated with headache. Abso lute contraindications to COC use \200 Migraine with aura. \200 Migraine without aura i n women with >1 risk factor for stroke (above). \200 Severe migraine or migraine lasting >72h (status migrainosus). \200 Migraine treated with ergot derivatives. Hormonal contraception: further details Check BP, BMI and health status after 3 months then annually. Do cervical smear if due (p271). Aim to use lowest-dose Pill to give good cycle control (ie no breakthrough bleeding). \200\207If breakthrough bleeds screen for chlamydia . Progesterone issues Norethisterone and levonorgestrel-containing CoCs may cause breakthro ugh bleeding, acne, headaches, so prompted search for new progesterones, eg gestodene or de sogestrel (Femodene , Marvelon , Mer- cilon , Triadene ), but see problems with \200 \200 thrombosis (p303). 302 \200 Drospirenone (DRSP) is a spironolactone-like progesterone with antiandro- genic/antimineral ocorticoid action (said not to \200\200weight; useful in those with acne or polycystic ova ries); thrombosis risk, see opposite. Levonorgestrel containing pills seem safest (try \201 rst). Thrombotic risk of dienogest (Qlaira ), is currently unkown. Switching from PoP: If to a CHC, start without g ap. Use condoms for 7 days (9 if Qlaira ). If to a progesterone-only Pill (POP), start as the old pack \201 nishes. Switching from CHc: If to a CHC, start immediately with no horm one-free interval. If to a PoP, start immediately the CHC preparation is \201 nished. Sta rt CHcs/PoPs on day 1 of cycle, on day of TOP, \211 21 days postpartum, or \211 2wks afte r fully mobile post major surgery. If starting CoC on day 1 \200\2235, cover is imme- diate , no other precautions (condoms) are needed. If later start (and not preg- nant, p297), use condoms for 1wk. Qlaira: start on day 1 (condoms for 9 days). Stopping the Pill Tell to stop at once if she develops: \200 Sudden severe chest pain \200 Sudden breathlessness ( cough/bloody sputum) \200 Severe calf pain \200 Unexplained leg swelling \200 Seve re stomach pain \200 Unusual severe prolonged headache; sudden visual loss; collapse; dys phasia; hemi-motor/sensory loss; 1st seizure \200 Hepatitis, jaundice, liver enlargement. \200 BP \211 160/95 \200 4 weeks before leg or major surgery (p300) \200 Any CI (p3 00). See cautions on p300; low-risk non-smokers may continue in their 40s. On stopping, 66% menstruate by 6 weeks, 98% by 6 months; women amenorrhoeic post-Pill usually were before. Missed Pills (or severe diarrhea): Consult package inserts; advice varies. In general, if t he start delay is \211 48h, or >48h since last Pill continue Pills but use condoms too for 7 days (+ days of diarrhea); if this includes Pill-free days, start next pack without brea k (omit inactive Pills in \200\230ED \200\231 formulations). If 2 pills of 1st 7 days in p ack forgotten, use emergency contraception if unpro- tected intercourse since end of last p ack. Vomiting <2h post-Pill: take another. Non-enzyme-inducing (p300) broad-spectrum antibi otics need extra precau- tions only if causing diarrhea or vomiting. Postcoital options: p2 99. Progestogen-only Pills (POP=mini-Pill) Low-dose progestogen renders cer- vical mucus ho stile to sperm. Desogestrel 75 g is more eff ective, inhibiting ovulation in 97%. Take at the same time of day ( 3h), ( 12h for desogestrel). PoPs can be used in most women with p roblems CI combined Pills, eg migraine, past thrombosis, immobility, major surgery, \200 \200BP, (also if lactating). Avoid if on enzyme inducers (p300); breast cancer in last 5y; IHD, stroke or migraine with aura develop on \200\224; GTD (p264); cirrhosis (metabolism p roblem); active viral hepatitis; liver tumors. Extra precautions are needed for 48h for lat e Pills, for time of use +28d if enzyme inducers given. Postnatal Start 21 days after birth : eg CoC if not breastfeeding; PoP, Depo- Provera (or Nexplanon ) if breastfeeding. IUCD : \201 t 4 weeks postpartum. At the menopause Stop PoP if >50yrs old with >1 year \200 \231s amenorrhoea (2yrs if <50yrs old) \200\224as a rough guide. A spermicide and sponge ma y then be ad- equate in view of declining fertility. As CoC masks the menopause, aim to sto p at 50yrs, and replace with a nonhormonal method. Flying and high altitude Avoid immobilit y if \202 ight \211 3h. If trekking higher than 4500 meters for \211 1 week consider a lternative. y g o o c e a n y G l 303 Terminology 1st generation Pills are the original Pills containing 50 g estrogen. 2nd gene ration Pills are those containing \211 35 g estrogen and levonorgestrel, norethisterone, norgestimate, or cyproterone acetate. 