Gynae Common OPD Cases

Stethogram

Abnormal Uterine Bleeding (AUB)


Clinical Features

  • Heavy menstrual bleeding
  • Passing blood clots
  • Prolonged menstruation
  • Intermenstrual bleeding
  • Fatigue and weakness
  • Iron deficiency anemia

Treatment

  • Tranexamic Acid 500 mg–1 g orally three times daily during heavy bleeding for up to 5 days.
  • Mefenamic Acid 500 mg orally three times daily during menstruation.
  • If contraception required: Ethinylestradiol 30 mcg + Levonorgestrel 150 mcg, one tablet daily for 21 days.
  • Iron supplementation if anemia is present.

Acute Heavy Uterine Bleeding


Clinical Features

  • Sudden onset excessive bleeding
  • Passage of large clots
  • Dizziness
  • Weakness
  • Tachycardia
  • Features of acute blood loss

Treatment

  • Tranexamic Acid 1 g orally or IV three to four times daily.
  • Medroxyprogesterone Acetate 10 mg orally three times daily for 7 days.
  • Iron supplementation if required.
  • Hospital admission if hemodynamically unstable.

Primary Dysmenorrhea


Clinical Features

  • Lower abdominal cramps during menstruation
  • Backache
  • Nausea
  • Vomiting
  • Headache
  • Pain beginning shortly before menstruation

Treatment

  • Mefenamic Acid 500 mg stat then 250–500 mg orally three times daily.
  • Ibuprofen 400 mg orally three times daily.
  • Continue during painful menstrual days.
  • Heat therapy and exercise may help.

Secondary Dysmenorrhea


Clinical Features

  • Pelvic pain associated with menstruation
  • Pain worsening with age
  • Dyspareunia
  • Heavy menstrual bleeding
  • Associated endometriosis or adenomyosis

Treatment

  • Ibuprofen 400 mg orally three times daily.
  • Mefenamic Acid 500 mg orally three times daily.
  • Treat underlying cause.
  • Referral for imaging if indicated.

Polycystic Ovary Syndrome (PCOS)


Clinical Features

  • Irregular menstrual cycles
  • Oligomenorrhea
  • Acne
  • Hirsutism
  • Obesity
  • Infertility

Treatment

  • Combined Oral Contraceptive Pill once daily for 21 days each cycle.
  • Metformin 500 mg once daily initially.
  • Gradually increase Metformin to 500 mg three times daily.
  • Spironolactone 50 mg orally twice daily for hirsutism.
  • Lifestyle modification and weight reduction.

Premenstrual Syndrome (PMS)


Clinical Features

  • Mood swings
  • Irritability
  • Breast tenderness
  • Bloating
  • Fatigue
  • Sleep disturbances

Treatment

  • Fluoxetine 20 mg orally once daily.
  • Alternative: Sertraline 50 mg orally once daily.
  • Regular exercise.
  • Stress reduction.

Vulvovaginal Candidiasis


Clinical Features

  • White curdy vaginal discharge
  • Severe itching
  • Burning sensation
  • Dyspareunia
  • Vulval redness

Treatment

  • Fluconazole 150 mg orally as a single dose.
  • Alternative: Clotrimazole vaginal tablet 500 mg single insertion.
  • Maintain genital hygiene.

Bacterial Vaginosis


Clinical Features

  • Thin grey vaginal discharge
  • Fishy odor
  • Mild itching
  • Positive whiff test

Treatment

  • Metronidazole 400–500 mg orally twice daily for 7 days.
  • Alternative: Metronidazole vaginal gel once daily for 5 days.
  • Avoid vaginal douching.

Trichomoniasis


Clinical Features

  • Frothy greenish vaginal discharge
  • Vaginal itching
  • Burning micturition
  • Strawberry cervix
  • Dyspareunia

Treatment

  • Metronidazole 2 g orally as a single dose.
  • Alternative: Metronidazole 400–500 mg orally twice daily for 7 days.
  • Treat sexual partner simultaneously.
  • Avoid sexual intercourse until treatment completed.

