What are the management strategies for the most common gynecological (Gyne) outpatient department (OPD) cases?

Management of Common Gynecological OPD Cases

Dysmenorrhea (Painful Menstruation)

NSAIDs are the first-line treatment for dysmenorrhea due to their effectiveness in blocking prostaglandin formation, with hormonal contraception as an excellent alternative for those with inadequate response.

Diagnosis

• Evaluate for primary vs. secondary dysmenorrhea
• Primary: painful cramping without underlying pathology
• Secondary: associated with conditions like endometriosis, fibroids, or PID

Management Algorithm

1. First-line treatment: NSAIDs

   • Ibuprofen 600-800 mg every 6-8 hours with food for first 24-48 hours of symptoms 1
   • Start at onset of menses or pain
   • Continue for 2-3 days as needed

2. If inadequate response after 3 menstrual cycles:

   • Add hormonal contraception (combined oral contraceptives or LNG-IUD) 2, 3
   • LNG-IUD particularly beneficial for those with heavy bleeding (reduces menstrual flow by ~90% over time) 4

3. If no improvement within 6 months of NSAIDs and hormonal therapy:

   • Refer for laparoscopy to evaluate for endometriosis or other pathology 3

4. Adjunctive non-pharmacologic approaches:

   • Heat therapy (topical application)
   • Regular physical exercise
   • Consider vitamin supplements (B1, B6, E) or omega-3 fatty acids 5

Pelvic Inflammatory Disease (PID)

Immediate broad-spectrum antibiotic treatment is essential for PID to prevent long-term sequelae such as infertility, chronic pelvic pain, and ectopic pregnancy.

Diagnosis

• Minimum criteria: lower abdominal tenderness, adnexal tenderness, cervical motion tenderness
• Supporting criteria: fever >38.3°C, abnormal cervical discharge, elevated ESR/CRP, documented infection with N. gonorrhoeae or C. trachomatis

Management Algorithm

1. Determine need for hospitalization 6:

   • Surgical emergencies cannot be excluded
   • Pregnancy
   • No response to oral therapy
   • Unable to follow/tolerate outpatient regimen
   • Severe illness, high fever, nausea/vomiting
   • Tubo-ovarian abscess
   • Immunodeficiency
   • Adolescent patient
   • Follow-up within 72 hours cannot be arranged

2. Outpatient treatment regimens 6:

   • Regimen A:

     • Ofloxacin 400 mg orally twice daily for 14 days OR
     • Levofloxacin 500 mg orally once daily for 14 days
     • WITH or WITHOUT Metronidazole 500 mg orally twice daily for 14 days

   • Regimen B:

     • Ceftriaxone 250 mg IM single dose OR
     • Cefoxitin 2g IM single dose plus Probenecid 1g orally
     • PLUS Doxycycline 100 mg orally twice daily for 14 days
     • WITH or WITHOUT Metronidazole 500 mg orally twice daily for 14 days

3. Follow-up:

   • Reevaluate within 72 hours if not improving
   • Switch to parenteral therapy if no improvement
   • Ensure all sexual partners are treated

4. Patient education 6:

   • Take all medication regardless of symptom improvement
   • Avoid sexual intercourse until treatment completion
   • Ensure partner evaluation and treatment
   • Return for follow-up evaluation

Contraception Management

Long-acting reversible contraception (LARC) methods such as IUDs and implants are recommended as first-line options due to their superior efficacy (<1% failure rate) and ease of use.

Contraceptive Options by Effectiveness

1. Highest effectiveness (>99%):

   • Levonorgestrel IUD (0.1-0.2% failure rate) 4
   • Copper IUD (0.8% failure rate) 4
   • Contraceptive implant (0.05% failure rate) 4
   • Sterilization (female: 0.5%, male: 0.15% failure rate) 4

2. High effectiveness (94-97%):

   • Injectable contraception (DMPA) (0.3-6% failure rate) 4

3. Moderate effectiveness (91-95%):

   • Combined oral contraceptives 4
   • Progestin-only pills 4

4. Lower effectiveness:

   • Male condoms (14% failure rate) 4
   • Female condoms (21% failure rate) 4
   • Diaphragms with spermicide (20% failure rate) 4
   • Fertility awareness methods (25% failure rate) 4
   • Withdrawal method (19% failure rate) 4

IUD-Specific Management

• Copper IUD effective for up to 12 years 4
• Hormonal IUD duration varies: 13.5 mg LNG-IUD (Skyla) - 3 years; 52 mg LNG-IUD (Mirena) - up to 7 years 4
• Safe for nulliparous women 4
• No backup contraception needed when initiating 4

Abnormal Uterine Bleeding

LNG-IUD is an excellent first-line option for abnormal uterine bleeding, with approximately 50% of users experiencing amenorrhea or oligomenorrhea by 2 years of use.

Management Algorithm

1. Rule out pregnancy and malignancy

2. First-line medical management:

   • LNG-IUD (especially for women with fibroids, anemia, severe dysmenorrhea) 4
   • Combined hormonal contraceptives
   • Tranexamic acid
   • NSAIDs (ibuprofen 600-800 mg every 6-8 hours)

3. Second-line options:

   • Progestin therapy
   • DMPA injections

4. For refractory cases:

   • Endometrial ablation
   • Hysterectomy for definitive treatment

Common Pitfalls and Caveats

1. For dysmenorrhea:

   • Don't delay hormonal therapy if NSAIDs fail after 3 cycles
   • Don't miss secondary causes (endometriosis, adenomyosis, fibroids)
   • Consider laparoscopy if no improvement after 6 months of combined therapy

2. For PID:

   • Don't delay treatment waiting for culture results
   • Don't forget partner treatment
   • Don't use inadequate antibiotic coverage (must cover N. gonorrhoeae, C. trachomatis, anaerobes)
   • Don't miss criteria for hospitalization

3. For contraception:

   • Don't overestimate effectiveness of user-dependent methods
   • Don't exclude nulliparous women from IUD options
   • Don't forget to counsel about side effects (irregular bleeding with hormonal methods)