3rd generation Pills contain desogestrel or gestodene as the progesterone. Although designed to be more lipid friendly 3rd generation Pills have not been proven to be better in those with cardiac risk factors and are more thrombogenic. 158 Risk of venous thromboembolism Risk of thromboembolism is increased by combined hormonal pr eparations; whether pill, ring or patch. \200\225159 Figures are not well known for proges terone only preparations but they do not ap- pear to be thrombogenic. Carriage of factor V Leiden mutation particularly increases risk of thrombosis ( \200\200 risk \211\21035). 3rd generation Pills particularly increase resistance to our natural an- ticoagulant (activate d protein C, APC), so increasing thrombosis. With an- tithrombin 3, protein C or S de \201 ciency have thrombosis rates \200\200 \211\2105. Counsel those starting the Pill that it does increase the risk of thrombosis, particu- larly in 1st year of use, but it is still a rare event. The Pill and travel: If immobile for >5h, the BNF recommends mid-journey exerc ises support stockings. The Pill and surgery: Stop estrogen containing contraception 4wk s pre-op when immobilization expected and arrange alternative contraception. EURAS study 2007 160 not on Pill levornorgestrel drospirenone others pregnant 44 : 100,000 80 : 100,000 91 : 100,000 91 : 100,000 291 : 100,000 y g o o c e a n y G l When to use emergency contraception (eg missed-Pill) \200\225161 \200 CoC: if 3 or more 3 0 \200\22335 g pills or 2 or more 20 g pills forgotten in 1st 7 days of pack and unprotec ted sexual intercourse (UPSI) occurred in those 1st 7 days or pill-free week. PoP: if 1 or more PoPs have been missed or taken >3h late (>12h if Cera- zette ) and UPSI has occurred in the 2 days following this. IUCD/IUS: if complete or partial expulsion identi \201 ed or midcycle removal has been necessary and UPSI in the 7 days preceding this. Progesterone injection: if >14 weeks from last Depo-Provera or >10 weeks from Noristerat injection and UPSI occurred. Barrier method: failure of method (eg splitting, slippage). Depot, implant, patch, and ring contraception Depot progestogen ( \200\230the injection \200\231) Simple, safe and eff ective, 2 preparations are available: medroxy- progesterone acetate 150mg given deep IM 12-week- ly; start during the 1st 5 days of a cycle (postpartum see p95) or norethisterone enanthate (Noristerat ) 200mg into gluteus maximus 8-weekly \200\224licensed for short-term use only, but can be used immediately postpartum (p95). Exc lude pregnancy biochemically and use condoms for 7 days after late injections >2 weeks late . They inhibit ovulation and thicken cervi- cal mucus. CI: Pregnancy; breast cancer, undiag nosed vaginal bleeding; acute liver disease; severe cardiac disease. Problems: Irregular va ginal bleeding usually set- tles with time with amenorrhoea then supervening so encourage p erseverance: eg 33% amenorrhoeic after 6-months \200\231 use; 50% for 1 year, and 60% for 1 8 months (14%, 27%, and 33% respectively for Noristerat ). If very heavy bleeding occurs, exclude pregnancy; give injection early (but >4 weeks from previous dose) and give estrogen if not CI: (eg Premarin 1.25mg/24h PO for 21 days or a CoC). Fears of osteoporosis in us ers prompted the Committee of Safety of Medicines to recommend review after 2 years \200 \231 use in all users and avoidance in adolescents unless the only acceptable method. Bone mass den- sity increases when stopped. 162 Other problems include weight gain (up to 2kg in 70% of women). Special uses: Depot injections may be particularly useful: \200 To cover major surgery. If given when stopping combined Pill 4 weeks before 304 \200 Advantages \200 Secret \200 No estrogen content (no thrombosis risk, etc) OK if breastfeeding \200 Fewer compliance problems Good when GI disease \200 Protects against ectopics Fewer ovarian cysts \200 Less endometriosis \200 Less endometrial cancer (risk \200\201 5-fold) \200 Abolishes menor- rhagia eventually \200 Reduces PMS (p254) \200 Reduces PID (p286) y g o o c e a n y G l surgery it gives contraceptive cover for the next 8 or 12 weeks. Sickle-cell disease (reduces incidence of sickle-cell crises). \200 Epileptics, \201 t frequency may be reduced. They are suitable for use with en- zyme inducers (p300) without d ose or interval change. 