Cervicitis


Clinical Features

  • Vaginal discharge
  • Post-coital bleeding
  • Dyspareunia
  • Lower abdominal discomfort
  • Inflamed cervix on examination

Treatment

  • Azithromycin 1 g orally as a single dose.
  • Alternative: Doxycycline 100 mg orally twice daily for 7 days.
  • Partner treatment if STI suspected.

Pelvic Inflammatory Disease (PID)


Clinical Features

  • Lower abdominal pain
  • Fever
  • Abnormal vaginal discharge
  • Cervical motion tenderness
  • Adnexal tenderness
  • Dyspareunia

Treatment

  • Ceftriaxone 500 mg IM single dose.
  • Doxycycline 100 mg orally twice daily for 14 days.
  • Metronidazole 400–500 mg orally twice daily for 14 days.
  • Advise abstinence until treatment completion.

Urinary Tract Infection (UTI)


Clinical Features

  • Dysuria
  • Frequency of urination
  • Urgency
  • Burning micturition
  • Suprapubic pain

Treatment

  • Nitrofurantoin 100 mg orally twice daily for 5 days.
  • Alternative: Fosfomycin 3 g oral single dose.
  • Increase oral fluid intake.

Atrophic Vaginitis


Clinical Features

  • Postmenopausal vaginal dryness
  • Dyspareunia
  • Vaginal burning
  • Itching
  • Spotting after intercourse
  • Recurrent urinary symptoms

Treatment

  • Vaginal estrogen cream 0.5 g daily for 2 weeks.
  • Thereafter 0.5 g twice weekly for maintenance.
  • Vaginal lubricants during intercourse.
  • Adequate hydration and genital hygiene.

Endometriosis


Clinical Features

  • Chronic pelvic pain
  • Progressive dysmenorrhea
  • Dyspareunia
  • Infertility
  • Pain during defecation
  • Pain during menstruation

Treatment

  • Mefenamic Acid 500 mg orally three times daily.
  • Combined Oral Contraceptive Pills continuously.
  • Dienogest 2 mg orally once daily.
  • Gynecology referral if symptoms persist.

Functional Ovarian Cyst


Clinical Features

  • Lower abdominal pain
  • Pelvic discomfort
  • Irregular menstruation
  • Often asymptomatic
  • Adnexal fullness on examination

Treatment

  • Observation in most cases.
  • Ibuprofen 400 mg orally three times daily for pain.
  • Follow-up ultrasound as advised.
  • Surgical referral if large or persistent.

Mittelschmerz (Ovulation Pain)


Clinical Features

  • Mid-cycle pelvic pain
  • Usually unilateral pain
  • Short duration pain
  • Mild spotting occasionally

Treatment

  • Paracetamol 500–650 mg orally three times daily.
  • Ibuprofen 400 mg orally three times daily if required.
  • Reassurance.

Infertility (Anovulatory)


Clinical Features

  • Failure to conceive after one year
  • Irregular menstrual cycles
  • Features of PCOS may be present
  • Absent ovulation

Treatment

  • Letrozole 2.5–5 mg orally daily from Day 2–6 of cycle.
  • Alternative: Clomiphene Citrate 50 mg orally daily from Day 2–6.
  • Weight reduction in obese women.
  • Further infertility evaluation if unsuccessful.

Iron Deficiency Anemia due to Menorrhagia


Clinical Features

  • Fatigue
  • Weakness
  • Pallor
  • Breathlessness on exertion
  • Heavy menstrual bleeding history

Treatment

  • Ferrous Ascorbate equivalent to 100 mg elemental iron once or twice daily.
  • Folic Acid 5 mg orally once daily.
  • Diet rich in iron.
  • Treat underlying cause of bleeding.

Chronic Pelvic Pain


Clinical Features

  • Pelvic pain lasting more than 6 months
  • Dyspareunia
  • Backache
  • Pain unrelated to menstruation
  • May affect daily activities

Treatment

  • Ibuprofen 400 mg orally three times daily.
  • Paracetamol 650 mg orally three times daily.
  • Investigate and treat underlying cause.
  • Gynecology referral if persistent.

