Rapid review: gynaecology

Presenting picture. Periods that are heavy or prolonged enough to affect quality of life; repeated flooding, clots, fatigue, intermenstrual or postcoital bleeding may be present. Watch for pressure symptoms, pelvic pain or rapid onset in an older woman.

Single most likely diagnosis. Heavy menstrual bleeding (HMB) secondary to ovulatory dysfunction when there is no structural cause; fibroids if the uterus is bulky or distorted; endometrial polyps or pathology if there is persistent intermenstrual bleeding.

Best first test. Take a focused history and examine the abdomen and pelvis. Carry out a full blood count for every woman with HMB, in parallel with any treatment offered ^[1]. Consider testing for a bleeding disorder if HMB has been present since menarche with a personal or family history suggesting one ^[1]. Use hysteroscopy as the first-line investigation when the history suggests submucosal fibroids, polyps or endometrial pathology, and transvaginal ultrasound as the first-line imaging for a bulky, tender or fibroid uterus ^[1].

Do not do. Do not carry out female hormone testing, and do not carry out thyroid testing unless other thyroid features are present ^[1]. Do not use saline infusion sonography or MRI as the first-line diagnostic tool for HMB ^[1].

Best first treatment. NICE NG88: consider levonorgestrel-releasing intrauterine system (LNG-IUS) as the first treatment when there is no identified pathology, fibroids under 3 cm that are not distorting the cavity, or suspected or diagnosed adenomyosis ^[1]. If an LNG-IUS is declined or not suitable, consider tranexamic acid, NSAIDs, combined hormonal contraception, or cyclical oral progestogens ^[1]. Explain that at least 6 cycles may be needed to see the full benefit of an LNG-IUS ^[1].

Commonest wrong answer. Starting investigation and treatment by ordering hormone panels, MRI or "dilatation and curettage alone", then performing major surgery before a credible trial of an LNG-IUS or medical therapy ^[1].

Full topic. gynaecology/abnormal-uterine-bleeding

Presenting picture. Primary: never menstruated by the expected age, often with absent secondary sexual characteristics. Secondary: periods stop for several months in a previously menstruating woman. Consider pregnancy, weight change, stress, exercise, drugs, thyroid disease, galactorrhoea and hot flushes.

Single most likely diagnosis. Pregnancy in secondary amenorrhoea; polycystic ovary syndrome if there is oligo/amenorrhoea with hyperandrogenism; hypothalamic amenorrhoea after weight loss, severe stress or excessive exercise; premature ovarian insufficiency if there are menopausal symptoms before age 40.

Best first test. A pregnancy test first. Then tailor tests to the pattern: prolactin and thyroid-stimulating hormone if there are galactorrhoea or thyroid features; FSH and LH to distinguish hypothalamic/pituitary causes from ovarian failure; assessment for hyperandrogenism where features suggest polycystic ovary syndrome. Weight loss of over 15% of ideal body weight is associated with menstrual dysfunction and secondary amenorrhoea ^[10].

Do not do. Do not prescribe a combined hormonal contraceptive to 'regulate' periods before the cause has been sought, and do not miss pregnancy in someone with irregular cycles.

Best first treatment. Treat the underlying cause: restore nutrition and energy balance in hypothalamic amenorrhoea; use cyclic or continuous progestogen to protect the endometrium when oestrogen is present; refer for oestrogen replacement when ovarian insufficiency is confirmed. In polycystic ovary syndrome, manage symptoms and cardiometabolic risk, with ovulation induction only when fertility is desired.

Commonest wrong answer. Calling a shortened or irregular cycle 'normal', or reassuring a patient that stress alone explains absent periods when red-flag features such as headache, visual change or galactorrhoea are present.

Full topic. gynaecology/amenorrhoea

Presenting picture. Chronic pelvic pain with dysmenorrhoea severe enough to limit daily life, deep dyspareunia, cyclical gastrointestinal or urinary symptoms, and sometimes infertility in women of reproductive age.

Single most likely diagnosis. Endometriosis, including disease not seen on a normal scan.

Best first test. Transvaginal ultrasound to look for an ovarian endometrioma or deep endometriosis and to exclude other pathology ^[2]. A normal ultrasound does not exclude endometriosis ^[2].

Best first treatment. NICE NG73: a short trial (about 3 months) of paracetamol or an NSAID, alone or in combination, and hormonal treatment such as the combined oral contraceptive pill or a progestogen for suspected, confirmed or recurrent disease ^[2]. Hormonal treatment reduces pain without permanent negative effects on later fertility ^[2].