163 \200 After vasectomy while awaiting partner \200\231s \200 \230sperm-free \200\231 ejaculates. \200 Where bowel disease may aff ect oral absorption. There may be some delay in return of ovulation on stopping injections (median delay 10 mon ths) but long-term fertility is not reduced. Implants Progesterone implants give up to 3 ye ars \200\231 contraception with one implantation. Nexplanon is a radiopaque \202 exible rod containing etonogestrel 68mg which is implanted subdermally into the medial surface of the upper arm. It inhibits ovulation and thickens mucus. Contraceptive eff ect stops when the implant is removed. <23% of users become amenorrhoeic after 12 months \200\231 use. Inf requent bleeding occurs in 50% in the 1st 3 months \200\231 use; 30% at 6 months. Prolonged bleeding aff ects up to 33% in 1st 3 months; frequent bleeding aff ects <10%. Eff ective c ontraception may not occur in overweight women (BMI >35kg/m2) in the 3rd year, so consider earlier changing of implant. Liver enzyme inducers (p300) reduce effi cacy, so use other eg barrier contra- ception if they are started. Avoid if breast cancer. Patches Containing es trogen and progesterone eg Evra are similar to the combined Pill but breast discomfort an d breakthrough bleeding is commoner in \201 rst 2 cycles. Relatively expensive, twice as many women discontinue due to side-eff ects, but compliance may be better. 164 Thrombotic r isk is similar to the CoC. 165 They are aff ected by enzyme inducers (p300). Vaginal rings Combined contraception (CHC p300) with better cycle control. 155 305 Sterilization Sterilization is popular. Each year 47,000 women and 64,000 men are steri- lized (UK). 25% of women rely on sterilization for contraception. Ideally see both partner s and consider the following: \200 Alternative methods. Do they know about depot progeste rone injections, coils, and implants? Give written information (in relevant language) about alternative contraception and \200 and \200 sterilization. \200 Consent. Is it the w ish of both partners? Legally only the consent of the partner to be sterilized is required but the agreement of both is desirable. Those lacking mental capacity to consent require Hi gh Court judgment. Who should be sterilized? Does she fear loss of femininity? Does he see it as being neutere d? Does the \200 really want or need hysterectomy? Examine the one to be sterilized. y g o o c e a n y G l Irreversibility. Reversal is only 50% successful in either sex. Tubal surgery in- creases t he risk of subsequent ectopics. Sterilization should be seen as an ir- reversible step. Ste rilizations most regretted (3 \200\22310%) are those in the young (<30yrs), childless, at t imes of stress (especially relationship problems), or immediately after pregnancy (terminat ion or delivery). Explain reversal or subsequent fertility treatment is rarely funded by th e NHS. For sterilization at cesarean section, explain that it will only be done if the baby is nor mal and healthy. Counsel and agree \211 1 week pre-op. \200 Warn of failure rates \200 \22410-year follow-up of 10,863 USA women gave preg- nancy rates of 18.5 : 1000 procedures, 166 no better than new IUCDs (Copper T 380S , Mirena , GyneFIX ). Advise seeking medica l con \201 rmation if future pregnancy suspected or abnormal vaginal bleeding or abdominal pain. If pregnancy occurs there is \200\200 risk of ectopic (4.3 \200\22376%). \200 Sid e eff ects. A women who has been on the Pill for many years may \201 nd her periods unacceptably heavy after sterilization. \200\207Record in the notes: Knows it \200 \231s irreversible; lifetime failure rate discussed, eg 1 : 2000 for vasectomy, and 1 : 200 for \200 sterilization; see above. Female sterilization The more the tubes are damaged, the lower the failure rate and the more diffi cult reversal becomes. In the UK, most steril izations are carried out laparoscopically with general anesthesia. Filshie clip occlusion i s recommended 167 with local anesthetic applied to tubes (or modi \201 ed Pomeroy operatio n at mini-laparotomy if postpartum or at cesarean). Do pregnancy test pre-op. Advise use of eff ective contraception until the operation and next period. Remove IUCD after the next p eriod in case an already fertilized ovum is present. Alternatively, hysteroscopic steriliza tion using fallopian implants under local anesthetic or IV sedation is endorsed by NICE. \200 168 Vasectomy This is a simpler procedure than female sterilization and can be perform ed as an outpatient. The vas deferens is identi \201 ed at the top of the scrotum and is l igated and excised or the lumen cauterized. Fascial interpo- sition improves eff ectiveness . 169 Bruising and haematoma are complications. No-scalpel techniques reduce these complica tions. 