Unit 549

May 2018

Female reproductive

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Female reproductive system
Unit 549 May 2018

About this activity 3

Case 1 Zhen has missed her period and has bleeding and pain 4

Case 2 Janine has worsening period pain 9

Case 3 Jennifer has dyspareunia 13

Case 4 Sarah attends for a repeat script of her pill 16

Multiple choice questions 22

The five domains of general practice

Communication skills and the patient–doctor relationship

Applied professional knowledge and skills
Population health and the context of general practice
Professional and ethical role
Organisational and legal dimensions
 About this activity check Female reproductive system

About this activity GP Synergy. Professor Magin’s main Victoria (FPV), Dr Pearson coordinates
research interests are the in-practice the Family Planning Alliance Australia’s
Women account for 56% of all general
clinical and educational experience of (FPAA) National Certificate course in
practice consultations;1 12% of
general practice registrars, and reproductive and sexual health for
presentations are for problems affecting
management of transient ischaemic doctors and Implanon NXT training.
the reproductive system.2 Common
attacks and minor stroke in community Her clinical experience is in general
reasons for such presentations include
settings. practice, family planning organisations
genital check-ups and cervical
and private gynaecology centres. Dr
screening, pregnancy, pregnancy- Rachel Turner (Case 4) MBBS BSc
Pearson has provided education for
related problems, contraceptive advice (Hons) DFSRH, DCH is an academic
medical students, general practice
and menstrual problems. general practice registrar at the
registrars and GP supervisors, as well
University of Newcastle, NSW. Dr
Menorrhagia affects about 20% of as being a longstanding examiner for
Turner completed a BSc (Hons) in
women, and pelvic pain about 15%.2 the RACGP. She has written articles on
Experimental Psychology at the
Referrals to obstetricians and women’s reproductive health for
University of Bristol, UK before going on
gynaecologists occur at a rate of 0.8 per RACGP publications check and
to complete her medical degree at
100 consultations with women, and Australian Family Physician, as well as
University College London Medical
these are for conditions such as ovarian Medicine Today and RANZCOG’s O&G
School, UK. She completed a Diploma
cysts and endometriosis.2 magazine.
of Faculty of Sexual & Reproductive
As the first point of contact, general Health from the Royal College of Abbreviations
practitioners are required to manage the Obstetrics & Gynaecology, UK in 2014.
AFP alpha-fetoprotein
various presentations relating to the Her special interest is women’s health,
β-hCG β-human chorionic
female reproductive system and identify in particular access to contraception.
gonadotropin
those problems requiring referral to She is currently undertaking research at
BMI body mass index
emergency services or specialists. This the University of Newcastle in
COCP combined oral contraceptive pill
issue of check includes case studies on partnership with the ReCEnT Study
ENG etonogestrel
some common presentations relating to exploring GP registrars’ prescribing of
FPAA Family Planning Alliance
the female reproductive system. LARCs and the barriers to use.
Australia
Sara Whitburn (Case 1) BMBS, FSRH Faculty of Sexual and
Learning outcomes
FRACGP, DRANZCOG, DCH (UK), Reproductive Healthcare
At the end of this activity, participants FSRH (UK), is a general practitioner and GnRH gonadotropin-releasing
will be able to: family planning doctor who works at hormone
Belmore Road Medical Centre in HPV human papillomavirus
• outline the management of bleeding
Balwyn, Victoria. Dr Whitburn has a IOTA International Ovarian Tumor
in early pregnancy
special interest in women’s health. Analysis
• describe the assessment of ovarian
IUD intrauterine device
cysts
Peer reviewers LARC long-acting reversible
• discuss the approach to diagnosing
contraceptive
and managing endometriosis Kathy McNamee MBBS, FRACGP,
LDH lactate dehydrogenase
• describe the diagnosis and treatment DipVen, GradDipEpiBio, MEpi is the
LMP last menstrual period
of lichen sclerosis Medical Director of Planning Victoria. She
MEC medical eligibility criteria for
• summarise current recommendations co-authors Contraception: an Australian
contraceptive use
for contraceptive use. clinical practice handbook and is an
NSAID non-steroidal anti-inflammatory
adjunct lecturer in the Department of
Authors drug
Obstetrics and Gynaecology at Monash
PCR polymerase chain reaction
Gayle Fischer (Case 3) OAM, MBBS, University. She is the clinical lead for
Rh Rhesus
FACD, MD is an associate professor in provision of medical abortion at Family
RhIg Rh(D) immunoglobulin
Dermatology at Sydney Medical School Planning Victoria.
STI sexually transmissible infection
Northern.
Ushma Narsai MBBCh, FRACGP
Carol Lawson (Case 2) MBBS, FRACGP currently work as a part-time general References
is a general practitioner in Brunswick, practitioner and part-time medical 1. Bettering the Evaluation and Care of
Victoria. She previously worked in the advisor for Avant. Dr Narsai has Health. General practice activity in Australia
Department of General Practice at experience in clinical research. 2015–16. Sydney: Sydney University Press,
2016. Available at www.smh.com.au/
Monash University and has an interest cqstatic/gkpu9e/BEACH-feature-
Suzanne Pearson MBBS (Hons),
in medical education. chapter-2015.pdf [Accessed 17 April 2018].
FRACGP, GradCert Clin Teach is a
Parker Magin (Case 4) PhD, FRACGP is general practitioner who is enthusiastic 2. Bayram C, Pollack AJ, Wong C, Britt H.
Obstetric and gynaecological problems in
conjoint professor, Discipline of General about working in education for health
Australian general practice. Aust Fam
Practice, University of Newcastle and professionals. Currently the senior Physician 2015;44(7):443–45.
Director Research and Evaluation Unit, medical educator at Family Planning

3
Case 1 check Female reproductive system

CASE Question 3

1 Zhen has missed her period

and has bleeding and pain
What investigations would you do?

Zhen is 30 years of age and is one of your regular patients.

She comes to see you with her husband as she had some
irregular bleeding and crampy pain the night before, 10
days after her period was due. She had made an
appointment to see you before the pain began, because
she had had a faintly positive home pregnancy test two
days ago.

Question 1
What further information would you elicit on history taking?

Further information

Zhen’s blood pressure is 110/60 mmHg and her heart rate is

80 beats per minute. She does not feel lightheaded and
feels she is managing the pain and bleeding. You request a
blood test and organise for her to have an ultrasound scan.
The tests are marked urgent and you advise Zhen to go
home, with an explanation of the risk of an ectopic
pregnancy, and to go to the emergency department if the
pain becomes more severe or if she begins to feel faint. Her
serum β-human chorionic gonadotropin (β-hCG) is
Further information 1500 IU/L and her blood type is O-positive with negative
antibodies. Her ultrasonography report is shown in Box 1.
Zhen states that the pain ‘comes and goes’ and feels like
period pain. Initially, the bleeding was a very light spotting but
now is like a light period. Zhen and her husband have one Box 1. Zhen’s ultrasonography report
child, aged one year. Her last pregnancy was uncomplicated
and she delivered vaginally at 39 weeks. Her current Last menstrual period (LMP) by dates is = 6 weeks 0 days
pregnancy was unplanned, but Zhen wants to continue the The anteverted uterus contained a gestation sac of 16 mm. A yolk
pregnancy. She was using condoms for contraception. She is sac of 4 mm was present. No embryo was visualised. Possible
haemorrhage is present.
usually fit and well, has no other medical history and is on no
The cervix appeared long and closed (30.0 mm).
regular medications.
The right ovary was identified and contained a 22 mm corpus
luteum.
Question 2 On the left, an 85 x 85 x 83 mm (volume 333 mL) mulitfocular
cyst with a large central solid component contains mobile,
What examination is required? low‑level echoes and multiple tiny cystic spaces. Within the larger
central component there is a 46 x 44 x 31 mm solid avascular
projection containing echogenic flecks with ring-down artefact.
Peripheral flow was seen in the lateral septum. This is probably of
ovarian origin.
A 20 x 12 x 9 mm left fibril cyst was identified.
No free fluid was present.
Conclusion
It is too early in gestation to identify an embryo within the
interuterine gestation sac. Recommend repeat ultrasonography
examination in nine days to confirm or exclude embryonic
viability. Normal right ovary. Large cyst identified in the left ovary
containing a solid avascular protection with suspicious features,
and anatomopathological study is highly recommended.

