Master CPS - Reproductive Health
for MSRA

Core Concepts

Reproductive health covers physical, mental, and social well-being related to the reproductive system. Key physiology revolves around the Hypothalamic-Pituitary-Gonadal (HPG) axis, which regulates gonadal function (ovaries/testes) via GnRH, FSH, and LH. These hormones control the production of sex steroids (oestrogen, progesterone, testosterone), which exert effects on target organs. Understanding the menstrual cycle, spermatogenesis, and fertility windows is fundamental for managing reproductive conditions.

Clinical Presentation

• Abnormal Uterine Bleeding (AUB): Menorrhagia, metrorrhagia, post-coital bleeding (PCB), post-menopausal bleeding (PMB).
• Pelvic Pain: Acute (e.g., PID, ruptured cyst), chronic (e.g., endometriosis, adhesions), dysmenorrhoea, dyspareunia.
• Vaginal Discharge/Itch: Pruritus vulvae, malodorous or discoloured discharge.
• Scrotal Pain/Lumps: Acute pain, gradual onset pain, swelling, palpable masses.
• Lower Urinary Tract Symptoms (LUTS) in men: Frequency, urgency, hesitancy, weak stream, nocturia, haematuria (macroscopic or microscopic).
• Erectile Dysfunction (ED): Inability to achieve/maintain erection.
• Infertility: Inability to conceive after regular unprotected intercourse for 12 months (or 6 months if >35 years).
• Menopausal Symptoms: Hot flushes, night sweats, vaginal dryness, mood changes, sleep disturbance.
• Sexual Health Concerns: Dysuria, genital lesions, contact with STI.

Diagnosis (Gold Standard)

Diagnosis begins with a thorough history and clinical examination.

• Vaginal/Cervical Swabs:
  • High Vaginal Swab (HVS) for Candida, Bacterial Vaginosis, Trichomonas.
  • Endocervical Swab (ECS) or urine sample (first-pass urine) for Chlamydia and Gonorrhoea (NAAT).
• Urine Tests: Dipstick and Midstream Urine (MSU) for UTI; Urine cytology for haematuria.
• Blood Tests:
  • FBC (anaemia in AUB), TFTs, Prolactin (AUB, galactorrhoea, infertility).
  • FSH/LH/Oestradiol (menopause, PCOS, infertility).
  • Testosterone (PCOS, ED).
  • PSA (Prostate Specific Antigen) for prostate cancer screening/monitoring (after discussion of pros/cons).
• Imaging:
  • Pelvic Ultrasound (Transvaginal preferred for gynaecology): Uterine fibroids, ovarian cysts, endometrial pathology, PCOS.
  • Scrotal Ultrasound: Differentiate testicular torsion vs. epididymitis, characterise testicular/epididymal lumps (hydrocele, varicocele, tumour).
• Cervical Screening: Cervical cytology +/- HPV testing as per national guidelines.
• Semen Analysis: Initial investigation for male infertility.

Management (First Line)

• Contraception: Offer tailored advice based on individual needs, medical history, and contraindications. Options include COCP, POP, implant, injection, IUD/IUS, barrier methods.
• Abnormal Uterine Bleeding:
  • Menorrhagia: Tranexamic acid, Mefenamic acid, Mirena IUS (highly effective), COCP.
  • Post-Coital Bleeding (PCB): Exclude cervical pathology (smear), infection. Cervical ectropion can be cause.
  • Post-Menopausal Bleeding (PMB): Urgent 2-week wait referral to gynaecology to exclude endometrial cancer.
• Pelvic Pain:
  • Dysmenorrhoea: NSAIDs, COCP, Mirena IUS.
  • Pelvic Inflammatory Disease (PID): Oral antibiotics (e.g., Doxycycline + Metronidazole). Partner notification and screening.
  • Endometriosis: NSAIDs, COCP (continuous use), specialist referral for GnRH analogues or surgery.
• Vaginal Discharge:
  • Candidiasis: Topical (e.g., Clotrimazole) or oral (Fluconazole) antifungals.
  • Bacterial Vaginosis (BV): Oral or topical Metronidazole.
  • STIs (Chlamydia, Gonorrhoea, Trichomonas): Specific antibiotics (e.g., Doxycycline for Chlamydia, Ceftriaxone for Gonorrhoea). GUM referral for contact tracing and management.
• Menopause: Lifestyle modification, Hormone Replacement Therapy (HRT) – oestrogen-only (if hysterectomy) or combined oestrogen + progestogen. Vaginal oestrogen for localised symptoms.
• Benign Prostatic Hyperplasia (BPH): Lifestyle advice, alpha-blockers (e.g., Tamsulosin), 5-alpha reductase inhibitors (e.g., Finasteride). Refer to urology if symptoms persist or for complications.
• Erectile Dysfunction (ED): Address underlying causes (diabetes, CVD), lifestyle changes. First-line medical: PDE5 inhibitors (e.g., Sildenafil).
• Infertility: Initial advice on timed intercourse, basic investigations (FBC, TFT, prolactin, semen analysis, pelvic USS), referral to secondary care after 12 months (or 6 months if female >35).

Exam Red Flags