Commonest wrong answer. Stopping the consultation because the ultrasound is normal, or proceeding straight to laparoscopy before a credible analgesic and hormonal trial.

Full topic. gynaecology/endometriosis

Presenting picture. Lower abdominal or pelvic pain with pelvic tenderness, cervical motion tenderness, abnormal vaginal discharge, fever or abnormal bleeding; often after a new sexual partner or an untreated lower genital infection. It may be mild or clinically silent.

Single most likely diagnosis. Pelvic inflammatory disease (PID) from an ascending infection, usually chlamydia or gonorrhoea, often with anaerobes.

Best first test. Clinical diagnosis supported by nucleic acid amplification testing (NAAT) for chlamydia and gonorrhoea, pregnancy testing and a vaginal/cervical swab. Ultrasound helps exclude a tubo-ovarian abscess or ectopic pregnancy. Treatment should not wait for results when PID is likely.

Best first treatment. Empirical broad-spectrum antibiotics covering chlamydia, gonorrhoea and anaerobes. Metronidazole remains a first-line agent for bacterial vaginosis and is commonly included in PID regimens ^[6]. Arrange partner notification and treatment, and review for complications such as infertility and chronic pain.

Commonest wrong answer. Waiting for culture results, treating a single organism only, or treating the woman without partner management.

Full topic. gynaecology/pelvic-inflammatory-disease

Presenting picture. Sudden severe unilateral pelvic pain, nausea and vomiting, often with a known ovarian cyst or mass; pain may be intermittent as the ovary twists and untwists.

Single most likely diagnosis. Adnexal/ovarian torsion with venous congestion progressing to ischaemia; delay risks loss of the ovary.

Best first test. Ultrasound is the first-line imaging modality in suspected torsion ^[5]. Look for an enlarged ovary, abnormal position and the whirlpool sign; do not exclude torsion simply because colour Doppler flow is still present.

Best first treatment. Urgent laparoscopy with detorsion and ovarian conservation whenever the ovary is viable; avoid routine oophorectomy.

Commonest wrong answer. Dismissing torsion because Doppler flow is preserved, or delaying surgery while repeating scans.

Full topic. gynaecology/ovarian-torsion

Presenting picture. A woman wants to start, change or stop contraception, or a method has failed. The presenting question is usually choice and eligibility, not pathology: bleeding pattern, past thrombosis, migraine with aura, cancers, medicines, postpartum status and the need for sexually transmitted infection (STI) protection.

Single most likely diagnosis. No diagnosis is required; the task is to match a suitable method to the woman's priorities and medical eligibility.

Best first test/assessment. Take a medical, gynaecological and sexual history and check blood pressure before offering combined hormonal contraception. Review current medicines and any conditions that contraindicate oestrogen-containing methods. ^[4]

Best first treatment. World Health Organization guidance: implants, intrauterine devices and sterilisation are highly effective, long-lasting methods; pills, injections, patches and rings work well when used correctly; condoms are the only methods that protect against both pregnancy and STIs, and are effective when consistent ^[4]. Offer long-acting reversible contraception when a woman wants highly effective, user-independent contraception; combined or progestogen-only methods when she prefers self-administered methods; emergency contraception when indicated. Use the WHO medical eligibility criteria or national equivalent when there is any doubt.

Commonest wrong answer. Prescribing combined hormonal contraception despite a contraindication such as migraine with aura, a thromboembolic risk or a relevant cancer history; or forgetting that condoms are the only option given here that also prevents STIs ^[4].

Full topic. gynaecology/contraception

Presenting picture. Twelve months of regular unprotected intercourse without conception in a woman of reproductive age ^{[10] [11]}; polycystic ovary syndrome may present with oligo/amenorrhoea, acne, hirsutism, weight gain and acanthosis.

Single most likely diagnosis. In infertility, often "unexplained" after initial testing; tubal or male factors and ovulatory disorders are common identifiable causes. In polycystic ovary syndrome, Rotterdam-style criteria: at least 2 of 3 of oligo/anovulation, hyperandrogenism and polycystic ovaries; if two core features are present, ultrasound is not necessary for diagnosis ^[10].

Best first test. For infertility, take a sexual and menstrual history and do tests for both partners: semen analysis with WHO 2010 reference values, confirmation of ovulation (mid-luteal progesterone greater than 3 ng/mL), and hysterosalpingography as a first-line tubal screen in women with no suspected pelvic disease ^[10]. If semen analysis is abnormal, repeat it within 2 to 4 weeks; if normal, one analysis is sufficient ^[10]. For polycystic ovary syndrome, do not make the diagnosis on ultrasound alone; combine clinical and biochemical assessment ^[10].

