Female pelvic problems

2015

FocusFemale pelvic problems

Obstetric and gynaecological problems in Australian general practice

Volume 44, No.7, 2015 Pages 443-445

Clare Bayram

Allan Pollack

Carmen Wong

Helena Britt

Published literature provides information about the prevalence of obstetric and gynaecological problems in the population. Many of these conditions are more prevalent in specific age groups. For example, approximately 20% of women of reproductive age have menorrhagia.1 Chronic pelvic pain affects 15% of women aged 18–50 years,2 and pelvic floor disorders (urinary incontinence, faecal incontinence and pelvic organ prolapse) affect 24% of women aged ≥20 years and 50% of those aged ≥80 years.3 Population prevalence estimates do not provide insight into the impact of these problems on workload in general practice.

The Bettering the Evaluation and Care of Health (BEACH) program has already shown that general practitioners (GPs) in Australia refer female patients to gynaecologists and obstetricians at a rate of 0.8 per 100 GP–female patient encounters, most commonly for menstrual problems, ‘other’ genital disease (eg ovarian cyst, endometriosis), abnormal test results, uterovaginal prolapse and infertility/sub-fertility.4 This reflects the type of problems requiring specialist care, but we know little about the overall workload associated with management of obstetric and gynaecological (O&G) problems in general practice. The aims of this study were to describe the frequency of management of O&G problems at encounters with female patients in general practice, and to investigate differences by patient age.

Method

This is a secondary analysis of data from the BEACH program, a national study of general practice activity in Australia. BEACH methods are described in detail elsewhere.5 In summary, every year approximately 1000 randomly sampled GPs record details of 100 consecutive encounters with consenting patients on structured paper recording forms. Ethics approval for the BEACH program was obtained from the Human Research Ethics Committee of the University of Sydney (HREC 2012/130).

For this study, analyses of all encounters with female patients for the data period April 2004 to March 2014 were undertaken. O&G problems were defined as all problems classified in the International Classification of Primary Care, version 2 (ICPC-2)6 as ‘female genital’ (X chapter) and ‘pregnancy and family planning’ (W chapter); and selected urogenital problems classified in the urological chapter (including urinary incontinence, urethritis, and prolapse).

Results

O&G problems were managed at a rate of 19.2 per 100 encounters with female patients, accounting for 12.0% of all problems managed for female patients. The majority of O&G problems managed were for women aged 25–44 years (48.2%), followed by women aged 45–64 years (25.4%), 0–24 years (19.0%) and ≥65 years (7.4%).

Figure 1. Ten most common gynaecological/obstetric problems managed at encounters with female patients in Australian general practice (2004–14)
*Includes multiple ICPC-2 or ICPC-2 PLUS codes (see Appendix 1, available online)

Figure 1 shows the 10 most commonly managed O&G problems. The different colours illustrate the proportion of each problem managed in each age group. Overall, these 10 problems accounted for 73.3% of all O&G problems managed. Certain age groups predominated in each problem. For example, genital check-up/Pap smear was managed at a rate of 3.9 per 100 GP–female patient encounters, but the majority of these problems were managed for women aged 25–44 years (43.3%) and 45–64 years (39.5%). By contrast, malignant breast neoplasm was managed at a rate of 0.4 per 100 GP–female patient encounters; 46.3% of these problems were managed among women aged 45–64 years, and 45.1% among those aged ≥65 years (Figure 1).

 

Figure 2. Age-specific management of the most common gynaecological/obstetric problems among females at Australian general practice encounters (2004–14) (95% confidence intervals)
*Includes multiple ICPC-2 or ICPC-2 PLUS codes (see Appendix 1, available online)

As there were marked differences in the age-related distribution for each problem, we investigated the age-specific management rate (Figure 2). The proportion of all problems accounted for by O&G problems in each age group, and the most common O&G problems managed by GPs are described below.

0–24 years: O&G problems were managed at a rate of 19.2 per 100 encounters with female patients in this age group, and accounted for 14.9% of all problems managed with these patients. The most commonly managed problems were oral contraception (4.9 per 100 encounters in this patient group), pregnancy (3.1), menstrual problems (2.1), and check-ups related to the genital system/Pap smears (2.0 per 100 encounters) (Figure 2).

25–44 years: An average of 36.8 O&G problems were managed per 100 encounters with women aged 25–44 years, and these problems accounted for one-quarter of all problems managed for women in this age group. Pregnancy and pregnancy-related conditions (7.9 per 100 encounters) were the most commonly managed, followed by genital check-up/Pap smear (6.7), oral contraception (4.4) and menstrual problems (2.5).

45–64 years: O&G problems were managed at a rate of 17.7 per 100 encounters with women in this age group and these problems accounted for 10.5% of all problems at these encounters. The most common were genital check-up/Pap smear (5.6 per 100 encounters), menopausal symptoms (4.5), menstrual problems (0.9) and malignant breast neoplasm (0.7).

≥65 years: At encounters with older women, O&G problems were managed at a rate of 5.0 per 100 encounters and accounted for 2.7% of all problems. The most commonly managed were genital check-up/Pap smear (1.0 per 100 encounters), menopausal symptoms (1.0), malignant breast neoplasm (0.7; Figure 2) and urinary incontinence (0.4; results not shown).

