Spotlight on … primary care

Links between the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners (RCGP) are well established, and the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG) has been the examination for generalists interested in obstetrics and gynaecology since 1949. Women's health is a large component of primary care, and the RCGP training curriculum includes a comprehensive module on women's health for which articles from The Obstetrician and Gynaecologist (TOG) provide timely, succinct information. TOG reviews and infographics help with examination preparation and may also be of interest to other members of the primary care team, including specialist nurses, pharmacists and physician associates. In each edition of TOG there are reviews with great relevance to women's health in primary care, and in this Spotlight some have been selected to illustrate the range of topics that have been covered. General practitioners (GPs) encounter every kind of menstrual dysfunction and the associated complex conditions that accompany them, such as premenstrual syndrome (PMS), polycystic ovary syndrome (PCOS), endometriosis and irritable bowel syndrome: diagnostic challenges abound. Prospective charting to identify core and variant PMS or premenstrual dysphoric disorder was advocated by Walsh et al., and their review indicated that hormonal contraception carefully tailored to the individual may also improve PMS symptoms (TOG 2015;17:99–104). We were reminded that pelvic pain caused by endometriosis and irritable bowel syndrome requires detailed history taking and that women may be reassured that long-term laxatives and antidiarrhoeal medication will not damage the bowel (TOG 2016;18:9–16). Menstrual disorders in early reproductive life were discussed in an early volume (TOG 2003;5:136–41), and non-menstrual bleeding in women under 40 years of age was covered the following year (TOG 2004;6:153–8). The modern approach to uterine fibroids was published in 2016 (TOG 2016;18:33–42), giving clear information on the various treatment modalities. The particular challenges of managing menstruation in women with learning and physical disabilities has been addressed, and again the usefulness of contraceptive methods was illustrated (TOG 2013;15:106–12). The majority of women in the UK obtain their method of contraception free of charge on the National Health Service, from their GP. GPs and specialist nurses are expected to be knowledgeable about the benefits, risks, bleeding patterns and management of side effects of contraception. A number of reviews on hormonal contraception and long-acting reversible contraception – injectables, implants and intrauterine devices/systems – have been published. The contraceptive needs of certain groups of women have been covered in TOG: for young women under 16 (TOG 2008;10:22–6), women with addictions (TOG 2014;16:269–71), women with cardiac disease (TOG 2018;20:21–9), women requiring postpartum contraception (TOG 2018;20:159–66) and, very recently, trans individuals (TOG 2019;21:11–20). The developments in our understanding of the aetiology and management of PCOS have been reviewed recently by Balen and by Sagili and Chandrasekaran (TOG 2017;19:119–29 and TOG 2018,20:245–52). Lifestyle, medical and surgical approaches were discussed. GPs are ideally placed to help women with personalised advice and support to help to tackle obesity and increase the knowledge of reproductive and metabolic consequences of PCOS. The 2009 article on hirsutism in young women by Swingler et al. (TOG 2009;11:101–7) remains a useful and practical guide for clinicians. The primary care team may also be caring for women who are pregnant after bariatric surgery (TOG 2013;15:37–43). Women with early pregnancy complications often present to primary care practitioners for their initial management, and TOG has published on ectopic pregnancy (TOG 2014;16:193–8 and TOG 2017;19:13–20) and miscarriage (TOG 2007;9:102–8). Fertility is a challenging subject, and women may present with unplanned pregnancies or with subfertility, requesting information about the causes, investigations and treatment available to them. A generalist will find the reviews in TOG cover topics such as an overview of assisted reproductive technology and its potential complications (TOG 2018;20:167–76 and TOG 2018;20:177–86) and unexplained subfertility (TOG 2016;18:107–15). Young women who have been treated for chlamydia trachomatis may ask about its effect on their fertility, and TOG has published an article on the place of tubal patency tests (TOG 2014;16:37–45). Women also need their GPs to be up-to-date with perimenopausal contraception (TOG 2017;19:289–97), hormone replacement therapy (HRT) (TOG 2014;16:20–8) alternatives to HRT (TOG 2013;15:19–25), vulval disorders (TOG 2017;19:307–15), sexual problems (TOG 2010;12:1–6) and urinary problems (TOG 2011;13:98–106 and TOG 2014;16:169–77). The impact of obesity on the health of women in midlife (TOG 2015;17:201–8) is a good summary of the effect of obesity on hormonal profiles around the perimenopause and the effect of obesity on menopausal symptoms – a relevant topic, as women often believe weight gain is caused by HRT. While generalists are not obstetricians, women and their partners present with many questions about pregnancy-related issues. TOG has published on the following topics and common conditions affecting pregnancy: constipation (TOG 2015;17:111–5), headaches (TOG 2014;16:179–84), vitamin supplementation (TOG 2012;14:175–8), asthma (TOG 2013;15:241–5), vaccinations (TOG 2015;17:257–63), prescription drug use (TOG 2012;14:87–92), inflammatory bowel disease (TOG 2016;18:205–12) and, very importantly, postpartum psychosis (TOG 2013;15:145–50). This was first covered in two parts in 2008 by Oates (TOG 2008;10:145–50 and TOG 2008;10:231–5). TOG reviews are not often written by a GP, but in 2011 Barnie-Adshead co-authored a review on severe nausea and vomiting in pregnancy (TOG 2011;13:107–11). This problem may cause misery and disruption to a woman and her family and requires a sympathetic and knowledgeable approach. Other articles on more complex obstetric topics are easily accessible for a rapid revision. It is hoped that the topical infographics published alongside select articles in each issue of TOG will also be attractive to primary care staff and patients; all infographics are freely availabe at onlinetog.org. A virtual issue of all TOG articles applicable to primary care is also available at onlinetog.org.