Gynaecology

Dr Riley Harrison
Case list
Pain
• Primary dysmenorrhea*****
• Ovulation pain****
• Endometriosis****
• Cyclical mastalgia***
• Bleeding per vagina
• Pubertal menorrhagia**
• Myoma**
• Expelled Mirena*****
• Cervical ectropion*
• Atrophic vaginitis**
• Endometrial hyperplasia*
Amenorrhoea
• Primary PPH*
• Secondary PPH***
• Puerperial pyrexia (Mastitis/Endometritis)****
Infections
• Recurrent candidiasis**
• Recurrent genital ulcers**
• Trichomoniasis**
• Bacterial vaginosis**
• Honeymoon cystitis****
• Pyelonephritis*****
• Bartholin’s abscess ****
• Urinary retention herpes simplex**
• Lichen sclerosis****
• Genital warts***
Counselling
• Mirena*
• Vulvovaginitis suspected abuse****
• Subfertility***
• HRT counselling 1*****
• HRT counselling 2*****
• OCP request*****
• Permanent sterilization*
• Request for removal of the uterus*
• STD screening*
• Pap test result***
Miscellaneous
• 6 weeks postpartum check-up***
• UVP*
• Stress incontinence****
• Urge incontinence****
Pain
Primary dysmenorrhoea
You are a GP. You are going to see a 23 years old lady, Karen, coming to you with pain during period.
In USG findings : there is a maturing follicle and endometrial thickness of 8mm. There is a cyst in right
ovary measuring 2.5 cm. Pelvic examination not done. UPT negative.
Your tasks :
• Take history
• Explain the USG
• Explain DDx

History
• First time? When did this pain begins?
• Pain questions (where, when , Is that happening during the whole period or at the start of the
period or before the period? how long, radiation, nature, continuous or intermittent, relieving,
precipitating factors)
• Associated features (differentials)– fever, (PID) discharge(PID), itchiness(infections), mass
(Myoma), Dragging sensation down below?
• Are you sexually active? Any chance that you get pregnant? (miscarriage, ectopic)
• Other symptoms (to exclude endometriosis)– Dyspareunia – any pain during sexual
intercourse? Dyschesia – Any pain while opening of the bowels? Dysuria – Any pain while
passing urine?
• 5 P – periods, Pills, partner, parity, pap test
• Past medical, surgical, SADMA
• When did this ultrasound taken? (ans: two weeks after the period)

• Explanation – In your ultrasound, the endometrial thickness is 8mm, which is the thickness of
the lining of the womb. This is the normal thickness in the middle of the cycle. Also there is a
mature follicle which means that this follicle which contains the egg. This follicle will rupture
releasing the egg at the time of ovulation, which usually occurs two weeks before the period.
We also found an ovarian cyst in right ovary, which is a fluid-filled pocket in the ovary, which is
most likely the functioning cyst containing the maturing follicle which is a normal occurrence.
Your ovaries normally grows follicles each month which produces female hormones maintain
the menstrual cycle.

• DDx – the cause of your painful menstruation is most likely a primary dysmenorrhea. It’s the
cramping pain that comes before or during the period. This pain is caused by natural chemicals
(prostaglandins) released from the lining of the womb. This causes the muscles and blood
vessels of the womb to contract causing the pain. When bleeding continues and the lining of the
womb is shed, this chemical level falls so the pain lessen.
• Other DDx – endometriosis which is the wrong location of the inner womb lining on the other
organs like ovaries and ligaments, adenomyosis which is the wrong location of inner womb
lining on the outer surface of the womb, Myoma or fibroid which is the benign tumor in the
womb. But all these are unlikely according to your history and ultrasound result. Or it could be
PID which is an infection down below but less likely since you don’t have any discharge and your
pain is not consistent.
Ovulation Pain
A 25 years old female, Ivy, is coming to you. You are a HMO at the hospital. She is having right sided
lower abdominal pain. Now her pain is relieved. You did the blood tests and a USG. Blood tests shows
no abnormality including the inflammatory markers and liver function tests. Ultrasound shows stones
in the gallbladder, maturing follicles in the ovary, minimal fluid present in the pouch of Douglas.
Appendix isn’t visible. UPT is negative.
Your tasks:
• Take relevant history
• Explain the ultrasound result to the patient
• Diagnosis and differential diagnosis to the patient
• Further management to the patient

Differential diagnoses
O&G
• Incomplete abortiom
• Primary/secondary dysmenorrhoea
• Ectopic pregnancy
• Mid cycle pain
• PID
• Complication of ovarian cyst
• Endometriosis
Medicine and surgery
• Appendicitis
• Stone
• Gastroenteritis
• Urinary tract infection

History
• Are you in pain now? Pain killers?
• Pain questions – 1st time? Severity? Site? How long? How frequent? Radiation? Nature?
Persistent or off and on? Relieving/aggravating factors?
• DDx- Fever, Nausea, vomiting, tummy distension? (appendicitis), problem with Poo and pee?
(UTI) yellow dislocoratione? Bloating? (gall stones)
• 5 P – Period? Do you think your pain is related to period? LMP? Cycles? Days of bleeding? Did
the pain happened in between menstruations?
• Partner – Stable partner? Safe sex? Any problem with intercourse? Any STI before?
• Pills
• Pregnancy – By any chance, any possibility of being pregnant?
• Past medical, surgical
• SADMA

• Explain the USG. USG shows there is maturing follicles in the right ovary and small amount of
fluid in the space called POD which is a space between womb and bowel. The means the
ovulation is happened which a matured follicle ruptured, released the egg and a small amount
of fluid. This is showing that it is the time of ovulation. It is not a serious condition. It is a good
 sign of fertility. And also there are small stones present in the gall bladder but there is no signs
of inflammation.

• This pain occurred during ovulation is called Mittelschmerz pain.

• DDx – Appendicitis which is the inflammation of the appendix, infections in the urinary tract,
inflammation of the gall bladder due to stones but less likely.
• Treatment – The released follicular fluid irritates the covering of the tummy and causing pain.
(Mittelmertz) The treatment is mainly supportive. For gall stones, I can refer you to the specialist
but most likely we keep it conservative as it’s a common finding.
• Pain – Panadol, warm packing the painful area
• Red flag – similar pain with fever and vomiting – come to ED

Endometriosis
You are a general practitioner. A 27-year-old lady, Katy, came to you with pain during menstruation.
Your tasks:
• Take history
• Physical examination from the examiner
• Tell the diagnosis and management to the patient

PEFE card
• Abdominal examination - Lower abdominal tenderness
• Digital examination of the vagina- Fixed retroverted uterus
• Nodularity of the uterosacral ligaments and POD
• Speculum examination may reveal: Unremarkable
• Other systems examination normal

History
• First time?
• Pain questions (where, when, how long, radiation, nature, continuous or intermittent, relieving,
precipitating factors)
• Associated features (differentials)– fever, (PID) discharge (PID), itchiness(infections), mass
(Myoma)
• Other symptoms – Dyspareunia – any pain during sexual intercourse? Dyschesia – Any pain
while opening iof the bowels? Dysuria – Any pain while passing urine?
• 5 P – periods, Pills, partner, parity, pap test
• General wellbeing
• SADMA

Examination from examiner

- abdomen (inspection, palpation, percussion, auscultation)
- pelvic examination (inspection, sterile speculum exam, bimanual)
• DRE
• UDT
 • Diagnosis – draw a picture and explain the condition, endometriosis (wrong location of the inner
womb lining deposited on the other organs like ligaments supporting the uterus, ovaries and the
pouches in the tummy. Those cell deposits are responding to estrogen during periods, creating
flow of menstruation. So, this blood has got nowhere to go out, so they form clots, scars and
adhesions resulting irritation and pain)
• Confirm – USG (gold standard – laparoscopy)
• Management – refer to gynaecologist. Options – medical treatment to create a
pseudomenopause (OC pills, Depo, IUCD, other male hormonal pills like Danazol, Gestrinone
and anti-estrogen GnRh analouges) or
• surgical– laparoscopy where a flexible tube with light source is introduced into the tummy via
small holes and look for those deposits - (curative as well, remove those tissues with heat or
laser)
• Review and Reading materials

Cyclical Mastalgia
You are a GP. Your next patient is a 26 years old lady, Anna, presenting to you with lumpy feeling and
pain in her both breasts.
Your tasks:
• Take history
• Explain the provisional diagnosis
• Advice the management

History
• Pain questions – where? Both breasts? Duration? Continuous or off and on? Associated with
period? Character? Radiation? Aggravating/ relieving factor?
 • Lumpy feeling? Any lumps? Associated with period?
• DDX – Cyclical mastalgia – how is your period? LMP? Injury? Infection –any redness ? Ca – any
nipple discharge? Skin changes? Loss of weight? Loss of appetite? Irritability, bloating? (PMS),
trauma?
• 5 P (any possibility of being pregnant? And other Ps)
• Past medical, surgical, family history (breast cancer)
• SADMA

• Most likely – your symptoms are pointing to cyclical mastalgia

• Cyclical – related with period, mastalgia – breast pain
• Common in your age due to hormonal changes in cycles of period
• It is not cancer or not associated with cancer
• To make sure, I will do PE and USG which will likely to be normal
• Management -
• Simple measures – Panadol, adequate bra size and supportive bra, reduce coffee, tea, alcohol,
keep a diary (pain chart), note aggravating and relieving factors, days in pain
• Evening primrose oil
• Next step – hormonal – OC pills (relief for some women and exacerbate for some), Danazol
(male hormone), tamoxifen, Bromocriptine
• We will go step by step
• Any concern? Mom ca – talk about breast cancer screening, Follow-up 2 weeks, reading material

Bleeding PV
Myoma
A 35-year-old female, Elena, comes to your GP clinic complaining of heavy menstrual flow for several
months. she has 2 children 6 and 8 year. Her FBE showed low hemoglobin.
Tasks:
• History
• Physical examination (Specific findings will be given only when asked)
• Explain the diagnosis

History
• hemodynamically stable?
• Are you bleeding now? Since when? How many pads? Are the pads fully soaked? any clots as
well? the duration of your periods? Do you feel dizzy, palpitations, fainting? Any pain during
your periods? Do you have bleeding between periods? LMP?
• any bleeding disorders? Any abdominal any pelvic pain? Any problem with passing water? Any
problem with your bowel? Any weather preference?
• Are you sexually active? Are you in a stable relationship? Any chance you could be pregnant?
Previous pregnancies?
• Are you on any contraceptive? Have you or your partner ever been diagnosed with STDs? Pap
smear? bleeding disorders or gynecological tumors/cancers?
• (SADMA, medical, surgical history)

Physical Examination
• General appearance (Pallor, BMI)
 • Vital signs
• Abdomen: Visible masses, organomegaly, tenderness
• Pelvic Exam:
• Inspections:
• Speculum Exam: cervical os close/open
• Bimanual: enlarged irregular uterus about the size of 12 weeks’ GA. No palpable adnexal
masses. CMT negative.
• Urine dipstick, BSL, urine PT

Diagnosis and Management

• From the history and examination, the most likely cause of your heavy periods is uterine fibroid
or myoma.
• However, I need to do some investigations to confirm the diagnosis. The investigations are beta-
hcg, iron studies, coagulation profile, urine MCS, and TVS.
• A fibroid is a benign tumor which is formed inside the uterus. It is very common in the
reproductive age group. Let me reassure you that it is not a cancer. The exact cause is
unknown, but it is suspected that the sex hormones, estrogen and progesterone, play a
significant role.

