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Five-minute Practitioner: March 2008

Only got five minutes? Then just read these key points on: vaginal discharge, pelvic organ prolapse, ectopic pregnancy and MMR and autism

Only got five minutes? Then just read these key points on: vaginal discharge, pelvic organ prolapse, ectopic pregnancy and MMR and autism

Vaginal discharge

It is normal for women of reproductive age to have a physiological vaginal discharge. This alters throughout the menstrual cycle. In prepubertal children, vaginal discharge is not normal. In postmenopausal women, a thin, greyish-white discharge may be present.

It is important to determine when the discharge started and whether it is associated with an unpleasant odour or has changed in colour or consistency. GPs should ask about associated symptoms, such as superficial or deep dyspareunia, itching and dysuria. A sexual history needs to be taken, particularly in young women.

Bacterial vaginosis is typically associated with a fishy smell and a thin discharge. Candidiasis is associated with itching and soreness and often causes superficial dyspareunia.

In women with a low risk of an STI and no symptoms of infection, treatment should be empirical and based on sexual and clinical history. For all other patients a full pelvic examination should be carried out and triple swabs taken.

Pelvic organ prolapse

Around half of all parous women lose pelvic floor support, resulting in some degree of prolapse. This is often accompanied by urinary, bowel, sexual or local pelvic symptoms. The risk of prolapse increases with age. Symptoms are often related to the site and type of prolapse. Symptoms common to all types of prolapse are a feeling of dragging, a lump in the vagina, or ‘something coming down'.

Patients should be assessed following clinical examination of the pelvis. Cystometry and uroflowmetry are recommended. Imaging should be considered when the symptoms and signs of prolapse do not correlate.

Conservative treatment should always be offered before a patient is referred.

Ectopic pregnancy

Ectopic pregnancy is relatively common with a rate of 11.1 per 1,000 pregnancies.

Damage to the fallopian tube is the most common reason for ectopic pregnancy. A history of pelvic infection, endometriosis, previous abdominal or pelvic surgery, the presence of a coil, the progestogen-only pill and infertility are all associated with ectopic pregnancy. However, it can occur in women without pre-existing risk factors.

The classic presentation is at six weeks' gestation, with unilateral pain and bleeding, but symptoms may be variable. In women of reproductive age who present with diarrhoea and vomiting and/or fainting, the possibility of ectopic pregnancy should be considered. Tachycardia, hypotension and tachypnoea are all important indicators.

Urine pregnancy tests will normally be positive two weeks after fertilisation.

Close monitoring and immediate access to hospital is required.

MMR and autism

There is now an overwhelming body of evidence that has found no link between MMR and autism. Studies examining time trend links between autistic spectrum disorder (ASD) and MMR have failed to find an association between the introduction or cessation of MMR vaccination and the rate of autism diagnosis, and a large case-control study in the UK reported no association between patient vaccination and ASD diagnosis. Biological studies, using methods designed specifically to identify the measles virus, have also failed to find evidence of its persistence in peripheral blood.

Despite the strength of the evidence and extensive national debate, the failure to improve vaccine coverage significantly highlights the vital role of primary care in making evidence-based advice available to parents regarding MMR immunisation; specifically that there is no support for an association with ASD.

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