4
 Female reproductive system check Case 1

Further information
Question 4
Zhen has another ultrasound 10 days later. This time her
What are Zhen’s current issues?
report states that ‘LMP by dates is 8 weeks 3 days. The
anteverted uterus contains a gestation sac of 26 mm. A yolk
sac of 5 mm was present. There was no fetus visible in the
sac. There was evidence of bleeding around the sac.’

Question 7
What does the report mean?

Question 5
What are the next steps in your management of bleeding in
early pregnancy?

Question 8
What are some possible complications of ovarian cysts?

Question 6
What are the next steps in your management of the ovarian
mass?

CASE 1 Answers

Answer 1
You should ask Zhen about the date of her last menstrual
period, if she previously had regular cycles and if she uses
contraceptives. You should obtain a pain history, including
intensity, site, radiation and whether the pain is constant or
fluctuating. The amount of bleeding should be quantified.
You should also sensitively enquire about her thoughts about
the pregnancy and what her plans are about wanting to
continue the pregnancy. She may not know at this stage and
may need to return to discuss it over further appointments.

5
Case 1 check Female reproductive system

Other questions should include if there is any radiation or If Zhen is haemodynamically stable, it may be appropriate to
other associated symptoms such as nausea, vomiting or do initial pregnancy screening urine and blood tests (Box 2) at
diarrhoea. A review of Zhen’s medical history would also be the same time as her first serum β-hCG, but this can be done
useful to asses her other medical conditions, medications after the viability of the pregnancy is established.2
and allergies.
Box 2 Initial screening tests in pregnancy
Answer 2
• Urine dipstick for protein (send for urinary protein:creatinine ratio
For women with vaginal bleeding in early pregnancy, it is if ≥1+ proteinuria)
important to first consider haemodynamic stability by • Midstream urine for asymptomatic bacteriuria
assessing appearance, blood pressure and pulse.1 The degree • Full blood evaluation and electrophoresis if appropriate
of pain and bleeding should also be determined. An • Human immunodeficiency virus test
abdominal examination is performed, looking for pain • Hepatitis B test
guarding or rigidity, or signs of distension. A fundus is • Syphillis serology
palpable above the symphysis pubis from 12 weeks gestation. • Rubella serology
Speculum examination is performed to assess the amount • Varicella serology if no definite history of chickenpox or varicella
and site of ongoing bleeding. It is particularly important to immunisation
remove tissue from the cervical os if the patient is
haemodynamically unstable, as there may be cervical shock.
Answer 4
Tissue present in the open cervical os must always be
removed and sent for histopathology to confirm products of Current issues for Zhen are:
conception.1 Bimanual examination is performed to assess
• bleeding in early pregnancy with pregnancy of unknown
uterine size, dictation of the cervical os and cervical excitation.
viability
Women who are haemodynamically unstable should be
transferred to the emergency department by ambulance.1 • ovarian cyst with suspicious features.
Twenty to forty per cent of pregnant women will experience
Answer 3
bleeding during the first trimester of pregnancy.1 The major
Zhen requires confirmation of pregnancy with a test for urine causes are miscarriage (10–20% of clinical pregnancies) and
and serum (β-hCG). The urine test is useful for confirming ectopic pregnancy (1–2%).1 Bleeding in early pregnancy can
pregnancy. The serum test will take longer, but provides a also be related to endometrial implantation. Rarer cases
quantitative result that can be followed up. Serum β-hCG include cervical and vaginal lesions and uterine infection.
levels rise exponentially up to six to seven weeks of gestation, Gestational trophoblastic disease should be considered as
increasing by at least 66% every 48 hours.1 Following repeat this condition can present with vaginal bleeding early in
measurements, 48–72 hours apart, a falling β-hCG is pregnancy. 1
consistent with a non-viable pregnancy but is not an
Ovarian masses or cysts are very common and, in the US, up
indication of the location. Ultrasonography for pregnancy
to 10% of women have an operation during their lives for
assessment in the first trimester should be performed
investigation of an ovarian mass.3 Typically, these masses are
transvaginally by an experienced sonographer to assess for
found in asymptomatic women who have imaging for other
uterine or ectopic location, as well as the viability of
reasons or for investigation of non-specific abdominal or
pregnancy. On transvaginal ultrasound, a gestational sac is
pelvic pain. In pre-menopausal women, these cysts are
visible from four weeks and three days after the last menstrual
typically benign; however, it is important to determine
period, assuming the dates are correct and menstrual cycle is
whether further investigation is needed. The overall incidence
regular. Most institutions suggest that a gestational sac can
of a symptomatic ovarian cyst in a premenopausal woman
be seen on ultrasound once β-hCG levels rise above 1500–
being malignant is approximately one in 1000, increasing to
2000 IU/L, but this can vary depending on the skill of the
three in 1000 at the age of 50 years.3
sonographer and the quality of the ultrasound.2
An ovarian cyst is defined as ‘a fluid-containing structure
As stated assessment of Zhen’s haemodynamic stability is
>30 mm diameter’.4 Women with small cysts (<50 mm
important. If the β-HCG confirms pregnancy. Zhen would
diameter) generally do not require follow up as these cysts
need blood tests to determine her blood group and Rhesus
are very likely to be physiological and usually resolve within
(Rh) status. She has bleeding and may need resuscitation if
three menstrual cycles.4 Women with simple cysts of
there is substantial bleeding. She may also need to have Rh
50–70 mm diameter could have yearly follow-up with
(D) immunoglobulin (RhIg) if she is Rh (D)-negative to prevent
ultrasonography; cysts >70mm diameter need further
sensitisation. RhIg can be obtained through emergency
investigation.4
departments, blood banks and some pathology services;1 250
IU anti-D is required for a first trimester sensing event such as For ovarian cysts that are not simple cysts, the International
miscarriage. This should be given within 72 hours of the Ovarian Tumor Analysis ( IOTA) group has developed a list of
sensitising event, though administration of RhIg can be given characteristics for benign and malignant masses.5 The rules
up to 10 days later.1 have a reported sensitivity of 95% and specificity of 91%.3

6
 Female reproductive system check Case 1

Surgical management involves surgical evacuation of the

Table 2. IOTA group ultrasound rules to classify masses as
products of conception. It is the treatment of choice for
benign or malignant5
women with haemorrhage and/or sepsis. Women may also
Benign (B-rules) Malignant (M-rules) choose surgical management if they feel they are unable to
manage the pain, bleeding or duration of expectant
Unilocular cysts Irregular solid tumour
management.1
Presence of solid components Ascites
where the largest solid Answer 6
component <0.7 cm
Zhen’s family history should be explored in greater detail,
Presence of acoustic shadowing At least four papillary structures particularly to see if she has a family history of breast and
ovarian cancer, as having a first-degree relative with breast or
Smooth multilocular tumour with Irregular multilocular solid ovarian cancer would increase her risk for malignancy.
largest diameter <10 cm tumours with largest diameter
>10 cm For premenopausal women with simple ovarian cysts on
ultrasound, a serum CA-125 assay does not need to be
No blood flow Very good blood flow undertaken.3 CA-125 is unreliable in differentiating between
benign and malignant ovarian masses in premenopausal
women because of an increased rate of false positives and
In pregnancy, ovarian masses are usually an incidental finding.
reduced specificity. This is due to CA-125 being raised in
The majority of these masses are benign and can be managed
numerous conditions including fibroids, endometriosis,
expectantly, as at least 50% resolve spontaneously during
adenomyosis and pelvic infection. It can also be raised in
pregnancy.6 If a simple cyst is identified early on a dating
pregnancy.
ultrasound, repeat ultrasonography at 12–14 weeks should be
performed to check if the cyst has resolved.6 CA-125 should be measured only if the ultrasound appearance
of a mass raises suspicion of malignancy. Lactate
The cyst seen in Zhen’s ultrasound has suspicious signs. It is
dehydrogenase (LDH), alpha-fetoprotein (AFP) and β-hCG
multilocular with a solid central vascular area. The area
should be measured in all women under the age of 40 years
surrounding the solid component shows low-level echoes.
who have complex ovarian masses, given the possibility of
This means that the cyst is completely fluid-filled (it has the
germ cell tumours.3 If a woman has a serum CA-125 that is
appearance of ground glass), suggesting there is other cellular
>200 units/mL, referral to a gynaecological oncologist is
material in the cyst. This means that Zhen’s ovarian mass
recommended.3
should be further investigated, and an urgent referral to a
gynaecologist is required. Surgery in pregnancy is required only if one or more of the
following apply:6
Answer 5
• Malignancy is suspected.
Zhen requires a repeat scan to assess the viability of her
• There is an acute complication.
pregnancy. It is also important to speak to Zhen and her
partner about the pregnancy. As she has had bleeding and • The size is likely to cause obstetric or other problems.
pain, it is possible that she may be having a miscarriage. Zhen
The best time for an operation is after the first trimester, as
and her partner may need support and counselling in
this decreases the miscarriage rate and risk of teratogenicity.6
managing their feelings and concerns around pregnancy loss.
Perinatal and/or psychological counselling, as well as Zhen’s cyst shows a solid element with vascular flow and,
pregnancy loss support groups, may be useful. hence, she should have CA-125, LDH and AFP measured. She
should also be referred to a gynaecologist or a gynaecological
Options for management of miscarriage include expectant,
oncologist for further investigation.
medical and surgical treatments. Expectant management
involves allowing the miscarriage to occur without
Answer 7
intervention, via the natural expulsion of the products of
conception. Women should be informed that there can be Zhen’s second ultrasonography report shows no embryo
pain and bleeding, and that they should seek emergency growth within the gestational sac. A non-viable pregnancy is
medical care if there is heavy bleeding or severe pain. diagnosed on ultrasonography under either or both of the
Expectant management can take time to resolve; 60% of following circumstances:8
women have complete exclusion of products in two weeks,
• No live fetus is visible in a gestational sac where the mean
and 90% by six to eight weeks.7
sac diameter is >25 mm.
Medical management involves the use of misoprostol, a
• A fetal pole with crown rump length of >7 mm is visible,
prostaglandin E1 analogue, which is effective at stimulating
with no fetal heart activity after a period of observation of at
the uterus to evacuate the products of conception. Medical
least 30 seconds.8
management should be performed only by a service that has
experience with this form of management.1 According to these criteria, Zhen has a non-viable pregnancy.

