Top ten advice and guidance requests in gynaecology

In the next in our series sharing expert insights on the most common advice and guidance (A&G) requests in key specialties, consultant gynaecologist Dr Pallavi Latthe and gynaecology trainee Dr Bara’a Elhag highlight the ten most common requests received in their Gynaecology A&G service and explain how these are managed

Note all requests feature hypothetical cases created for illustrative purposes

1. Heavy menstrual bleeding (HMB)

Q: A 40-year-old woman with one previous caesarean section and one vaginal birth has a long-term history of heavy menstrual bleeding that interferes with her activities of daily living. Her cycles are regular, bleeding associated with flooding and clots lasts about 7 days and she usually feels fatigued and light-headed especially in the first 3 days. Her mother had a hysterectomy in her 30s for heavy periods. Bloods show Hb 100, normal thyroid function. She has tried POP in the past but stopped taking it as it caused acne. She tried tranexamic acid in the last three periods, but feels this hasn’t made much difference. Her USS arranged via community is normal.

A: Clarify bleeding history. If there is history of intermenstrual or postcoital bleeding, do a speculum examination, ensure smear history is up to date, and consider STI screen.

First line hormonal option would be levonogestrel IUS device for at least 6 months, especially if the patient is not planning to conceive. Other hormonal options are norethisterone 5mg TDS day 5-26 of cycle for 6 months initially; or injectable long acting progestogens every 12 weeks. Inform the patient of common side effects such as irregular spotting, low mood or weight gain. Combined pill is relatively contraindicated over 35 years of age.

If the patient is unresponsive to oral treatments or prefers surgical treatment like endometrial ablation or hysterectomy, refer to secondary care.

2. Ovarian cyst (premenopausal)

Q: A 34-year-old woman presents with a 6-week history of persisting lower abdominal discomfort, particularly on the right side which has now subsided. She has no other associated symptoms. She is sexually active, uses regular oral contraceptives and is up to date with her cervical smears which have been normal. An USS pelvis, arranged when she was in pain, shows a right ovarian cyst that measures 5cm ? dermoid cyst. How should I proceed?

A: The majority of ovarian masses/cysts are benign in pre-menopausal patients. A serum CA-125 assay does not need to be undertaken in all premenopausal women when an ultrasonographic diagnosis of a simple ovarian cyst has been made.

As the patient is under age 40, order blood tests to measure lactate dehydrogenase (LDH), α-FP and hCG, to rule out the possibility of germ cell tumour. Mature cystic teratomas (dermoid cysts) grow over time, increasing the risk of pain and ovarian accidents.

As the cyst is between 5-7cm and she is asymptomatic, it can be followed up with another scan in 12 months. If it increases in size or symptoms recur, she can be referred to secondary care for surgery.

3. Hormone replacement therapy

Q: A 52-year-old woman with 3 children presents with a 6-month history of hot flushes, mood swings and night sweats disrupting her sleep. She works as a primary school teacher, leads an active, healthy lifestyle and is a non-smoker. Her BMI is 33. She had an episode of DVT in first pregnancy and her last period was 7 months ago and she has with migraines with aura. She requests HRT. How should I proceed?

A: This patient gives a history of a provoked DVT therefore the recommendation would be to avoid any oral preparations of HRT but you can offer transdermal patches or oestrogel (2 pump actuations) with utrogestan 100mg daily for first 12-14 days every month. The transdermal preparation has no associated increased risk of thromboembolism. If the DVT had been unprovoked, HRT would be contraindicated unless she is on anticoagulation. In this case, there is no need for additional investigations such as thrombophilia screen.

As she is less than 1 year since last menstrual period and under 54 years of age, use sequential HRT. With a history of migraines, she can increase the dose of oestrogen gradually (eg, quarter patch twice a week for 2 weeks and then half a patch twice a week for 2 weeks before starting on 1 full patch twice a week).

Other options to consider depending on symptoms are vaginal oestrogen and non-hormonal treatments (lifestyle measures, cognitive behavioural therapy, clonidine, pregabalin, gabapentin, SSRI/SNRI).

4. Prolapse and urinary incontinence

Q: A 58-year-old retired childminder is complaining of a low abdominal bulge that has become more uncomfortable over the past few months and is worse after prolonged standing. She has stress incontinence. She also wets without warning and has urgency. She needs to use up to 4 pads per day. She has well controlled hypertension, and takes duloxetine for diabetic neuropathy. She has a BMI of 38. A trial of pelvic floor exercises in the community for 3 months has had little effect. She is currently on solifenacin 5mg daily. What next?

A: Evaluate for nocturia, incomplete emptying, dysuria, poor flow, fluid intake (caffeine, fizzy drinks) and constipation. She can maintain a 3-day bladder diary to assess the types of fluids she is drinking, functional bladder capacity, episodes of leaks associated with activity and urgency.

