Women’s Healthcare

In General Practice

Dr Zelie Gaffney Daly, 2019

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 Topics to be dealt with today
Introduction
1: Health:

Definition:

Influence of Gender on Women’s Health:

Women’s Health Care Concept:

Role of GP in Women’s Health Care:

2: Role of Folic Acid in Pre-Pregnancy Care

Consultations for discussion today

1: Contraception
2: Cervical Smear Testing
3: Pregnancy Care
4: Postnatal Check up
5: Menstrual Problems
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 Health

WHO:
Health is a state of complete physical, mental and social wellbeing and not
just the absence of disease and infirmity.

2007 National Women’s Health Strategy (Gov of Ireland)

Irish women’s life expectancy at birth is below both the EU 15
and the EU 25 (HSE 2005b)

Eurostat 2007
1. The second highest rate of Heart Disease in women in the EU15.
2. The second highest rate of Cancer in women in the EU15.

 Ireland has an ageing population

 By 2030 the predicted life expectancy for women is 84 years.

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INFLUENCE OF GENDER ON WOMEN’S
HEALTH

2001 WHO: Recognised gender as a key determinant of health

What are the factors influencing women’s health?

Although it is true that women consult their doctor more often than
men from the crude figures, many of the diseases are gender related.

Because of their reproductive role women experience a unique and

additional health burden.

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 Women’s Health Care Concept

Key Components:

Models of women’s health care need to be safe, clinically effective,

efficient, patient centred and enhance the individual woman’s
experience.

Bring together multiple providers to delivery high quality women’s

health care.

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 Women’s Health Concept
The New Model of care as promoted by the RCOG Expert Advisory Group Report
(July 2011): High Quality “Women’s Health Care: A Proposal for change” (1)

The aim is to promote a proactive service in preventing ill health rather than just a reactive fire
fighting response to disease.

The model of care questions whether the service currently configured is the most effective way for
service delivery and cost effectiveness.

The Principles of Care:

1. Women should be at the centre of their own care
2. Health care standards should be consistent, evidence based and applicable to all providers.
3. Care must be the right care at the right time in the right place and provided by the right
person.
4. Care should be provided closer to home (accepting that women may require to access very
specialist care).
5. Quality of care should be uniform.

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 Women’s Health Network

Women’s health network concept

Is about a woman-centred life course approach
based on the principle of:-
the RIGHT care,
at the RIGHT time,
in the RIGHT place
and
provided by the RIGHT person

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 Women’s Health Concept
The Role of the General Practitioner
General Practice provides a large proportion of the health care of women though out their lives
“Cradle to the Grave”.
It is imperative that within the General Practice setting this concept is accepted and welcome.

This approach needs to be adequately resourced if it is to be successfully implemented and

maintained at a consistently high level standard of care in the long term.

The General Practitioner is in a unique position to link with the individual woman to facilitate her
care and promote inter-disciplinary care in the pre-hospital community and hospital setting.

Example:
Linking in the community setting with the Public Health Nurse, Dietician, Physiotherapist,
Occupational Therapist as well as the hospital based services.

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 FROM CRADLE TO GRAVE

Child Adolescent

Care of Older
women Contraception

Lifestyle, Diet,
Physical Exercise
Smoking

Menopause STI Screening

Pregnancy Pre Pregnancy

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 Pre-Conceptual Counselling: Folic Acid

The important role of Folic Acid in Pregnancy 2015:(Ref.2)

Folic acid plays an important role in ensuring a healthy pregnancy.
Research shows that adequate intake of the group b vitamin folic acid in developing foetuses (babies) can help
prevent neural tube defects (spina bifida / hydrocephalus / anencephaly) among other illnesses and defects.
Ireland has the highest incidence of neural tube defects compared to other European countries.
Spina bifida is the most common type of neural tube defect (NTD) in Ireland.
An NTD may be present before a mother realises she is pregnant.

Sources of Folic Acid:

As folic acid is not made in the body it has to be taken through food as a supplement or in tablet form.
Diet alone is not sufficient to provide the extra amounts of folic acid needed during pregnancy.

Recommendations:
It is recommended that all women take folic acid ideally for 3 months prior to conception and every day during
the first trimester of their pregnancy
(1st trimester = first 14 weeks of pregnancy).
It is recommended that a minimum of *400ug of Folic Acid per day is taken by all women (OTC- no
prescription required).
Women who are identified as potentially at high risk of having a baby with an NTD (Neural Tube Defect) are
advised to take a higher dose of Folic Acid by prescription.