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Case 1 check Female reproductive system

Answer 8
Some of the possible complications of ovarian cysts include
rupture and torsion. When a cyst ruptures, patients typically
present with lower abdominal pain; an ultrasound scan shows
free fluid in the abdomen with a collapsed cyst.9 Rupture of an
uncomplicated cyst can be managed in the community with
oral analgesia, but if a woman’s symptoms are not controlled
referral to a gynaecologist or admission to hospital should be
considered. Symptoms usually resolve within 24–72 hours. In
women with a complicated cyst rupture and a large amount of
free fluid/haemoperitoneum, management in a hospital
setting with fluid resuscitation is recommended, with
laprascopy as required.9

Torsion involves partial or complete rotation of the ovary on its

supporting ligaments, cutting off its blood supply. Presenting
symptoms usually include sudden-onset lower abdominal
pain, nausea and vomiting with a palpable adnexal mass.9 The
main risk factor for ovarian torsion is an ovarian mass >5cm.9
Suspected ovarian torsion requires urgent gynaecological
review. Torsion is most commonly associated with benign
conditions.

Resources for patients

• SANDS Australia. Pregnancy loss support, www.sands.org.au

References
1. Breeze C. Early pregnancy bleeding, Aust Fam Physician
2016;45(5):283–86.
2. Department of Health and Ageing. Clinical practice guidelines:
Antenatal care – Module I. Canberra: DoHA, 2012. Available at
www.health.gov.au/internet/main/publishing.nsf/Content/phd-
antenatal-care-index/$File/ANC_Guidelines_Mod1_v32.pdf
[Accessed 12 February 2018].
3. The Royal College of Obstetricians and Gynaecologists. Ovarian
masses in premenopausal women, management of suspected
(green-top guideline No. 62). London: RCOG, 2018. Available at
www.rcog.org.uk/en/guidelines-research-services/guidelines/
gtg62 [Accessed 13 Feburary 2018].
4. Yeoh M. Investigation and management of an ovarian mass. Aust
Fam Physician 2015;44(1):48–52.
5. Levine D, Brown DL, Andreotti RF, et al. Management of
asymptomatic ovarian and other adnexal cysts imaged at US:
Society of Radiologists in Ultrasound Consensus conference
statement. Radiology 2010;256(3):943–54.
6. Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-
based rules for the diagnosis of ovarian cancer. Ultrasound Obstet
Gynecol 2008;31(6):681–90.
7. Nanda K, Lopez LM, Grimes DA, Peloggia A, Nnada G. Expectant
versus surgical treatment for miscarriage. Cochrane Database
Syst Rev 2012.
8. Australasian Society for Ultrasound in Medicine. Guidelines for the
performance of first trimester ultrasound. Sydney: ASUM, 2014.
Available at www2.asum.com.au/wp-content/uploads/2015/09/
D11-Policy.pdf [Accessed 21 February 2018].
9. Bottomley C, Bourne T. Diagnosis and management of ovarian
cyst accidents. Best Pract Res Clin Obstet Gynaecol
2009;23(5):711–24.

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 Female reproductive system check Case 2

CASE Further information

2
Four years later, Janine, now aged 22 years, returns because
Janine has worsening her period pain is getting worse. She has been using
period pain naproxen, which was very effective until about six months ago.
Since then, she has had more severe and more prolonged
Janine, aged 18 years, is in her final year of secondary
period pain, as well as some pelvic pain between periods.
school. She has come to see you today about period pain.
Janine is now in her fourth year of medical studies. She has
Janine has always had some period pain, but it has been
been in a monogamous relationship with her boyfriend, James,
getting worse over the past 12 months. Janine is hoping
for the past nine months, and they are using condoms for
for a place in Medicine at university next year and is
contraception.
concerned that her period pain is starting to interfere with
her ability to study.

Question 3
How will you approach Janine’s current presentation?
Question 1
What additional information do you need about Janine’s
symptoms? What physical examination would you do?

Question 4
Further information
Are any investigations indicated?
After taking a more detailed history, it is clear that Janine’s
symptoms are typical of primary dysmenorrhoea. Janine has
never been sexually active.

Question 2
What management can you offer?

Further information

In addition to worsening period pain, Janine has been having

some deep dyspareunia, but no bowel or bladder symptoms.
Pelvic examination elicits moderate left adnexal tenderness. A
urine pregnancy test and polymerase chain reaction (PCR)
testing for chlamydia, gonorrhoea and mycoplasma

9
Case 2 check Female reproductive system

genitalium from a cervical swab are negative. Janine’s Question 7

transabdominal and transvaginal pelvic ultrasound is reported
What are the effects of endometriosis on fertility?
as normal.

Question 5
Should Janine have a laparoscopy?

Question 8
What is the role of laparoscopy for Janine at this stage?
Futher information

Janine would prefer to avoid laparoscopy if possible.

Question 6
What types of empirical treatment are available for Janine?

CASE 2 Answers

Answer 1
Dysmenorrhoea is defined as painful cramps that occur with
menstruation.1 Prevalence estimates vary from 45% to 95%.2
Symptoms typically begin in adolescence and can lead to
Further information absenteeism from school or work, as well as limiting social,
academic and sporting activities.1,2
After you have explained to Janine the presumptive diagnosis
of endometriosis and the treatment options available, she It is important to ascertain whether Janine’s symptoms are
elects to try the levonorgestrel intrauterine system. This consistent with primary dysmenorrhoea (menstrual pain in the
provides reasonable control for her pelvic pain. absence of pelvic pathology).1 Primary dysmenorrhoea typically
begins 6–12 months after menarche. Pelvic pain usually starts close
You next see Janine when she is 27 years of age. She is
to the onset of menstrual flow and lasts from 8 to 72 hours. Pain in
working as a general practice registrar, and she and her
the lower back or thighs, as well as nausea, vomiting and diarrhoea,
partner would like to start a family in the next one to two
may also occur.2
years. Janine has decided she would like to see a
gynaecologist to confirm the presumptive diagnosis of Symptoms that may suggest underlying pathology (secondary
endometriosis and to discuss any potential fertility issues. dysmenorrhoea) include a change in the pattern or intensity of