• Fibroids often cause no problems but occasionally, it can be associated with:

➢ Anemia
➢ Urinary problems
➢ Infertility
➢ Miscarriage and premature delivery

• I will need to refer you to the gynecologist for further assessment and management.
• (((Treatment depends on the location, size, and number of fibroids. If fibroids are small and not
causing symptoms, we may just observe. The other options are medications and surgery.)))

Expelled/displaced Mirena
A 42 years old Fiona came to see you because she’s got the heavy periods for 2 months. She has two
children.
Tasks:
• Take History for 5 mins
• PEFE card from the examiner
• Tell the possible DDx

PEFE card
• Vitals – normal
• Abdomen – unremarkable
• Pelvic examination – speculum –as in the picture
• Bimanual examination – unremarkable, uterus anteverted, size normal, no Adenexal mass
History
• Ok. I will tell you more about this concern. But first, let me ask you some questions.
• Details of bleeding:
• Severity - Dizziness, SOB, palpitation?
• 5 P questions
• If Hot flashes was also complaint – perimenopausal symptoms - are you generally anxious?
How’s your sleep? Mood? Any racing of heart?
• Ddx –
• Endometriosis –any pain during intercourse?
• -Infections – any discharge? Any itchiness? Any fever? Any pain in down below? Retained
tampon? Any pain in tummy?
• -Drugs- any blood thinning medications? Stopping or changing? (Withdrawal bleeding), IUD?
Check the thread? Cramp in the tummy? Why was Mirena inserted? (Treatment for heavy
periods?)
• -Growths, Fibroids – any heaviness or dragging sensation in lower tummy?
• -Cancer – LOW, LOA
• Endocrine – neck swelling? Weather preference? Any acne? Excessive hair growth? (PCOS)
• any trauma?
• Past medical, past surgical, family history of cancers
• SADMA

• DDX – Displaced Mirena/expelled Mirena

• Because of this, DUB (hormonal imbalance) can be resulted. DUB and hot flashes are quite
common as perimenopausal age because the hormone levels are fluctuating
• fibroids – which are the benign growths in the womb, endometriosis which is the wrong location
of inner lining of the womb, blood clotting disorder, thyroid, abortion less likely

Cervical Ectropion
You are a GP and a 40-year-old female, Laura, comes to you complaining of vaginal bleeding after
intercourse for the last 7 days. She is a mother of 4 kids. Her husband passed away 2 years ago and
she has a new partner recently.
Tasks:
 • Relevant history
• Physical examination findings from examiner
• Management.

Differential Diagnoses
• Atrophic vaginitis
• Cervical ectropion, Cervicitis (Chlamydia, Gonorrhoea, Trichomonas), Cervical polyp, Cervical
cancer
• Endometrial cancer
• Bleeding disorder
• IUCD

History
• Please tell me more about the bleeding? Was it related to intercourse the first time you had
bleeding? How many pads are you using for the bleeding at the moment? Any clots? Any
discharge apart from the bleeding? (to rule out chlamydia, gonorrhoea, trichomonas). Any
itchiness? At the moment do you have any dizziness, N/V, lightheadedness?
• Any problems passing water? Any bleeding from anywhere else in the body (nose, gums)?
• 5 P questions
• How is your general health? Any history of high blood pressure, DM, bleeding disorders, thyroid
problems?
• SADMA? FHx: gynecological cancers, bleeding
• Do you have any weight loss? night sweats? Tiredness? Any pain anywhere in the body? Any
lumps you have noticed?

Physical examination:
• General appearance: BMI
• Vital signs: postural BP
• Abdomen: obvious abdominal distention, tenderness on palpation, mass (can I find out if it is
uterine or ovarian in origin) is it tender?
• Lymph nodes especially inguinal lymph nodes
• Heart and lungs
• Pelvic examination
• Inspection: discharge, rash, bleeding, clots
• Pelvic examination: evidence of ectropion (seen as very red patch over cervix which bleeds
upon touching – ring around excernal cervical os.
• Bimanual examination: palpate mass, tenderness, whether os is open or close, cervical
excitation, adnexal mass that I can feel?
• Urine dipstick and pregnancy test

• IF Cervical ectropion
• Cervix has got an outer and an inner part. The outer part is called ectocervix and it is lined by flat
cells or squamous cell. And inner part called endocervix tall cells or columnar cells and these two
meets at the os called the SCJ.
• Cervical ectropion occurs when the rim of the cervix rolls outwards exposing the endocervix into
the vagina and this endocervix has got a reddish appearance.
 • It is quite common in teenagers, in Pregnant, and also in women on COCs. It is usually
asymptomatic.
• Mx –We will also do some blood tests including FBE, LFTs, UEC, TFTs, MSU for MCS. First Pass
Urine for chlamydia, gonorrhoea.
• refer to gynae and cautery (electro / cold coagulation) (no treatment if it is asymptomatic), stop
OC pills and use alternatives

• If cervical growth
• From the history and examination, my concern is a mass we have noticed to be arising from the
cervix. Do you understand what I’m saying? Do you want me to call someone for you?
• Are you alright to continue? The first step would be to confirm the diagnosis with the help of a
procedure called colposcopy and biopsy. It will be done by the specialist gynecologist. We will
also do some blood tests before the biopsy including FBE, LFTs, UEC, TFTs, MSU for MCS. First
Pass Urine for chlamydia, gonorrhoea.
• Once the diagnosis is confirmed, they will do CT scans of the chest, abdomen and pelvis to find
out at which stage the disease is at.

Pubertal Menorrhagia
Your next patient in GP practice is a 12-year-old, Marinda, who is having heavy periods for the last 10
days. Talk to the mother Lizzie.
Tasks:
• History
• Physical examination
• Diagnosis and management

History
• Is my patient hemodynamically stable? any postural drop?
• Bleeding - when did the bleeding start? How many pads per day? Are they fully soaked? Is it
getting worse or better? What is the color of the blood? Is it smelly? Any clots? bleeding from
anywhere else? Any bleeding disorder running in the family?
• Any dizziness, SOB, fainting or palpitations? Is there any tummy pain? Any possibility of trauma
or foreign body down below?
• Do you know if your daughter is sexually active?
• Any weight loss?
• How about the development of breast and pubic hair? Is she on any kind of medications? Have
you considered vaccination against HPV?

Physical Examination:
• General appearance: distressed, pallor, dehydration, jaundice (distressed, pale, tenderness in
lower abdomen; postural hypotension; tachycardia)
• Vital signs: postural hypotension, tachycardia, RR, Temperature and oxygen saturation normal
• Examination of the skin for signs of abnormal bleeding (eg, petechiae and/or bruising)
• Palpation of the abdomen for uterine or ovarian mass, organomegaly, tenderness
• Neck swelling (thyroid), Chest and heart.
• Tanner staging
 • Pelvic exam: inspection for blood clots, signs of trauma, sexual abuse; development of genitalia.
• No PV, just inspection in virgins

Explanation
• condition called pubertal menorrhagia (i.e. excessive period bleeding) which is not uncommon.
Menstrual cycles - irregular in the first years after menarche due to fluctuating levels of
hormones. It is a diagnosis by exclusion.
• It could be due to bleeding disorders and thyroid problems as well.
• Because Marinda is not stable, and her BP is falling, I would like to organize an ambulance,
and start IV lines.
• I will take blood for investigations:
• FBE, Coagulation profile, Blood group and crossmatching.
• TFTs
• Pregnancy test – Say I am sorry to say but is there any possibility to be pregnant? In all cases of
puberty menorrhagia, it is mandatory to exclude pregnancy, especially an incomplete abortion
or ectopic pregnancy.
• Trans-abdominal Ultrasound (do not do transvaginal ultrasound if not sexually active)
• MDT comprising of a hematologist, O&G. At the hospital she will be seen by a specialist and they
will start her on some female hormones for some time plus Tranexamic acid to control the
bleeding.
• Depending on the results, they might do blood transfusion. Once she is stabilized, they may put
her in tranexamic acid, NSAID, uninterrupted/continuous OCPs (progesterone or COC according
to the guideline) plus iron tablets until her hemoglobin is normal for at least 3 months. This is
not for contraception but for bleeding.
• Reassure patient that heavy bleeding is common in the first 18 months of onset of menses and
this will probably settle down, however we are worried about her anaemia so it is best to treat
her.

Atrophic Vaginitis
A 55-year-old lady, Winnie, came to see you with a complaint of vaginal discharge. You are a GP.
Tasks:
• Try to explore more
• Physical examination from the examiner
• Diagnosis and differentials

History
• Details of the discharge – Duration, amount, color, nature, smell, related to menstrual cycle
• Association – itchiness, fever, abdominal pain, mass, urinary symptoms (frequency, burning,
incontinence), any mass or lump down below?
• 5 P, association with sexual intercourse, sexual life? Hot flushes, mood changes, palpitation?
• Medical history, Family history of cancers, bleeding disorders,LOW, LOA
• SADMA

• PEFE – General, Anaemia, Abdominal, Pelvic – inspection, Speculum, Bimanual, UDT and BSL
• Diagnosis – Atrophic vaginitis (draw a picture), this is your down below. And there are layers of
cells lining the inner wall of down below. These layers are proliferated under the influence of
 oestrogen. When menopause, there is less oestrogen resulting in thinning of those layers and
being easily inflamed.
• DDx – endometrial hyperplasia and malignancy, cervical malignancy, polyp (cervical,
endometrial), Blood thinning medications
• Mx –USG for endometrial thickness, endometrial sampling, depending on the result - refer to
Gynaecologist for hysteroscopy and biopsy,
• Treatment – local estrogen cream

Endometrial Hyperplasia
You are a general practitioner. Your next patient is a 58 years old woman coming to you with a
bleeding per vagina for a few months. You did USG abdomen and the endometrial thickness is 11mm,
• Your tasks:
• Explain the result
• Provisional Dx/DDx
• Further management

DDX for BPV after menopause

• Endometrial hyperplasia
• Atrophic vaginitis
• Cervix problems
• Ca endometrium
• Ca cervix
• Side effects of medication (HRT)