170 Late pain aff ects 3% from sperm granulomata, which are less common if thermal c autery (rather than electrical cautery) is used. Warn of risk of chronic testicular pain. The major disadvantage of vasectomy is that it takes up to 3 months before sperm stores are used up. Obtain 2 ejaculates \200\230negative \200\231 for sperm (the \201 rst 8 weeks post-op; 2nd 2 \200\2234 weeks later) before stopping other methods of contraception. Rever sal is most successful if within 10 years of initial oper- ation. SE: Evidence of \200\200 risk of prostate cancer post-vasectomy. Meta-analysis suggests a small risk which may be du e to bias rather than causal. 171 Urinary malfunction Control of bladder function Continence in women is maintained in the ur e- thra by the external sphincter and pelvic \202 oor muscles maintaining a urethral pres sure higher than bladder pressure. Micturition occurs when these mus- cles relax and the bl adder detrusor muscle contracts. 306 \200 Incontinence or threat thereof dominates many people \200\231s lives. Ask about incontinenc e impact, role limitations, physical and social limitations, personal relationships, emotio ns, sleep/energy, and symptom severity. Ask patients to keep a diary of micturition for 3 d ays. Determine if symptoms indicate stress incontinence, urge, or mixed (NICE says this can be determined from history). \200 172 If mixed, treat the detrusor overactivity (DOA) \201 rst (OPPOSITE) as this can be made worse by operations for stress incontinence. In all women exclude UTI and diabetes. Exclude pelvic mass (PV exam), and residual palpable bladd er. In some postmenopausal women urgency, increased frequency, and nocturia is helped by es triol 0.1% cream PV or estradiol vaginal tablets used long term. Urge incontinence \200 \234If I \200\231ve got to go, I \200\231ve got to go now \200\235. The bladder may be over active, with high detrusor muscle activity. Treatment: see opposite. Stress incontinence Sm all quantities of urine escape as intra-abdominal pressure rises, eg during sneezing. It is commoner in parous women (pregnan- cy, not mode of delivery is the risk factor). 173 Exami nation may reveal prolapse (p290) or incontinence (ask her to cough). Overactive bladder (O AB) usually presents with urge incontinence, but in 25% presents as stress symptoms. It is a common cause of incontinence (33% of women; 50% of men, of the UK 3.5 million incontinent population). 174 Management \200 Exclude UTI and diabetes (dipstick urine; fasting gluco se). \200 Stress incontinence may respond well to pelvic \202 oor exercises. Arrange su pervised physiotherapy, (eg with weighted graduated vaginal cones) \200\2248 contractions, 3 times daily for 3 months to improve muscle tone. A vaginal tampon supports the bladder ne ck, stopping leaks, eg while playing sport. \200 Duloxetine (a serotonin/norepinephrine u ptake inhibitor) 40mg/ 12h PO can reduce stress incontinence. Licensed for use in moderate to severe stress incontinence in the UK, NICE recommend it as an alternative to surgery, us ed in combination with physiotherapy. y g o o c e a n y G l Surgery for severe stress symptoms aims to increase intraurethral pressure and reduce prola pse. NICE says cystometry is not needed before primary surgery1 (but without it, incontinen ce from detrusor instability is missed in 5 \200\22310%, \200\225175 so investigate if pre vious treatments have failed). Peri-urethral bulking may help, but eff ects may wear off af ter 1 \200\2232yrs. Mid-urethral tension free tape inserted under local anesthetic, or synt hetic slings can cure. If previous surgery has failed arti \201 cial sphincters may be nee ded. True incontinence Continuous leakage may be due to congenital abnormal- ity, eg ectopic ure ters, or to acquired problems, eg vesicovaginal \201 stula due to trauma (eg post-abdomin al hysterectomy in developed countries, after long labors, p90, in developing countries), m alignancy, or radiotherapy. If surgery is impossible, seek the help of the continence advis er. Interstitial cystitis Pathogenesis may involve loss of the bladder \200\231s glycos- am inoglycan protective layer and a high number of activated bladder mast cells. Symptoms: fre quency, urgency, bladder pain, and dyspareunia for >6 months. Symptoms are exacerbated by s tress, ovulatory hormones, and certain foods. \200\224: Dietary modi \201 cation, bladder training, biofeedback, antide- pressants, anticholinergics, NSAIDs, and bladder hydrodiste nsion may be tried. Food diaries + \200\201exposure to coff ee, alcohol, tomatoes, vinegar , spicy foods, chocolate, and some fruits may help.181 1 Unless DOA clinically suspected, anterior prolapse, previous stress surgery, voiding diff i culty. 