On the occasion of International Women’s Day, Dr Stephanie de Giorgio shares these key tips to improve women’s health. Dr de Giorgio is a GP with an interest in women’s health, perinatal mental health and is National Clinical Lead and Advisor to NHSE.
There seemed no better medical way to celebrate International Women’s Day 2019 than to write a blog with some of the most important things to remember when managing women’s health in primary care. With such a large range of conditions and experiences to consider, I have tried to include the latest guidelines for the issues which seem to cause most confusion amongst GPs, as well the things causing most difficulty for women that I speak to from all over the country.
Thank you to Dr Nikita Kanani for asking me to write this for IWD, to Dr Zoe Norris, my friend and co-presenter on my Women’s Health Teaching job and my NHSE job share friend Dr Carrie Ladd. What a wonderful, professional and knowledgeable group of doctors I am lucky enough to work with.
- Continuous flexible pill taking for the COCP is the most efficacious way to prescribe according to the evidence. The 21/7 regimen is outdated, risks pregnancy and this method controls cyclical symptoms, both physical and psychological. If women wish to have a monthly bleed, only give a 4 day break. For more info
https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/fsrh-combined-hormonal-contraception-guideline-february-2019.pdf - Menopause symptoms are hugely variable amongst women and cause huge distress. Mood disturbance, muscular and joint pains, itching and insomnia are all common. HRT is the most effective treatment and should be considered for women in the perimenopause and menopause with no risk factors. It is a clinical diagnosis for the majority and treatment should be started early and continued for as long as she needs it.
https://www.nice.org.uk/guidance/ng23/chapter/Recommendations#individualised-care - Transdermal preparations are the safest form of HRT. This can be in combined preparations in the form of a patch, or oestrogen gel/patch alongside progestogens in the form of a Mirena IUS or oral utrogestan (micronized progesterone) . For more information
https://thebms.org.uk/wp-content/uploads/2016/04/HRT-Guide-160516.pdf - Vaginal moisturisers, lubricants and oestrogen can be vital in helping women with vaginal symptoms of menopause and can be used alongside systemic HRT or instead of for women who don’t wish to have systemic treatment.
https://www.womens-health-concern.org/help-and-advice/factsheets/vaginal-dryness/ https://www.mymenopausalvagina.co.uk/ - Perinatal Mental Illness is common. Suicide is the leading cause of death is women between 6 weeks and 1 year postnatally. We have a huge role to play in primary care in identifying the women who are suffering but there are huge barriers to women disclosing such as societal stigma, fear of social services, concerns about medication and feeling rushed. Ask these two questions and really listen to the answers.Look behind the smile.
- How are you finding being a mum (again)?
- Tell me about the birth.
https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/perinatal-mental-health-toolkit.aspx
- Do not stop psychotropic medication if a pregnant woman comes to see you. Women are at huge risk of relapse and need careful assessment of the risk and benefits before medication is stopped. The risks of stopping the medication may well outweigh the risks of continuing. Most areas of the country now have community perinatal psychiatry teams who you can ask for advice.
https://www.sussexpartnership.nhs.uk/node/1516/attachment - Pelvic floor problems, including urinary but particularly faecal urgency and incontinence are underreported and therefore often go untreated. Remember to ask women specifically about these symptoms if you see them postnatally or even during appts for other gynaecological issues. They often won’t disclose otherwise, as they may think it’s “normal after you have had a baby”. Refer for physiotherapy or specialist care and many women have found the Squeezy app very helpful.
https://www.uclh.nhs.uk/OURSERVICES/SERVICEA-Z/WH/MAT2/POSTNATALCARE/Pages/Postnatalphysiotherapy.aspx https://www.squeezyapp.com/ - The experience of heavy menstrual bleeding will be very subjective and taking a good history with regards to the effects of the heavy bleeding on a woman’s life is vital. How many pads/tampons per hour or day? Is she having to get up in the night? Is she stuck at home or missing work or school? This shouldn’t be considered a fact of life that women have to deal with and further details of management can be found here https://www.nice.org.uk/guidance/ng88/chapter/Recommendations#history-physical-examination-and-laboratory-tests
- Approximately 60% of our female patients are now overweight or have obesity. This has health implications, including higher rates of gynaecological cancers but also means we need to know how to look after our patients with obesity properly. Things we need to do in primary care
- Learn the science behind obesity
http://www.mdbriefcase.net/uk/obesity?regionID=16&Home=true
https://cdn.easo.org/wp-content/uploads/2018/05/16195602/practicalguide-a5_print.pdf - Avoid stigma, overweight women attend less for healthcare, have worse health outcomes and have lower rates of smear tests.
https://cdn.easo.org/wp-content/uploads/2018/08/16195609/Weight-Stigma-8pg-April-27-2018.pdf - Women with a BMI >26 need double dose of levonelle for EC and women who have had malabsorptive bariatric surgery cannot have oral contraception https://www.fsrh.org/documents/fsrh-overweight-obesity-guideline-for-public-consultation/
- Learn the science behind obesity
- Premenstrual syndrome and Premenstrual Dysphoric Disorder are a significant cause of morbidity. A good history including effect on her everyday life and a symptom diary are the key to making the diagnosis. For further management, including the use of SSRI and hormonal contraception can be found here
https://cks.nice.org.uk/premenstrual-syndrome#!scenario