Primary Care Guidelines: HEAVY REGULAR MENSTRUAL BLEEDING <16 years old Refer onto Secondary Care / Unsure Arrange for pelvic ultrasound scan Is ultrasound scan NORMAL or only fibroids of <3cm diameter 1. Patient presents with Heavy menstrual bleeding NB: if woman has regular menstrual bleeding then DO NOT undertake the following: FSH LH Prolactin TFTs Ferritin 2. Investigations Take history Examination Triple Swabs if sexually active (results need to be within the last 3 months) HVS Chlamydia Gonorrhoea Full Blood Count (FBC) 3. Is abdominal and pelvic examination needed? Examination normal? 4. Consider trialling the following for at least 6 9 months in the following sequence: 1st line: Levonorgestrel- releasing intrauterine system (LNG-IUS Mirena ). 2nd line: Combined oral contraceptive/ Tranexamic acid (stop if no improvement after 3 cycles)/nsaids Mefenamic acid 3rd line: rethisterone 5mg TDS from day 5 to day 26 of period Injected long acting progestogens Refer onto Secondary Care Is there any of >16yrs the following?: Exclusion Criteria refer to Secondary Care when: <16 years old Menorrhagia with: Multi-fibroid uterus arises above Symphysis Pubis or palpable per abdomen Scan result available and states uterine length >11cms/single fibroid with largest diameter >3cm Pelvic Pain Intermenstrual bleeding Post Coital bleeding Failure of medical treatment/mirena/ius device for 9 months/1 year or who would prefer a surgical procedure te: For girls aged between 16 20 years take: INR APPT Is blood clotting abnormal? If yes refer to Secondary Care haematology te: for those >45 years consider endometrial biopsy ALWAYS INCLUDE RESULTS OF INVESTIGATION IN REFERRAL Continue management in primary care 5. Any improvements? >45 years: Refer for an endometrial biopsy <45 years: consider trialling 2nd line treatment from 4. improvement refer to IGS Refer to Intermediate Service Severity indicated by an increase in menstrual flow with one or more of the following symptoms: Failed medical management Presence of clots in menstrual loss Flooding through sanitary wear/needing to double up menstrual protection (pad and tampon) Also in association with the woman s Quality of Life
Primary Care Guidelines: IRREGULAR BLEEDING Uterus palpable abdominally Referral to Secondary Care Investigations: History Examination (speculum and bimanual) Triple Swabs (results must Positive Chlamydia/Gonorrhoea: Treat patient (and partner) according to guidelines be within the last 3 Patient presents with: Intermenstrual Post coital Irregular cyclicity Prolonged Is NOT: Post menopausal bleeding months): Chlamydia Gonorrhoea HVS 4. Ensure that cervical screening is up to date and negative 5. Related to hormonal contraception? - change contraception 6. Perform smear if due 7. Exclude pregnancy 8. TVS to assess endometrial cavity Outcomes Post-coital bleeding Polyps NORMAL smear and cervix - observe for ONE month ABNORMAL smear or history of previous cervical treatment or ectropian >35years Refer to the Intermediate service If persistent after one month: Refer to the Intermediate service Refer to Colposcopy Unit RED FLAGS refer under 2WW guidance ABNORMAL looking cervix Refer under 2WW Patient has clinical features suggestive of cervical cancer on examination Patient not on HRT with post-menopausal bleeding Patient on HRT with persistent unexplained post-menopausal bleeding after cessation of HRT for 6 weeks Patient taking Tamoxifen with post-menopausal bleeding Patient with an unexplained lump Patient with vulval lump or vulval bleeding due to ulceration With palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or from GI or urological origin Intermenstrual bleeding >45years <45 years Urgent Referral to Secondary Care (not 2WW) Treat with: Oral contraceptive OR rethisterone 5mg daily for days 5-256of cycle for 3 months If no improvement after 3 months refer to The Intermediate service
Primary Care Guidelines: SUPERFICIAL DYSPAREUNIA GP can identify Lichen Sclerosus Lichen planus Refer to intermediate Investigations: History Known other vulval skin diseases e.g. psoriasis Consider Referral to Intermediate Dermatology Examination Triple swabs (results need to be within 3 Any known Patient presents with superficial Dyspareunia months) Chlamydia Gonorrhoea HVS If positive results treat Dermatological conditions? Post- Menopausal woman Management in primary care: Premarin Consider using topical oestrogens for up to 6 weeks i.e.: Estriol 0.1% intravaginal cream improvement after 6 weeks Refer to the intermediate gynaecology service as appropriate INCLUDE ALL RESULTS IN REFERRAL Refer patient to the perineal clinic Pre- Recent onset of SD Menopausal woman since an obstetric event? Refer to the intermediate gynaecology service Refer to Secondary Care: Any vulval pathology visible Refer via 2WW pathway Deep dyspareunia complete swabs and Ultrasound and refer to Secondary Care If visible warts refer to GUC
