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At the heart of general practice since 1960

What not to do - women's health

GP Dr Fiona Cornish guides you through the facets of a women’s health consultation that you no longer need to undertake

Patient assessment

Do not use basal body temperature charts to confirm ovulation1

These charts do not reliably predict ovulation and are not recommended, although there are more sophisticated ovulation prediction kits available commercially. Used carefully, these can help couples gauge when to have intercourse to maximise chance of pregnancy.

Do not perform auscultation of the foetal heart routinely2

This is not recommended as it is unlikely to have any predictive value. Foetal movements indicate that the baby is alive, and auscultation offers nothing extra, but we must not underestimate the benefit to mothers who find it very reassuring to know the heart is beating, and there are zero cost implications. A Sonicaid, or similar handheld ultrasound device, which gives a loud galloping sound of the foetal heart, always brings a smile to the anxious mother. It is probably time to relegate the trumpet-like foetal stethoscope, but don’t abandon the handheld ultrasound device.

Investigations

Do not take routine smears in women under 253

It is no longer recommended to take routine smears in women under 25 as the benefits are outweighed by the harms.

If 100,000 women aged 20-24 were invited for a smear test, research shows that up to 23 cancers overall would be prevented. When they excluded very early-stage cancers, where the treatment is often the same as for pre-cancers, routine screening prevented only three to nine cancers from developing, but this would also mean that an estimated 3,000 young women would be treated unnecessarily.

Screening picks up changes in the cervix that, in younger women, almost always return to normal without treatment. Screening under-25s means many would be treated unnecessarily for changes that would not have caused any harm if left alone, and treatment brings side-effects, as well as great anxiety.

This research makes it clear that the policy change to stop cervical screening in women aged between 20 and 24 in England is well justified from a health perspective, and is not a cost-cutting exercise.

Do not carry out hormone testing in heavy menstrual bleeding (HMB)4

This is of no benefit in these patients. The main purpose of investigation is to exclude endometrial cancer or atypical hyperplasia, so ultrasound and biopsy are the appropriate investigations. Then suitable medical treatment can be started if necessary.

Do not offer pregnant women screening for bacterial vaginosis2

Evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk of pre-term birth or other adverse reproductive outcomes. Of course, if a pregnant woman presents with vaginal discharge, it is entirely appropriate to take a vaginal bacterial swab. 

Do not offer pregnant women routine screening for group B streptococcus2

Evidence of the clinical and cost-effectiveness of this remains uncertain. Testing for group B streptococcus becomes very relevant post-delivery if a neonate becomes unwell.

Do not perform a high vaginal swab (HVS) unless clinically indicated

A routine HVS used to be a requirement before inserting an intrauterine contraceptive device (IUCD), but our local guidelines have now changed to say that the HVS only has to be done if clinically indicated. So for a woman with a regular partner, who is coming for a change of IUCD, we no longer ask for routine swabs. They seldom produced any positive results and were an inconvenience for the woman, as she had to make an extra visit to the surgery and then ring for the results, before coming for the fitting appointment itself. We now only do chlamydial swabs before IUCD insertion if the woman is in the under-25 age group or is at clinical risk, for example, because of having multiple partners. The pre-IUCD counselling would highlight the dangers of infection with a device in situ, and include advice about reducing risky sexual behaviour.   

Do not perform an HVS if the woman has no concerns or history of STI

These are no longer necessary before empirical treatment on the basis of symptoms and signs. Reducing the number of swabs benefits patients, and allows immediate treatment without follow-up appointments. Bacterial vaginosis and candida (thrush) can be diagnosed on the basis of symptoms, with a speculum examination if necessary. If there is a risk of STI, the first investigation is a low vaginal swab for chlamydia, which the woman can take herself.

Treatment

Do not refer women with HMB for hysterectomy4

Hysterectomy has virtually no place nowadays in the treatment of heavy menstrual bleeding as so many drug treatments are available, from tranexamic acid to progesterone in the form of Mirena.

Do not advise women to take additional contraception during or after a course of antibiotics5

New guidelines from the Royal College of Obstetricians and Gynaecologists and Faculty of Sexual and Reproductive Healthcare in 2011 confirmed that women are no longer advised to take additional contraceptive precautions during or after a course of antibiotics. If vomiting or diarrhoea occur, additional precautions are still necessary. 

Do not double the dose of Cerazette in women over 70kg

For the older progestogen-only pills (POPs), such as Micronor and Femulen, it was recommended to double the dose in women over 70kg, but this is not necessary for the newer POP, Cerazette. This is related to the fact that it inhibits ovulation, which the older POPs did not. A major advantage of Cerazette over the older POPs is the 12-hour window for taking the pill; the previous three-hour window made compliance difficult.

Do not offer iron supplementation routinely for pregnant women2

This does not benefit the mother’s or the baby’s health and may have unpleasant maternal side-effects, most commonly constipation and abdominal pain.

Avoid oral treatments for vaginal candidiasis in pregnancy2

The effectiveness and safety of oral treatments, for example fluconazole, are uncertain and the advice is to avoid these and stick to a one-week course of topical treatment, such as clotrimazole.

Dr Fiona Cornish is a GP in Cambridge and a former president of the Medical Women’s Federation

References

  1. NICE. CG156: Fertility. London: NICE; 2013
  2. NICE. CG62: Antenatal care. London: NICE; 2008
  3. NHS Cervical Screening Programme, 2013
  4. NICE. CG44: Heavy menstrual bleeding. London: NICE; 2007
  5. Faculty of Sexual and Reproductive Healthcare. Drug interactions with hormonal contraception. 2011
  6. Faculty of Sexual and Reproductive Healthcare. Progestogen-only pills. 2008

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Readers' comments (7)

  • good article - I bet even clued up GPs learnt at least one thing from this (I did) and nice to see the references to back it up
    thank you

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  • PS how refreshing to read "GPs must not" article rather than "GPs must"!

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  • As someone in the middle of an under 25 year old cervical cancer death legal case, I must disagree with the current screening policy. I can understand the curret evidence, but the interpretation of the data is flawed.

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  • Dear 12.52 anonymous, please say why you think the interpretation on data on screening is wrong.
    I have to say that I find the only to start screening at 25years sounds very rounded and simplistic.
    There should be a better start date, such as 8years after first intercourse, or age 23 if more than 5 partners.

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  • Excellent article. Tiny point: US assessment of foetal heart takes (negligible) time but it has to be multiplied by the number of times it is done nationwide annually to see the true cost. It diverts time and effort away from more productive activities in order to only provides false reassurance.
    If no GPs did it we wouldn't be expected to conform to patient expectations

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  • useful article . very informative .

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  • very useful. helpful

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