Explanation
• Draw a womb, this is the inner lining called endometrium. After menopause it should be thin
like less than 5mm, But in your case – it is 11mm, and means that it is endometrial hyperplasia.
• This condition can happen because of hormonal changes after menopause, other risk includes
advanced age, early menarche, obesity, smoking, never get pregnant, some medical disease and
family history of cancers
• Endometrial hyperplasia is just a benign condition.
• But sometimes, the thickness can mask the patient especially the nasty condition of inner lining
of the womb.
• Aim – to make sure there is no nasty condition inside the womb
• Other differentials – less likely as we have got USG result
• Invx – FBE,
• refer to gynaecologist and do hysteroscopy (thin flexible tube with light source and camera will
be passed from down below) and biopsy of inner lining,
• Pap test if due
• If the result is no Ca, we will go for regular observation and USG monitoring, 6 monthly or yearly
biopsy control bleeding with medicines (progesterone). And if not controlled, we can try
removal of uterus.
 • If unfortunately Ca, we still have effective management for those kinds of Ca. Remove the
uterus followed by adjuvant therapy.
• So now, I will refer you to gynaecologist

Amenorrhoea
Exercise induced Amenorrhoea
28 years old woman, Anna, Amenorrhea for one year, patient is not concerning her husband asked her
to see a doctor.
• Take hx and explain Dx

History
• Amenorrhoea (5P TEA)
• Details of period – was it regular? Cycles? Days of bleeding? Was it lost suddenly or gradually?
• Pregnancy: Are you sexually active? Any chance you could be pregnant? Any breast tenderness?
Early morning N/V?
• Pills: are you sexually active? What do you use for contraception?
• POF: Do you have hot flushes or mood swings? Is intercourse painful?
• Prolactinaemia: Have you suffered from headaches or any visual disturbance? Have you noticed
milky discharge from your nipples? Are you taking any regular medicines?
• PCOD: Have you noticed excessive hair growth on face, acne, thinning of your hair or deepening
of your voice? Weight gain, polyuria, polydipsia (insulin resistance)?
• Thyroid: Any weather preference?
• Eating Disorder- Can you please tell me about your eating habits and exercise level?
• Are you doing heavy exercises? (If present, how many hours a day, how many days)
• Asherman- Have you ever had any surgeries or gynecological procedures.
• 5P TEA (Pills, Prolactin, Pregnancy, POF, PCOD, Thyroid, Eating disorder/exercise, Asherman)
• Any stress? How is your mood?
• SADMA

Physical Examination
• General appearance: Visible hirsutism, acne, puffy face or edema, BMI
• Vital signs
• Vision: visual fields, visual acuity
• Neck: thyroid enlargement
• Breast examination: nipple discharge
• Abdomen: masses, tenderness
• Pelvic exam:
• Inspection: discharge, atrophic vagina
 • Speculum: cervical os, bleeding
• Bimanual: size of uterus, adnexal masses, CMT
• Urine dipstick, BSL, Pregnancy Test (Pregnancy should be excluded in all patients presenting
with amenorrhea)

• Look Anna, let me draw a diagram here. The female hormones produced by our body has an
axis. This is hypothalamus in the brain, it produces GnRH which influences pituitary gland in the
brain to produces FSH and LH which work on the ovaries to produce female hormones.
• When there is heavy exercises, it inhibits GnRH in hypothalamus causing negative effects
throughout the axis. Lesser female hormones produced leading to loss of menstruation.
• There are some risk of thinning of bone because it has been a year already. We will sort it out
together.
• Ivx – Hormone levels (FSH, LH levels, Oestrogen, progesterone), TFT, USG, Bone dexa
scan(osteoporosis)

Primary Amenorrhoea
A 17-year-old , Mary, hasn’t got her period.
Your tasks:
• History
• Physical examination from examiner
• Investigations and causes

History
• Let me ask you some private questions. Secondary sex characters – development of breasts
and pubic hair, acne, oily skin?
• sisters, mother’s menarche
• any chronic illness?
• Ovulation pain
• Sexual life? Only ask as third question. Like some people started at this age, how about you?
• 5P TEA as the previous case
• General health, medical, surgical
• SADMA

• PEFE – Check BMI, BP (CAH), secondary sex characters (breast, armpit, pubic hair) features of
Turner’s syndrome like Web neck and broad chest. Check thyroid. Just inspection in vaginal
examination, status of hymen. No speculum or bimanual in virgin

• Explain –most likely late menarche, physiological delay, investigations –Baseline blood tests,
USG, Hormones test. If these are unremarkable, we wait and see for 1 year, probably your
period will start during this, repeat them after 1 year if not yet started. If anything positive in the
tests now, we will go for further tests like gene tests (karyotyping).

PCOS
You are a GP. A 20-year-old Jenny came to see you with irregular period. She is having a BMI of 31.
She only had 2 periods in 12 months.
Your tasks:
• Ask history
• PEFE
• Invx to patient
• Management to patient

History
• Complaint in details – when did it start? Regular before? Menarche? How irregular? Lighter and
lighter?
• LMP?
• BMI is 31 but her main concern is period.
• DDX- PCOS – Have you noticed excessive hair growth on face, acne, thinning of your hair or
deepening of your voice? Weight gain, polyuria, polydipsia (insulin resistance)?
• Prolactinoma – headache, visual disturbance?
• Premature ovarian failure – hot flushes, agitation
• Thyroid – hot or cold intolerance
• ((Excessive exercise))
• Cushing’s – skin bruises easily, purple stretch marks
• 4P
• Any plan to become pregnant?

PEFE
• General, BMI, BP, Blood glucose, face-acne, hair pattern, skin – acathosis nigricans, abdominal,
VE normal, pregnancy test
• Invx – Serum prolactin, LH, FSH and ratio(2:1 or 3:1), Testosterone levels, HCG level, Serum IGF
level (insulin like growth factor), thyroid function tests, Dexamethsone suppression test etc
• -transvaginal USG

Explain
• cysts, producing male hormones
• Management – lifestyle modification -many patients responded to Lifestyle measures, reduced
body weight, Diet, exercises, Dietician
• Period – hormone replacement – OC pills (for period and male changes)
• Metformin – (for increased sensitivity to insulin and fertility)
• Keyhole surgery to remove follicles
• Fertility – clomiphene, IVF
• Refer to Gynaecologist
• Reading materials

Infections
Recurrent Candidiasis
You are going to meet a 25-year-old lady, Grace, complaining of recurrent white vaginal discharge. She
was diagnosed with monilial infection and was given treatment for that. She has now come to you for
further advice.
Tasks:
• History
 • Examination findings from examiner
• Diagnosis and management

History
• When did this episode start? What is the color? Any blood stains?
- DDX- PID - Any pain down below? Tummy?
- Trichomoniasis – itchy? (also itchy in candidiasis), Discharge foul smelling?
• UTI- Any tummy pain, nausea, vomiting? Any issues with water work? Any burning sensation
while passing urine?
• Allergy – new brands of underwear, perfumes or creams, some people use toys for sexual
enjoyment, how about you?
• Systemic candidiasis – tiredness? Oral thrush? Infections in toes and nails? Joint pain?
• 5P (1 . don’t forget LMP in period
• 2. also chance of STI in Partner and self!)
• and risks factors – BMI, OC pills, steroid, DM, long term antibiotics
• General health, SADMA

Physical examination
• General appearance and BMI
• Vital signs
• Chest and heart
• Abdomen: masses or RIF/LIF tenderness
• Pelvic examination:
• Inspection: nature of discharge, color, smell, thick, blood stain, vulvar erythema
• Speculum: cervix is healthy with discharge; Ask about any cervical ectropion
• Bimanual: per vagina examination for any CMT, adnexal masses
• Urine dipstick, BSL, pregnancy test (optional)
• Vaginal swab just sent to laboratory
• pH of the discharge

Explanation
• a condition called recurrent Moniliasis or candidiasis.( It is a fungal infection caused by Candida
albicans. It is a common condition and there are some risk factors leading to repeated attacks. )
• Risks - long-term use of OCPs, DM, pregnancy, obesity, long-term use of steroids, antibiotics and
wearing tight clothing.
• Now – I would like to suggest you to stop OCPs and I can book another appointment to discuss
the alternative methods of contraception. Until then, I would advise you to use condoms. It is
not STD but it is best to abstain from intercourse until the condition resolves
• check the BSL, FBE and do swab to exclude STIs and DM
• Rx - fluconazole oral tab and review regularly (Duration varies 2 weeks to 6 months)
• Regular follow-up
• Note : for the first attack of candidiasis it is appropriate to select one of the range of vaginal
imidazole therapies (clotrimazole, econazole, miconazole for 1–7 days or nystatin (Nystatin,
although less effective, is generally better tolerated than the imidazoles)
• Recalcitrant cases (proven by microscopy and if not pregnant)
• Fluconazole 50 mg once daily or
 • Itraconazole 100 mg once daily
• Duration – 2 weeks to 6 months

• Maintenance therapy after remission

• Fluconazole 150-300mg oral weekly
• Itraconazole 100-200mg oral weekly
• Clotrimazole 500mg pessary intravaginally weekly
• Nystatin 100000units/5g vaginal cream intravaginally(applicator) weekly

• Vaginal candidiasis (thrush) in pregnancy

• All topical antifungal treatments can be used during pregnancy but oral treatments should not
be given to either pregnant women or to nursing mothers
• GVH – wear loose cotton underwears, keep the area dry and clean, avoid foams and douche,
clean from front to back.

Recurrent Herpes
You are a GP. You are going to see Hazel, a 32 years old woman with recurrent ulcer in the vulva.
Tasks:
• take history
• dx and ddx
• management to the patient

History
• CONFIDENTIALITY!!! (some questions might be sensitive)
• ulcer - When first noticed, Onset, Duration, Progression – increase in size, Predisposing events,
Aggravating/ Relieving factors, is it similar to previous attack?
• Previous attacks – how many before? When was the first attack? How long did it last? How did it
relieve?
• Associated symptoms: fever? discharge - from where? Any swelling/ growths/ ulcers/bleeding?
• Any pain? What about the previous attacks? Any pain while passing urine? Any itchiness?
• Any trauma? Any allergy history? New brands of skin products or underwear?
• 5 P history, partners in details
• Partners –are you sexually active? Stable partner? How long? all partners in last 6mnths:
• How many?
• any partner STIs ?
• condom use
• Type of the intercourse? (oral, anal, vaginal)

• Any immunocompromised and stress features: SOB, fever, night sweats, loss of weight, loss of
appetite? Any diarrhoea? Lumps or bumps in body? Any stress at work or home? Occupation?
• Recent travel?
• Past medical- any underlying medical condition I should be aware of? Any medications?
(immunosuppresants)
• surgical history - Past history of genitourinary disease, previous STIs? Ever checked before?
 • SADMA

Explain
• There are many causes leading to these recurrent ulcers. But among them, most likely the
condition is HSV infection. Most of the cases of recurrent genital ulcers are caused by type 2 of
this virus.
• It’s a sexually transmitted infection but sometimes it’s asymptomatic in males.
• Once the patient is infected with that virus, it stays in the nerves of the body for life long. So the
relief of the symptoms doesn’t necessarily means the virus is dead. It stays in the nerves and can
be reactivated in some circumstances when there is stress, infections, pregnancy or whenever
the patient has low immunity.
• Other causes would include other STI like syphilis, chlamydia or gonorrhea but less likely in your
case.

