Gynaecology Outpatient Clinical Note & GP Letter

Age: 41 Obstetric History: - G2 P2, Spontaneous Vaginal Delivery (SVD), 2010, at term, uncomplicated. - G2 P2, Spontaneous Vaginal Delivery (SVD), 2013, at term, uncomplicated. Family Complete: - Yes. Chief Complaint: The patient presented with a history of chronic pelvic pain and severe deep dyspareunia, significantly impacting her quality of life and daily activities. History of Presenting Illness: - Onset of chronic pelvic pain approximately eighteen months ago. - Symptoms have significantly worsened over the last six months. - Pain is a constant, heavy ache in the lower abdomen and pelvis, radiating to the lower back. - Pain becomes sharp and cramping during the menstrual cycle. - Pain is aggravated by defecation and deep penetration during sexual activity. Menstrual History: - Regular cycle. - Frequency: 28 days. - Duration: 5 days. - Flow: Heavy. - Intermenstrual bleeding: Negative. - Postcoital bleeding: Negative. Pain History: - Location: Lower abdomen and pelvis, radiating to the lower back. - Character: Constant heavy ache, becoming sharp and cramping during menses. - Severity: 4-5/10 constantly; 8/10 during menstruation. - Radiation: Lower back. - Timing: Chronic, cyclical exacerbation. - Aggravating factors: Menstruation, defecation, deep penetration. - Relieving factors: Over-the-counter analgesics (slight relief), heat packs (temporary relief). - Relationship to menstrual cycle: Severe dysmenorrhoea. Bowel Symptoms: - Constipation, particularly cyclical around menses. - Diarrhoea: Negative. - Rectal bleeding: Negative. - Tenesmus: Negative. Bladder Symptoms: - Urinary urgency: Positive. - Urinary frequency: Normal. - Dysuria: Negative. - Haematuria: Negative. Vaginal Discharge: - No abnormal vaginal discharge noted. Vulval Symptoms: - Negative for pruritus, pain, swelling, or lesions. Impact on Quality of Life: - Requires time off work (up to two days per month) due to cyclical pain. - Significant impact on intimacy due to dyspareunia. - Reports feeling irritable and anxious. - Constant discomfort is exhausting, impacting psychological wellbeing. Cervical Smear History: - Date of last smear: Late 2022. - Result: Normal. Past Gynaecological History: - Laparoscopic ovarian cystectomy approximately twenty years ago for a benign cyst. Sexual History and Contraception: - Current contraception: Condoms. - Related concerns: Severe deep dyspareunia. Past Medical History: - Hypothyroidism, managed. Past Surgical History: - Laparoscopic ovarian cystectomy (approx. 20 years ago), uncomplicated. - Appendicectomy (childhood), uncomplicated. Current Medications: - Levothyroxine, 100 micrograms, once daily, orally. Allergies: - Penicillin: Generalised urticarial rash. Family History: - Mother had severe dysmenorrhoea requiring hysterectomy in her forties (diagnosis unspecified). Examination: Vital Signs: - Vital signs are stable. General Physical Examination: - Unremarkable. Abdominal Examination: - Mild tenderness on palpation in the suprapubic region. - No palpable masses. Pelvic Examination: - Speculum examination: Healthy cervix and vagina. - Bimanual examination: Uterine retroversion noted. Significant tenderness in the posterior fornix and adnexal regions. Assessment: Clinical Impression: - Pelvic Endometriosis. Discussion: Patient Education and Counselling: - Education provided regarding the clinical impression of pelvic endometriosis based on history and examination findings. - Rationale for initial investigations (TVUS and CA-125) explained to assess for endometriomas, adenomyosis, and rule out other pelvic pathology. - Discussion regarding the need for definitive diagnosis and management, potentially involving diagnostic laparoscopy. - Pain management strategy using NSAIDs explained. Discussed Options: Outpatient Hysteroscopy (Awake) - This is a quicker procedure, typically lasting 5-10 minutes, with a total time in the department of less than 60 minutes. - It is associated with more pain and discomfort, with average pain scores of 5-6/10. Small cohort severe pain or unwell during or after. - Pain relief options discussed included gas and air (Entonox) and local anaesthetic, with gas and air being the preferred option due to its rapid onset and ease of administration. Hysteroscopy under General Anaesthetic (Asleep) - This option is associated with the lowest level of pain and discomfort. - It requires a longer hospital stay (approximately 6 hours) and a period of fasting beforehand. - It carries slightly increased procedural risks, including a small risk of damage to the womb or cervix. Plan: Treatment Plan: - Arrange Transvaginal Ultrasound Scan (TVUS). - Arrange serum CA-125 level. - Initiate cyclical pain management with NSAIDs. - Discuss definitive surgical plan (e.g., diagnostic laparoscopy) following investigation results. Medications Prescribed: - Naproxen, 500 mg, twice daily, orally, starting two days prior to expected menses and continuing for five days. Follow-up Plan: - Follow-up appointment scheduled in four weeks to review investigation results (TVUS and CA-125) and discuss definitive management strategy. Dear GP, Mrs. Eleanor Vance, a 41-year-old G2 P2 patient whose family is complete, attended today reporting chronic pelvic pain and severe deep dyspareunia, ongoing for eighteen months and worsening over the last six months. Her pain is cyclical, rated 8/10 during menses, and is associated with heavy menstrual flow and cyclical constipation. She reports significant impact on her work and psychological wellbeing. Past gynaecological history includes a laparoscopic ovarian cystectomy twenty years ago. She has a known allergy to Penicillin (urticarial rash) and takes Levothyroxine 100 micrograms daily for hypothyroidism. Examination revealed mild suprapubic tenderness and significant tenderness upon bimanual examination in the posterior fornix and adnexal regions, with uterine retroversion. The clinical impression is highly suggestive of pelvic endometriosis. Investigations arranged include a Transvaginal Ultrasound Scan and serum CA-125 level. Management initiated includes Naproxen 500 mg twice daily orally, taken cyclically for pain relief. Hysteroscopy options (outpatient vs. general anaesthetic) were discussed for potential future management. A follow-up appointment is scheduled in four weeks to review investigation results and determine the definitive surgical plan. Yours sincerely,