Bartholin Cyst


Clinical Features

  • Vulval swelling
  • Usually painless
  • Discomfort while walking
  • Discomfort during intercourse

Treatment

  • Warm sitz bath several times daily.
  • Paracetamol 500–650 mg orally three times daily if painful.
  • Observation for small asymptomatic cysts.
  • Gynecology referral if persistent.

Bartholin Abscess


Clinical Features

  • Painful vulval swelling
  • Difficulty walking
  • Difficulty sitting
  • Fever may be present
  • Tender fluctuant swelling

Treatment

  • Amoxicillin-Clavulanate 625 mg orally three times daily for 5–7 days.
  • Paracetamol 650 mg orally three times daily.
  • Incision and drainage if abscess present.
  • Warm sitz bath.

Genital Herpes


Clinical Features

  • Painful genital ulcers
  • Burning sensation
  • Fever
  • Inguinal lymphadenopathy
  • Recurrence may occur

Treatment

  • Acyclovir 400 mg orally three times daily for 7–10 days.
  • Adequate hydration.
  • Avoid sexual contact during active lesions.
  • Counsel regarding recurrence.

Genital Warts


Clinical Features

  • Multiple genital growths
  • Cauliflower-like lesions
  • Itching
  • Discomfort during intercourse
  • Usually painless

Treatment

  • Podophyllotoxin 0.5% solution applied twice daily for 3 days.
  • Repeat cycles as advised.
  • Cryotherapy if required.
  • HPV vaccination counseling.

Menopausal Syndrome


Clinical Features

  • Hot flushes
  • Night sweats
  • Mood changes
  • Sleep disturbances
  • Vaginal dryness
  • Reduced concentration

Treatment

  • Venlafaxine 37.5–75 mg orally once daily.
  • Hormone Replacement Therapy where indicated.
  • Regular exercise.
  • Adequate calcium and vitamin D intake.
  • Lifestyle modification.

Postmenopausal Bleeding


Clinical Features

  • Any vaginal bleeding occurring after menopause
  • Spotting or frank bleeding
  • May be associated with endometrial pathology
  • Possible weight loss or pelvic pain in malignancy

Treatment

  • Urgent gynecological evaluation.
  • Transvaginal ultrasonography.
  • Endometrial biopsy if indicated.
  • Treatment depends upon underlying cause.

Vaginal Discharge Syndrome


Clinical Features

  • Abnormal vaginal discharge
  • Vaginal itching
  • Foul smell
  • Burning sensation
  • Dyspareunia

Treatment

  • Cefixime 400 mg orally single dose.
  • Azithromycin 1 g orally single dose.
  • Metronidazole 2 g orally single dose.
  • Partner treatment when STI suspected.

Chronic Cervicitis


Clinical Features

  • Persistent vaginal discharge
  • Post-coital bleeding
  • Pelvic discomfort
  • Inflamed cervix on examination

Treatment

  • Doxycycline 100 mg orally twice daily for 7 days.
  • Alternative: Azithromycin 1 g orally single dose.
  • Treat sexual partner if STI suspected.

Mastalgia (Breast Pain)


Clinical Features

  • Breast pain
  • Cyclical or non-cyclical pain
  • Breast tenderness
  • Discomfort affecting daily activities

Treatment

  • Paracetamol 650 mg orally three times daily.
  • Ibuprofen 400 mg orally three times daily.
  • Proper breast support.
  • Reduce caffeine intake.

Fibroid Uterus


Clinical Features

  • Heavy menstrual bleeding
  • Pelvic pressure
  • Pelvic pain
  • Infertility
  • Abdominal lump in large fibroids

Treatment

  • Tranexamic Acid 500 mg–1 g orally three times daily during bleeding.
  • Mefenamic Acid 500 mg orally three times daily.
  • Iron supplementation if anemia present.
  • Surgical referral when indicated.