10
 Female reproductive system check Case 2

period pain, pelvic pain between periods, dyspareunia and infiltrating bowel endometriosis, and some ultrasound
irregular or intermenstrual bleeding.2 providers offer specialised services for endometriosis
diagnosis. 7 However, as it is of little use in identifying the
Pelvic examination is unnecessary in young women who have
more common type of peritoneal disease,9 ultrasonography
never been sexually active and whose symptoms are typical of
alone cannot be used to exclude the presence of
primary dysmenorrhoea.1 In women who are sexually active,
endometriosis.7
an early pregnancy complication or a pelvic infection can
cause painful bleeding. These problems should be excluded
Answer 5
with pelvic examination and appropriate testing.1 Screening
for chlamydia is recommended for all sexually active people Janine is quite likely to have endometriosis, as it is the most
up to age 29 years because of high prevalence in this group.3 common cause of chronic pelvic pain for women in developed
countries and frequently begins in adolescence. Laparoscopy
Answer 2 with histology is the gold standard test for diagnosis of
endometriosis.7 However, there is an argument for starting
First-line treatment of primary dysmenorrhoea is with non-
empirical medical therapy in some situations before
steroidal anti-inflammatory drugs (NSAIDs) or with the
considering an invasive investigation such as laparoscopy.7
combined oral contraceptive pill (COCP).1
Reasons to recommend laparoscopy include the woman’s
There is high-quality evidence that NSAIDs are very effective desire for a definitive diagnosis, investigation and
in the management of primary dysmenorrhoea, but management of infertility, and evidence of extensive disease
insufficient evidence to recommend any particular NSAID.4 A such as ovarian or rectal endometriomas on ultrasound.7
systematic review found that paracetamol was no more While it is common practice for diagnostic laparoscopy to be
effective than placebo.5 performed if the patient does not react favourably to the
prescribed medical or hormonal pain treatment, a response to
There is limited evidence for pain improvement with the use
hormonal therapy does not always predict the presence or
of the COCP in women with dysmenorrhoea.6 However, small
absence of endometriosis.7
randomised controlled trials have shown a response rate of up
to 80%.1 Other hormonal contraceptives, including the
Answer 6
etonogestrel implant, the levonorgestrel-releasing intrauterine
system and the medroxyprogesterone depo injection, can be The Endometriosis Guideline Development Group
effective for some women.1 recommends that women with symptoms presumed to be due
to endometriosis can be treated empirically with adequate
The severity of pain is significantly associated with smoking,
analgesia as well as either the COCP or progestogens,
obesity, alcohol consumption and stress2, so offering advice
provided they have been thoroughly counselled about the
about these factors is useful.
presumptive nature of the diagnosis.7

Answer 3 The COCP is widely used, either cyclically or continuously, to

treat endometriosis-related pain; however, good-quality
Janine’s symptoms are now more suspicious for secondary
evidence for its effectiveness is limited.7 For general
dysmenorrhoea, as described above. Common causes of
practitioners and patients, the COCP has the advantage of
secondary dysmenorrhoea include endometriosis, pelvic
being a well-known and generally well-tolerated medication.9
infection, adenomyosis and fibroids.1 Ask Janine about any
Progestogens, including depo-medroxyprogesterone acetate,
other symptoms. Dyspareunia, dysuria and/or pain with
the etonogestrel implant and the levonorgestrel intrauterine
defaecation can be associated with endometriosis.7 Vaginal
system, can all decrease pain symptoms,7 and may be more
discharge could indicate pelvic infection, while menorrhagia is
effective than the COCP.9 Dienogest, an oral progestogen
often found with adenomyosis.1 Non-gynaecological causes of
indicated for management of endometriosis, is available in
pelvic pain, such as irritable bowel syndrome or interstitial
Australia but is not PBS-listed.10
cystitis, may also need to be considered.1
Other hormonal medications used to treat endometriosis-
A vaginal examination is indicated. In endometriosis, there
related pain include gonadotropin-releasing hormone (GnRH)
may be reduced uterine mobility, adnexal masses or
agonists, aromatase inhibitors and the androgenic drug
uterosacral nodularity.7 Signs of pelvic infections include
danazol.9 All are effective at reducing pain but have significant
cervical motion tenderness, uterine or adnexal tenderness and
side effects. For this reason, they are not recommended as
mucopurulent cervical discharge.1
empirical therapy without a definitive diagnosis of
endometriosis.7 GnRH agonists and aromatase inhibitors
Answer 4
produce a hypo-oestrogenic state, which leads to atrophy of
A pregnancy test is prudent. Collect an endocervical swab for endometriotic lesions but also to side effects such as hot
PCR testing for chlamydia, gonorrhoea and mycoplasma flushes and potential loss of bone density.9 Danazol has
genitalium.8 Transabdominal and transvaginal complex effects on the hypothalamo-pituitary axis and the
ultrasonography can identify uterine adenomyosis or fibroids.1 uterus, but can lead to androgenic side effects such as acne,
Specialist ultrasonography has been shown to be highly hirsutism, voice changes, weight gain, vaginal spotting and
accurate in the diagnosis of ovarian endometriomas and deep emotional lability.7,9

11
Case 2 check Female reproductive system

Answer 7 1998;105(7):780–89. Available at www.ncbi.nlm.nih.gov/

pubmed/9692420 [Accessed 27 March 2018].
The prevalence of endometriosis is estimated to be 2–10% in 6. Wong CL, Farquhar C, Roberts H, Proctor M. Oral contraceptive
women of childbearing age, but up to 50% in women with pill as treatment for primary dysmenorrhoea. Cochrane Database
subfertility.10 For couples where the woman has Syst Rev 2009 Apr 15;(2):CD002120 Available at www.ncbi.nlm.
endometriosis, there is a reduced monthly fecundity rate nih.gov/pubmed/19370576 [Accessed 27 March 2018].

(2–10%), compared with couples with normal fertility 7. European Society of Human Reproduction and Embryology.
Guideline on the management of women with endometriosis.
(15−20%).11 All grades of endometriosis, from minimal to
Grimbergen, Belgium: European Society of Human Reproduction
severe, result in a reduction in fertility, but the mechanisms for and Embryology, 2018–2020. Available at www.eshre.eu/
this are not completely understood.11 guidelines-and-legal/guidelines/endometriosis-guideline.aspx
[Accessed 27 March 2018].
Answer 8 8. Australian Sexual Health Alliance. Australian STI Management
Guidelines for use in primary care. Darlinghurst, NSW: ASHA,
Laparoscopy is used for diagnosis of endometriosis, for 2018. Available at www.sti.guidelines.org.au [Accessed 27 March
treatment of pain and for management of fertility difficulties. 2018].
9. Black K, Fraser IS. Medical management of endometriosis. Aust
Laparoscopy with excisional biopsy and histology, is the gold Prescr 2012:35:114–47. Available at www.nps.org.au/australian-
standard for diagnosis of endometriosis.7 Laparoscopic prescriber/articles/medical-management-of-endometriosis
excision or ablation of identified lesions reduces pain and [Accessed 27 March 2018].
improves quality of life in most patients.7,9 However, 10. Dienogest for endometriosis. Australian Prescriber 2015:38:138-
endometriosis can recur after conservative surgery – one 39. Available at www.nps.org.au/australian-prescriber/articles/
dienogest [Accessed 24 April 2018].
study found that 10–20% of treated women showed signs of
recurrence within one year.9 Postoperative hormone treatment 11. Fadhlaoui A, de la Joliniere JB, Feki A. Endometriosis and infertility:
How and when to treat. Front Surg 2014;1:24. Available at www.
with the COCP or with progesterone should be considered in
ncbi.nlm.nih.gov/pmc/articles/PMC4286960 [Accessed 27
women not immediately desiring pregnancy, as it can reduce March 2018].
the rate of recurrent symptoms.7,9

Laparoscopy also has a role in improving fertility. In women

with minimal-to-mild endometriosis, laparoscopic excision of
visible lesions, along with division of adhesions, is effective at
increasing the live birth rate.7 For women with moderate-to-
severe endometriosis, there are no trials comparing surgical
treatment with expectant treatment. In one observational
study conducted over 24 months, the spontaneous pregnancy
rates without treatment were 30% (moderate endometriosis)
and 0% (severe endometriosis).7 Cohort studies have shown
pregnancy rates after laparoscopic treatment of 57–69%
(moderate endometriosis) and 52–68% (severe
endometriosis).7

Resources for patients

• Endometriosis Australia, www.endometriosisaustralia.org

References
1. Osayande A, Mehulic S. Diagnosis and initial management of
dysmenorrhea. Am Fam Physician 2014;89(5):341–46. Available at
www.aafp.org/afp/2014/0301/p341.html [Accessed 27 March
2018].
2. Proctor M, Farquhar C. Diagnosis and management of
dysmenorrhoea. BMJ 2006;332(7550):1134–1138. Available at
www.ncbi.nlm.nih.gov/pmc/articles/PMC1459624 [Accessed 27
March 2018].
3. The Royal Australian College of General Practitioners. Guidelines
for preventive activities in general practice. 9th edn. Melbourne:
RACGP, 2016. Available at www.racgp.org.au/your-practice/
guidelines/redbook/6-communicable-diseases/62-sexually-
transmissible-infections [Accessed 27 March 2018].
4. Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal
anti-inflammatory drugs for dysmenorrhoea. Cochrane Database
Syst Rev 2015;7:CD001751. Available at www.ncbi.nlm.nih.gov/
pubmed/26224322 [Accessed 27 March 2018].
5. Zhang W, Li Wan P. Efficacy of minor analgesics in primary
dysmenorrhoea: A systematic review. Br J Obstet Gynaecol

12
 Female reproductive system check Case 3

CASE Question 2

3 Jennifer has dyspareunia

What is your provisional diagnosis? What investigation do you
need to confirm the diagnosis?