307 Managing detrusor overactivity (overactive bladder) \200 Refer if any neuropathy, prolaps e, pelvic masses, or haematuria. \200 Avoid caff eine (it is a mild diuretic and stimulat es detrusor activity). \200 Bladder training to increase time between voiding. Train for 6 weeks. \200 Pelvic \202 oor muscle physiotherapy if stress incontinence symptoms. \200 Antimuscarinic drugs may be eff ective, 174 eg oxybutynin, starting with 2.5mg/12h, i ncreasing slowly up to 5mg/6h (12 hourly if elderly; SE: dry mouth, blurred vision, nausea, headache, constipation, diarrhea, abdo pain \200\224SEs are less if modi \201 ed-release once-daily tablets are used \200\22420mg/ day of Lyrinel XL may be tolerated; approach th is by weekly 5mg jumps). Tolterodine eg 2mg/12h is also eff ective; with lower side-eff ect pro \201 le. Solifenacin (5mg PO daily; up to 10mg as needed) is an alternative which may \200\200 bladder capacity and \200\201episodes of incontinence by 50%. 177 \200 Noctur ia may respond to desmopressin (unlicensed use). 174 \200 Overactive bladders are occasio nally treated with botulinum toxin, sacral nerve stimulation, augmentation cystoplasty, or urinary diversions. 172 y g o o c e a n y G l Voiding diffi culty Voiding diffi culty is rarer in women than detrusor overactivity. \200 \207Remember fecal impaction as a cause of retention with over \202 ow. Causes CNS: Suprap ontine (eg stroke); cord le- sions (cord injury, multiple sclerosis); peripheral nerve (pro lapsed disc, diabetic or other neuropa- thy); or re \202 ex, due to pain (eg herpes infect ions). Obstructive: Early oedema after bladder neck repair is a common cause. Others: uteri ne pro- lapse, retroverted gravid uterus, \201 broids, ovar- ian cysts, urethral foreign body, ureterocele, bladder polyp, or cancer. Bladder overdistension \200\224eg after epidur al for childbirth. Detrusor weakness or myopathy causes incomplete emptying + dribbling ove r \202 ow incontinence. Diagnosis: cystometry; electromyography.177 Causes: neurological c onditions and interstitial cystitis (p306). It may lead to a con- tracted bladder, eg requi ring substitution enterocystoplasty.178 Drugs: Especially epidural anesthesia; also tricycl ics, anticholinergics. Tests: MSU (?UTI) + ultrasound for residual urine and bladder wall t hickness: >6mm on transvaginal scan is associated with detrusor overactivity.179 Then: \200 Cystourethroscopy. \200 Urodynamic studies: uro \202 owmetry (a rate of <15mL/sec for a volume of Symptoms \200 Poor \202 ow \200 Straining to void \200 Hesitancy \200 Intermitten t stream \200 Incontinence (eg over \202 ow) Retention (acute or chronic) Incomplete emptying \200 UTI from residual urine >150mL is abnormal). Do this before any surgery is contemplated. Subtraction cystometry is a subtraction of intra-abdominal pressure from measured intravesi cal pressure to give detrusor pressure (intravesical measure is a mix of bladder pressure a nd intra-abdominal pressure). Treatment Acute retention may require catheterization (suprapubic if needed for several day s). For persistent conditions (eg CNS conditions) self- catheterization may be learned, eg with a Lofric gel coated catheter. Detrusor weakness may respond to drugs to relax the ur ethral sphincter or stimulate detrusor: \200 -blockers, eg tamsulosin 400 g/24h, relax th e bladder neck; diazepam relaxes the sphincter. Surgery may overcome obstructive causes, eg urethrotomy for distal urethral stenosis (uncommon). Gynecological surgery Hysterectomy Abdominal hysterectomy is usually total (uterine body + cervix removed), but may be Wertheim \200\231s (extended to include local lymph nodes and a cuff of vagina) \200\224used for malignancy. At vaginal hysterectomy the uterus is brought down through the vagina. Hospital stay is shorter but diffi culties may arise at operation if the uterus is very bulky. Lower-segment cesarean section and nulliparity may also imped e operation. Healthy ova- ries are usually conserved, especially in young women, whichever route the uterus is removed by, unless the hysterectomy is for an estrogen-dependent tumor. Complication: residual ovary syndrome (pain, deep dyspareunia, ovar- ian failure). Laparos copic hysterectomy was developed for patients in whom problems with open surgery are antici pated (eg extensive adhesions with endometriosis), but most of these patients can have a va ginal hysterectomy \200\224 which is much quicker (77 minutes vs 131 minutes), with a simil ar complication rate. Hospital stays are shorter, but total recovery not quicker. 