Primary Care Guidelines: FAILED SMEAR unable to locate cervix Refer to the Intermediate Service Presentation: GP unable to locate 1. History cervix Too painful for patient to take smear Severe anxiety/fear 2. Examination PLEASE INDICATE WHY PATIENT IS BEING REFERRED Is the patient premenopausal? In post menopausal women consider using: Premarin (low cost Refer to the Intermediate Service of having smear option) Has the issue Or topical oestrogens for 6 weeks: resolved and smear can be taken? Estriol 1% intravaginal cream (easy application) Continue management in primary care NB: Abnormal laboratory smears or repeatedly inadequate smears are to be referred directly to Colposcopy unit
Primary Care Guidelines: Six month history of secondary amenorrhoea Refer via the Infertility Pathway ensure all tests are carried out Hirsuitism/acne: cyprotine and ethi- Assessment: nyloestradiol combination or COCP Patient presents with: 6 months history of secondary amenorrhoea symptoms EXCLUDE PREGNANCY History: Menstrual sexual contraceptive Medical drugs psychiatric (including eating disorders) Diet/recent weight loss Does the patient wish to become pregnant? Blood tests If Polycystic Ovaries Syndrome (PCOs) suspected, i.e. raised LH/FSH ratio, hirsuitism and FAI >6 TVS to confirm PCOS Needs contraception: COCP, POP or intauterine or implanted progestogen-only device Re-assess in 12 months Amenorrhoea continues Stress exercise For all: FBC TFT All rmal Reassure, offer review in 3 months If amenorrhoea persists, repeat all tests and refer Refer to intermediate Check BMI weight loss FSH if necessary Free Androgen Index (FAI) Testosterone Sex Hormone Binding Globulin Raised FSH and LH Consider menopause (SHBG) Repeat prolactin (if 400- Examination: Hirsuitism Severe acne Low FSH, LH, low oestradiol, raised Prolactin <1000 1000) and give Combined Oral Contraceptive Pill (COCP) prolactin Prolactin >1000 Refer to Endocrinology
Primary Care Guidelines: VAGINAL DISCHARGE Woman is post menopausal Refer Immediately 2WW to Mucopurulent discharge Woman is premenopausal Consider referral to GUM Assessment: Positive for infection Review therapy Patient presents with: Sexual History External Examination Pelvic Examination Check Smear is up to date HVS Review lab results Negative for infection If swabs negative and examination negative: discharge, reassure - causes are likely physiological Vaginal Check for chlamydia Discharge and gonorrhoea Check for foreign body (i.e. tampon) and Cervical ectropion Watchful waiting for >3months If no improvement after 3 months - Refer to intermediate remove if present Cervical polyp Refer to Intermediate Positive chlamydia/ gonorrhoea screening Treat patient and partner/ Refer to GUC for contact tracing
Primary Care Guidelines: PELVIC PAIN (see additional sheet with questions to rule out other conditions) Consider a non gynaecology cause i.e. Gastroenterology (see list of questions) Abnormal 1. Assessment: Examination uterus fixed/tender or adnexal mass Arrange ultrasound and refer as appropriate Refer onto Secondary Care Pelvic pain symptoms in premenopausal woman History Is the pain (or was is initially) menstrual or pre-menstrual? Is it new/altered dysmenorrhoea? Is there (or was there initially) deep dyspareunia? Is the menstrual 2. Investigations: Exclude/treat infection Triple swabs: (results need to be within 3 months) Chlamydia Gonorrhoea HVS Bimanual Examination rmal Examination TVS cycle abnormal? Lack of GI symptoms rmal Fibroids (<3cm) Ovarian Cyst <5cm and normal CA125 Complex Ovarian Cyst and/or raised CA125 Fibroid >3cm Ovarian Cyst >5cm with normal CA125 If tender or endometriosis suggested 1. COCP or progestogen only contraceptive (oral, injectable or intra-uterine) Urgently Refer to Refer to Secondary Care 2. n-opiate analgesia, paracetamol, NSAID 3. Consider psychological factors. Anti- depressants? REVIEW IN 3 MONTHS Symptoms still persist? Refer to Intermediate
Pelvic Pain possible causes Possible Speciality Key Questions: Possible Alternative Diagnosis Gynaecological Primary dysmenorrhoea Is the pain cyclical; dysmenorrhoea; pre-menstrual; Endometriosis dyspareunia? Adenomyosis Is the menstrual cycle abnormal? Ovarian Cyst Cyclical pain on defecation? Gastrointestinal Altered bowel habit? Inflammatory bowel disease PR bleeding? Irritable bowel syndrome Weight loss? Vomiting? Urological Spasmodic pain related to full or emptying of bladder? Interstitial cystitis Musculoskeletal Pain related to position or movement? Psychosomatic Past history of mental health problems depression, anxiety? Consider alongside rather than after organic causes Current life events, stress factors? History of medically unexplained symptoms?