Jennifer is 55 years of age and has been seeing you for

many years. Her last period was 18 months ago and she is
not on menopausal hormone therapy. Her past history
includes Hashimoto’s disease and hypertension. She has
been happily married for 30 years, enjoying an active sex
life. She has three children, who are now adults, and she
works as a high school teacher.

Over the past three years, Jennifer has noticed worsening

vulval itching, which wakes her at night. She assumed it
was thrush and on the advice of her chemist treated it
with antifungal creams and pessaries. She has a busy life
and ignored the problem until she started to experience
dyspareunia six months ago. Too embarrassed to see you,
she visited another general practitioner, who prescribed Question 3
oestrogen pessaries without examining her. Even after
What initial treatment should you offer?
three months on treatment there has been no
improvement.

Her condition continued to deteriorate, and she is now

unable to have intercourse. She has started to avoid
physical contact with her husband. She is now worried
that her vulva has changed shape and suspects that
something is very wrong.

Question 1
What are the possible diagnoses for persistent vulval itching
Further information
associated with dyspareunia in a post-menopausal woman?
Jennifer returns to see you after four weeks on treatment. She
feels much better, the itching has resolved and the white
plaque is rapidly fading; however, the dyspareunia has not
improved. Now that she has examined her vulva herself, she is
upset at what she sees as disfigurement. She does not want
her husband to see this and blames herself for procrastinating
with seeking treatment. She also asks if the treatment you
have started will be dangerous. She has read on the internet
that it will cause thinning of her skin.

Question 4
What advice will you give Jennifer now?

Further information

You examine Jennifer and note that she has a white, thickened
plaque with haemorrhagic blisters encircling her vulva and
involving her perianal skin. Her labia minora are very small
and are fused with the labia majora. The perineum is fissured
and she is tender on digital vaginal examination. The vulval
vestibule appears dry and pale; however, the white plaque
does not extend into this area.

13
Case 3 check Female reproductive system

Further information Dyspareunia may be exacerbated by postmenopausal vaginal

dryness co-incident with any vulval skin problem; however,
Jennifer still has dyspareunia, although all her other
treating this alone without addressing the dermatosis will only
symptoms have resolved.
partially relieve symptoms.

Answer 2
Question 5
The examination findings are typical of lichen sclerosus, which
What is your ongoing management?
has a prevalence of 3% in postmenopausal women.3 This
condition is relatively rare on other parts of the skin and is
seen most often in the genital area. Although not proven that
lichen sclerosus itself is auto-immune, it is associated with
other auto-immune conditions, particularly Hashimoto’s
thyroiditis, vitiligo and pernicious anaemia.4

If lichen sclerosus is not treated, it commonly causes scarring

of the vulva and loss of labia minora, clitoral substance and
fusion of the labia minora, which may reduce the size of the
vaginal opening. It is commonly complicated by painful
fissuring and sometimes by haemorrhagic blisters. Bleeding
from such lesions may be very concerning, as patients are not
aware that the source is the skin rather than the vagina.

Further information Lichen sclerosus is a serious condition and should be treated

as such. Not only can it cause irreversible scarring of the
Jennifer is worried about her prognosis.
vulva, but it can be complicated by vulval carcinoma, with a
risk of 5% in untreated women.5

Question 6 The diagnosis is readily confirmed with a 3-mm punch

biopsy from a white area. This is a simple procedure and can
What will you tell her?
be done in the office under local anaesthetic. A large
specimen is not required. In Jennifer’s case, thyroid status
should be checked.

Answer 3
Jennifer should be commenced on a super-potent topical
corticosteroid ointment, such as betamethasone dipropionate
0.05% in optimised vehicle. This is the gold standard
treatment for lichen sclerosus.6,7 The corticosteroid is applied
twice a day until the itching has ceased (usually one to two
weeks) and then once a day until the skin normalises. This can
take several months and should be monitored, initially at six
weeks, then every three months.8

This treatment will not reverse the scarring, but most patients
CASE 3 Answers are able to resume intercourse once their skin is normal and
oestrogen lack is addressed.

Many patients (and doctors) are reluctant to apply potent

Answer 1
topical corticosteroid to the vulva. It is important to spend
The most common causes of an itchy vulvitis in a time explaining the rationale and evidence for using it.
postmenopausal woman are lichen sclerosus, psoriasis and
dermatitis. These conditions all involve the external genital Answer 4
skin and do not involve the vagina. Dyspareunia can occur if
Although the very potent steroid is usually not required for
there are erosions from scratching or fissuring associated
more than three months, ongoing treatment of lichen
with the underlying rash.1
sclerosus is for life. Cessation of treatment results in an 85%
Vaginal candidiasis is very unlikely in postmenopausal women chance of relapse. Patients require long-term monitoring, but
who are otherwise healthy and not taking menopausal side effects are rare.9 In the case of lichen sclerosus, ongoing
hormone therapy.2 It should never be assumed that any vulval treatment with topical corticosteroids at appropriate strength
condition in this group is thrush. Patients should always be will not cause thinning of the skin, although it can produce
examined and a vaginal swab taken. some erythema.8,10

14
 Female reproductive system check Case 3

At this point Jennifer also needs counselling regarding her 10. Cooper SM, Gao X-H, Powell JJ, et al. Does treatment of vulval
body image and guilt around not seeking treatment. She lichen sclerosus influence its prognosis? Arch Dermatol
2004;104:702–06.
should be reassured that if she wants to be sexually active,
this will be possible and, although the scarring is irreversible,
it does not have to be a cause for embarrassment or sexual
dysfunction.

Answer 5
Although lichen sclerosus is very treatment-responsive,
improvements in the skin condition with topical
corticosteroids may not always result in immediate resolution
of dyspareunia. It is important to manage postmenopausal
vaginal dryness concurrently, and Jennifer should re-start
vaginal oestrogen.

Jennifer’s ongoing problem may also be complicated by pelvic

floor spasm and loss of libido related to the emotional impact
of the diagnosis and the appearance of her vulva. She may
require assistance from a pelvic floor physiotherapist and
ongoing counselling.

Answer 6
It is important to be positive with patients with lichen
sclerosus. When well managed, it has an excellent prognosis,
and research indicates that ongoing treatment will prevent the
complications that can occur. Once the skin has returned to
normal, the strength of the corticosteroid can be titrated to a
dose that maintains normality. Patients who adhere to this
treatment long term generally remain very well. You can
confidently reassure Jennifer that both the topical
corticosteroids and oestrogen have an excellent safety record.

