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To Hospital (Hopkins, 1958B) Were on Account of Gynaecological With IV GYNAECOLOGICAL DISORDERS IN GENERAL PRACTICE PILnIP HOPKINS, M.R.S., L.R.C.P. Hampstead I have tried to find out something of the incidence of gynaeco- logical disorders in general practice, and the sort of treatments that can be afforded these patients by their own general practitioners. The General Register's Office's study of eight practices during the 12 months from April 1951 (Logan, 1953) showed that some 3.5 per cent of all consultations were on account of gynaecological disorders. During the survey carried out by Logan (Logan and Cushion, 1958) in which I participated, it was found that just under 3 per cent of all consultations were for gynaecological disorders. During the year of this survey 102 of the 917 women " at risk" (i.e., on my National Health Service list) consulted me with gynaecological disorders. During the three years 1955-56-57, only 64 out of 1,225 referrals to hospital (Hopkins, 1958b) were on account of gynaecological disorders (5 per cent). I have been able to follow up 178 of the women who consulted me with gynaecological symptoms since the 1st January 1957. These 178 women consulted me about 221 gynaecological disorders, or perhaps I could use the term episodes. To make this clear, a patient who consulted on account of her fear of being sub-fertile, later for amenorrhoea and again, after three months, for threatened mis- carriage, would be considered to have consulted during three gynaecological episodes. The incidence of women with gynaecological symptoms follows closely the distribution according to age-groups, but was lowest in the age-groups 30-34 (11.4 per cent) and 35-39 (19.1 per cent), rising to 30.7 per cent in the age-group 45-49. When the 57 women with amenorrhoea due to pregnancy are taken out of the totals, we find that only 8 per cent of women in age-group 30-34, and 11.8 per cent in age-group 35-39 complained of gynaecological symptoms. The incidence was 20.3 per cent in age-group 40-44 and 30.7 per cent in age-group 45-49. Another 13 episodes were concerned with the pregnancies-three threatened miscarriages, with subsequent recovery and normal confinements, one accidental haemorrhage, also with recovery, J. COLL. GEN. PRACT., 1959, 2, 246 GYNAECOLOGICAL DisoiwREs IN GENERAL PRACrCF4 247 and one haemorrhage due to placenta praevia. The remaining eight women had complete miscarriages. This leaves 141 gynaecological disorders which can be divided into two groups. The first includes all conditions associated with the menstrual cycle, and they are shown in table I. TABLE I ANALYSIS OF 94 GYNAECOLOGICAL DISORDERS IN GROUP I-ASSOCIATED WITH THE MENSTRUAL CYCLE. Number of women Menstrual disorder Single Married Amenorrhoea (not due to pregnancy) 12 (1)* 8 Epimenorrhoea (all but one occurring during the climacteric) .. .. .. 7 21 Menorrhagia .. .. 8 (2) 15 (7) Dysmenorrhoea .. .. 15 4 Inter-menstrual dysmenorrhoea ("Mittelschmerz") 1 Premenstrual tension .. .. .. .. 1 2 Totals .. .. 44 (3) 50 (7) (*Figures in () denote number of patients referred to a gynaccologist.) There is space to point out only some of the more interesting features. Only one of the single women had primary amenorrhoea, and a gynaecologist confirmed that she had an infantile uterus. The other eleven single women with amenorrhoea were all suffering from emotional tension. Some feared themselves to be pregnant, and the remainder had other problems mainly concerned with sexual conflicts. All these patients complained, in addition to the amenorrhoea, of insomnia, headache, dyspepsia, some change in bowel-habit or other physical symptoms, and many were frankly anxious or depressed. In a small number it was only on direct questioning about their menstrual history that the amenorrhoea was revealed. It is interesting to compare the almost complete absence of other symptoms in the majority of the 49 married women with amenorrhoea due to a wanted pregnancy. Of the eight married women over 40 with amenorrhoea only one was pregnant, and she unfortunately miscarried in her fourth month. The other seven of this group were menopausal. 248 Pimp HOPKINS My usual method of dealing with amenorrhoea not associated with pregnancy depends on the age of the patient. When it is thought to be due to the climacteric no action is required other than careful examination to exclude the possibility of pregnancy. In younger women it is necessary, in addition to physical examination, to discuss any possible causes of emotional tension. I sometimes prescribe tabs. amytal gr. j t.d.s. for seven days with the assurance that a period will follow. An appointment to see the patient two weeks later is arranged at the same time. In five of the thirteen in this group normal menstruation followed this simple discussion. Four were subsequently given amytal as described above, with return of menstruation. Another four were later given a course of oral oestrogen, with resultant withdrawal bleeding in three of them. The fourth did not respond, but six