The Safe Food Campaign 2015:

‘Babies know the facts about folic’ – has stressed that all women who are sexually active and who could
become pregnant should take folic acid daily, irrespective of whether or not they are planning a pregnancy.
 Update Report on Folic Acid and the prevention of
Birth Defects in Ireland. May 2017
 In the Republic of Ireland 236 babies with an NTD (Neural Tube Defect) were born between
2009 & 2011. On average around 80 babies are born every year with an NTD.
 Taking Folic Acid as a supplement could potentially prevent 70% of these cases.
 Folic Acid intake in women planning to have a child or already pregnant is suboptimal in Ireland.
It is currently estimated that only 36% (1/3) of women of childbearing age in Ireland have blood
folic levels for optimal protection against NTD’s.
 A scientific report published by the FSAI (Food Safety Authority of Ireland) highlights the need
for women of childbearing age to have higher intakes of Folic Acid, in order to reduce the
incidence of severe birth defects in Ireland.
 The Irish rate of NTD’s (such as Spina Bifida and Anencephaly) are among the highest in the
world, despite the fact that since 1993 the policy in Ireland has been to advise all women in
Ireland of child bearing age to take 400ug of Folic Acid daily as a supplement.
 The FSAI Report proposes that one of two options should be implemented to prevent the risk of
NTD affected pregnancies in Ireland:-
Option 1: Mandatory fortification of bread or flour in Ireland, together with voluntary fortification
and advice on supplementation.
Option 2: Voluntary fortification with advice of foods with folic acid together with advice on
supplementation.

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 Pre-Conceptual Counselling: Folic Acid

Autism and Folic Acid:

A study published in Norway in 2013 of 85,000 children born between 2002 -2008, showed
that folic acid Supplements may also reduce the incidence of autism.
The study established that women who took folic acid supplements at least 4 weeks prior to
conception and 8 weeks into the pregnancy had a 40% reduced risk of having a child
with reduced autism.

High dose Folic Acid recommendation:

5mg pre pregnancy and early pregnancy supplementation.
Certain women are recognised to potentially have an increased risk of delivering a baby
with a neural tube defect.
For these women a higher dose Folic Acid Supplementation 5mg is recommended
(prescription only) :-
1. Women with a previous delivery of a child with neural tube defect.
2. Women on anti-seizure medication.
3. Women who suffer from malabsorption. Eg. Coeliac disease
4. Women who are diabetic / obese or history of PCOS
5. Probably for women with a history of delivery of a child with cardiac defects or facial
clefts.
6. Renal transplant patients
7. Women where there is a close family history (first and second degree relative)
of neural tube defects for either partner.
 Consultations to discuss today

1: Contraception

2: Cervical Smear Testing

3: Pregnancy Care

4: Postnatal Check up

5: Menstrual Problems

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1) Contraception

An 18 year old student presents to your surgery

to discuss contraception:-
 What are her options?
 How effective are the individual options?
 What questions would you ask her at the consultation?

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2) Cervical Smear Test

A 35 year old lady presents enquiring if she should

undergo a cervical smear test:-
 What is the aim of a cervical smear test?
 What are the barriers for a woman to undergoing a cervical smear test?
 How do you explain the process of having a cervical smear test to the patient?
 What aids might you use to help provide this information?
 What stage of her menstrual cycle is this test ideally performed?
 How long does it take to get a result?
 How much does it cost ?
 What happens if the result is not normal?

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3) Pregnancy

A 27 year old lady presents to surgery and wishes to

confirm if she is pregnant:-

 How do you confirm that she is pregnant?

 What tests do you perform in the surgery at the booking visit?
 What is meant by the term “ combined care in pregnancy”?
 When can she expect to have her hospital clinic visit?
 When is she likely to have her first scan in the pregnancy ?
 What is meant by the “ mother and child scheme”?
 What Vaccinations are recommended in pregnancy and why?
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4) POSTNATAL CHECK UP

A 32 year old lady presents 4 weeks after delivery for her

postnatal check up?

 What are the relevant questions to assess her physical recovery

 What advice do you give her about return of her fertility?

 What are the relevant questions to assess her psychological recovery

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5) Menstrual

47 year old lady presents with heavy periods for the past 2
Years:-
1) What questions would you ask to define how heavy these periods are?

2) What blood tests would you consider sampling?

3) What tests could be helpful that cannot be performed in the surgery?

4) Where would you refer this patient if you are going to refer her?

