GP ON THE MOVE

https://www.gponthemove.com/

TOPIC #1: Menorrhagia – abnormally heavy or prolonged menstrual bleeding

“KEY KNOWLEDGE – KK”:

RED FLAGS - looking for structural abnormalities or infection.
Note well, none of these would trigger a 2 week cancer referral based on most recent NICE guidelines:

1.	Persistent intermenstrual bleeding
2.	Pelvic pain or pressure
3.	Dysmenorrhea
4.	Post coital bleeding
5.	Dyspareunia
6.	Vaginal discharge

In the absence of any of these, a trial treatment can be initiated without examination or further investigations. However, if any of these symptoms are present, an examination is recommended, often with swabs for MC&S and chlamydia and gonorrhoea. 

And remember, you must take a sexual history.

KEY ELEMENTS FROM THE HISTORY/EXAMINATION.

1.	If examination is normal, but the following risk factors are present, you are referring a patient for a hysteroscopy with +/- endometrial biopsy:
a.	persistent intermenstrual or irregular bleeding
b.	obesity/PCOS (Polycystic Ovary Syndrome) and infrequent, but heavy bleeding
c.	on tamoxifem
d. 	or finally no risk factors, but initial treatments have failed 

2.	If however these symptoms are present, send patients for an USS, preferably a transvaginal one:
a.	pelvic pain
b.	dysmenorrhea
c.	abdominal examination reveals a pelvic mass thought to be a fibroid
d.	or the examination was inconclusive for whatever reason

Remember though, if on examination ascites is present or there is a suspicious pelvic mass not thought to be a fibroid - cancer pathway for ovarian cancer.

Extra tip number 1

What is a hysteroscopy? Hysteroscopy is a procedure where a small camera at the end of a long tube is inserted through the vagina into the womb. This allows the doctor or specialist nurse to have a look inside the womb to look for any causes for the ongoing symptoms. It is usually done as a day case and staying overnight is not required. The procedure can be done with local anaesthetic - by numbing the area of the womb or under general anaesthetic - meaning you are asleep during the procedure. The procedure can take up to 30 minutes, but occasionally can be completed within 5-10 mins.

INVESTIGATIONS/TESTS:
1.	All women should have a Full Blood Count
2.	Up to date smears – every 3 years 25-49 year olds, every 5 years 50-64 year olds
3.	Can consider TFTs if hypothyroidism suggested by other symptoms such as fatigue, constipation, cold intolerance, hair and skin changes
4.	Consider coagulation tests if heavy bleeding since menarche, evidence of other bleeding problems, there is a positive family history for bleeding disorders

MANAGEMENT:
1.	First line – Mirena coil
2.	Second line – Tranexamic acid, which is an antifibrinolytic. The dose is 1g three times a day for up to 4 days, initiated when menstruation has started; alternatively, mefenamic acid – NSAID (500mg three times a day) is especially helpful if periods are painful. These two can be combined and are considered “non-hormonal” methods. Second-line, you can also consider combined hormonal contraception if appropriate 
3.	Third line – Oral progestogen like medroxyprogesterone acetate 10mg or norethisterone 5mg TDS between D5 and D26. These are the same drugs one would prescribe for patients wishing to postpone periods. The former is preferred in patients at risk of VTE (venous thromboembolism). An alternative to these two is long-acting progestogens such as 12 weekly depot injection

Extra tip number 2

If the patient has a fibroid larger than 3cm and the first two options have failed for this - refer for consideration of surgical management. Finally, if trials of treatment are failing or no cause for the heavy menstrual bleeding has been found - refer.

GP ON THE MOVE

GP ON THE MOVE #1 Menorrhagia

GP ON THE MOVE

https://www.gponthemove.com/

TOPIC #2: Erectile Dysfunction – the inability to attain and maintain an erection required for satisfactory sexual intercourse

“KEY KNOWLEDGE - KK”:

All patients can have a trial of Phosphodiesterase-5 (PDE-5) inhibitors (sildenafil, avanafil, tadalafil, vardenafil) provided there are no contra-indications and these are:
1.	Recent history of heart attack or stroke
2.	Poorly compensated heart failure or unstable angina
3.	Men receiving nitrates in any form, for instance – isosorbide mononitrate or nicorandil
4.	If systolic BP <90

(...)

GP ON THE MOVE #2 Erectile Dysfunction (Preview)

GP ON THE MOVE

https://www.gponthemove.com/

TOPIC #3: Palpitations - a noticeably rapid, strong, or irregular heartbeat

“KEY KNOWLEDGE - KK”:
Red flags: - to assess for serious cause and consider arranging emergency admission or referral. The first three require consideration of emergency admission:

1.	Persistent breathlessness 
2.	Chest pain
3.	Haemodynamic instability - hypotension
4.	Syncope or near syncope – urgent referral
5.	Onset of palpitations precipitated by exercise – urgent referral
6.	Ask about family history of sudden cardiac death in <40 – urgent referral
7.	History of heart disease: IHD, Heart failure, Cardiomyopathy, Valve disease

(...)

GP ON THE MOVE #3 Palpitations (Preview)

"GP on the Move" is an audiobook that comprises clinical management guidelines to 30 common GP scenarios with additional extra tips to help in everyday General Practice.

It has been designed as a helpful and time-efficient educational resource to ensure your knowledge is up to date and can be useful whilst preparing for RCGP exams as a GPST, coming back to GP after a break in practice, before a GP placement as an FY2, or just making sure you are fresh with latest clinical updates. Be it in the car on your daily commute or at the gym, "GP on the Move" is an easy to listen audiobook packed with only the most relevant information to give you the confidence you need for plain sailing through your sessions in practice.

"GP on the Move" is the 2nd edition of the sold out "CSA on the Move".

Topics expanded and updated for 2020 according to most recent NICE, SIGN and NHS guidelines.

https://www.gponthemove.com
https://awesound.com/MichaelPoplawski/audiobook/gp-on-the-move