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Five-minute Practitioner: March 2007

Only got five minutes? Then just read these key points on: endometriosis, cervical screening and palliative care

Only got five minutes? Then just read these key points on: endometriosis, cervical screening and palliative care


Endometriosis is a common gynaecological condition found almost exclusively in women of reproductive age. The symptoms are variable and often unrelated to the extent of the condition. The diagnosis of endometriosis should be considered in all women of reproductive age who have cyclic pelvic pain. Investigations should be undertaken to exclude other causes of pelvic pain.

Empirical treatment with simple painkillers, combined oral contraceptives (COCs) or progestogens can be considered before referral if swabs for infection are negative, bowel symptoms are absent and scan is normal.

Although there are no specific guidelines on which women need secondary care, those in the following groups should be considered for referral:

• Abnormal signs such as endometriotic nodules and adnexal mass

• Failed empirical treatment

• Age >40 years, previously fit and well, presenting with significant pelvic pain

• Pain and infertility

• Irregular bleeding over the age of 45 years.

Cervical screening

Cervical screening can prevent around 75 per cent of invasive cervical cancer. Screening should be regarded as the management and treatment of risk. Regression is less likely and progression more likely with increasing degrees of CIN.

Since 2000, screening coverage has been declining in all age bands up to 35-39 years, and rates of invasive cancer are likely to increase if this trend continues. Women might be more likely to accept their invitations if they knew how effective screening was in preventing cervical cancer. Patients should be properly informed about the reasons for follow-up of low-grade cytology, the risk of high-grade CIN, its frequency in young women and that treating women when they are young has averted an epidemic of invasive cervical cancer.

Persistent hrHPV has the potential to cause high-grade CIN. This is the rationale for cytological follow-up of women with low-grade abnormalities, and for investigation if the changes persist.

Although high-grade cytology reporting rates may be increased by LBC, increased detection of high-grade CIN has not been confirmed and there is no clear evidence of greater sensitivity or specificity. The main advantage of introducing LBC in the UK has been the dramatic fall in the rate of inadequate tests (from around 10 per cent to 1-2 per cent) at the pilot sites.

Palliative care

in acute on chronic pain in the terminal stages of an illness, changing the dose of a fentanyl patch will produce a relatively slow change in plasma levels. The easiest and most effective way to control pain is to supplement the patch using continuous subcutaneous infusion (CSCI) of opioid via a syringe driver.

When switching between opioids, conversion tables should be consulted. It is safest to reduce the dose of the new opioid by one-third to allow for the fact that the patient will have developed some tolerance to the new opioid through previous opioid exposure.

It is important to take a careful pain history, as patients often have more than one pain and these may have different aetiologies. For example, the patient may need gabapentin for the neuropathic element.

Incident pain, which is pain caused by an action of the patient, such as movement, is a particular problem with bone metastases. It is best managed with the prophylactic use of a normal-release opioid, for example oral transmucosal fentanyl citrate (OTFC).

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