Management
• I will examine you and take the swab for HSV test to confirm the diagnosis.
• I will also arrange for some baseline blood tests like blood counts, liver and kidney functions,
blood sugar and urine dipstick for infections and pregnancy test.
• I will prescribe a course of oral antiviral after that and also a numbing gel to apply (if any pain)
• If you have any pain, you can also try sitz bath to relieve pain.
• It is advisable to avoid sexual intercourse during treatment. Also wear loose cotton underwear.
• With your consent, I would like to arrange for the screening other STI namely, HIV, Hepatitis B
and C, Gonorrhoea, Syphilis, Chlamydia, Human Papilloma Virus and etc. The samples will be
urine, swab and blood.
• Reporting to DHS is not necessary at this stage but will be needed if any STI positive.
• Also, I would like to arrange the screening for these in your current partner.
• Follow up after the results
• Once you resume the sexual life, it is recommended to practice safe sex.
• If recurrences six or more in a year, you may need a long-term suppression therapy with
antiviral.
• Reading materials.

Trichomoniasis
A 25-year-old university student, Jane, sees you in your GP surgery for advice. She has noticed some
generalized lower abdominal discomfort over the last 2 months with some vaginal discharge causing
irritation in the vagina and itchiness around the introitus.
Task:
• Focused History
• Physical Examination
• Management
History
• Discomfort? Where? What do you mean? you please tell me more about discharge? Since
when? first time? Any pain or bleeding down below? Any itching? the consistency (sticky or
watery), color and smell? How many pads do you use per day? Are they soaked?
• any fever recently? Any trouble with water works, any burning while passing urine? Any back
pain? Any tummy pain? Any allergies?
• your periods? Are they normal? How many days? How many days apart? Any Bleeding in
between the periods? Any increased pain during periods?
• some personal questions? Are you fine with it? Are you sexually active? Do you have a stable
partner? Any trouble with sexual intercourse? Do you use contraception? Which one? What
about your husband? Does he have similar symptoms? Have you or your partner ever been
diagnosed with any STI?
• Have you been pregnant before? Any chance you are pregnant now?
• Now about your general health. Any medical condition you are having? Any recent course of
antibiotics? Any recent use of cream or pessaries (consider allergic reaction)? Sexual enjoyment
with the toys?
• Pap smear? Gardasil?
• SADMA
PEFE
• General appearance: pallor, jaundice, dehydration, BMI
• VS: temperature, PR, RR, BP
• Auscultation of chest/heart
• Abdominal examination: tenderness, organ enlargements, mass, bowel sounds
• Inspection: of pelvic area – bleeding, discharge, color, quantity, and smell
• Sterile speculum: discharge ? position/condition of the cervix; take a swab and send for culture
and wet mount. (trichomoniasis – cervix is typically erythematous with punctate haemorrages)
• Bimanual palpation – adnexal mass, cervical excitation, check size/position of uterus and cervix
 • Get urine dipstick / finger BSL
• Pregnancy test
• Invx: FBE, UEC, Urine culture
• Consent: Swab culture: Wet film of the vaginal secretions with patient consent to see the
organism. pH of the secretions.
• STD screening

Explanation
• Most likely from the history and PE, what you have is a vaginal infection called Trichomonas
vaginitis. It is caused by a parasite called T. vaginalis, usually transmitted thru sexual contact. It
is a most common STI worldwide and is common in females of child-bearing age.
• Up to 50% of infected women are asymptomatic, possible to carry organism without signs and
symptoms. Gives symptoms like itching, burning of urine, watery greenish discharge with smell.
• Infections in male are asymptomatic.
• (Associated with PROM, pre-term delivery and low birth weight, Post-partum sepsis.)
• Diagnosis is by visualizing the organism within the vaginal secretion under the microscope.

Treatment:
• Metronidazole 2 g SD with food (+ antiemetic – due to SE of N/V, metallic taste) or 400 mg BD x
5 days
• or
• Tinidazole 2 g as a single dose
• Avoid alcohol with metronidazole and tinidazole treatment and for 24 hours thereafter.
• Alternative for pregnant women: Clotrimazole 100 mg vaginal tablet daily for 6 days during
pregnancy.
• Important to prevent complications: UTI, PID, Recurrent trichomoniasis – infertility
• Higher chances of developing other STIs especially HIV → important to test for other STIs
(consent)
• Practice good genital hygiene – wash vaginal area before and after intercourse. Do not share
towels. Remember to shower after swimming.
• Practice safe sex with condoms. Advise no sexual contact for 7 days after treatment is
administered and their current sexual partner is treated.

Cystitis
A recently married 19-year-old woman, Jane, sees you after having returned from her honey moon in
Thailand. She tells you that over the last 5 days she had some very uncomfortable feeling in her
genital area.
Tasks:
• History
• Physical examination
• Diagnosis
• Management

History
• What do you mean by uncomfortable? Any pain?
 • Since when you have urinary frequency? How many times do you have to go Any change in
colour or odor of the urine?
• UTI - Is it painful to wee? Any burning sensations? Nausea and vomiting? Is it the first time?
Infection - Any rash? Any discharge?
• Do you have any fever/Chills/Rigors/back pain (pyelonephritis)? Do you feel thirsty more than
usual? DM - Do you feel tired? Increased urine output?
• Any past history of DM HTN? Any sort of kidney problems? Any past history of UTI?
• 5Ps: Menstruation LMP? Regular? Normal? Pregnant before?
• Any chance you could be pregnant? (In a stable relationship?) Any problems during sex? Do you
know if your partner ever diagnosed with STDs?
• SADMA

Examination
• General appearance: pallor, jaundice, dehydration
• Vital signs
• Chest/heart is ok
• Abdomen: distention? Tenderness on palpation especially in the RIF/LIF. Any mass palpable?
Organ enlargement? Bowel sounds? Hernia? Supra pubic tenderness, no other mass. Any renal
angle tenderness.
• Pelvic – inspection (any discharge rash), Speculum (cervical, vaginal wall), Bimanual (any
tenderness)
• Urine dipstick (leukocytes and nitrates), pregnancy test, Blood sugar
• Diagnosis: acute uncomplicated cystitis / lower UTI / honey moon cystitis
• From history and examination, you most likely have an infection in the lower urinary tract. In
your case we can also label it as Honeymoon Cystitis. It’s a common condition after sexual
activity. The bug is usually bacteria which come from either your partner or your back passage.
Most common organism is E. coli. Also, as you don’t have any fever or loin pain I don’t think of
any infection in the kidney.
• Reassurance: a very common problem, often following intercourse, caused by normal bacteria
from the bowel that colonize the perineum. But don’t worry it’s not a sexual transmitted
disease.
• We will do a urine test for the type of bacteria and you will be on ABs
• Before culture result,
• Trimethoprim (Bactrim) 300 mg orally at night for 3 days (First Line) (But not in pregnant)
• If she is pregnant Cephalexin 500mg twice a day for 5 days or
• Amoxicillin + clavulanic acid (500mg/125mg 2x a day for 5 days (especially if pregnant)

Pyelonephritis
You are HMO. 26 years old, Monica, presented to you because she is unwell. She thinks she has flu.
Your tasks:
• Take history
• PEFE
• Diagnosis and Ddx
• Management

• History – flu symptoms – fever? Cough? Sorethroat? Aches and pains? Runny nose?
 • Fever in details – how high? Chills and rigor? How long?
• Jaundice (cholangitis), Travel history (Malaria)
• (if presentation is tiredness – go for HEMIFADO) For this particular case, we can just do EMIA
• ENT – any discharge from ears? Urinary tract – burning sensation? Pain? nausea, vomiting?
Burning positive – urine color and smell ?
• Any diarrhoea?
• LOW, LOA, lumps and bumps?
• Any medical illness? Steroids? Any medications?
• Menstrual history, sexual history.
• SADMA

• PEFE – don’t forget renal angle tenderness UDT

• DDx- Pyelonphritis (provisional), Cystitis, stones in the kidney and urinary tract, Diabetes and all
tiredness differentials if tiredness is there.
• Treatment – Pyelonephritis, draw a picture – infection of the right kidney ascending from the
urine tract, bugs from back passage.
• If not treated – infection can spread through blood – septicaemia or damage the kidney
• Rx - admission, specialist will check, do the blood tests, kidney functions and urine tests, USG
• Antibiotics through veins (Amocixillin or Gentamycin) and change according to culture results.
• Prevention –GVH – general vulval hygiene (cleaning from front to back, cotton underwear)

Bartholin’s Abscess
A 30 years old lady, Sandra, complained a painful lump down below.
Tasks:
• history
• PEFE
• DDx to patient

History
 • Lump – How long? Where exactly is it? Rt or lt? Persistent or come and go? Any pain? Fever?
Discharge? Urinary symptoms? How’s it affecting daily activities and sexual life? Did you have
any treatment to the down below before it appeared?
• Causes – history of ingrown hair or shaving, waxing or laser treatment
• 5 P questions –
• Periods, partner, pills, pregnancy, Pap test
• Past medical, Past surgical
• SADMA

PEFE
• General appearance, vitals
• Abdomen
• Pelvis – inspection – swelling, discharge, redness, size, temperature, tenderness, fluctuation test
• I will skip speculum examination because the patient is in pain
• UDT, BSL
• Dx – Bartholin’s abscess. Draw a pic. The Bartholin’s glands are the glands located beneath the
vulva (Labia majora). They secretes the lubricating mucus during the sexual arousal. When these
glands became obstructed, the swelling occurs and when they became infected (usually by E.coli
or Strept), it results in pain.
• An uninfected cyst can be left untreated but in your case, it is infected so we will need the
treatment.
• The conditions leading to this are sexually transmitted infection, ingrown hair or shaving, waxing
or laser treatment. The other possibilities are lipoma, haemangioma, other kind of abscess or
Batholin’s gland tumor but unlikely,
• Treatment (not in the task) : sitz baths or bathing in a mix of warm water and salt (around a
teaspoon of salt per litre of water)
• antibiotics which you usually take as a tablet but may need to take through an IV drip, especially
if you are having surgery.
• drainage or surgery to remove the build-up of pus and bacteria, or to open the abscess and
stitch its walls to the surrounding skin so it stays open. You may need to have a gland removed if
you have a cyst or abscess that keeps coming back. And also sitz bath after surgery to improve
healing.