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 Contraception
The various options: -
 Barrier Methods, Condoms
 Combined Oral Contraceptives (COC’s) /Contraceptive Patch/Ring
 Progestogen only Pill (POP)
 L.A.R.C: Long Acting Reversible Contraception
Depoprovera Injection
Implanon Nxt
Intra-Uterine Mirena/ Kylena /Jaydess, and Copper IUD)
 Male & Female Sterilisation
 Emergency Oral Contraception : Oral/Intra-uterine.
Oral Levonelle licensed for Pharmacy dispensation under specific guidelines.
Does require a prescription from the GP.
Oral Ullipristal does require a GP Consultation and prescription.
The Copper coil is also an option for emergency contraception.

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 Contraception

1. Worldwide hormonal contraception has been a part of clinical practice for 50 years.
It is estimated that each year family planning programmes prevent 187 million
unplanned pregnancies. BMJ 2009.

2. ISHHR STUDY.
The most common reason for not using contraception in teenagers is that they were

not prepared for or had unplanned sex.

Contraceptive effectiveness is the single most important reason for choosing a

contraceptive method.
Women’s perception of efficacy may be inaccurate.
Eisenberg DL,et al American Journal Obstetrics and Gynaecology 2012 :206:479 (3)

Unplanned pregnancy potentially places a greater burden on healthcare resources

from a medical and economic perspective.

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 Contraception – A GP Perspective

4): Dr Tina Peers presentation at the ESG in September 2013: -

1) It is estimated that 44% (almost 1:2) pregnancies in Europe currently are unintended
(unplanned). 64% end in termination

2) Unintended Pregnancies have significant complications associated:-

a) For the Fetus:

Less likely that the mother would have taken folic acid pre-conceptually.
More likely that the mother will smoke and take alcohol in the pregnancy.

b) For the Mother:

Young mothers in particular may not have the opportunity to finish their education.

c) Healthcare Resources:-
May be called upon to provide termination facilities .
Mother and baby care may find themselves in less supportive environments and require
increased care resources.

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 Contraception Guidelines For Prescribing
The World Health Organization (WHO) developed a set of internationally agreed
norms for providing contraception to individuals with a range of medical conditions
that may contraindicate one or more contraceptive methods.

The first edition of the WHO Medical Eligibility Criteria for Contraceptive Use
(WHOMEC) was published in 1996. The fifth edition was published in 2015 and is
available on the WHO website.

The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) offers guidance
to providers of contraception regarding who can use contraceptive methods safely.

The recommendations allow for consideration of the possible methods that could be
used safely by individuals with certain health conditions (e.g. hypertension) or
characteristics (e.g. age) to prevent an unintended pregnancy.

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 Contraception: CPG
(Clinical Practice Guidelines)

PRACTITIONER PATIENT

OPTIONS
EFFICACY

PSYCHOLOGY
PHARMACOLOGY Women’s Concerns
Safety
B – Bleeding Pattern
Doctors Concerns P - PMS
S – Skin
V – Venous W - Weight
A – Arterial
C – Cancer
O - Other TASK

Best Choice for Individual Patient

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 Effectiveness: Typical Versus Perfect Use
For every 100 women using the following methods, this is the failure rate expected in the first year of use 2

Percentage (%) of women experiencing an unwanted pregnancy

Method Typical User Perfect User e.g. in Clinical Trials

No Method 85 85

Condoms – Male 15 2

Combined pill & Progestogen – only pill 8 0.3

Evra patch 8 0.3

Depo-Provera 3 0.3

IUD – copper T 0.8 0.6

IUS – Mirena (LNG) 0.2 0.2
Implanon 0.05 0.05

Female sterilisation 0.5 0.5

Male sterilisation 0.15 0.10

WHOMec 2009 (2) Ref

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 FACULTY OF SEXUAL & REPRODUCTIVE HEALTHCARE
CLINICAL GUIDANCE . June 2015.( Ref 3.)

INTRAUTERINE CONTRACEPTION.
 Women should be advised of the very low failure rates associated with the use of
Intrauterine Contraception.
 Use of intrauterine methods should not be restricted on parity or age alone.
 Health Professionals should check UKMEC to assess an individual woman’s eligibility for
Intra Uterine Contraception.