weeks later, when she decided to end her engagement to a rather unsuitable young man, there was release of her emotional tension, and a normal period followed. The majority ofwomen with epimenorrhoea were in the climacteric and required no special treatment. Whereas it is now commonly accepted that anxiety and other emotional tension states can and frequently do produce amenor- rhoea, it is not yet as well realized, nor accepted, that the same applies to menorrhagia, dysmenorrhoea, vaginal discharge, pruritus vulvae, and dyspareunia. Two of the single women, and seven of the married women with menorrhagia were referred for gynaeco- logical opinion, while the remainder were amenable to treatment well within the scope of the family doctor. It is interesting to note that only three patients are recorded as having come primarily on account of symptoms associated with premenstrual tension. It must be realized that most patients suffer- ing from premenstrual tension usually have dysmenorrhoea, some- times with menorrhagia or other menstrual irregularities, and in this analysis I have put patients under single diagnostic " labels" according to their presenting symptoms when they were first seen. There was considerable over-lap, but usually one symptom was predominant. The three patients here labelled as having had premenstrual tension responded well to simple discussions of their problems-none of them required hormone therapy. Table II shows an analysis of the 47 conditions in the second group of gynaecological disorders, and it is immediately apparent that apart from the first three Qf these conditions, the remainder are GYNAEcoLOGIcAL DISORDERS IN GENERAL PRACTICE 249Q essentially surgical in character, and accordingly most were referred for treatment by a gynaecologist. TABLE II ANALYSIS OF TE 47 GYNAEOLOGICAL DISORDERs iN GROUP Ia. Number ofwomen Gynaecological disorder Single Married ? Sub-fertility .. .. .. 6 (3)* Dyspareunia (and/or frigidity) .. _.. 5 Pruritus vulvae .. .. .. .. 2 2 Bartholin's abscess .. .. 2(1) 1 Acute vaginitis (vaginal discharge) .. 8 (2) 5 (1) Irregular vaginal bleeding (metrorrhagia) .. 5 (5) Acute salpingitis .. .. .. .. .. 3 (3) 2 (2) Ruptured ectopic tubal pregnancy .. .. 1 (1) Ovarian cyst (1 ruptured; 1 symptomless) .. 2 (2) Stress incontinence (cystocoele) .. .. .. - 3 (3) Totals .. .... 15 (6) 32(17) (*Figures in () denote number of patients referrd to a gynaecologist.) It is of the utmost importance to differentiate between menor- rhagia, which is excessive menstrual bleeding, and metrorrhagia which is irregular vaginal bleeding not related to the menstrual cycle. In addition the two symptoms may occur together. Table III shows an analysis of the causes of the menorrhagia and metrorrhagia in the twenty-eight women in this series. It will be seen that all five women with metrorrhagia were referred to a gynaecologist. Their final diagnoses were: carcinoma of the cervix in a 36 years old, married woman who, incidentally, com- plained only of three episodes of inter-menstrual bleeding during the past two months; three had uterine polypi, and the last an erosion of the cervix. Only nine of the 23 women with menorrhagia were found to have fibroids; six were referred for a gynaecological opinion. Four required hysterectomy, and one myomectomy. This last one sub- sequently became pregnant, but, unfortunately, miscarried during the fourth month. 250 PEuP HOPIUN TABLE III ANALYSIS OF TWENTY-IGHT WOMEN WrIH MENORRHAGIA AND MERORRHAGIA. Age groups Totals 10-19 20-29 30-39 4049 50-59 S. M. S. M. S. M. S. M. S. M. S. M. MENORRHAGIA, due to: Fibroid uterus .. 1 3 5 _ _ 3 (2)* 6 (4) No physical cause 2 2 4 3 1 1 1 5 9 (3) Totals .. ..2 2 4 - 4 4 6 1 8 (2) 15 (7) METRORRHAGIA, due to: Carcinoma ofcervix . 11(1) Erosionofcervix ..- - - _ _ 1(1) Uterinepolyp.. .2 - 1 3(3) Totals. .. 4 - 1 5(5) (*Figures in () denote number of patients referred to a gynaecologist.) Fourteen of the patients with menorrhagia had no apparent physical cause, and most of them responded satisfactorily to simple discussions of their emotional problems. The diagnosis menor- rhagia psychogenica, as first suggested by Blaikley (1949) would therefore be justified for these patients. In none of the women with menorrhagia was there need to pre- scribe any hormonal preparations-quite contrary to the frequently encountered advertisements that urge us to prescribe this or that hormone for any disturbance of the menstrual cycle, or more dangerously for bleeding not actually related to the cycle. Space does not permit description of the investigations that can be carried out in general practice for women complaining of vaginal discharge, or fearing the possibility ofsub-fertility. Nor is it possible to include here any of the numerous case histories of patients with such diverse conditions as pruritus vulvae, frigidity and dyspareunia, dysmenorrhoea, amenorrhoea, and menorrhagia who have responded well to a simple psychotherapeutic approach rather than the more usual prescribing of various hormone preparations.
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