Counselling
Mirena counselling
You are a GP. A 35 years old Yasmin came to see you because she wanted to know about Mirena.
Tasks :
• History
• Explain her about Mirena

History
• Why? Other methods?
• 5P
• Contraindications to Mirena absolute – pregnancy, PID, ectopic, vaginal bleeding, uterus
abnormality, fibroid
• Relative contraindications – scar (caesarean), infective endocarditis, Nullip os
 • Explain –
• it is a progestrone containing plastic device, T shape, base is treads. Gynaecological examination
done and speculum is inserted to visualize. Then Mirena is inserted, after fitting, the stylet or
applicator is removed. Thread will be hanging down in the female tract.
• Side effects – cramping, pain, increased menstrual flow(heavier, longer), vaginal discharge, risk
of infection
• Advantages – Effective method (0.2% failure), long acting (upto 5 years), does not interfere with
sex and breastfeeding, easily removable, quick return of fertility, not user dependent
• Disadvantages – risk of STD, not suitable if multiple partners, risk of PID, perforation, expulsion
• Follow-up- 3 weeks after insertion, cramps and bleeding intolerable, miss period, change in
thread length
• Condom for safe sex
• Barium sulphate (content in Mirena) not related to Sulphur allergy and safe to use

Vulvovaginitis
A 4 year old girl, Hazel came with her mother to your GP clinic and her mother complained her that
Hazel has yellowish vaginal discharge and has been complaining of pain during passing urine.
Tasks:
• Take history from mother
• Examination findings from examiner
• Diagnosis and management

History:
• Discharge details: since when? Colour? Any foul smelling? Is it blood stained? Associated with
itching?
• Any similar episode previously
• UTI: toilet trained? Pain during urination? Any burning sensation? Is it foul smelling? Colour of
urine? Increased frequency? Fever?
• Bowel Habits? Any worms have you noticed in backpassage (Does she scratch her bottom at
night)? Any time child has been gone unsupervised or inserted any foreign body? (Do you think
she might have put something in her private area)
• Tummy pain? Any trauma? Polydipsia? Any abnormal behaviour?
• BINDS:Social - r/o child abuse: how is home situation? Who is the primary carer? Does she go
to childcare? Does she complaint anything? (Divorced and child visiting her father every
weekend - ask about the mother’s partner now as well)
• Any past h/o allergy? Eczema?
• Risk factors: What is she wearing (Tight clothes/jeans)? Any use of soaps, bubble baths? Playing
in sand? Any change of cosmetics use? Does she go to swimming (moisture)? Is she toilet
trained? Is she obese?( not able to sit on toilet)

Examination:
• General appearance - well
• Vitals and growth chart - normal
• Systemic examination - normal
• bruising in the body, any marks - Nil
• urine dipstick, BSL - normal
 • Pelvic inspection - clear discharge, vulval area only redness can be seen, no scratch marks, no
sign of penetration

Explanation:
• Your child has a condition called vulvovaginitis: as children has low estrogen or female hormone
level at this age, the lining of vulva or private area very thin and are prone to infection. Bug can
come from back passage and cause discharge and painful urination.
• ***Reassure that less likely to be abuse
• Traetment is simple: Avoid bubblebaths, use cotton underwears and loose clothing, general
vulval hygiene, wipe bottom from front to back to avoid infection, warm shallow bath with a cup
of vinegar, advise zinc cream or castor oil to relieve redness.
• No need of antibiotics
• Red flags and reading materials
• Note: any time suspect child abuse or even if mother is concerned about child abuse but no
+ve finding in history : then notify and involve child protection authority (VFPMS – Victorian
Forensic Paediatric Medical Service)

Urinary retention because of Herpes

Your next patient in hospital is a 20 years old Jane complaining about not having been able to pass
urine for about 18 hours.
Your tasks:
• Take a further history
• Examine the patient
• Explain the most likely diagnosis and management to the patient

History
• How are you today? Are you ok to answer my questions or do you want me to relieve the pain
first?
• Since when did you not pass urine? Is this the first time? Do you have a rash down below? What
kind of rash? Since when? Any discharge? Any trauma? Would you like some painkiller and see if
you can pass the urine?
• Before that did you have any problem with your water-work? Can you control your water-work?
• Sexual history? What about bowel motions? Any constipation?
• 5Ps
• Are you on any medication? Any past medical or surgical history?
• SADMA?

Examination:
• GA: (distressed, in a lot of pain, wants to pass urine, vitals normal)
• Lower abdomen mildly tender with bladder palpable and dull percussion 6 cm above symphysis.,
mass on suprapubic with tenderness, no organomegaly
• Pelvic examination:
• Inspect for morphology of rash (vesicular rash in the vulva). The genital area is reddened and
swollen with several reddish lumps on the labia, some with blisters
• NO Speculum or Bimanual Exam. She is too tender to insert a speculum.
Explanation
• I want my patient to try passing urine under warm sitz bath. And also I will give here some
lignocaine to decrease pain. If not successful, suprapubic tapping.
• If no vesicles, I will put Foleys catheter with consent of my patient and under full sterile
conditions.

• You have a condition called acute retention of urine because of genital herpes. It is a viral
infection which is transmitted through sexual contact. It is a common condition..
• In female’s vesicles develop around the opening and just inside the vagina on the labia and
perhaps on the inner aspect of the thigh, around the anus and also buttocks. Patient’s
micturition may be painful and urinary retention can happen.
• For now, I will call the registrar to do a suprapubic tap to relieve the symptoms and give you
pain relief and some local analgesia like lignocaine gel.
• Antiviral medication (acyclovir, famciclovir and valaciclovir for 5 days) reduce the severity and
duration of the infection. If recurrences occur frequently, these drugs can be given daily as
suppressive treatment for 6-12 months or even longer. It is not curable; the virus can stay in the
body at the nerve endings and can get recurrence when there is reduction of immunity.
• You can try Sitz salt bath to relieve pain and improve healing. Wear loose clothing. Avoid
scratching to prevent spread and infection.
• Later, you may need to be screened for other STDs.
• When the vesicles are present, you’ll need to avoid intercourse. Please practice safe sex after
all these treatments to prevent other STDs.

Lichen sclerosus
A 70-year-old lady is you next patient at your GP. She complaint of severe itching in her vulva for the
past 2 months.
Tasks:
• Further relevant history
• Examination findings from examiner
• Investigations
• Management
History
• Where exactly is the itch? for how long have you had itching in your vulva? (Past 2 months), first
time?
• has it started suddenly? Is it constant or does it come and go? Is it getting worse? (Continuous,
worsening)
• is there itching anywhere else?
• Severity – how does it affect your daily life?
• Does anything make it better or worse?
• DDx – Atrophic/infections Do you have any bleeding or discharge from you vagina? Fever?
• Lichen sclerosus - Any whitish colour changes over your private area?
• UTI - Any burning sensation while passing urine? (also can be + in lichen sclerosus)
• Any rash, ulcers, or vesicles around the area? do you have any skin condition like eczema,
psoriasis?
• Allergies - Have you changed your cosmetics like shower gel or soups? do you use any vaginal
douches? Any allergies?
• any medical illnesses like diabetes? do you use any medications? (Steroids)

Explanation
• Condition
• From the history and examination, most likely you have a condition called lichen sclerosis. It is a
chronic inflammatory skin condition. It is not infection or contagious.
• Clinical feature
• this usually presents with severe itching and causes white, wrinkled plaques in your genital area.
• Cause
• Exact cause is unknown but thought to be an autoimmune disease. The immune system of your
body usually protects the body against infections, but in autoimmune conditions, the system can
get confused, and it starts attacking your own body cells rather than protecting it.
• Complication
• It can result to scar formation and it can join up with the surrounding genital skin leading to
adhesions. Occasionally can turn nasty in few percentage
• Course of the disease
• because this is an autoimmune condition, there is no permanent cure for lichen sclerosis. But
we can keep the condition under control.
 • Management
• You need to be seen by the specialist because the multiple punch biopsy needs to be done.
• the treatment is with local steroid creams which you need to apply twice daily for the first one
month then once daily for the second month and then depending upon your response the
strength and number of applications can be reduced.
• Also, maintenance therapy of a lifelong 1-2 applications per week will be given.
• If not responding to steroids, we can use retinoids or ultraviolet therapy.
• If there is scar formation or adhesions, and also if there is any malignant change or cancer, we
go for surgery.
• Also please maintain a good genital hygiene
• Keep your HPV and mammogram up to date
• You need to be on a lifelong follow-up because of possible nasty changes. First with 6 monthly
intervals, and then annually.
• Red flags: in case you experience any bleeding, abnormal discharge, or if the itching is becoming
worse, please report back.
• Review, follow-up, reading materials

Genital warts
27 year old lady comes with rough skin at private part for many years.
Task
• History for 4 min
• pic comes after 4 min
• dx with reason
• Management and further advice regarding future risk

• Say confidentiality. May I ask a few relevant questions? If not first time or older, When
did you have your last pap smear? What was the result?
• When was your LMP? Cycles regular? At the moment, do you have any symptoms,
vaginal discharge, bleeding, or itching? Any contraceptives? I understand you are
sexually active, are you in a stable relationship at the moment? How many partners
have you had previously? Did you always practice safe sex with the use of condoms?
Have you or your partner ever been diagnosed with a STI (warts)?
• Any pain during intercourse? Any chance you might be pregnant now? Have you ever
been pregnant before?
• How is your general health? SADMA? Do you have a family history of gynaecological
cancers or breast cancer?
• Management (as per STI guideline AU)
• Refer to specialist. Full STI screening.
• Patient applied podophyllotoxin cream or paint topically applied, twice a day for 3 days,
then 4 days off, repeated weekly for 4-6 cycles until resolution. Paint is more suited for
use on external keratinised skin. Cream is best used in perianal area, introital area and
under the foreskin.
• OR
 • Patient applied imiquimod 5% cream topically, 3 times per week at bedtime (wash after
6-10 hours) until resolution (up to 16 weeks)
• OR
• Cryotherapy by specialist (which is using extreme cold to destroy these)

Counselling
OCP Request 1
• A 15 years old Naomi came to your clinic. She wants to talk to you as she is going to start her
sexual life and want to talk about some advice on OC pills.
• Tasks:
• Take relevant history
• Physical examination from the examiner
• Explain about OC pills

History
• Greetings
• Any knowledge on other contraceptive methods? Wanna know?
• Some questions may be private and sensitive, please bear with me.
• Ever tried contraception before? Which method?
• I understand that you are going to start a sexual life. May I know how old is your boyfriend?
• Period Q (LMP, menarche, cycle, bleeding days, pain, regular)
• Pregnancy (esp if older) any plan to become pregnant near future?
• Gardasil vaccine?
• Contraindications – Clotting problems, nasty growth in breast and womb, active liver disease,
bleeding from down below without reason, Any recurrent headache?
• SADMA
• Family history of CA

