Gynaecology

What you need to know in primary care:

ovarian-cysts

vulval-concerns

Amenorrhoea

polycystic-ovarian-syndrome

menorrhagia-presentation

1. Do a smear if due, even if concerns about cervical appearance, as most will not be carcinoma
2. PCB– refer on if ongoing for 3 or more cycles unless obvious cervical abnormality, as most will settle over this time/ectropion can undergo squamous metaplasia and heal
3. IMB– refer on if ongoing for 3 or more cycles for hysteroscopy
4. HMB– use the secondary care referral form on the PRESS Portal to ensure treatments have been considered in primary care for 3-6 months first unless other risk factors

Ensure up to date FBC

Consider pipelle if other risk factors e.g. BMI >30/ PCOS – can be done in PCS Community Gynaecology clinic +/- Mirena if not available in own practice (referral form on Dashboard under Sexual Health)

5. Fibroids <3cm are not usually symptomatic and Mirena can still be fitted and effective unless there is distortion of the endometrial cavity/ they are submucous
6. Ovarian cysts (useful RCOG green top guidelines available)

Pre-menopausal simple cysts 5cm or less don’t need follow up or action unless symptomatic

Annual monitoring if 5-7cm, refer if >7cm, no need for CA125 if simple

If complex cyst – CA125

Post-menopausal – if less than 3cm – CA125 and USS 4 monthly for a year – if no change or it reduces – no action, if it increases – refer on

Dermoids – refer on if symptomatic (usually <3cm not significant and on action needed)

6. PCOS– most cases managed in primary care unless fertility concerns. Hormonal treatment to ensure at least 4 bleeds per year (or Mirena) and advice re: weight loss if needed
7. Painful periods/ endometriosis concerns – Mirena/ COCP effective and can be used to treat before referral, especially in older women if no fertility concerns. Mirena also works well for adenomyosis
8. Prolapse– helpful to note if patient has a preference towards surgical or conservative management.  Pessary fitting available via the PCS Community Gynaecology clinic (forms on Dashboard under Sexual Health) if not available in own practice.  Consider referral to continence services (forms on Dashboard under Urology) if haven’t tried PFEs/ mild urinary symptoms/ family not complete so surgery not ideal.
9. Sterilisation– remember to discuss Mirena as an alternative option – more effective and added benefit on menses
10. Urogenital symptoms – remember to consider vaginal oestrogens for vaginal soreness/ dryness/ urinary urgency/ recurrent UTI. Use for at least 3 months for full effect – long term use recommended if helps – equivalent dose to taking only one oral HRT tablet per year. Also remember emollients e.g. Hydromol, and moisturisers e.g. Replens and lubricants e.g. Yes
11. Lichen sclerosis – fine to try treatment in primary care if typical diagnostic features – figure of 8 distribution/ pallor or erythema/ ecchymoses/ itch – not all need biopsy, use clobetasol ointment as per BASHH guidelines, initially nightly for a month on reducing schedule. Refer if not effective or diagnostic uncertainty/ concerns re: appearance.  Annual review recommended
12. Lost coil threads– Hartmann’s crocodile forceps or urethral forceps can be a handy tool which can be used in Primary Care to retrieve threads curled in os. If not available to locate, scan to check coil still in situ and refer to Sexual Health Services to retrieve.
13. Endometrial thickness – if no PMB, ET up to 10mm is acceptable as a coincidental scan finding in post-menopausal women. Traces of fluid in the cavity with no other symptoms are not usually significant

1) Abnormal Uterine Bleeding in Primary Care/ Menorrhagia– An Update (PRESS PORTAL)

2)PCS Community Gynaecology Referral forms

– Cervical Polyp Removal Referral form 

– IUS Fit for Gynaecological Reasons Referral form

– First Fit Ring Pessary Referral form

3) Royal College of Obstetrics and Gynaecology

4) The Primary Care Women’s Health Forum 

This is a charity dedicated to the education and support of healthcare professionals across the UK caring for female patients. The charity promotes best practice through supportive materials, educational meetings and informative webinars. There are a number of useful publications on their website such as NICE Guidance on the Menopause, Tips for Safe Practice with Nexplanon Insertions, Top 10 Tips for Premenstrual Syndrome, etc

5) The following presentation was delivered by Gynaecology CASES GPs at a HASL clinical council in 2017 and at a CCG PLI in February 2020:

Gynaecology2020Tips_HASL_11.05.2017

6) The following presentation on Adolescent Healthcare was given by Dr Emma Park.

Surfing-the-Crimson-wave

7) Rock My Menopause  

8) Womens health concern 

9)British menopause society 

10) Menopause matters 

11)The menopause doctor

12) BASSH – for useful guidance on lichen sclerosis/ recurrent thrush