308 \200 38,831 hysterectomies were performed in England in 2005 \200\2236, most for menorrhagia or \201 broids, and rates vary widely. Femininity and sexuality are bound up with the uterus . Subtotal hysterectomy leaves the cervix behind so remember to go on smearing these cervic es. The cervix is left in the belief that orgasm is less disrupted (controversial, and not borne out in systematic review)182 but late cervical problems (including bleeding) are rela tively com- mon (11%). \200\207Women who are counseled, and make their own decision about surgery, are less likely to have regrets. Operative mortality: 0.06%. Severe complications occur in 3% and are commoner in younger women and with laparoscopically assisted surgery. Hysterectomy doesn \200\231t cause \200\200psychological/ sexual morbidity when compared w ith ablation (below) at 1yr post-op. Manchester repair (Fothergill \200\231s operation) Pre gnancy is still possible after this operation for uterine prolapse. The cervix is amputated and the uterus is supported by shortening the ligaments. It is an operation rarely perform ed. Dilatation and curettage (D&C) The cervix is dilated suffi ciently to admit a curette t o scrape out a sample of endometrium for histology. D&C is a proce- dure for diagnosing abn ormal bleeding (but outpatient endometrial sampling (p279) and hysteroscopy may make D&C un necessary). Adequate sampling occurs in 75% but in 10% abnormal pathology may be missed. Ev acuation of retained products of conception from the uterus after miscarriage (ERPC), or te rmination of early pregnancy, are carried out by dilatation and suction. Hysteroscopy \200 \225183 As an outpatient alternative to D&C, a hysteroscope can be inserted through the cer vix into the uterus to visualize the endometrium. \200\230Blind \200\231 samples may then be taken using a sampler. Mainly used in the diag- nosis of abnormal uterine bleeding or wo rk up of infertility, it is also useful for some outpatient operative procedures: endometri al polypectomy, removal of small submucosal \201 broids, endometrial ablation, removal of lost IUCDs, and transcervical sterilization. Use of saline distension medium gives better views, reduced vasovagal episodes, reduced procedure time and the ability to use cautery. S mall scopes (2.7mm with 3 \200\2233.5mm sheath) reduce discomfort. NSAID taken 1h pre-proce dure PO reduces post-procedure discomfort. Consider in- tracervical/paracervical local anes thesia for postmenopausal women and if cervical stenosis (hence need for dilatation) antici pated: it is needed if large (>5mm) scopes used. Endometrial ablation/resection by laser, d iathermy, microwave, or other ablative method (under GA or spinal paracervical block) re duces bleeding by achieving a deliberate Asherman \200\231s syndrome (p251); as an alternat ive to hys- terectomy, it has fewer complications. Endometrium may be thinned pre-op y g o o c e a n y G l by leuprorelin or danazol. By 4 months 10% have menorrhagia again. Compli- cations (major i n 4% requiring further surgery in 1%): hemorrhage; infection (eg late necrotizing granuloma tous endometritis); uterine perforation; haema- tometra, vesicovaginal \201 stula, \202 uid overload from irrigation \202 uid can cause \200\200BP, \200\201Na+, pulmonary oed ema, CNS symptoms, and haemolysis. Some endome- trium remains in most (so give progesterone -containing HRT later, if needed). Pregnancy and endometrial cancer can still occur after a blation: p253. Laparoscopy The laparoscope is inserted umbilically. Instruments are in- ser ted through ports in the iliac fossae. Occasionally a Verres needle is placed suprapubicall y to insuffl ate and aid manipulation of organs. This procedure al- lows visualization of t he pelvic organs and is used for diagnosis of pelvic pain and ectopic pregnancy. The patien t is spared a full laparotomy unless needed for treatment. A \200\230lap and dye \200\231 demonstrates tubal patency. Sterilization and hysterectomy may be laparoscopically carried out, and ectopic pregnancies treated. Colporrhaphy or \200\230repair \200\231 The lack of support from the vaginal wall in cases of prolapse is recti \201 ed by excising redundant mucosa and doing a fascial repair. It is not an operation to correct urinary incontinence. The operation may be combined with Manchester repair or vaginal hysterectomy. The more muco sa is removed, the