Physical examination
• General appearance
• Vitals esp BP
• BMI
• With consent – breast examination
• Abdominal – liver
• VE – only inspection if virgin

Advice
• Before I explain, let me know how much do you know about OC pills? Now you are starting a
sexual life, are you aware of the consequences after starting sexual life? Any idea how to
prevent them? (Assessing maturity and understanding of a minor)
• It’s a pill containing two female hormones, oestrogen and progesterone. These are naturally
secreted by the ovaries in the body under the influence of hormones produced by brain.
• When they are supplied from outside, they alter the cycle and stop the ovaries to produce eggs.
• (Different types – Monophasic – the amount of hormone is constant throughout the cycle and
triphasic – varying doses with less progetrogen and more estrogen)
 • Failure rate – 1%
• Package – 28 pills cards – 21 hormone pills and 7 sugar pills
• Best time to start - you can start at any time. The best time is within 5 days from your first day of
bleeding. If this is beyond that, you will need to use condoms for 7 days
• To be taken every day at the same time
• Side effects – N,V, weight gain, breakthrough bleeding, minor mood changes, but disappear
within 2-3 months
• Benefits – reduction of menstrual disorders, reduction of benign breast diseases, reduce risk of
cysts and CA
• Drawbacks – long term – increased risk of breast CA, endometrial and cervical CA, clotting
problems
Missed pill (can be omitted if no time)
• If you missed pill - <12hr from usual dose – take one immediately and continues as usual
• >12 hr from usual dose – take one immediately but use alternative method (condoms) for 7 days
• Effectiveness may reduce by some medications (some antibiotics, drugs for epilepsy)- may result
in failed contraception. Always tell that you are on OC pills when there is medical consultation.
• Does not protect STI, must practice safe sex
• Red flags – migraine, leg pain, SOB, chest pain, irregular bleeding – return ASAP
• Reassess –ask the patient 1-2 questions about what you have explained. (Because minor)
• The need of Gardasil if not yet

OCP request 2
35 years old came to your clinic. She wants to talk to you as she is going to have OC pills from
Condoms.
• Tasks:
• Take relevant history
• Explain about OC pills

History
• Greetings
• Any knowledge on other contraceptive methods? Wanna know?
• Some questions may be private and sensitive, please bear with me.
• Ever tried contraception before? Which method?
• Period Q (LMP, menarche, cycle, bleeding days, pain, regular)
• Pregnancy – how many kids? any plan to become pregnant near future?
• Pap test
• Partner – stable? STI?
• Contraindications – Clotting problems, nasty growth in breast and womb, active liver disease,
bleeding from down below without reason, Any recurrent headache?
• Any medical or surgical history (epilepsy in this case), which medication are you having for it?
• SADMA
• Family history of CA

Advice
 • Before I explain, let me know how much do you know about OC pills? It’s a pill containing two
female hormones, oestrogen and progesterone. These are naturally secreted by the ovaries in
the body under the influence of hormones produced by brain.
• When they are supplied from outside, they alter the cycle and stop the ovaries to produce eggs.
• (Different types – Monophasic – the amount of hormone is constant throughout the cycle and
triphasic – varying doses with less progetrogen and more estrogen)
• Failure rate – 1%
• Package – 28 pills cards – 21 hormone pills and 7 sugar pills
• Best time to start - you can start at any time. The best time is within 5 days from your first day of
bleeding. If this is beyond that, you will need to use condoms for 7 days
• To be taken everyday at the same time
• Side effects – N,V, weight gain, breakthrough bleeding, minor mood changes, but disappear
within 2-3 months
• Benefits – reduction of menstrual disorders, reduction of benign breast diseases, reduce risk of
cysts and CA
• Drawbacks – long term – increased risk of breast CA, endometrial and cervical CA, clotting
problems

Missed pill (can be omitted if no time)

• If you missed pill - <12hr from usual dose – take one immediately and continues as usual
• >12 hr from usual dose – take one immediately but use alternative method (condoms) for 7 days
• Effectiveness may reduce by some medications (some antibiotics, drugs for epilepsy)- may result
in failed contraception. Always tell that you are on OC pills when there is medical consultation.
• Does not protect STI, must practice safe sex
• Red flags – migraine, leg pain, SOB, chest pain, irregular bleeding – return ASAP
• So far, I didn’t find any contraindication for OC pills in you. But you recently diagnosed with
epilepsy and you are taking Cabamazapine/Topiramate for it, it may affect the level of OC
pills. So I need to double the Oestrogen dose for you which is Microgynon 50.
• Other options – barrier, Mirena, Copper IUD and Depo
• (Note: talk about this first if you couldn’t manage your time!)

Notes: If Epilepsy
• Type of anti-epileptics, for example, Carbamazapine, Enzyme inducer. Sodium Vulporate, Non-
enzyme inducer.
• Special case is Lamotrigine, OC pills reduce its levels and causing fits.
• Please read about Enzyme inducing and non-inducers.
• Enzyme inducer-
• double the estrogen dose. Microgynon-30 (not given) to microgynon 50
• Other options – barrier, Mirena, Copper IUD and Depo
• Not an option –Implanon, vaginal ring, Mini pills

Subfertility
Your next patient in GP practice is the wife of a young couple who comes to you because they have
been trying to conceive for the last 12 months. They are happily married for 3 years and have not
sought any medical attention before. She is Winnie.
Tasks:
• History
• Counsel patient about management

History
• how are you today? Confidentiality. How can I help you today? How long have you been trying
to conceive? Do u or your partner have previous relationship? Have you ever been pregnant
before? Any history of miscarriages? Pregnancy from any previous relationships? Does your
husband have kids from any previous relationship?
• Have you ever used any method of contraception? What was it? like Depo-Provera
• Periods: menarche, regular, how many bleeding, how many days apart? How is the flow? Any
bleeding in between period? When was your LMP? Do you get any severe pain when you have
your periods? (Endometriosis)
• Any issues with intercourse? How often do you have intercourse? Are you aware of your
fertile/infertile days? Have you ever been diagnosed or screened for STIs? Any history of pelvic
infections? Fever or any offensive discharge down below.
• PCOS: Have you noticed any abnormal hair growth on your body or acne? Have you gained
weight recently?
• Trying to reduce her weight? Do you exercise a lot?
• Prolactin: Have you noticed any milky discharge from the breast? Any problem with your vision?
Any headache- Pituitary adenoma
• Asherman: Any history of previous surgeries or gynecological procedures?
• Pap smear
• Fibroids: Any heaviness towards abdomen. Any problems because of that?
• Any history of diabetes, thyroid or increased blood pressure? Any FHx of infertility from your
side or your partner’s side?
• Any issues with your married life? Any stress? Are you a happy couple? Do you have problems
with your waterworks or bowel? SADMA?

Examination:
• General Appearance, BMI, Hirsutism, acne, obesity, webbed neck
• Vitals
• Eye exam – Exophthalmos, Bitemporal hemianopia
• Thyroid exam
• Breast exam – Galactorrhea
• Pelvic exam- start with vulva and vagina
• Speculum- cervix healthy or not
• Bimanual- CMT - positive in PID, ectopic
• Uterus- size, mobility, tenderness, position, Adnexa, nodularity/tenderness in Pouch of Douglas
(Endometriosis).

Management
• I could not find anything positive in the history other than the frequency of your intercourse
which could be the cause of not having a baby. Always refer every case as subfertility (this term
is a preferable way of describing the condition to the patients).
• Better to treat both partners. Offer to see her partner.
 • Tell her about fertile period, and Ovulation Assessment. Do you know which days you are
fertile?
• Get Ovulation kit (Urinary luteinizing hormone kits. Accuracy may be improved by use on
midday or evening urine specimens, which correlate better with the peak in serum luteinizing
hormone levels)
• Calendar method – I will calculate for you
• BBT- 0.2 degrees’ rise, bb thermometer under the tongue, get it from pharmacy, they will give a
chart. Before getting out of bed measure temperature and note, then if 0.2-degree rise for 3
days-ovulation
• Billing's methods- Cervical mucus method. At time of ovulation- wet, increased in amount. After
ovulation- it changes to thick tacky mucus
• At this time, it is recommended you have more frequent intercourse or at least 3x a week. Still, I
would like to organize some investigations to rule out the other causes of not having a child. I
would advise for your partner to have semen analysis.
• For you, we will start with mid-luteal progesterone, and early USG (day 5-9 of the cycle), and
Rubella immune status. We will do semen analysis on your partner as well.
• If needed, we will do TFTs, prolactin, estrogen, androgen, and if required, the specialist might
consider doing hysteroscopy or laparoscopy, Ct of the head (pituitary fossa) and Chlamydia
(cervical culture).
• Do not worry. I understand that it is a very difficult time for you but I am here to help.
• Reading material. I will review you again with initial investigation result and will decide further
management depending on it. Hopefully everything will be normal.

HRT 1
47-year-old lady, Hannah, presented in GP clinic, complaining of hot flushes and irregular periods.
TASKS:
• History for 3 mins
• Choice of further investigation
• Hormone replacement therapy risks and benefits

History
• 5 P, dryness in down below? Night sweats? Sleep problems? Racing of heart? Mood changes?
Weight changes?
• How is it affecting your life (quality of life)
• Any LOA, LOW, any history of breast cancer, blood clotting in legs, stroke? Heart disease?
• Family history of breast cancer, womb cancer? Heart disease?
• Medical, surgical, SADMA
• So, to know the cause of your irregular periods, we need to run a few investigations including
baseline investigations like your full blood cell count, kidney functions, liver functions,
ultrasound, thyroid hormone levels and prolactin hormone, may be FSH levels (which is
female hormone stimulating hormone which is high in perimenopausal) Once your period
ceased for 12 months, we will also offer bone scan and blood cholesterol levels and also
female sex hormone levels to confirm. You will have to be under breast cancer screening as
well once you turn 50.
 • Now, let me tell you about HRT. HRT is medication containing the hormones that a woman’s
body stops producing after menopause. HRT is used to treat menopausal symptoms. It consists
of oestrogen and progesterone.
• HRT reduces menopausal symptoms such as
• hot flushes and night sweats
• vaginal dryness
• mild urinary incontinence
• aches and pains
• insomnia and sleep disturbance
• cognitive changes, such as memory loss
• reduced sex drive
• mood disturbance
• palpitations
• hair loss or abnormal hair growth
• HRT also reduces the likelihood of some debilitating diseases such as osteoporosis, colorectal
(bowel) cancer and heart disease.
• On the other hand,
• certain types may increase the chances of developing a blood clot in legs or stoke or breast
cancer and endometrial cancer when used long-term
• The other side effects that will usually settle within the first few months of treatment and may
include:
• breakthrough bleeding
• breast tenderness
• bloating
• nausea.

