In the second of this two-part series, Cecilia Bottomley discusses patients with gynaecological presentations. This piece covers intermenstrual bleeding and pelvic pain
Intermenstrual bleeding (IMB) is quite common and often no cause is found. The focus of discussion at remote consultation is different depending on whether the woman is using hormonal contraception.
IMB occurs in 20% of women in the first three months of starting the combined oral contraceptive pill (COCP) and in 30% with the progesterone-only pill, and some form of initial irregularity occurs in most women with the contraceptive implant or levonorgestrel-releasing intrauterine device, so it does not require further assessment unless it’s prolonged or there are red flag symptoms (see part 1 of this series).
The traditional ‘five Cs’ should be considered if the woman is taking the contraceptive pill and has prolonged bleeding:
- Compliance (poor).
- Chlamydia (or other sexually transmitted infection).
- Cervical pathology (cancer, ectropion or polyp).
- Co-existing illness (such as diarrhoea that is impeding absorption).
- Conception (pregnancy).
Of these situations, pregnancy, poor compliance and co-existing illness can be ascertained remotely. Chlamydia status can be tested using a home STI testing kit, available online. Face-to-face assessment is needed to assess for cervical pathology when the other causes have been excluded.
For women who are not using hormonal contraceptive, midcycle (periovulatory) IMB is usually physiological. However, older women and those with persistent IMB should be seen or referred for further investigations, including:
- An ultrasound scan to assess for endometrial polyps or possible endometrial hyperplasia or malignancy.
- A speculum examination to assess for polyps, ectropion or malignancy.
- A sexual health screen.
While malignancy is the most important concern, most postcoital bleeding is due to a cervical ectropion or an endocervical polyp, which can only be assessed in person with a speculum examination. An STI also must be ruled out, though this can be done using a home test.
Painful periods (dysmenorrhoea)
Although endometriosis is often a fear for women with dysmenorrhoea, most women with painful periods will not have endometriosis and some women with endometriosis do not have painful periods.
Primary dysmenorrhoea – when periods have been painful since menarche – usually does not have an identified pathological cause and the focus at remote consultation should be on management.
In secondary dysmenorrhoea, there is a high chance that the cause is treatable and it should be investigated with:
- An ultrasound scan to assess for any evidence of endometriosis.
- A sexual health screen.
Immediate management should be with mefenamic acid and paracetamol. Encourage the woman to start these as soon as she is aware of the period rather than waiting for symptoms to be bad. Further management, as with menorrhagia, includes the combined pill (if there are no contraindications), the progesterone-only pill (though this might cause more irregular bleeding initially) or the Mirena IUS, which requires a face-to-face consultation. However, if the ultrasound scan shows pathology, such as endometrioma or other abnormality, referral should be made.
Non-menstrual pelvic pain
This should alert the GP to the possibility of gynaecological pathology, like an ovarian cyst, and should warrant an ultrasound scan. If the pain is severe, or sudden in onset but not midcycle – which is suggestive of ovulation pain (Mittleschmirtz) – the woman may require same-day emergency care in case of an ovarian accident, such as torsion or rupture. In this case, the woman should also have a pregnancy test even if she believes she couldn’t be pregnant because she has had a recent bleed or uses contraception.
Endometriosis may also present with noncyclical pelvic pain, although pain with periods or with intercourse commonly co-exist. It is reasonable to start a trial of management with analgesia or hormonal contraception on the basis of a remote consultation, as NICE guidance recommends.
Consider referring women to a gynaecology service if:
- They have severe, persistent or recurrent symptoms of endometriosis.
- They have pelvic signs of endometriosis.
- Initial management is not effective, not tolerated or is contraindicated.
However, given the anatomical proximity of the bladder, recto-sigmoid, ureters and ovaries, women may not be able to distinguish the pain source.
In my practice I spend time taking a detailed history of bowel habit (consistency, frequency, mucus, blood and bloating) and of potential bladder or ureteric symptoms. Where pain is non-menstrual and an ovarian cyst and infection have been ruled out with an ultrasound scan, further gynaecological review is usually fruitless.
Pain with intercourse (dyspareunia)
A good history can be taken remotely to ascertain a likely cause of the dyspareunia. Vaginismus – an involuntary pelvic floor muscle spasm, so the woman feels there is an ‘obstruction’ – is common and treatable generally with specialist women’s health physiotherapy. Vulvodynia is a more focal pain and is usually best managed by a referral for specialist vulval assessment.
Deepdyspareunia, which may be reported both during and after intercourse, requires further assessment with ultrasound and sexual health screen, and, assuming they are normal, non-urgent secondary care referral.
Miss Cecilia Bottomley is a consultant gynaecologist and clinical lead for gynaecology governance at University College London Hospitals
- FSRH Clinical Guideline: Problematic bleeding with hormonal contraception. 2015
- FSRH UK Medical Eligibility Criteria for Contraceptive Use (UK MEC), 2016
- NICE. Heavy menstrual bleeding: assessment and management, updated 2021. NG88.
- NICE. Endometriosis: diagnosis and management, 2017. NG73
For the first part of this article, click here