tighter the vagina. Enquire before surgery if she is sexually active. Ca theterization circumvents post-operative retention of urine. Cone biopsy A cone of tissue ( point inwards) is cut out around the external cervical os, using knife or laser. This remov es neoplastic tissue for histology, and may be curative. Complications: (immediate) bleedin g, (long-term) cervi- cal stenosis or incompetence. Pelvic exenteration Consider this optio n when initial surgery fails to control neoplasia of the cervix, vulva, or vagina. It invol ves removal of the pelvic or- gans \200\224ie ultra-radical surgery, which should only be c ontemplated if there is a chance of cure. Do your best to establish whether disease has spr ead to the pelvic sidewall or nodes, eg with MRI or CT scans and intra-operative biopsy wit h frozen section: if so, exenteration is probably not worthwhile. Only 20% of possible can didates for surgery meet this criterion: in addition the patient should be quite \201 t, and ideally have a supportive partner. We know that pal- liative exenteration in those with unresectable disease is not worthwhile. 5-yr survival: 50%. Operative mortality: 5%. Com plications: GI obstruction/ \201 s- tulae; urinary \201 stulae. Remember to give full pr e-operative counseling about colostomies, and sexual function (refashioning of the vagina m ay be possible). Enhanced recovery This looks at patient pathways with a view to optimiz- i ng preoperative and postoperative care with the aim of minimizing inpatient length of stay. Measures adopted include admission on the day of operation, early removal of drips and cat heters and early postoperative feeding. Daily ward rounds and good pain management are an i ntegral part of care. 309 y g o o c e a n y G l Chronic pelvic pain This is intermittent or constant lower abdominal pain of >6 months \200 \231 duration not associated exclusively with menstruation, intercourse, or pregnancy. Pain may cause, or be exacerbated by, emotional problems. She may be depressed. Adequate time n eeds to be given to allow women to tell their story, express their views as to the cause of pain, and explore psychological aspects and past abuse. A multidisciplinary approach eff e cts most all round improvement. 184 310 \200 Laparoscopy may reveal a likely cause: chronic pelvic infection, endome- triosis, adenomyos is, adhesions (eg residual ovarian syndrome and trapped ovarian syndrome), \200\225185 or congested pelvic veins. Consider also irritable bowel syndrome (OHCM p268), and interstitia l cystitis (p306). If pain is quite cyclical ovarian suppression (Pill/Zoladex ) may help. Pelvic congestion Congested lax pelvic veins (seen at laparoscopy) cause pain worse on stan ding, walking, and premenstrually. Typically variable in site and intensity, there may be u npleasant postcoital ache. Deep palpation reveals maximal tenderness over ovaries. Vagina a nd cervix may look blue as congestion. Look for associated posterior leg varicosities. Remedies include explanation ( \200\230pelvic migraine \200\231), ovarian supression, mi- g raine remedies (OHCM p450) and relaxation techniques. For severe symptoms bilateral ovarian vein ligation, radiological embolization, or hysterectomy with salpingo-oophorectomy ( HR T) may cure. Mittelschmerz This is mid-cycle menstrual pain which may occur in teenag- ers and older women around the time of ovulation \200\224from the German mittel (=middle) and S chmerz (=pain). y g o o c e a n y G l Dyspareunia This means pain during intercourse. There may be a vicious circle in which anti cipation of pain leads to tense muscles and lack of lubrication, and so to further pain. \200\207The patient may not volunteer the problem so ask about intercourse. Her attitude to pelvic examination may tell you as much as the examination itself. Ask her to show you whe re the problem is. If the problem is actually vaginismus do not insist on examination and c onsider counseling and sex therapy (p384). Was there \200\230female circumcision \200\231 (p247)? \200 Dyspareunia may be super \201 cial (introital) eg from infection so look for ul- ceration and discharge. Is she dry? If so is the problem estrogen de \201 ciency (p256) or lack of sexual stimulation? Has she had a recent postpartum per- ineal repair? A suture or scar can cause well-localized pain which is cured by massage or by removing the suture and injectio n of local anesthetic. If the introitus has been rendered too narrow, she may need surgery. Deep dyspareunia is felt internally (deep inside). It is associated with en- dometriosis