References
1. Fischer G. The commonest causes of vulval disease: A
dermatologist’s perspective. Australas J Dermatol 1996;37:12–18.
2. Fischer G, Bradford J. Vulvovaginal candidiasis in postmenopausal
women: The role of hormone replacement therapy. J Lower Genital
Tract Dis 2011;15:263–67.
3. Goldstein AT, Marinoff SC, Christopher K, Srodon M. Prevalence
of vulvar lichen sclerosus in a general gynecology practice. J
Reprod Med 2005;50:477–80.
4. Harrington CI, Dunsmore IR. An investigation into the incidence of
auto-immune disorders in patients with lichen sclerosus et
atrophicus. Br J Dermatol 1981;104:563–66.
5. Bleeker MC, Visser PJ, Overbeek LI van Beurden M, Berkhof .
Lichen sclerosus: Incidence and risk of vulvar squamous cell
carcinoma. Cancer Epidemiol Biomarkers Prev 2016;25:1224–30.
6. Dalziel KL, Millard PR, Wojnarowska F. The treatment of vulval
lichen sclerosus with a very potent topical corticosteroid (clobetasol
propionate 0.05%) cream. Br J Dermatol 1991;124:461–64.
7. Corazza M, Borghi A, Minghetti S, Toni G, Virgili A. Clobetasol
propionate vs mometasone furoate in 1-year proactive
maintenance therapy of vulvar lichen sclerosus: Results from a
comparative trial. J Eur Acad Dermatol Venereol 2016;30(6):956–
61.
8. Lee A, Bradford J, Fischer G. Long-term management of vulvar
lichen sclerosus: A prospective cohort study of 507 women. JAMA
Dermatol 2015;151:1061–67.
9. Renaud-Vilmer C, Cavalier-Balloy B, Porcher R, et al. Vulvar lichen
sclerosus. Effect of long-term topical application of a potent
steroid on the course of the disease. Arch Dermatol
2004;140:709–12.

15
Case 4 check Female reproductive system

CASE Further information

4
Sarah has no medical conditions and does not take any
Sarah attends for a repeat medications, including over-the-counter drugs. She has never
script of her pill had breast cancer. She has had Pap tests every two years
since the age of 18 years. A few months ago, she had her first
Sarah, 25 years of age, attends your practice requesting a
human papillomavirus (HPV) test as part of the new cervical
repeat script for the combined oral contraceptive pill
screening program. She has never had an abnormal result.
(COCP) containing levonorgestrel and ethinyloestradiol.
Her periods are every 28 days, and she bleeds for around five
She has been taking this contraceptive since she was 18
days. She describes her flow as normal. She denies any
years of age. She is not currently in a relationship and has
intermenstrual or postcoital bleeding. Her last period started
no plans for children ‘for a few more years yet’. You review
six days ago and ended yesterday. She as screened for
her past history and note she has no medical problems
asymptomatic sexually transmissible infections (STIs) six
and takes no regular medications. She is a non-smoker.
months ago, which was normal, and has not had any form of
sexual intercourse for over a year.

Following further assessment, you conclude that Sarah has no

Question 1
contraindications to the use of the etonogesterel (ENG) implant.
What would be your approach to this consultation? Sarah says some of her friends who have tried this method had
‘bad’ side effects and asks if you can tell her more about this.

Question 3
What side effects would you discuss with Sarah?

Further information

You use the contraceptive option tool (Figure 1) to discuss

options with Sarah. She would like to know more about the
contraceptive implant.

Question 2 Question 4
What key factors would you address in Sarah’s history to What further information would you discuss with Sarah to
assess her suitability for this method? complete your consultation prior to insertion?

16
 Female reproductive system check Case 4

Figure 1: Efficacy of contraception methods6

Further information CASE 4 Answers

Sarah is on day six of her cycle. She would like to come back
later in the week for insertion before she leaves for a one week
holiday. You arrange a time for Sarah to come back for insertion. Answer 1
This is the perfect opportunity to discuss other general
contraceptive options and sexual health with Sarah. Many
Question 5
women taking contraceptives are not fully counselled
What should you advise Sarah regarding timing of the insertion? regarding the options that are available to them. You should
take this opportunity to do so before making a decision to
continue the COCP.

There is a sound rationale for Sarah to consider other

contraceptive options. Two-thirds of Australian women of
reproductive age currently use contraception, and 85% have
used contraception at some time in their lives.1 However, more
than 50% of women will have an unplanned pregnancy2 and
one in four pregnancies in Australia are terminated;1 this is
among the highest rates in the developed world.3 Unintended
pregnancies that do not result in abortion are related to poorer
infant and maternal outcomes, with effects on women’s
economic, physical, psychological and social outcomes.4

17
Case 4 check Female reproductive system

Long-acting reversible contraception (LARC) has been Ask about any history of liver disease or liver tumours, and
shown to be the most effective form of available assess history of arterial disease and risk factors for
contraception. The advantages of LARC are well cardiovascular disease.
documented:2 they eliminate the issue of user error, have a
Take a careful drug history to ascertain if the patient is
high efficacy, are long-term methods with minimal
taking any medications that induce liver enzymes,
maintenance once in place and are the most cost-effective
remembering that some of these may be over-the-counter
long term. LARC includes hormonal contraceptive implants
medications. Examples are phenytoin, carbamazepine,
(available in Australia as ‘Implanon NXT’), hormonal
barbiturates, primidone, some anti-retrovirals and St John’s
intrauterine devices (available in Australia as ‘Mirena’), non-
wort. The ENG implant is not recommended for women
hormonal intrauterine devices (copper IUD) and hormonal
taking concurrent long-term medications that induce liver
contraceptive injectables (medroxyprogesterone depot).
enzymes.13 However, if the treatment is short term, the
The Contraceptive CHOICE project provided evidence that
patient may proceed with the implant and be advised to use
when women are offered LARC first when discussing
contraceptive options, the majority (72%) choose this
method when financial barriers are removed and insertion Table 1. Definition of UK Medical Eligibility Criteria
could be immediately performed.5 Family Planning Alliance categories for contraceptive use12
Australia (FPAA) provides a resource to aid in decision-
making with patients regarding the efficacy of different MEC 1 A condition for which there is no restriction for the use
of the contraceptive method
methods (Figure 1).6 These resources should be used when
discussing contraceptive options with Sarah. MEC 2 A condition where the advantages of using the method
generally outweigh the theoretical or proven risks
The COCP is the most common method used by women
(up to 40%), followed by condoms (20–23%).1 However, up MEC 3 A condition where the theoretical or proven risks
to nine pregnancies occur for every 100 women using a usually outweigh the advantages of using the method.
COCP over a three-year period, compared with less than The provision of the method requires expert clinical
one for women using LARC.7 The uptake of LARC is judgement and/or referral to a specialist contraceptive
comparatively poor, with estimates in 2013 of only 3.2– provider, since use of the method is not usually
recommended unless other more appropriate methods
8.9%1 of Australian women using these methods; however,
are not available or not acceptable
more recent data suggest this is modestly increasing to
12.5%8. The uptake of LARC is currently a health priority in MEC 4 A condition which represents an unacceptable health
the UK9 and USA. The FPAA advocates for increasing risk if the contraceptive method is used
research, training and incentives to increase LARC uptake
in Australia.10
Table 2. MEC criteria for etonogestrel implant for
General practitioners (GPs) see 86.9% of the Australian
significant conditions12
population every year and have a critical role in the
provision of family planning services.11 Contraceptive MEC criteria for significant conditions
problems are managed at a rate of 6.1 per 100
consultations by established GPs.2 Therefore, GPs can play MEC category
a pivotal part in increasing the uptake of LARC.
Arterial disease and risk factors

Answer 2 Develops IHD, stroke or TIA during use 3

Assessment of a patient’s suitability for different
Past history of IHD, stroke or TIA 2
contraceptive methods should always be made in reference
to the UK Medical Eligibility Criteria (MEC)12 (Table 1), Breast conditions
which is an evidence-based and internationally recognised
tool that enables the doctor to match a woman’s medical Current breast cancer 4
history with appropriate contraceptive options.
Past history of breast cancer 3
While it is important to take a thorough history of women
prior to inserting the ENG implant, the absolute Reproductive tract conditions

contraindications to its use are few, as summarised in

Unexplained vaginal bleeding (suspicious 3
Table 2. for a serious condition) before evaluation
The patient’s past medical history should be explored. In
Gastrointestinal conditions
particular, ask about current or past history of breast
cancer. Note that a family history of breast cancer is MEC Severe (decompensated) cirrhosis 3
1, and having known gene mutations associated with breast
cancer is MEC 2, so the ENG implant can be used in these Benign hepatocellular adenoma 3
patients. Other conditions that are MEC 2 include a past
Malignant liver tumour 3
history of deep vein thrombosis and migraine with aura.

