Women’s Health – Gynaecology Foundations (Phase 3a)

# Women’s Health – Gynaecology Foundations (Phase 3a) **Executive Summary:** This report provides comprehensive UK-focused guidance on common gynaecological conditions. We cover abnormal uterine bleeding (AUB, including menorrhagia), amenorrhoea, menstrual disorders (e.g. PCOS, PMS), dysmenorrhoea, menopause (and associated genitourinary symptoms), pelvic pain (acute and chronic), dyspareunia, vulval/vaginal lesions (lumps, rashes, discharge), pelvic organ prolapse, and urinary incontinence. For each topic we detail “must know” facts, typical presentations with differential diagnoses (highlighting red flags), diagnostic approach (history, exam, investigations), evidence-based management (emphasising NICE/RCOG guidance, first-line drugs with UK dosing and monitoring), emergency red flags, referral criteria (including NICE ‘two-week wait’ rules), and exam-style checklists. We include tables summarising differential diagnoses, investigations (indications and interpretation), and first-line treatments (drug, dose, contraindications). Algorithmic flowcharts (Mermaid) illustrate acute pelvic pain and acute AUB pathways. Advice is rooted in the latest NICE/CUK guidelines and UK practice (NICE NG88, NG73, NG23, NG123, RCOG Green-tops, etc), and citations are given throughout.

## Abnormal Uterine (Vaginal) Bleeding (AUB) ### Core Knowledge - **Definition:** Any change in normal menstrual bleeding (volume, regularity, timing) or bleeding outside the expected cycle. Includes **menorrhagia** (heavy regular bleeding affecting quality of life), **metrorrhagia** (intermenstrual bleeding), **post-coital bleeding**, and **post-menopausal bleeding (PMB)** (any vaginal bleeding >12 months after menses stops). Menorrhagia is often operationally defined as loss >80 mL per cycle or needing superabsorbent pads hourly. Emphasise *impact on quality of life*, not just volume. - **Classification (PALM-COEIN):** Coagulation disorders (e.g. von Willebrand’s), Ovulatory dysfunction (PCOS, thyroid), Endometrial pathology (infection, chronic endometritis), *Leiomyoma* (fibroids), *Adenomyosis*, *Malignancy* (endometrial cancer), *Coagulopathy*, *Ovulatory dysfunction*, *Endometrial*, *Iatrogenic* (IUD, drugs), *Not yet classified*. - **“Must know” priorities:** Pregnancy test for any reproductive-age bleed; differentiate life-threatening causes (see red flags below); suspect endometrial cancer in PMB; initiate basic resuscitation if haemodynamically unstable; recognise **menorrhagia** (heavy periods) as a major cause of anaemia and referral for management.

### Presentation and Differentials **Typical presentation:** Women may report heavy periods (soaking >1 pad/hour or flooding), prolonged menses (>7 days), frequent/unpredictable cycles, intermenstrual spotting, or bleeding after intercourse. History should quantify flow (pad/tampon count, clots), pattern (cycle length variability), and symptoms (dizziness, syncope, fatigue, clots). Ask about systemic symptoms (weight loss, night sweats), bleeding elsewhere (epistaxis, easy bruising) or anticoagulant use. Always confirm last menstrual period, contraceptive/HRT use, and pregnancy risk. **Quality-of-life impact** (work, social life) guides urgency. **Differential diagnoses (pre-menopausal):** - **Structural:** Fibroids (leiomyoma), endometrial polyps, adenomyosis, cervical polyps or cancer, vaginal atrophy, thickened endometrium (hyperplasia). - **Coagulopathy:** Von Willebrand’s disease, thrombocytopenia. - **Endocrine:** Anovulatory cycles (PCOS, thyroid disease, hyperprolactinaemia), hypothalamic amenorrhoea. - **Infection:** Endometritis (rare outside puerperium), cervicitis. - **Medication:** Intrauterine device (copper), anticoagulants, hormone therapies. - **Functional:** Dysfunctional uterine bleeding (by exclusion). **Postmenopausal bleeding (PMB) (>12 months no menses):** *Red flag* for endometrial carcinoma. **Urgent referral** (two-week wait) is indicated for any PMB. Other causes: vaginal atrophy (atrophic vaginitis), hormone therapy bleed, cervical/vaginal carcinoma, uterine polyps. **Red flags (seek urgent help):** Heavy acute hemorrhage causing hypotension/shock; signs of severe anaemia (heart failure); persistent bleeding after >55y; PMB (urgent 2ww referral); intermenstrual bleeding + cervical abnormalities; systemic symptoms (weight loss, anorexia); suspicious pelvic mass.

### Diagnostic Approach **History:** Quantify bleeding (frequency, volume, clots), pain (dysmenorrhoea suggests fibroids or adenomyosis), systemic symptoms, and contraception/medications. Ask about pregnancy risk. Screen for coagulopathy history (nosebleeds, bruising, family bleeding disorders). Clarify impact on life (fatigue, work absenteeism). **Examination:** Begin with vitals (pulse, BP). Look for pallor (anaemia). Abdominal exam for pelvic masses (fibroid uterus, ovarian masses). Speculum exam to identify bleeding source: cervix (erosion, polyps, cervicitis, carcinoma), vagina (atrophy, lichen sclerosus, polyps, carcinoma). Bimanual exam to palpate uterus (size, mobility, tenderness – e.g. boggy in adenomyosis) and adnexa (tenderness or masses). Perform a pelvic exam **before any invasive investigations or IUS insertion**. Pap smear if due or if cervical lesion suspected. **Immediate tests:** - **Pregnancy test (β-hCG):** Mandatory for any AUB in reproductive-age women (rule out pregnancy complications). - **FBC:** Assess anaemia. Start iron if anaemic. - **Coagulation screen:** In adolescents or women with lifelong heavy periods, or personal/family bleeding history. - **Other bloods:** Not routine: avoid thyroid or hormone panels unless indicated by other symptoms. - **Urinalysis:** Check infection. - **Swabs:** If discharge or chorioamnionitis suspected.

