GP Educational Evening 12 th February Matthew Long MD FRCOG.
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Transcript of GP Educational Evening 12 th February Matthew Long MD FRCOG.
![Page 1: GP Educational Evening 12 th February Matthew Long MD FRCOG.](https://reader034.fdocuments.in/reader034/viewer/2022051401/56649c885503460f94940205/html5/thumbnails/1.jpg)
GP Educational Evening12th February
Matthew Long MD FRCOG
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Matthew Long
• Qualified 1983• MRCOG 1988 / FRCOG 1990• Appointed Consultant 1993• MD (University of London) 1995 • RCOG preceptor for advanced MAS
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Matthew Long - main interests
• Pelvic organ Prolapse and incontinence
• Heavy menstrual bleeding / fibroids / endometriosis
• Menopause, HRT including female testosetreone replacement therapy
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Themes
• Menopause• Urinary urgency• Prolapse
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Case 1
• 55 years old• Menopause aged 52• Menopausal Sx• Estradiol improves Sx • Progestogenic S/E with oral progestogens• Superficial dyspareunia despite oral estradiol• Reduced energy / libido• Gritty eyes/ soreness
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Progesterone effect on endometrium
• Cyclical progestogens with HRT induce withdrawal bleed
• Hyperplasia rate approx 6% (Sturdee)• Continuous progestogens < 1% hyperplasia• Recommendation to change women form
cyclical HRT to CCHRT after 5 years• Erratic bleeding initially due to secretory effect
then settles when inactive
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Mirena and ERT
• Endometrial anti proliferative effect prevents estradiol stimulation and hyperplasia
• License for 4 yrs use• No need for oral/systemic progestogen• Route of estradiol delivery not relevant eg,
oral, patch, gel or implant• If previous erratic bleeding on HRT exclude
other pathology
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Case 1
• 55 years old• Menopause aged 52• Menopausal Sx• Estradiol improves Sx • Progestogenic S/E with oral progestogens• Superficial dyspareunia despite oral estradiol• Reduced energy / libido• Gritty eyes/ soreness
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Vaginal Oestrogens
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Vaginal Oestrogens
• Creams / Tablets / Rings• Reduce urogenital Sx and possibly UTI’s• Can reduce irritative bladder symptoms• NB -25% women on HRT urogenital atrophy• long term use needed as atrophic Sx return
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Long Term Vaginal Oestrogens
• Endometrial data - no significant risk with tablets or rings (local)
• No need for Progesterone challenge• Breast Ca – minimal risk studies ongoing for women
with a Hx of breast Ca• Thrombotic data sparse but risk extremely small• Conclusion – safe in longer term• Vagifem 10 micrograms licensed for long term use
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Case 1
• 55 years old• Menopause aged 52• Menopausal Sx• Estradiol improves Sx • Progestogenic S/E with oral progestogens• Superficial dyspareunia despite oral estradiol• Reduced energy / libido• Gritty eyes/ soreness
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Testosterone
• Hypoactive Sexual Desire Disorder• HSDD• Some evidence testosterone improves libido• Study in hysterectomised women also on ERT
under age of 60• Transdermal testosterone – 300mcg/24 h
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Testosterone
• Now not available
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Testosterone
• Testogel or Testim gel• Not licensed for use in women – UULP• 1/16th sachet daily initially• Counsel about S/E and use in women• Testosterone levels after 3 weeks and then
adjust dose
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Dry Eye Syndrome
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Dry Eye Syndrome
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Dry Eye Syndrome
• Warm eye compresses• Flax seed• Artificial tears• Ophthalmology intervention – eg. punctal
duct plugs
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TestosteroneDry Eye Syndrome
• Some evidence low testosterone levels associated
• USA small study shown improvement with testosterone
• Idiopathic or Sjogren’s syndrome reduce activity of meibomian glands
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Female Testosterone therapy and dry eyes
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Female Testosterone therapy and dry eyes
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Case 2
• Urinary frequency• Urgency, occ urge incontinence• Nocturia 2-3x• No USI
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Exclude
• UTI• Diabetes• Voiding disorders• Pelvic masses• Utero-vaginal prolapse
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Fibroids
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Minimal Access Hysterectomy
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Prolapse
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Pessaries
• Ring pessary – cystocoele/vault• Shelf pessary – vault + high cystocoele• Gelhorn – vault + high cystocoele• Hodge pessary used for anteverting a
retroverted uterus – rarely now• NB Pessaries do not control
enterocoele/rectocoele well
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Overactive Bladder
• Urinary leakage due to an unprovoked detrusor contraction
• Detrusor hyper reflexia - above due to neurological problems eg. MS, cord injury, prolapsed IVD
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OAB Therapies
• Success Relapse• Bladder Drill 70% 40%• Biofeedback 80% 50%• Hypnosis 86% 40%• Acupuncture 87% ?