Do not do. Do not investigate the woman alone, and do not start ovulation induction before semen analysis and tubal patency have been assessed.

Best first treatment. Address modifiable factors: weight optimisation, smoking and alcohol. For anovulatory polycystic ovary syndrome, NICE/ESHRE aligned guidance lists letrozole 2.5 to 5 mg on days 3 to 7 as first-line pharmacological ovulation induction ^[10]. If letrozole is unavailable or not permitted, other ovulation-induction agents or lifestyle-first approaches are used; escalation moves through ovulation induction, intrauterine insemination and in vitro fertilisation.

Commonest wrong answer. Focusing on the woman while ignoring semen analysis, or diagnosing polycystic ovary syndrome from an ultrasound view of multicystic ovaries without oligo/anovulation or hyperandrogenism.

Full topics. gynaecology/infertility and gynaecology/polycystic-ovary-syndrome

Presenting picture. Vasomotor symptoms (hot flushes and sweats), sleep disturbance, mood change, joint aches and genitourinary symptoms with menstrual change in a woman usually aged 45 or older.

Single most likely diagnosis. Perimenopause or menopause diagnosed clinically without laboratory tests in an otherwise healthy woman aged 45 or over with menopause-associated symptoms ^[3].

Best first test. Usually none. In women aged 40 to 45 with menopause-associated symptoms, or in women under 40 when menopause is suspected, consider serum FSH to confirm menopause ^[3]. Do not use FSH in women using combined oestrogen and progestogen contraception or high-dose progestogen, and do not use anti-Mullerian hormone, inhibin A/B, oestradiol, antral follicle count or ovarian volume to diagnose menopause at any age ^[3].

Best first treatment. NICE NG23: offer hormone replacement therapy (HRT) for vasomotor symptoms ^[3]. Consider menopause-specific cognitive behavioural therapy in addition to HRT, or when HRT is contraindicated or declined ^[3]. Do not routinely offer SSRIs, SNRIs or clonidine as first-line treatment for vasomotor symptoms alone ^[3]. Offer vaginal oestrogen for genitourinary symptoms, alone or with non-hormonal moisturisers or lubricants ^[3].

Commonest wrong answer. Ordering FSH in a 48-year-old with a classic clinical picture, or offering systemic HRT alone for vaginal atrophy when local vaginal oestrogen is first line.

Full topic. gynaecology/menopause

Presenting picture. Often asymptomatic and found on screening; intermenstrual, postcoital or postmenopausal bleeding, offensive discharge or pelvic pain in symptomatic disease. Almost all cases are caused by persistent oncogenic human papillomavirus (HPV) infection ^[9].

Single most likely diagnosis. Cervical cancer or high-grade cervical intraepithelial neoplasia when a visible cervical lesion or abnormal screening test is present.

Best first test. HPV vaccination for prevention and regular screening for precancer ^[9]. NICE/WHO-aligned practice: screen from age 30 with HPV-based methods, from age 25 in women living with HIV ^[9]. A visible lesion needs histology; cytology and HPV testing are screening, not diagnostic, tools.

Best first treatment. Prevention and early detection: HPV vaccination of girls and appropriate screening, then treatment of precancer and early invasive disease pathways. Women living with HIV have a markedly higher risk and should be screened earlier ^[9].

Commonest wrong answer. Reassuring a woman with a visible, friable cervical lesion that a normal smear excludes cancer.

Full topic. gynaecology/cervical-cancer

Presenting picture. Vague but persistent symptoms: abdominal distension or bloating, early satiety, pelvic/abdominal pain, urinary urgency or frequency; possible ascites or pelvic mass. It is often diagnosed late.

Single most likely diagnosis. Epithelial ovarian cancer when persistent new symptoms occur, especially in women aged 50 or over, with ascites, pelvic mass or raised cancer antigen 125 (CA125).

Best first test (NICE NG12). In women under 40 with persistent symptoms suggestive of ovarian cancer, do not use CA125 alone for decision making; consider an urgent direct-access pelvic ultrasound ^[8]. In women 40 or over with persistent symptoms, measure serum CA125 and arrange an urgent direct-access ultrasound according to age and CA125 thresholds ^[8]: 35 IU/mL or greater at ages 40 to 49, 31 IU/mL or greater at 50 to 59, 24 IU/mL or greater at 60 to 69, 25 IU/mL or greater at 70 to 79, and 31 IU/mL or greater at 80 or over ^[8]. NICE's ovarian cancer guideline recommends CA125 in secondary care (plus alpha-fetoprotein and beta-hCG in women under 40) and an ultrasound of abdomen and pelvis as the first imaging test in secondary care ^[7].