an d pelvic sepsis; treat the cause if possible. Ovaries lying in the rectovaginal pouch (or a fter hysterectomy) may be subject to coital thrusts; try other positions or ventrosuspensio n if a \200\230cure \200\231 can be obtained with trial use of a Hodge pessary. Dermatographism is a rare cause of dyspareunia: look for itchy vulval wheals some minutes a fter calibrated dermatographometer application. It can occur on any surface. It is the comm onest physical cause of urticaria, and the clue to its presence is linear wheals with a sur rounding bright red \202 are (but no angio-oedema) elsewhere on the skin, in response to a \201 rm stroke. Cause is unknown. Relief of dyspareunia in these cases has been achieve d by 2% adrenaline (epinephrine) cream, and cetirizine 10mg/24h PO. 311 Ovarian hyperstimulation This is a systemic disease resulting from vaso- active products re leased by hyperstimulated ovaries. The incidence for severe cases is 3 \200\2238% in women having ovarian stimulation (mild cases occur in 22 \200\22333% of treatment cycles). It is com- moner in conception cycles, especially if multiple pregnancy. Other risk factors: see MINIBOX. Asso- ciated complications are ascites, reduced intra- vascular volume, pulmonary eff usions and (rare) pericardial eff usions. Thromboembolic compli- cations may ensue (esp ecially in upper limb and cerebral vessels). Presentation Abdominal discomfort, nausea, vom iting, and abdominal dis- tension dyspnoea. Presentation is usually 3 \200\2237 days aft er human chorionic gonadotrophin (HCG) administration, or 12 \200\22317 days, if pregnancy has ensued. Prevention Note: In vitro maturation (IVM, p293) avoids the need for ovar- ian stimulation so is especially suitable for women with polycystic ovaries. In those in whom h yperstimulation is suspected (peak serum oestradiol >6000pg/mL and >30 follicles stimulated ), the surest way to avoid hyperstimu- lation is to avoid administration of HCG so the stim ulated follicles do not ovu- late, thereby canceling the cycle of treatment (or discontinue gonadotrophins and delay HCG injections until the serum oestradiol returns to \200\230saf e \200\231 levels). Some selectively cryopreserve embryos for later transfer. Management Ad mit to hospital unless just mild pain. Give adequate anal- gesia (opiates if necessary, avo id NSAIDs). Check FBC, U&E, creatinine, LFT, and coagulation pro \201 le. Do CXR if chest pathology suspected; ECG and echo if pericardial eff usion suspected; blood gasses if tachy pnoeic or dyspnoeic. Chart urine output (if oliguria suspected catheterize and measure \202 uid output hour- ly). Measure abdominal girth and weigh daily. Ovarian size is a guide to sever- ity unless oocytes have been harvested (eg, mild, ovarian size <8cm; moderate 8 \200\22312cm; severe >12cm). To avoid thromboembolism use antiembolic stockings, encourage leg mobility, and use heparin (p16) during inpatient stay 186 and pos- sibly for 1st trimes ter if pregnancy ensues. \200\225187 Risk factors \200 Age <30yrs \200 Asthenic habitus \200 Pregnancy \200 Luteal phase HCG stimulation Polycystic ovarian syn \200 Serum oestradiol >4000pg/mL Multiple follicles (>35) \200 Previous hyperstimula- y g o o c e a n y G tion l Hyperstimulation is severe if haematocrit is >45%, WCC >15 \211\210109/L, there is massive ascites, oliguria, mild renal, or liver dysfunction. Put up IVI, and con- sider CVP monitor ing. Fluid replacement may be required, eg 500mL albumin over 2 hours. Paracentesis of asci tes using ultrasound to avoid cysts may be needed to reduce discomfort, relieve breathing a nd for persistent oliguria (can improve renal function). The situation is critical if the h aematocrit is >55% and WCC >25 \211\210109/L, there is tense ascites and renal failure, thr omboembolic phenomena, and acute res- piratory distress syndrome (OHCM p178). Admit to ITU. Symptomatic pleural eff usions may need drainage. Use antiembolic measures as above. Pay m eticu- lous attention to \202 uid balance. Aim to maintain intake at 3L/24h using normal saline if unable to tolerate oral \202 uids. Beware hyponatraemia. The severity of eff us ions determines the time to recovery. In non-conception cycles with little ascites there wi ll be resolution with menstruation. In con- ception cycles cysts may persist for weeks. Res olution usually occurs, but exceptionally termination of pregnancy may be needed. Deaths ha ve been reported but are extremely rare ( 1 : 500,000 stimulated cycles). 312 4 Psychiatry s d n m g n g n a h C i Part I: First principles 314 i