JULY 2015:

CEU STATEMENT ON PROVISION OF LARC METHODS

TO YOUNG WOMEN IN THE UK.
The safety of use of a contraceptive method is considered by a clinician for each individual
woman regardless of age.
Contraceptive failure rates are higher with contraceptive methods that are user dependent,
such as condoms and oral contraception (The Pill).
 UKMEC: UK Medical Eligibility for Contraception.-

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 Cervical Smear
1) The Aim of Cervical SMEAR Test is to Detect pre-cancerous changes in the Cervix
2) Barriers for a woman undergoing cervical smear test:
Embarrassment at an intimate examination
Not sure when or if they should have one
Concern re financial implications

3) Process of Smear test:

Vast majority of tests are performed in General Practice Setting

Eligible Age Group 25-60 years

Frequency of Cervical Smear
25-45 years: 3 yearly once results are normal
45-60 years: 5 yearly once results are normal
Area of cervix to be sampled
Transition zone of cervix: Columnar and Squamous Cell Epithelium Junction

Cervical Check:-
Specific Organised Programme dedicated to facilitate this screening process

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 Cervical Smear

4) Aids: Aids to Explain Cervical Smear Test

Specific leaflets provided by Cervical Check Programme

5) Ideal time to perform a test is mid-cycle

6) Results of Smear Test: 6 weeks usual time for result:

Result to Patients and G.P.

7) Cost: No fee if performed at the Cervical Check Invitation

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 Human PapillomaVirusVaccination
Human Papilloma Virus – more than 100 genotypes identified

Cervical Cancer is a long term complication of Infection

WHO 2004: HPV Infection is common lifetime risk of > 50%

Cervical Cancer “It all starts in the Teens”

Prof Henry Kitchener: Prof Obs Gynae Manchester:

Oncogenic Type (Cancer Inducing)
Types 16/18 – Associated with 70% Cervical Cancer

Five types associated with 80% Cervical Cancer

HPV Infection Associated with: -

1. Cervical Cancer
2. Cancer of the anus, vulva, vagina, penis head and neck
3. *Type 16 most important type for cancer development
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 HPV Testing of Cervical Smears

May 2015:
Cervical check commenced HPV triage.
Cervical smear tests sent to the laboratory and reported as either ASCUS or LSIL are
automatically tested for the presence or absence of certain HPV sub - types associated
with cervical intraepithelial neoplasia(CIN).

Routine recall ( 3-5 years) when the HPV is negative.

This reflects the low risk of developing high grade CIN in that interval if the HPV test
is negative. (Ref 4)

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 Booking Visit

Foundation or cornerstone visit of the pregnancy.

Aims
1) Confirm pregnancy-Urine check HCG
3)
Can obtain a precise level on HCG assay if
required by blood test sent to Biochemistry Dept.
2) Blood Tests with patient consent:-
FBC, Rubella, Hep B & C, HIV, VDRL &
Mother Hospital
TPHA/Varicella and Blood Group & Ab Screen
3 Urine : Standard quantitative urine culture should
be performed routinely at first antenatal visit. (5)
4) Referral to the hospital is usually processed at the G.P

time of the pregnancy confirmation

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 Pregnancy

4) Combined care refers to the care of the patient during pregnancy to be

shared between general practice and the hospital team.

5) Referral to hospital –First hospital visit and booking scan at approximately

12 weeks gestation.

6) Mother and Child scheme originally introduced by Dr. Noel Browne whereby
the government through the HSE support the financial burden of pregnancy
care visits in General Practice-currently not means tested.

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 Vaccinations in Pregnancy
1) Pertussis Vaccination in pregnancy:

Pertussis vaccination is now recommended for all pregnant women at each pregnancy.
(HSE information leaflets are available)

Reason:
Pertussis Infection (Whooping Cough)
Is most serious < 6 months of age
Babies < 6 months will not have been fully vaccinated against this disease.

Administration of the Vaccine:

No stand alone Pertussis Vaccine
Therefore administered as DTP:Diphtheria/Tetanus and Pertussis vaccine.
(Boostrix)
As for all vaccines one must ensure there is no contra-indications for an
individual woman prior to administration.
 MATERNAL DEATHS IN IRELAND (2009-2011)

Total 25 (rate of 8/100,000 maternities)

Direct maternal deaths Indirect Deaths Coincidental causes

(6) (13) (6)
PE (3) Cardiovascular Disease (5) Substance abuse (2)
Amniotic fluid embolism (1) Suicide (2) RTA (1)
Uterine Rupture (1) H1N1 Influenza (2) Metastatic Cancer (2)
HELLP (1) Epilepsy (2) CNS lymphoma (1)
COPD (1)
Bleeding Oesophageal varices (1)
 BENEFIT OF INFLUENZA VACCINATION in
Pregnancy

Influenza Vaccine: -
Women should ideally receive the influenza vaccine if planning pregnancy during flu
season.
*Influenza vaccine can be administered during pregnancy if no contraindication.