Pelvic Organ Prolapse


Clinical Features

  • Mass protruding per vagina
  • Pelvic heaviness
  • Difficulty in urination
  • Backache
  • Discomfort while walking

Treatment

  • Pelvic floor exercises.
  • Vaginal pessary insertion.
  • Treat chronic cough and constipation.
  • Gynecological surgery when required.

Vaginismus


Clinical Features

  • Pain during attempted intercourse
  • Involuntary vaginal muscle spasm
  • Difficulty with vaginal examination
  • Fear of penetration

Treatment

  • Counseling and reassurance.
  • Pelvic floor physiotherapy.
  • Graduated vaginal dilator therapy.
  • Sex therapy when indicated.

Dyspareunia


Clinical Features

  • Pain during sexual intercourse
  • Burning sensation
  • Pelvic pain
  • Vaginal dryness

Treatment

  • Treat underlying cause.
  • Water-based lubricants.
  • Vaginal estrogen in postmenopausal women when indicated.
  • Counseling and reassurance.

Adenomyosis


Clinical Features

  • Heavy menstrual bleeding
  • Progressive dysmenorrhea
  • Chronic pelvic pain
  • Enlarged tender uterus

Treatment

  • Mefenamic Acid 500 mg orally three times daily.
  • Tranexamic Acid 500 mg–1 g orally three times daily during menstruation.
  • Hormonal therapy when indicated.
  • Gynecology referral.

Amenorrhea


Clinical Features

  • Absence of menstruation
  • Infertility
  • Weight changes
  • Hormonal disturbances
  • Possible galactorrhea

Treatment

  • Identify and treat underlying cause.
  • Correct nutritional deficiencies.
  • Hormonal therapy depending on etiology.
  • Referral for endocrine evaluation if required.

Oligomenorrhea


Clinical Features

  • Infrequent menstrual periods
  • Cycles longer than 35 days
  • Often associated with PCOS
  • Subfertility

Treatment

  • Weight reduction if overweight.
  • Combined Oral Contraceptive Pills for cycle regulation.
  • Metformin 500 mg once daily gradually increased to 500 mg three times daily in PCOS.
  • Treat underlying cause.

Hyperprolactinemia


Clinical Features

  • Amenorrhea
  • Galactorrhea
  • Infertility
  • Headache
  • Visual disturbances in pituitary tumors

Treatment

  • Cabergoline 0.25 mg orally twice weekly.
  • Alternative: Bromocriptine 1.25–2.5 mg orally daily.
  • MRI pituitary if indicated.
  • Endocrinology referral.

Premature Ovarian Insufficiency


Clinical Features

  • Amenorrhea before 40 years
  • Hot flushes
  • Night sweats
  • Infertility
  • Vaginal dryness

Treatment

  • Hormone Replacement Therapy where appropriate.
  • Calcium supplementation.
  • Vitamin D supplementation.
  • Fertility counseling.

Leukorrhea


Clinical Features

  • White vaginal discharge
  • May be physiological or pathological
  • Associated itching in infections
  • Foul smell may be present

Treatment

  • Treat underlying cause.
  • Maintain genital hygiene.
  • Antifungal or antibiotic therapy when indicated.
  • Patient education and reassurance.

Recurrent Vulvovaginal Candidiasis


Clinical Features

  • Repeated episodes of vaginal itching
  • White curdy discharge
  • Burning sensation
  • Multiple recurrences per year

Treatment

  • Fluconazole 150 mg orally on Days 1, 4 and 7.
  • Maintenance Fluconazole 150 mg once weekly for 6 months.
  • Control diabetes if present.
  • Maintain genital hygiene.

Chronic Vulvitis


Clinical Features

  • Persistent vulval itching
  • Redness
  • Burning sensation
  • Skin excoriation

Treatment

  • Avoid irritants and allergens.
  • Topical emollients.
  • Treat fungal or bacterial infection if present.
  • Gynecology referral if persistent.
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