18
 Female reproductive system check Case 4

condoms for the duration of treatment and 28 days after insertion site for one or two weeks, the possibility of infection
ceasing the treatment. at the insertion site and possible allergic reactions to either
the local anaesthetic or implant material. Women should be
Take a thorough menstrual history. Ask about frequency of
informed that they will be left with a small scar at the site of
periods, number of days bleeding and any abnormal
healing, and those susceptible to keloid formation should be
symptoms, such as postcoital bleeding, intermenstrual
informed of this risk. Both the patient and doctor should
bleeding or pain on intercourse. Ask about previous testing for
palpate the implant after insertion. Women should be advised
STIs and assess the risk of STIs to guide the need for further
of the risk of difficulty in removing the implant. There is a
investigation at this stage. Ensure that the patient is up to
possibility of nerve or vascular damage if insertion has been
date with routine cervical screening. You should establish the
too deep, and they should seek medical review if they cannot
date of Sarah’s last menstrual period in order to plan
feel the ENG implant; ultrasonography or X-ray may be
appropriate timing of insertion, either day one to five of the
required to locate the implant if it is impalpable.
cycle for immediate contraceptive cover or at any other time
of the cycle by using the Quick Start method. Quick Start
Cost
includes advising that the method takes seven days to
become effective and requires that a repeat pregnancy test be There will be an initial cost of buying the ENG implant from
performed four weeks after insertion to ensure an early the pharmacy and a fee for insertion as determined by the
pregnancy is not missed. medical practice. There should be no further associated costs
until replacement is required.
Blood pressure should be taken and body mass index (BMI)
calculated (to assess a baseline for patients who may report Procedural Medicare Benefits Schedule (MBS) item numbers
weight gain as a side effect). for Implanon NXT are 14206 (hormone or living tissue
implantation by cannula) and 30062 (etonogestrel
Answer 3 subcutaneous implant, removal of, as an independent
procedure). Both MBS items can be claimed for removal/
The most common side effect of the ENG implant is an re-insertion. An attendance item may be used for the
altered bleeding pattern. Generally, around 20% of women counselling consultation prior to insertion.
have amenorrhoea, 35% have infrequent bleeding (fewer than
three episodes in a 90-day period), 20% have three to five Management of troublesome bleeding
episodes of bleeding in a 90-day period, and 25% have
frequent bleeding (more than five episodes in a 90-day period) A number of options can be trialled for the short-term
or prolonged bleeding (bleeding lasting for 14 days or more).14 management of troublesome bleeding, provided there are no
The majority of women report bleeding patterns are contraindications; however, there is limited evidence for their
acceptable when using the ENG implant.15 Other reported long-term use16. First-line options include:18
side effects of the ENG implant include headaches, mood • the COCP, taken continuously or cyclically for three months
changes, weight gain, breast tenderness, loss of libido and
abdominal pain; however, direct causal evidence is limited.16 • a five-day course of an anti-inflammatory drug, such as
ibuprofen 400 mg three times a day or mefenamic acid
Answer 4 500 mg two or three times a day

You should explain the method of insertion and discuss the • a five-day course of antifibrinolytic, such as tranexamic acid
risks and cost. It is also beneficial to discuss potential 500 mg twice daily.
management options of troublesome bleeding. Second-line options include:

Method of insertion • norethisterone 5mg three times a day for 21 days

You should ensure that Sarah fully understands the method of

• levonorgestrel progesterone-only pill 30 µg twice a day for
20 days
insertion and removal. You should tell her that the procedure
will take around 10 minutes. She will be lying down and the • doxycycline 100 mg twice a day for five days
position for insertion will be marked on the inner aspect of the
upper arm of the non-dominant arm 8–10 cm from the medial
• early removal and replacement of the implant.
epicondyle, over the triceps, avoiding the sulcus. A local Sarah should also be advised that the ENG implant will not
anaesthetic is injected into the area to ensure the procedure is protect against STIs.
painless. The ENG implant can remain in situ for three years,
at which time it should be removed and replaced if ongoing Answer 5
contraception is required. Sarah can be reassured that fertility
In 2016, the UK Royal College of Obstetrics and Gynaecology
returns to normal immediately after removal.17
Faculty of Sexual and Reproductive Healthcare (FSRH)
changed its guidance relating to switching from the COCP to
Risks
the ENG implant.19 Previously, the FSRH advised that if the
There are risks associated with insertion for which women COCP had been taken consistently, then the ENG implant
should be counselled. These include bruising and pain at the could be commenced at any time in the cycle and would be

19
Case 4 check Female reproductive system

effective immediately. The new guideline addresses the –– You can also directly contact your local Family Planning
possibility that if insertion is planned on day three to seven of Organisation to organise training. A list of these for each
the pill-free week, or in the first seven days of the active pills, state can be found at http://
ovulation may not be fully suppressed while waiting for the familyplanningallianceaustralia.org.au/services/
new method to become effective. With this in mind, and to
recommend a consistent and clear guideline that is easy to Resources for patients
remember, the FSRH now recommends that, regardless of
• The FPAA website includes links to all family planning
which day in the pack the patient is in, the COCP be
organisations for fact sheets and information services,
continued for seven days following insertion of the ENG
http:// familyplanningallianceaustralia.org.au/fpaa
implant. If this is done, there is no need for additional
precautions (condoms or abstinence). • Marie Stopes, www.mariestopes.org.au
As Sarah is already on the COCP, she can arrange to have her • Family Planning New South Wales, www.fpnsw.org.au
contraceptive implant inserted at any time before her trip.
• Jean Hailes, www.jeanhailes.org.au
Further information • Faculty of Sexual and Reproductive Healthcare, www.fsrh.org
Sarah informs you that she has sufficient supply to continue
References
her COCP for seven days following insertion.
1. Family Planning NSW. Reproductive and sexual health in
Australia. Sydney: Family Planning NSW, 2013.
Conclusion
2. Mazza D, Harrison C, Taft A et al. Current contraceptive
LARC is the most effective form of contraception currently management in Australia general practice: an analysis of BEACH
available. Australia has one of the highest rates of unintended data. Med J Aust 2012;6:367–75.

pregnancy and abortion rate in the developed world. Care 3. Mazza D, Bateson D, Frearson M, Goldstone P, Kovacs G, Baber R.
Current barriers and potential strategies to increase the use of
should be taken to provide women with appropriate
long acting reversible contraception (LARC) to reduce the rate of
information to enable informed choice of contraceptive unintended pregnancies in Australia: An expert roundtable
method. GPs are ideally placed to adequately counsel women discussion. Aust N Z J of Obstet Gynaecol 2017;57:1–7.
about the full range of contraceptive options available to them, 4. Gipson JD, Koenig MA, Hindin MJ. The effects of unintended
including information related to efficacy, methods of pregnancy on infant, child and parental health: A review of the
insertion/removal, risks and benefits, and side effects. literature. Stud Fam Plann 2008;39(1):18–38.
5. Secura G, Allsworth J, Madden T, et al. The Contraceptive CHOICE
Resources for doctors Project: Reducing barriers to long-acting reversible contraception.
Am J Obstet Gynecol 2010;203(115): e1–e7.
• Family Planning NSW, Family Planning Victoria and True 6. Family Planning Alliance Australia. Efficacy of contraceptive
Relationships and Reproductive Health. Contraception: An methods. Manly, Qld: Family Planning Alliance Australia, 2014.
Australian Clinical Practice Handbook, 4th Edition. Ashfield Available at http://familyplanningallianceaustralia.org.au/
wp-content/uploads/2014/11/FPAA_Efficacy_SCREEN.pdf
NSW 2016.
[Accessed 25 February 2018].
• Pearson S, Stewart M, Bateson D. Implanon NXT: Expert 7. Winner B, Peipert J, Zhao Q, et al. Effectiveness of long-acting
tips for best-practice insertion and removal. Australian reversible contraception. N Eng J Med 2012;366(21):1998–2007.
Family Physician 2017, Vol 46, No 3 pages 104–08. 8. Richters J, Fitzadam S, Yeung A et al. Contraceptive practices
among women: the second Australian study of health and rela-
• Consent forms for implant procedures are available at: tionships. Contraception 2016; 94(5):548–55.
www.racgp.org.au/download/Documents/ PracticeSuppor 9. Mavranezouli I, LARC Guideline Development Group. The cost-
t/201105implanonchecklist.pdf effectiveness of long-acting reversible contraceptive methods in
the UK: Analysis based on a decision-analytic model developed for
• ENG implant insertion training: a National Institute for Health and Clinical Excellence (NICE)
clinical practice guideline. Hum Reprod 2008;23:1338–45.
–– Training for doctors in implant insertion is required for
10. Family Planning Alliance Australia. Achieving change: Increasing
most medical indemnity insurers. the use of effective long acting reversible contraception (LARC).
Manly, Qld: Family Planning Alliance Australia, 2014. Available at
–– Implanon NXT manufacturer MSD provides formal
http://familyplanningallianceaustralia.org.au/wp-content/
training in Implanon NXT insertion. This comprises an uploads/2014/11/24447-Family-Planning-A4-Book-8pp_Proof2.
online module (which will open on 7 May 2018), followed pdf. [Accessed 25 February 2018].
by face-to-face insertion training. 11. Britt H, Miller GC, Henderson J, et al. General practice activity in
Australia 2015–2016. General practice series no. 40. Sydney:
–– Visit: http://implanonnxt.mymsd.com.au   Sydney University Press, 2016. Available at https://ses.library.
–– Once you have registered for an account, you can access usyd.edu.au/bitstream/2123/15514/5/9781743325148_ONLINE.
pdf [Accessed 28 March 2018].
information regarding training by selecting ‘IMPLANON
12. Faculty of Sexual and Reproductive Healthcare. UK medical
NXT’ under ‘Products’, which includes access to the
eligibility criteria for contraceptive use. London: FSRH, 2016.
online training modules and list of all training Available at www.fsrh.org/documents/ukmec-2016 [Accessed
organisations and trainers 25 February 2018].