1) Reduces maternal deaths and morbidity.

2) Improves outcome for foetus (baby)

Including:-
a) Pre-term delivery
b) Death within 1st week of delivery
c) Low Birth Weight.

GP’s have a role in promoting the vaccine uptake among pregnant women
 Post Natal Checkup

Bleeding Pattern: Lochia is the term for the blood loss at this time

Full Control of Bowel / Bladder

Is the Perineum healing

Caesarian Section Wound: Check if applicable.

General Health: Query if anaemic.

Breast: Check for infection (mastitis)- is she breast feeding?

Pelvic Floor Exercises:

Contraception: Family Planning Leaflet

Cervical Smear: Check her cervical smear status

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 Post Natal

Fertility: Can return as early as 4 weeks post delivery.

A woman is 19 times more likely to be admitted to a psychiatric

hospital in the first 6 weeks post delivery than at any other time in her
lifetime

The stimulus for the Edinburgh Postnatal Score

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 Edinburgh Post Natal Depression Scale / Score out of 30 (Ref 6)
I have been able to laugh and see the funny side of things Score Things have been getting on top of me Score

As much as I always could 0 No, I have been coping as well as ever 0

Not quite so much as now 1 No, most of the time I have coped quite well 1

Definitely not so much now 2 Yes, sometimes I haven’t been coping as well as usual 2

Not at all 3 Yes, most of the time I haven’t been able to cope at all 3

I have looked forward with enjoyment to things I have been so unhappy that I have had difficulty sleeping

As much as I ever did 0 No, not at all 0

Rather less than I used to 1 No, not very often 1

Definitely less than I used to 2 Yes, sometimes 2

Hardly at all 3 Yes, most of the time 3

I have blamed myself unnecessarily when things went wrong I have felt sad or miserable:

No, never 0 No, not at all 0

Not very often 1 Not very often 1

Yes, some of the time 2 Yes, quite often 2

Yes, most of the time 3 Yes, most of the time 3

I have felt worried and anxious for no good reason I have been so unhappy that I have been crying

No, not at all 0 No, never 0

Hardly ever 1 Only occasionally 1

Yes, sometimes 2 Yes, quite often 2

Yes, very often 3 Yes, most of the time 3

I have felt scared or panicky for no very good reason The thought of harming myself has occurred to me

No, not at all 0 Never, 0

No, not much 1 Hardly ever 1

Yes, sometimes 2 Sometimes 2

Yes, quite a lot 3 Yes, quite often 3

Score Total Score

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 Menstrual

 Check the number of pads used

 Are clots passed?
 How long do the periods last?
 Flooding episodes.
 Has she ever been told she was anaemic?
 Is she tired/dizzy?
 Is she taking iron?

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 Menstrual
Blood Tests:
FBC, Iron, +/- TFT’s, +/- FSH
What tests could be helpful that cannot be performed in the surgery?
U/S of pelvis
Check for the size of the uterus thickness of the endometrium, polyps or
fibroids. Check ovaries.

Potential Indications for referral to Hospital:

1. If any abnormality on the pelvic scan
2. If the patient is anaemic as a result of the heavy periods.

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 References
1. RCOG: Expert Advisory Group Report: July 2011: “High Quality Women’s Health Care:
A Proposal for Change:
2. The important role of folic acid in pregnancy: Forum September 2015 :Page 55 :Sinead Makk.
3. Food Safety Authority of Ireland. Update report on Folic Acid and the Prevention of Birth Defects in
Ireland. 2017 FSAI Website: www.fsai.ie/publications_folic_acid_update/.

4. FACULTY OF SEXUAL & REPRODUCTIVE HEALTHCARE CLINICAL GUIDANCE . June 2015

5. CervicalCheck Programme Office at Freephone 1800 454555.

Cervical Screening Management Recommendations Explanatory Guide April 2015.

6. SIGN Scottish Intercollegiate Guidelines Network:

Management of suspected bacterial urinary tract infection in adults. July 2006.updated July
2012.
7. “Saving Lives Improving Mothers Care”. Knight, M: Kenyon, S: Brocklehurst, P: Neilson, J:
Shakespeare, J: Kurinczuk, JJ: (eds) MBRRACE-UK. Dec 2014:
www.ucc.ie/en/media/acedemic/obstetricsandgynaecology/documents/SavingLivesImprovingMothersCareRepo
rt
8. Edinburgh Postnatal Score
Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression:
Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of
Psychiatry 150:782-786.
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