As gynaecology issues uncommonly present on the ward, many doctors have difficulties with the standard framework for addressing these issues. The classic referrals to gynaecology are:
- The nursing staff have noted vaginal bleeding. Could this be assessed?
- Could this abdominal pain be gynaecological?
- The abdominal scan has shown a pelvic mass or ovarian cyst. What shall we do?
Having a framework will enable you to provide a clear referral expediting care for your patient so bear in mind the important aspects listed below. Each section is linked to relevant resources for you to help categorise the exact condition your patient might be affected by.
Gynaecological History:
- PV bleeding
- Consider whether bleeding may be from the rectum or urethra
- When does the bleeding occur? e.g. postcoital, intermenstrual
- Are they on anticoagulation? Do they have symptomatic anaemia?
- Abdominal pain
- Never forget pregnancy in any woman of childbearing age (think ectopic)
- More detailed systems review of known gastrointestinal/urological & gynaecological disease
- For incidental mass on CT/MRI
- Focus on red flags: weight loss, fever, night sweats, bloating
- Risk factors: smoking, fertility history, family or personal history of cancer
- Vulval disorders
- Itch, discharge (quantity, colour, odour), burning sensation, bleeding, dyspareunia, dysuria, warts, lumps
- Consider autoimmune disorders & diabetes
- Menstrual history: Last menstrual period, duration, quantity (pads/tampons), menopause status
- Smear history
- Previous sexually transmitted infections
- Previous gynaecological procedures: hysteroscopies/laparoscopies
- Obstetric history: parity, mode of delivery, complications
- Contraception: type, duration, any problems
- Also for women of childbearing age, consider whether medications are teratogenic or reduce the efficacy of contraception
- Also, consider the impact of hormonal contraceptives which could interact with medication you’re prescribing
- If in doubt, check with your pharmacist!
- Associated symptoms: abdominal pain, fever, vomiting, gastrointestinal/urological/gynaecological disease
- Relevant medical history
- Medication history (have they tried anything in the past?)
- Abdominal examination (usual tenderness, peritonism & masses)
- Speculum
- If bleeding: identify whether this is external, vaginal, cervical or uterine & the extent of blood
- Bimanual (masses or adnexal tenderness)
Investigations:
- Usual bloods, pregnancy test (beta HCG) & tumour markers (CA 125)
- High vaginal swabs
- Consider abdominal ultrasound (particularly for abdominal pain)
- Transvaginal ultrasound scan is usually best
- Physiological from menstruation, fibroids, miscarriage, endometriosis/adenomyosis, ectopic pregnancy, trauma, deranged clotting
- Often on a ward setting, you are assessing a patient with postmenopausal bleeding
- Gynae: ruptured ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, endometriosis, adenomyosis, fibroids
- Non-gynae: gastrointestinal, urological, functional
- Atrophic vaginitis, lichen sclerosus, lichen planus, herpes simplex, syphilis, trichomonas, human papillomavirus, bacterial vaginosis, candidiasis, chlamydia, gonorrhoea
Written by Paula Busuulwa, FY3 London
Edits by Dr Akash Doshi CT2