20
 Female reproductive system check Case 4

13. Faculty of Sexual and Reproductive Healthcare. FSRH clinical

guidance: Drug interactions with hormonal contraception. London:
FSRH, 2012. Available at www.fsrh.org/documents/ceu-guidance-
drug-interactions-with-hormonal-contraception-jan [Accessed
25 February 2018].
14. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The
effects of Implanon on menstrual bleeding patterns. Eur J
Contracept Reprod Health Care 2008;13(Suppl 1):13–28.
15. Darney P, Patel A, Rosen K, Shapiro, L, Kaunitz A. Safety and
efficacy of a single-rod etonogestrel implant (Implanon): Results
from 11 international clinical trials. Fert Steril 2009;91(5):1646–53.
16. Faculty of Sexual and Reproductive Healthcare. Progestogen-only
implants. London: FSRH 2014. Available at www.fsrh.org/
standards-and-guidance/documents/cec-ceu-guidance-implants-
feb-2014/ [Accessed 25 February 2018].
17. Bennink HJ. The pharmacokinetics and pharmadynamics of
Implanon, a single rod etonogestrel contraceptive implant. Eur J
Contracept Reprod Health Care 2000;5(Suppl 2):12–20.
18. Family Planning NSW. Guidance for the management of
troublesome vaginal bleeding with progestogen-only long-acting
reversible contraception (LARC). Ashfield, NSW: FPNSW, 2017.
Available at www.fpnsw.org.au/health-information/
contraception/guidance-management-troublesome-vaginal-
bleeding-progestogen-only [Accessed 19 April 2018].
19. Faculty of Sexual and Reproductive Healthcare. Switching or
starting methods of contraception. London: FSRH, 2016. Available
at www.fsrh.org/documents/fsrh-ceu-switching-document-
july-2016 [Accessed 25 February 2018].

21
Female reproductive system check Multiple choice questions

ACTIVITY ID 130115 Question 2

In the absence of a definitive diagnosis of endometriosis, the
Female reproductive system recommended empirical therapy is:

This unit of check is approved for six Category 2 A. analgesia plus an oral contraceptive
points in the RACGP QI&CPD program. The expected
B. a gonadotropin-releasing hormone (GnRH) agonist
time to complete this activity is three hours and
consists of: C. an aromatase inhibitor

• reading and completing the questions for each case D. danazol

study

–– you can do this on hard copy or by logging on to

Question 3
the gplearning website, http://gplearning.racgp.
org.au In the management of endometriosis, laparoscopy would be
recommended for
• answering the following multiple choice questions
(MCQs) by logging on to the gplearning website, A. definitive diagnosis
http://gplearning.racgp.org.au
B. treatment of pain
–– you must score ≥80% before you can mark the
C. management of fertility difficulties
activity as ‘Complete’
D. all of the above
• completing the online evaluation form.
You can only qualify for QI&CPD points by completing Case 2 – Heidi
the MCQs online; we cannot process hard copy
Heidi is 54 years of age and presents with worsening vulval
answers.
itching and dyspareunia. She is otherwise healthy and is not
If you have any technical issues accessing this activity on any medications. Her last period was 18 months ago and
online, please contact the gplearning helpdesk on she has not had any postmenopausal symptoms.
1800 284 789.

If you are not an RACGP member and would like to

Question 4
access the check program, please contact the
gplearning helpdesk on 1800 284 789 to purchase Of the following conditions, the most likely to cause vulval
access to the program. itching in a postmenopausal woman is:

A. psoriasis

B. candidiasis
Case 1 – Samantha
C. vaginal dryness
Samantha, 20 years of age, comes to see you complaining of
worsening period pain. She has always had some period pain, D. all of the above
usually on the first day of her period, but in the past six months
the pain has become more severe and persists for several days. Further information
Samantha has been sexually active since the age of 18 years.
You examine Heidi and find white plaques and blisters on the
skin around the vulva and perianal area that are consistent
Question 1
with a diagnosis of lichen sclerosus.
Signs or symptoms that may suggest secondary
dysmenorrhoea include:
Question 5
A. pain in the lower back or thighs
Confirmation of a diagnosis of lichen sclerosus requires:
B. nausea, vomiting and diarrhoea
A. a sample from the blisters
C. irregular or intermenstrual bleeding
B. a 3-mm punch biopsy from the white area
D. pelvic pain that persists for up to 72 hours.
C. a 1-cm biopsy from the white area
Further information
D. a 1-cm biopsy from the white area and a vaginal swab
Further history-taking and examination suggest that
Samantha has secondary dysmenorrhoea and your
provisional diagnosis is endometriosis.

22
 Multiple choice questions check Female reproductive system

Question 6 Case 4 – Sally

Initial treatment of lichen sclerosus is with Sally, 30 years of age, saw you two weeks ago, after testing
positive on a home pregnancy test. You had organised for
A. a super-potent corticosteroid applied twice daily for two
Sally to have blood tests and ultrasonography to confirm the
weeks
pregnancy; however, ovarian cysts with suspicious features
B. a super-potent corticosteroid applied twice daily until the were seen on ultrasonography.
itching ceases

C. a super-potent corticosteroid applied twice daily until the

Question 9
itching ceases and then once daily until the skin normalises
A suspicious feature in an ovarian cyst that indicates
D. treatment of the itching with a super-potent corticosteroid
malignancy is the presence of:
applied twice daily until the skin normalises.
A. acoustic shadowing
Case 3 – Victoria
B. a smooth multilocular tumour of 8 cm
Victoria, 35 years of age, comes to see you to discuss
C. ascites
contraceptive options. She has three children and does not
want to become pregnant again, but she does not like the idea D. solid components of 0.5 cm.
of taking pills every day or having her tubes tied. She asks
about other methods that are long-acting but reversible. You
explain that long-acting reversible options include hormonal Question 10
implants, and hormonal and non-hormonal intrauterine
Further investigation of the cyst should include
devices. She asks if she can try the hormonal implant. You
measurement of:
take a thorough history to check if Victoria is eligible for the
hormonal implant. A. CA-125

B. lactate dehydrogenase

Question 7 C. alpha-fetoprotein

Victoria may not be eligible for the hormonal implant if she has D. all of the above.

A. a history of migraine with aura

B. a family history of breast cancer

C. a history of breast cancer

D. deep vein thrombosis

Further information

Victoria has no medical conditions or past medical history that

carry any risks with the use of the hormonal implant, and she
does not take any medications. She decides to try the implant.
She returns to see you a month later because she has been
having some troublesome bleeding.

Question 8
A first-line option for short-term management of troublesome
bleeding is

A. a five-day course of an anti-inflammatory drug, such as

ibuprofen 400 mg three times a day

B. levonorgestrel progesterone-only pill 30 µg twice a day for

20 days

C. early removal and replacement of the implant

D. doxycycline 100 mg twice a day for five days.

23
 Mean number of days of bleeding

0
2
4
6
8

0
1
2
3
4
5
6
MONTHS
7
8
9
10
11
12