If the urgency is still bothersome, consider increasing the solifenacin to 10mg daily.

Advise that she should avoid caffeine/fizzy drinks and reduce fluid intake to 1-1.5L per day.

The stress incontinence will improve by 50% if she manages to lose weight by BMI of 5 or more. Is she a candidate for weight loss medication given the fact that she also has type 2 diabetes and hypertension?

If there is evidence of vulvovaginal atrophy, consider vaginal oestrogen in the form of cream or pessaries.

She can consider support ring pessary insertion along with continuing pelvic floor exercises, which may help with the prolapse symptoms. This can be fitted by a GPSI in women’s health. Intravaginal devices like Contrelle or Diveen (available on GP prescription or to buy online) can reduce incontinence during physical activities like walking and exercise.

If she wishes to have surgery, she can be referred to secondary care. Some units will not offer surgery until BMI is 35 or below.

5. PCOS

Q: A 15 year-old student with a history of irregular periods since menarche and persistent acne has not had a period for 8 months. Her mother reports noticeable weight gain of around 9kg over the last year. Her hormonal profile is normal. She is embarrassed about excess facial and body hair. How should she be managed in the first instance?

A: Irregular menstrual cycles (<1 year post-menarche) represent normal pubertal transition. Adolescent PCOS is:

Irregular menstrual cycles defined according to years post-menarche; > 90 days for any one cycle (> 1 year post-menarche), cycles< 21 or > 45 days (> 1 to < 3 years post-menarche); cycles < 21 or > 35 days (> 3 years post-menarche) and primary amenorrhea by age 15 or > 3 years post-thelarche.
Hyperandrogenism defined as hirsutism, severe acne and/or biochemical hyperandrogenaemia (LH:FSH ratio >1.5), low SHBG, raised testosterone, raised free androgen index on blood tests ideally taken between D3-5 of her periods.

A pelvic ultrasound scan is not indicated under 18 years of age unless testosterone levels are high.

Take the following measures:

Recommend lifestyle measures to encourage weight loss to improve symptoms and overall health.
Check HbA1C which is raised in 30% of women with PCOS; also screen for sleep apnoea, cardiovascular disease, hypertension and anxiety/depression.
Suggest waxing or laser treatment to counter hirsuteness.
Consider prescribing the combined oral contraceptive (COC), provided there are no contraindications.
If her HbA1C is raised, she can be prescribed metformin.
If she is unwilling to take hormonal contraceptive pills, encourage weight loss and prescribe norethisterone 5mg three times a day for 7 days every 3 months to get a withdrawal bleed.

6. Chronic pelvic pain

Q: A 26-year-old woman with constant dull ache in her lower abdomen and intermittent sharp pain that worsens during her menstrual cycles has been referred to secondary care for possible endometriosis. She has menstrual dyschezia and dyspareunia. Her pelvic USS is normal. She tried CHC for 2 months but stopped due to low mood. She has been taking regular analgesia including naproxen but this is not helping enough and she is struggling with her work. Is there anything else we can try while she is waiting to be seen in the hospital?

A: She should have had an STI screen within the past 12 months.

Management includes a combination of analgesics (paracetamol, NSAIDs, nefopam and neuromodulators) and hormonal suppression. Encourage healthy lifestyle and ensure that there is no constipation.

Options include the POP like desogestrel or Slynd (drospirenone) 1 tablet daily continuously, or a Depo Provera injection every 12 weeks to see whether the pain improves. If she wants long-term contraception, she can consider having an IUS fitted.

7. Fibroids

Q: A 34-year-old woman presented with pain in her lower back pain and heavy menstrual bleeding. She does not have urinary or bowel symptoms. US pelvis shows 4 intramural fibroids, the largest being 5cm in diameter. She is trying to conceive. What advice should be given regarding management of fibroids and pregnancy?

A: Fibroids are the most common benign uterine tumours in women of reproductive age and are commonly diagnosed as an incidental finding on scan.

Check FBC to assess for iron deficiency anaemia. Offer analgesia (NSAIDs) and tranexamic acid that can be taken during menses.

There is an association between the presence of submucosal fibroids, subfertility and pregnancy loss. But studies suggest that non-cavitary-distorting intramural fibroids result in a reduced clinical pregnancy rate and live birth rate, depending on their location and size. While some studies show increased pregnancy rates after myomectomy for intramural fibroids, other studies have found no significant improvement, making the evidence inconsistent.

If she has been trying to conceive for 12 months, refer her to the fertility services with all the primary care investigations including partner’s semen analysis.