Comparison of the age-specific management rates reveals some interesting differences. For example, oral contraception was most frequently managed among females in the youngest age group, whereas other forms of contraception were managed most frequently among women aged 25–44 years. Pregnancy and pre/postnatal check-ups were more than twice as likely to be managed at encounters with women aged 25–44 years, compared with any other age group. By contrast, management rates of breast cancer were similar among women aged 45–64 years and those aged ≥65 years.

Discussion

One in eight problems managed at encounters with female patients were related to O&G problems. A significant proportion of problems involved preventive care, particularly genital check-ups/Pap smears. If the recommendations for changes to the cervical cancer screening program are adopted (5-yearly human papillomavirus testing instead of 2-yearly Pap smears),7 it is likely that these types of check-ups will decrease.

This study shows that the management rates and types of O&G problems differed considerably by patient age. Younger women were more likely to have contraception, pregnancy, and menstrual problems managed, whereas for older women, menopausal symptoms, genitourinary problems and breast cancer were more commonly managed. This article provides a quantitative description of GPs’ management of O&G problems and may provide context for other articles in this edition of Australian Family Physician.

Authors

Clare Bayram BAppSc (HIM) (Hons), PhD, Research Fellow and Project Manager, BEACH program, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW. clare.bayram@sydney.edu.au

Allan Pollack MBBS (Hons), MBiomedE, FRACS (Orth), Research Officer, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW

Carmen Wong BHS, MHI, Research Officer, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW

Helena Britt BA, PhD, Director, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

Acknowledgements

We wish to thank the general practitioners who participated for their generosity. During the data collection period of this study, the BEACH program was funded by the Australian Government Department of Health, AstraZeneca Pty Ltd (Australia), Novartis Pharmaceuticals Australia Pty Ltd, bioCSL (Australia) Pty Ltd, Merck Sharp & Dohme (Australia) Pty Ltd, Pfizer Australia Pty Ltd, Sanofi-Aventis Australia Pty Ltd, GlaxoSmithKline Australia Pty Ltd, National Prescribing Service Ltd; Janssen-Cilag Pty Ltd; Abbott Australasia Pty Ltd; Roche Products Pty Ltd; and the Australian Government Department of Veterans’ Affairs.

References

  1. Knight D, Robson S, Scott P. Menorrhagia. How to treat series. Australian Doctor 6 March 2009. p31–38. Available at www.australiandoctor.com.au/cmspages/getfile.aspx?guid=591d3bc7-5bd3-482f-a0af-0131a2f957c1 [Accessed 20 May 2015].
  2. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996 Mar;87:321–27.
  3. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–16.
  4. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013–14. Sydney: Sydney University Press, 2014.
  5. Britt H, Miller GC. The BEACH program: an update. Aust Fam Physician 2015;44:411–14.
  6. Classification Committee of the World Organization of Family Doctors. ICPC-2: International Classification of Primary Care. 2nd edn. Oxford: Oxford University Press, 1998.
  7. Department of Health, National Cervical Cancer Screening Program. Renewal of the National Cervical Screening Program: Medical Services Advisory Committee recommendations. Canberra: Commonwealth of Australia, 2015. Available at www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/MSAC-recommendations [Accessed 5 February 2015].

 

BEACH data coded using the ICPC-2 PLUS terminology are usually reported at the level of the ICPC-2 classification (for example, genital candidiasis female is ICPC-2 code X72). However, there are some exceptions where data are grouped either above the ICPC-2 level or across the ICPC-2 level. These grouped morbidities are marked with an asterisk in Figures 1 and 2, and are defined below.

Appendix 1. Code groups from ICPC-2

Group

ICPC-2 rubric

ICPC-2/ICPC-2 PLUS label

Female genital check-up/Pap smear

X30

Medical examination/health evaluation, complete, genital female

 

X31

Medical examination/health evaluation, partial, genital female

 

X37

Histological/exfoliative cytology, genital F

Menstrual problems

X02

Menstrual pain

 

X03

Intermenstrual pain

 

X05

Menstruation absent/scanty

 

X06

Menstruation excessive

 

X07

Menstruation irregular/frequent

 

X08

Intermenstrual bleeding

 

X09

Premenstrual symptom/complaint

 

X10

Postponement of menstruation

Oral contraception

W10

Contraception post-coital

 

W11

Contraception, oral

 

W50

Medication prescription/request/renewal/injection reproductive system

Pregnancy and pregnancy related problems

W01

Question of pregnancy

 

W78

Pregnancy

 

W79

Unwanted pregnancy

 

W05

Pregnancy nausea/vomiting

 

W84

Pregnancy high risk

 

W29

Pregnancy symptom/complaint

 

W03

Antepartum bleeding

 

W92

Complicated labour/delivery, livebirth

 

W90

Uncomplicated labour/delivery, livebirth

 

W81

Toxaemia of pregnancy

 

W99

Disorders of pregnancy/delivery

 

W70

Puerperal infection/sepsis

 

W93

Complicated labour/delivery, stillbirth

 

W96

Complications of puerperium

 

W91

Uncomplicated labour/delivery, stillbirth

 

W71

Other infection complicating pregnancy/puerperium

 

W75

Injury complicating pregnancy

Prenatal/postnatal check-up

W30

Medical examination/health evaluation, complete, pregnancy

 

W31

Medical examination/health evaluation, partial, pregnancy

 

 

Correspondence afp@racgp.org.au

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Declaration of competing interests *

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Type

Focus

2015