• At the moment, you still have your menstruation and you only have hot flushes. So I don’t
think you are a good candidate for HRT. (Giving or not depend on your own case)

HRT 2
You are a GP. You are going to see a woman, Emma, 62 years old lady coming to repeat her script of
HRT.
Your tasks:
• Take appropriate history
• Advice on further management

History
• Details of her HRT – how long has she been taking? What type of HRT? Are you taking it
regularly according to the prescription? Why were you prescribed with this? What were your
symptoms at that time? Was the symptoms improved? When did you get to menopause?
• Symptoms of menopause right now? Any hot flashes? Racing of heart beat? Sweaty? Sleep
problems? Mood swings? Any dryness down below? Any leakage of urine?
• Side effects of prolonged HRT – breast –any lump in the breast? Ovary – any swelling in the
tummy? Or discomfort in lower tummy? Endometrium – Any bleeding from down below? Any
lost of weight? Loss of appetite? Clots – any history of clots in the legs? Any history of heart
disease or stroke?
 • Other menopausal investigations – are you following up regularly for your HRT? Are you
updated with your mammogram? Cervical screening test? Have you done your bone
desitometry scan?
• Other P – Are you sexually active? Stable partner? Any problems like pain during the
intercourse? Do you have kids? How many?
• Past medical, past surgical history
• Any family history of breast, ovarian and womb cancer?
• SADMA

Explanation
• There is no limit on how long you can take HRT. But many women stop taking it once their
menopausal symptoms pass, which is usually after a few years.
• Woman who takes prolonged HRT has a little bit of higher risk of breast cancer than woman
never use HRT. Also, small chances of ovarian and womb cancer as well. But only a very small
percentage. These risks usually fall after the woman stops taking HRT.
• I am not scaring you; those are just a very few percentages only.
• So, if one’s symptoms are controlled, we may try gradually stopping the HRT and check your
symptoms. If the symptoms are not coming back, we can completely stop it. When you don’t
have serious menopausal symptoms, there is no benefit of continuing HRT.
• But if your symptoms reappear, we can restart HRT.
• We can also try to do lifestyle modifications as well like healthy diet, exercises, reduce coffee,
alcohol and spicy foods and stopping smoking.
• I will also arrange basic blood checks, mammogram, cervical screening test and bone
desitometry scan as well.

Sterilization
You are a GP, a 35 years old lady, Tina, came to see you. She is a mother of 4 children and now she is
on OC pills for 3 years. She made the appointment today as she was considering sterilization and
wants advice from you.
Your tasks:
• Take history (4 mins)
• Explain about sterilization

History
• Greetings?
• Why sterilization? Any knowledge for other methods?
• Pills – any side effects? Weight gain? Headache? Mood changes?
• Period questions
• Partner- stable? Chance of STI? safe sex?
• Pregnancy – 4 children? How old is the youngest? Pregnancy and delivery uneventful? Any plan
for more children in the future?
• Pap smear
• Past medical, past surgical (any surgery before)!! (if laparotomy +, laparoscopy not available)
• Social history
Explanation
• Before I explain about sterilization, do you want me to explain about other methods of
contraception? (Barrier – male, female condoms, natural – basal body temperature, cervical
mucus thickness, calendar, coitus interrupts), Depo, Implanon, IUCD. (STI – No IUCD!)
• Requirement for sterilization
➢ patient should be more than 30 years old
➢ Patient decision should be confirmed with informed consent
➢ Decision must be free from any pressure
➢ Patient’s medical problems

• Sterilization – draw uterus and fallopian tubes, ovaries. Procedure performed by key-hole
laparoscopy (multiple small holes in tummy) or mini laparotomy(incision in lower tummy).
• Follopian tubes which connects ovaries and womb are cut or sealed. (by mechanical – cut and
tied and stitched or electrocoagulation – electric current). This will block the way of the sperm
to travel to the egg and fertilized. Ovaries and womb are not involved in surgical procedure.
• Complications – bleeding, injuries to nearby structures, infections, less likely with expert hands
• The ovulation occurs as usual and will be absorbed by body.
• This procedure does not cause menopause and does not prevent STIs. (practice safe sex)
• Has to be considered as permanent. The reverse procedure is less successful, expensive and not
covered by Medicare)
• Final decision is yours but also you need to talk to the partner for consent
• Reading materials
• Review (may ask to take the husband next time and discuss about male sterilization as
alternative if he is willing to know) and refer after decision

Request for Hysterectomy

A 35 years old Fiona lady came to your clinic wanting to undergo hysterectomy.
Tasks: Take History
• PEFE card from the examiner
• Order Investigations required
• Counsel regarding hysterectomy

History
• Why do you want hysterectomy?
• Ok. I will tell you more about this concern. But first, let me ask you some questions.
• Details of bleeding:
• Severity - Dizziness, SOB, palpitation?
• 5 P questions
• Ddx –
• -Infections – any discharge? Any itchiness? Any fever? Any pain in down below? Retained
tampon? Any pain in tummy?
• -Drugs- any blood thinning medications? Stopping or changing ? (withdrawal bleeding), IUD?
• -Growths, Fibroids – any heaviness or dragging sensation in lower tummy?
• -Cancer – LOW, LOA
 - Endocrine – neck swelling? Weather preference? Any acne? Excessive hair growth?
(PCOS)
- any trauma?
• Past medical, past surgical, family history of cancers
• SADMA

• PEFE card everything normal

• Investigations – we will run some investigations including Complete blood count, HCG, some
female hormones, thyroid hormones, Liver functions, coagulation profile and an USG to look
into the womb. According to the results, we may need further investigations
• Regarding hysterectomy, we don't recommend you to undergo such an invasive procedure at
the moment. We need to find the underlying cause for the bleeding. Sometimes it can be fixed
with other measures than the surgery. Surgery itself has some risks like bleeding, risk of
anaesthesia, injuries to the nearby structures and infection.
• So I will check you again with the investigation results. Removal of the womb is necessary in
some cases only.

STD Screening
A 27-year-old lady, Judy, came to your GP because she had started a new relationship. They haven’t
started a sexual relation but they both have sexual relation with previous partners. She comes to your
GP now to check for STI. Her partner is not coming along today. She wants a ‘clear’ for STI before they
start a sexual life.
Tasks:
• Short history not more than 3 mins
• Counsel her
• Permission for sensitive questions

• 5 P approach
• Partner :
• Are you currently sexually active?
• How many sex partners have you had before?
• Was your sexual partner male or female?
• Practices :
• Does your partner have any other partners?
• I am going to be more explicit here about the kind of sex you’ve had to better understand if you
are at risk for STD. May I know what kind of sexual contact do you have or have you had?
• Protection from STDs Do you use condoms whenever you have sex?
• Past history of STDs : Have you ever been diagnosed with a STD?
• Have you ever been tested for HIV, or other STDs?
• Has your partner-to-be ever been diagnosed or treated from a STD?
• Have you ever got discharge from down below or ulcers there?
• When was your last Pap test?
• Prevention of pregnancy: Are you concerned about getting pregnant?
• ?Do you want any information about contraception?
 • STI consists of a list of viral and bacterial and viral infections namely HIV, Hepatitis B and C,
Gonorrhoea, Syphilis, Chlamydia, Human Papilloma Virus and etc. Some can be cured but some
conditions cannot. But the earlier we detect the disease, the better the prognosis we can
expect.
• Now let’s talk about the notorious one, HIV. HIV stands for the Human Immunodeficiency Virus.
As its name, it destroys the immune system which is the body defense system and causes the
person to be easily infected which may lead to death later. But if we detect the virus in early
stage, we can control it with very advanced medications so that it may not progressed to the
disease state we called AIDS. HIV test will include taking of the blood sample and check for the
presence of antibodies and antigens which are the evidence of virus. If the result came back as
negative, we need to repeat it again after 6 months as there is ‘window period’ from exposure
to development of antibodies or detectable antigen. If the result come back as positive
unfortunately, we need to run another test we called confirmatory test. If it is positive again, we
can say that the patient is positive for HIV. The next tests are Hepatitis B & C. The sample will be
the blood as well.
• The other tests are gonorrhoea, chlamydia and human papilloma virus, there is difference in
symptoms between men and women for these STDs . Women show almost no symptoms but
suffer very serious consequences like Pelvic Inflammatory Disease (PID), cervical cancer, and
infertility if untreated. The samples will include the blood, urine and a sample of discharge if
present.
• It is also important that both partners to be tested. So I would also suggest you to take your
partner on next visit. I really know that it must be exciting to test for STDs. But I want you to
know that even if something positive come out, there are a lot of things we can do to cure or
control it. You have made the right decision.
• Ok. So if u agree to test these, please sign the form for consent and we will move on.
• Do you have any questions? Ok. So I will see u again with results. I wish u get the ‘clear’ result u
want.

HPV Test Result

You are a GP and 27-year-old female, Anna, came to find out the result of her HPV test. HPV 16
present.
Tasks:
• History
• Explain result to patient
• Management accordingly

History
• nice to see you again. I have the results of the test with me. May I ask a few relevant questions?
If not first time or older, When did you have your last pap smear? What was the result?
• When was your LMP? Cycles regular? At the moment, do you have any symptoms, vaginal
discharge, bleeding, or itching? Any contraceptives? I understand you are sexually active, are
you in a stable relationship at the moment? How many partners have you had previously? Did
you always practice safe sex with the use of condoms? Have you or your partner ever been
diagnosed with a STI (warts)?
• Any pain during intercourse? Any chance you might be pregnant now? Have you ever been
pregnant before?
 • How is your general health? SADMA? Do you have a family history of gynaecological cancers or
breast cancer?
• As you know, cervical screening test is test for early asymptomatic cervical cancer. We usually
detect for the presence of the cancer causing virus in the cervix.
• At the moment, your results showed that there is presence of HPV 16 which can later leads to
cell changes and then cancer. It is not to be scared,. Now we detect it early and we can treat
accordingly. We will go for another test LBC which will show the cells changes and extent of cell
changes if present. There still some changes like low grade and high grade changes before cell
go through the stage of cancer.
• This virus induces temporary changes in the lining of the cervix.
• At this stage, I will refer you for colposcopy. It is a process where we introduce a small tube with
a camera into the cervix to look at the lining. If there is a suspicious lesion, then a piece of tissue
will be taken out. If not visible, acetic acid will be applied and a suspicious area will turn white
and a sample will be taken.
• After the biopsy, treatment according to the stage. Options include : cryosurgery (extreme cold),
laser ablation, loop excision, surgical removal.
• Reassure : detecting the presence of virus is the earliest stage. We can do every measure so that
it will not progress to cancer.