8. Adolescent dysmenorrhoea

Q: A 16-year-old with a background of regular menstrual cycles complains of severe dysmenorrhoea, sometimes associated with vomiting, diarrhoea, and dizzy spells. She reports that she starts feeling cramps 2-3 days before her period is due and this lasts throughout the bleeding phase. She has tried simple analgesia but with limited effect. The pain is so severe that she has to miss school for 2 days every month. She is worried about endometriosis. She is not keen on the COC as she is worried about weight gain. She has GCSE exams this year. What would you advise?

Is she sexually active and if yes, has she had an STI screen?

Does she have other symptoms suggestive of endometriosis, ie, cyclical or menstrual dyschezia, noncyclical pelvic pain or dyspareunia?

If not, it is likely that she has primary dysmenorrhoea and can be reassured. The most common cause of secondary dysmenorrhea is endometriosis which is present in 10% of women but initial management is no different.

Most adolescents who present with dysmenorrhea will respond well to empiric treatment with NSAIDs or hormonal suppression, or both.

Options include ibuprofen 800mg initially followed by 400mg every 8 hours for the 3-4 days when the cramps are severe. Alternatively, offer mefenamic acid 500mg three times a day whenever she has the period cramps.

Analgesic options include paracetamol 1g four times a day and buscopan up to 3 times a day, in addition to the NSAIDs along with hot water bottle.

Reassure the patient that COC does not cause weight gain, and suggest a trial of COC back to back for 3-4 packets, with repeat treatment after 4-7 day break, especially if NSAIDs alone are not adequate for symptom relief. Alternatively, try progesterone-only preparations or Depo Provera injection every 12 weeks.

Refer for pelvic ultrasound and outpatient gynaecology if symptoms do not resolve following 3- 6 months of treatment.

9. Vulval itching

Q: A 65-year-old woman has a 3 month history of severe itching and discomfort in the genital area. This has not improved with Canestan and 1% hydrocortisone cream. On examination she has thinning of the skin with pearly white labia in lower half and some vulvo vaginal atrophy. Do I need to refer her or can I start dermovate treatment in primary care?

A: Important aspects from the history include any dermatological conditions (eczema, dermatitis or psoriasis) and personal/family history of autoimmune disorders, eg, diabetes/thyroid dysfunction, associated with higher rates of lichen sclerosis/lichen planus.

Perform a thorough examination of the anogenital region as well as buccal mucosa and nails, elbows and knees.

If there is vulvovaginal atrophy, prescribe local oestrogen in the form of pessaries or cream (daily at night for 3 weeks and then twice a week for 3 to 6 months).

The clinical picture suggests lichen sclerosus. Prescribe dermovate (clobetasol propionate) ointment or cream daily at night for vulval application on affected area for 1 month, alternate night in the second month and then twice weekly thereafter.

She can use hydromol or E45-like emollients for washing and follow advice on vulval hygiene measures. Review again at 6 weeks and if symptoms have not improved refer to specialist vulva clinic or general gynaecology clinic.

10. Recurrent miscarriage

Q: A 36-year-old mother of 2 presents following her second spontaneous miscarriage. She had 2 previous vaginal deliveries 3 and 5 years ago. She had a spontaneous miscarriage at 7 weeks gestation 1 year ago and last month she had another spontaneous miscarriage at 8 weeks gestation. Her BMI is 45 and she smokes 3 cigarettes per week. Please advise on whether she would be suitable to be seen in recurrent miscarriage clinic.

A: Women who have had 3 miscarriages or more (do not have to be consecutive miscarriages) warrant referral to a recurrent miscarriage clinic for further investigation. Women often want to know what the cause of their miscarriage is, the majority of cases being chromosomal mismatch for which there is no treatment.

For this patient the most important advice to give is regarding smoking cessation and weight loss to maintain a BMI between 19 and 25, as both these risk factors have significant correlation with occurrence of first trimester miscarriage. You can also advise she reduces alcohol consumption and caffeine intake and improves sleep quality. Send blood tests for full blood count, vitamin D and thyroid function (abnormalities here have all been linked to recurrent miscarriage) and treat any abnormal results. Also advise the patient to take multivitamins. While multivitamins may play a role in preventing miscarriage, particularly when addressing specific deficiencies, they don’t universally reduce the risk of miscarriage. Specifically, folate and B vitamins, especially in women with recurrent miscarriage, may influence the risk of spontaneous miscarriage. Additionally, vitamin D deficiency is linked to a higher risk of miscarriage.

Women who experience miscarriage can be signposted to the Miscarriage Association UK and local charities for further information and psychological support.

Dr Pallavi Latthe is Consultant Gynaecologist and Clinical lead Paediatric and Adolescent Gynaecology, and Dr Bara’a Elhag is ST2 in Obstetrics and Gynaecology at Birmingham Women’s and Children’s NHS Foundation Trust