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OAB - Therapies
• Dietary/Fluid intake• Weight loss if BMI > 30 • Behavioural - Bladder drill – minimum 6 weeks• Physiotherapy• Biofeedback• Complimentary - acupuncture/hypnosis
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OAB - Mainly antimuscarinic
• Oxybutynine – 1st line • Tolterodine – 1st line • Darifenacin – 1st line• Solifenacin• Trospium• Propiverine• (DDAVP – Desmopressin – special circumstances) • Vaginal Estrogen
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Side Effects
• Dry mouth• Constipation• Dyspepsia/reflux• Dry eyes/blurred vision• Difficulty sleeping• Urinary retention• NB narrow angle glaucoma
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Preparations
• Long acting agents• Oxybutynine/Tolterodine• Transdermal – Oxybutynin• Reduced CNS absorption• Trospium
• Vagifem
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Success
Generally same for most drugs• 80 % patients improve• 40 - 60% reduction in symptoms• Do not offer generic oxybutynin to frail or
elderly women• Offer telephone or face-face consultation 4
weeks after starting drug therapy• 6 month to annual review
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Vaginal Oestrogens
• Creams / Tablets / Rings• Reduce urogenital Sx and possibly UTI’s• Can reduce irritative bladder symptoms• NB -25% women on HRT urogenital atrophy• long term use needed as atrophic Sx return• Offer to post-menopausal women – NICE 2013
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Mirabegron
Adapted from Betmiga Summary of Product Characteristics, December 20121 and Chu et al., 2006.3
1. Betmiga Summary of Product Characteristics, December 2012.2. Gras J. Drugs of Today 2012;48(1):25-32.3. Chu F, Dmochowski R. Am J Med 2006;119(3A):3S–8S.
Mode of action of OAB treatments1,3
Date of preparation: February 2013. BET13018UK
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Mirabegron
• Beta – 3 adrenoreceptor agonist• Reduces activity detrusor muscle• 50mg dose once daily• If renal/hepatic impairment then 25mg once
daily• Avoids anticholinergic S/E• Can cause palpitations• Abnormal cardiac rhythm uncommon
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Mirabegron
• Can take 2-3 weeks to have an effect• Alternative to anti- cholinergic agents
especially if S/E, intolerance or ineffectual • Can be used in addition to anti-cholinergic
agent• Average cost - £27 per 28 days • Generic oxybutynin £6.11 per 56 days (NB S/E)• Nice guidance – use as second line drug
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OAB only - What to do
• If normal voiding :-• General therapies• +/- drug therapy• +/- vaginal E2
• If abnormal voiding/ Failed treatment• Refer - urodynamic studies/cystoscopy
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Urinary Incontinence – Overactive Bladder
• 1st published 2006 CG 40• Now replaced by CG 171• Published September 2013• 116 recommendations – covers primary care
and secondary care• NICE Pathway 2013
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NICE Summary
• Decide type of incontinence – mixed picture treat predominant symptom
• Precipitating factors• Pelvic masses• Pelvic floor contraction strength• Urine dip• Screen for voiding dysfunction• Urinary diaries – minimum 3 days
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Pelvic Floor Contraction Strength
• Assess digitally - Oxford Scoring System– 0 = no contraction– 1 = flicker– 2 = weak– 3 = moderate– 4 = good– 5 = strong
• If prolapse seen reaching introitus refer onto specialist
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UI Referral Criteria
• Haematuria• Suspicion of neoplasia• Bladder pain• Voiding disorder• Benign pelvic mass• Failed conservative therapy
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Painful bladder syndrome
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UI Referral Criteria
• Previous continence or prolapse surgery• Significant prolapse - visible at introitus• Previous cancer therapy• Possible urogenital fistula• Associated faecal incontinence• Possible neurological disease
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Other Therapies
• Do not offer Transcutaneous Posterior Tibial Nerve Stimulation
• Do not offer Percutaneous Posterior Tibial Nerve Stimulation routinely - only after specialist review when other therapies have failed
• Do not offer Transcutaneous Sacral Nerve Stimulation routinely – only after specialist review when other therapies have failed
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Surgical Therapies
• Only after conservative and medical therapy has failed
• Botulinum A therapy after failure of medical therapy and patient able to perform CISC
• Augmentation cystoplasty – decreasing use• Urinary diversion – rare• Sacral Nerve Stimulation -rare
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Matthew Long
01293 82234407771 727546
www.specialistgynaecologist.co.uk
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Q & A’s
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