Miscellaneous
6 weeks Postpartum Check-up
You are a GP. A lady came to you for a check-up after 6 weeks postpartum.
Your tasks:
• Take history
• PEFE
• Counsel the patient

History
• Rapport
• Ask about the baby – doing well? Sucking well? Is it your first child?
• Congrats!
• Any concern? How was the baby delivered? Any complication before and after the pregnancy?
(this case has GDM positive)
• Bleeding, discharge, wound, delivery uneventful, fever, tummy pain, hospital stay?
• Sexually active – let me ask you some sensitive questions) have you restarted your sexual life?
Any problem?, any inconvenience?
• Breastfeeding? Breast pain? Any problems?
• Mood? sad? Support? Home situation? How are you coping with the baby?
• SADMA

• PEFE – general, vital signs, Breast, abdomen, Respiratory, CVS, and Pelvic examination (also
check the cough if incontinence positive) the wound, and lower limb, UDT, Blood sugar
• Counsel – GDM –check up again with OGTT now (6-12 weeks postpartum) and follow up 3
yearly(Fasting and HbA1C)
• Dyspareunia – dryness in down below because of temporarily low level of estrogen after child
birth and breast feeding- give local estrogen
 • Contraceptive methods – (breastfeeding should be exclusive if used, mini pill, Mirena, Implanon,
Condom, Depo
• Baby – regular check- up
• Immunization schedule
• You – nutrition, exercise, avoid smoking and alcohol
• Pelvic floor exercise (contract the muscles like stopping urination, hold for 30 secs and releases,
3-4 contractions in one time, 2-3 times a day)

UVP
Your next patient in general practice is a 58-year-old, Jane who has been told by one of your
colleagues that she suffers from an uterovaginal prolapse. She had a sensation of a vaginal lump
(“something is bulging in my vagina”) and bladder problems (discomfort and difficulty to micturate)
for a while. She also has a rash around the private area for several months.
Tasks:
• Relevant history
• Physical examination
• Diagnosis and management

History
• something bulging from your private area? Can you please tell me more about it? Since when?
how it happened? Is it increasing?
• any abdominal discomfort? the effect of this bulging on your life? And is there any condition
when that feeling of lump is reduced? Does it come and go or is it present all the time? Did you
notice that it appears when you’re straining? Do you have a dragging sensation or heaviness in
the tummy?
• swelling affecting your waterworks? Do you leak urine while you strain, cough, etc.? Do you
have a strong urge to void on the way to the toilet or do you leak a large amount of urine on the
way to the toilet? Constipation? Any long time cough?
• Have you noticed increased frequency or feeling that your bladder is emptying incompletely?
• Rash? Since when? Is it itchy? Can you describe the rash for me? Any discharge down below?
• 5 p (don’t forget STDs)
• Now please tell me do u have kids? How many? Was it difficult labor? Assisted labor? Assisted
delivery? Any history of big baby, instrumental deliveries? Are you aware of your weight
• mammography
• Past medical history: chronic cough, diabetes, asthma.
• SADMA

PEFE
• General appearance: BMI 29
• Vital signs
• Abdomen
• Pelvic examination:
 • Inspection for morphology of the rash (maculopapular rash around the introitus and groin area),
scratch marks, discharge, obvious bulge
• Speculum: wall of vagina, rash, discharge, blood, ask patient to cough (cervix comes up to the
introitus), leakage of urine
• With the patient in left lateral position using Sims speculum look at the anterior, posterior wall
to look for any rectocoele (rectum protrudes thru vagina), cystocele or urine leaking?
• Bimanual examination: any pelvic masses palpable, size of uterus, adnexal masses, CMT, ask
patient to squeeze two fingers to assess of pelvic muscle strength.

Degree of Uterine prolapse

• First-degree prolapse: the cervix remains within the vagina
• Second degree prolapse: the cervix is at or near the introitus
• Third degree prolapse: most or all of the uterus lies outside the vaginal opening (Cystocele or
rectocele are usually present)

• You have a condition called utero-vaginal prolapse with stress incontinence and candidiasis. It’s
a common condition where the cervix, uterus and sometimes the bladder (cystocele) or rectum
or loops of intestine (enterocele) protrudes into the vagina.
• This can cause symptoms such as a sensation of a vaginal lump, constipation, difficulty emptying
the bowel or bladder or problems with sexual intercourse..
• The uterus, bladder and bowel are supported by pelvic floor muscles. These muscles can be
weakened after a childbirth especially big babies.
• Another group of risk factors is being overweight, having chronic cough, constipation and heavy
lifting which are factors that increase intra-abdominal pressure. The last predisposing factor is a
low level of estrogen after menopause.
• So if these muscles are weakened or damaged, the uterus can slip down into the vagina. We call
it uterine prolapse.
Regarding management, we will start with LSM. The asymptomatic prolapsed does not require
invasive treatment and can be treated with pelvic floor exercises (referral to physiotherapist!),
• Reduce weight, SNAP.
• S – quit smoking’
• N – nutrition – balanced diet
• A – reduce alcohol
• P – more physical activity
• local antifungal cream, tablets for candidiasis. I would advise you to start with pelvic floor
exercises (contract pelvic floor muscles as if trying to hold urine) (effective for 1st and 2nd
degree). Healthy diet, plenty of fluid to avoid constipation.
• For the management I will refer you to a gynecologist for further assessment and to discuss
treatment options.
• If conservative measures do not work, the specialist might consider rings or pessaries to support
or doing surgery to fix the ligaments.

Incontinence
A 50-year-old woman, Rhea, who had 3 kids aged 29, 25 and 22 came to your GP clinic complaining of
leakage of urine.
Tasks:
 • History
• Appropriate investigations to patient
• Diagnosis and management

History
• how are you today? Since how long? What do you mean by losing urine? Is it small or large? Do
you lose urine when you laugh, cough, exercising or just normal? – Stress (in this urine loss is
small). How often ? How much urine do you lose each time?
• When you have an urge to go to the toilet, can you hold the urine? Do you lose a lot of urine
when you try to reach the toilet? How many times you need to get up at night to got to the
toilets?
• Any burning while passing urine? Frothy urine? Change in color? any particular situation that
aggravates it or relieves it? How this issue is affecting your lifestyle? (any pad? Social withdrawl)
• Any feeling of bulging masses down below? – Prolapse
• medical or surgical history? any chronic cough, constipation? Any medications you are taking?
• periods? Are they normal? Any symptoms of menopause like hot flushes, mood swings or
dryness of private area?
• Pap smear? Have you started with mammography?
• Now please excuse me, I have to ask some personal questions, will that be fine with you? Are
you sexually active? Do you have a stable relationship? Do you have any problem with the
sexual activity? Any previous history of STDs?
• Now please tell me do u have kids? How many? Was it difficult labor? Assisted labor? Assisted
delivery? Any history of big baby, instrumental deliveries? Are you aware of your weight?
• SADMA? Coffee intake?

Examination: (if asked)

• General appearance: BMI, dehydration, pallor, jaundice
• Vitals
• Chest/heart: chronic infections
• Abdomen –any palpable mass. If palpable after voiding suggests chronic retention
• Pelvic examination:
• I-Atrophy of vagina
• S-Ask examiner for any demonstrable stress incontinence and prolapse (ask patient to cough
and check for leakage of urine)
• B- any mass tenderness, any adnexa mass, tenderness.
• BSL and Dipstick
• FBE, UEC, MSU for MCS
• Pelvic USG for Post void residual volume (overflow incontinence)
• In urge and mixed incontinence- refer to a specialist go for full fledged urodynamic studies.

Explanation
• You most likely have a condition called stress incontinence, it is an involuntary loss of urine. It is
due to weakness of the valve at the outlet of your bladder, which keeps the urine inside and it is
most likely due to the pelvic floor muscle weakness.
• Sometimes it happens after multiparity, Big babies and vaginal child birth. The muscle might
have become more weakened. Menopause contributes to this as well. Due to the lack of
estrogen.

• I completely understand that it is a very frustrating condition for you, but let me assure you
that we can manage it.
• Initial treatment, for both urge urinary incontinence and stress urinary incontinence, is LSM and
pelvic floor muscle treatment. Pharmacotherapy has a limited place in stress incontinence.
• In the management we will first start from the LSM. I always tell my patient to have a health
lifestyle according to the SNAP lifestyle. Have you heard about it? SNAP stands for:
• S- stress-free, slim, smoking cessation as cigarette smoke also irritates the bladder
• N- have a health balanced diet, decrease caffeine intake as coffee also irritates the bladder
• keep alcohol consumption under 2 SDs
• P- at least of 30 minutes of physical activity
• Keep the bladder diary to record when you had incontinence and what you were doing at that
time.

• Avoid constipation (increase fibre, increase fruit) and coughing. Reduce weight. Treat the
underlying cause. Regular toileting habits with good posture, time for complete emptying.
• We can start with pelvic floor exercises (contract pelvic muscles as if your lifting your pelvis or
holding urine 40-50x daily at 3 months). With these exercises, 75% improved and 25% cured.
• At least 3 months’ trial with supervision (physiotherapist or continence nurse adviser) is needed
before determining its success. Refer to physiotherapist specially trained in PFMT.
• Surgery will only be indicated if conservative measures fail.
• (((Bladder neck suspension (sling surgery, in which a keyhole surgery is done to put a u-shaped
mesh is put around the bladder neck)
• Sub-urethral rings, and
• Local injection of collagen around the neck to make it tighter and tense.
• Colposuspension- stiches to lift up the bladder neck to fix it to pelvic bone.)))

• For urge incontinence: along with all the above plus

• Causes of urge incontinence
• The urgent and frequent need to pass urine can be caused by a problem with the detrusor
muscles in the walls of your bladder.
• The detrusor muscles relax to allow the bladder to fill with urine, then contract when you go to
the toilet to let the urine out.
• Sometimes the detrusor muscles contract too often, creating an urgent need to go to the toilet.
This is known as having an overactive bladder.
• The reason your detrusor muscles contract too often may not be clear, but possible causes
include:
• drinking too much alcohol or caffeine not drinking enough fluids – this can cause strong,
concentrated urine to collect in your bladder, which can irritate the bladder and cause
symptoms of overactivity, constipation, conditions affecting the lower urinary tract (urethra and
bladder) – such as urinary tract infections (UTIs) or tumors in the bladder, neurological
conditions, certain medicines
• Bladder re-training is the initial treatment for UUI, being noninvasive, inexpensive and easy. This
includes PFMT (Pelvic floor muscle training), a scheduled voiding program with gradual increases
in the duration between voids, and urge suppression techniques with distraction (e.g. playing
games, counting backwards) or relaxation. Refer to physiotherapist. Many cases resolve in 2
years.
• Anti-cholinergic medications, usually for one month, if effective continue for 6 months. In
Australia, the most commonly used anticholinergic drug is oxybutynin.