Best first treatment. Refer anyone with ascites or an unexplained pelvic/abdominal mass that is not obviously fibroids, or CA125 and ultrasound findings suggesting ovarian cancer, through a suspected cancer pathway to a gynaecological cancer multidisciplinary team ^{[7] [8]}. Do not wait for another imaging modality to become available.

Commonest wrong answer. Calling persistent bloating and urinary frequency 'irritable bowel syndrome' in a woman aged 50 or over, or relying on a normal CA125 in a younger woman as full exclusion.

Full topic. gynaecology/ovarian-cancer

Presenting picture. Unexplained postmenopausal bleeding is the classic symptom; intermenstrual or heavy bleeding in perimenopausal women; vaginal discharge, pelvic pain or haematuria in more advanced disease.

Single most likely diagnosis. Endometrial carcinoma, especially when postmenopausal bleeding occurs in a woman aged 55 or over or when metabolic risk factors are present.

Best first test (NICE NG12). Refer women aged 55 or over with unexplained postmenopausal bleeding that cannot be attributed to HRT through a suspected cancer pathway ^[8]. Consider an urgent direct-access pelvic ultrasound in those aged 55 or over with postmenopausal bleeding plus other specified features, and consider referral under 55 with unexplained postmenopausal bleeding ^[8]. Note that there is limited evidence for bleeding associated with HRT and no evidence-supported algorithm is provided ^[8].

Best first treatment. Suspected cancer pathway referral and specialist assessment rather than empiric medical treatment or repeat prescribing of HRT.

Commonest wrong answer. Treating postmenopausal bleeding as 'expected hormone fluctuation', or adjusting HRT without investigating the bleed.

Full topic. gynaecology/endometrial-cancer

Presenting picture. Change in colour, amount or odour of vaginal discharge, with or without pruritus, external dysuria, dyspareunia or lower abdominal pain. The cause is suggested by the character of the discharge and examination.

Single most likely diagnosis. Vulvovaginal candidiasis when discharge is white, thick and itchy; bacterial vaginosis when discharge is thin, grey and fishy-smelling; trichomoniasis when discharge is frothy and yellow-green; cervicitis due to chlamydia or gonorrhoea when there is mucopurulent discharge and cervical tenderness.

Best first test. A focused history and speculum examination with vaginal pH, microscopy and appropriate swabs or NAAT testing. Avoid starting antibiotics or antifungals blindly when the diagnosis is unclear; test first whenever feasible.

Best first treatment. Match treatment to the identified cause. Metronidazole remains a first-line treatment for bacterial vaginosis ^[6]; trichomoniasis requires metronidazole with partner treatment; vulvovaginal candidiasis is treated with an azole pessary or cream. For suspected chlamydia or gonorrhoea, treat according to the positive NAAT result and current national guidance.

Commonest wrong answer. Treating every discharge as 'thrush', or treating bacterial vaginosis repeatedly without testing for an STI, especially after a new partner.

Full topic. gynaecology/vaginal-discharge

Presenting picture. A woman notices a new lump, thickening, nipple change, skin dimpling, focal pain or nipple discharge. Most breast lumps are benign, but some are malignant, and the risk rises with age.

Single most likely diagnosis. A benign breast condition (cyst, fibroadenoma or normal nodularity) in a young woman; breast cancer if the patient is older or the lump is hard, irregular, fixed or associated with skin or nipple change.

Best first test/management. Use the suspected cancer pathway ^[8]. Refer urgently (suspected cancer pathway) women aged 30 or over with an unexplained breast lump, with or without pain, or with unilateral nipple discharge, retraction or other concerning changes at age 50 or over ^[8]. Consider non-urgent referral for women under 30 with an unexplained breast lump, with or without pain ^[8]. Skin changes suggesting breast cancer also warrant consideration of urgent referral ^[8].

Best first treatment. Refer to the appropriate breast cancer or benign breast service for triple assessment and definitive management; do not reassure and observe a clinically suspicious lump.

Commonest wrong answer. Reassuring a young woman that a hard, fixed or enlarging breast lump is 'hormonal', or following an older woman's self-detected lump with observation instead of referral.

Full topic. gynaecology/breast-lump