**Imaging and specialized tests:** - **Transvaginal ultrasound (TVUS):** First-line for suspected fibroids, polyps, adenomyosis or endometrial thickness (especially PMB). In PMB, an endometrial thickness ≤4 mm on TVUS has high negative predictive value for cancer; if >4–5 mm or if ultrasonographer indeterminate, proceed to hysteroscopy with biopsy. - **Outpatient hysteroscopy:** Consider if ultrasound suggests submucosal fibroid, polyp, or endometrial abnormality. NICE advises picking hysteroscopy vs ultrasound based on history (e.g. intermenstrual bleeding, suspected cavity pathology). - **Endometrial biopsy:** For women ≥45 or with risk factors (obesity, PCOS), or any PMB. Hysteroscopic-directed biopsy is best. - **MRI pelvis:** Rarely needed (e.g. adenomyosis, fibroid mapping before surgery). - **Other:** Thyroid, prolactin levels if screening suggests endocrine cause (oligomenorrhoea rather than pure menorrhagia). **Diagnostic criteria:** - **Menorrhagia (HMB):** Clinical – patient’s perception of excessive bleeding or soaking through protection frequently. (NICE emphasizes patient’s view over strict volume). - **Iron deficiency anaemia:** Hb < normal (NICE recommends checking Hb in all HMB cases).

### Management **General principles:** Focus on improving quality of life. Involve the patient in decisions about medical vs surgical options (shared decision-making). Treat underlying cause if found (e.g. infection, thyroid). **Medical management (NICE first-line):** - **Tranexamic acid:** 1–1.5 g three times daily during heavy days (maximum 4 days/cycle). Anti-fibrinolytic drug to reduce menstrual loss. (BNF: e.g. 500 mg tabs). Contraindicated in active thromboembolism, history of thrombosis, and active intravascular clotting. Monitor for thrombosis risk factors. - **NSAIDs (e.g. mefenamic acid):** 500 mg TDS for days 1–2 (or ibuprofen 400–600 mg TDS). Helps reduce pain and blood loss. Avoid if gastric ulcer or bleeding disorders. - **Oral contraceptives:** Combined pill (e.g. 20–30 µg ethinylestradiol with levonorgestrel) can regulate cycle and reduce bleeding. Contraindications: migraine with aura, obesity + age >35, smoking. - **Levonorgestrel IUS (Mirena®):** **First-line NICE recommendation for HMB** if not wanting immediate pregnancy. Releases 20 µg levonorgestrel/day. Can be used even without confirming no pathology if no other symptoms. (Contra: uterine cavity distortion, untreated cancer, infection). Insert in clinic (after exclusion of endometritis/PID). Continues for 5 years; monitor for expulsion or bleeding patterns. - **Oral progestogens:** e.g. norethisterone 5 mg TDS days 5–26 of cycle (off-license for HMB in UK); or medroxyprogesterone 10 mg TDS in luteal phase. Less effective than IUS or tranexamic. Short-term use only. - **Other hormones:** GnRH analogues (e.g. goserelin) or high-dose progestogens are generally for severe fibroids/adenomyosis pre-surgery (specialist use). RCOG may recommend if fertility preservation desired.

**Surgical management:** - **Dilatation & Curettage (D&C):** Rarely first-line; reserved if immediate control needed. - **Endometrial ablation:** Minimally invasive (hysteroscopic or device-driven) to destroy endometrium. For women who have completed childbearing. NICE: consider if medical tx fails. Contraindicated if submucous fibroids or desire future fertility. - **Myomectomy/Polypectomy:** If fibroids or polyps cause bleeding and patient desires fertility. Laparoscopic or open. Post-op may need GnRH analogues pre-op for fibroids. - **Hysterectomy:** Definitive for HMB when other measures fail or not suitable (e.g. large fibroids, completed family). Elective with informed consent. - **Prophylaxis:** Treat anaemia (oral iron, consider IV iron if Hb <80). **NICE-specific notes:** - If history suggests low risk of uterine pathology, **start medical treatment immediately** without waiting for investigations. Investigate only if treatment fails or red flags present. - **NICE recommends COC or LNG-IUS trial for 4 months before radical treatment**. - **Avoid routine ferritin or hormonal tests** in HMB without other indications.

### Emergency Recognition / Red Flags - **Massive haemorrhage:** Treat as PPH in non-pregnant: ABC resuscitation, IV fluids, blood transfusion, urgent gynaecology input. Consider uterine tamponade and emergency theatre (curettage, balloon tamponade, hysterectomy if life-saving). - **Signs of shock:** Tachycardia >100, BP <90 systolic, syncope. - **Hypershock symptoms:** Shoulder-tip pain (referred peritoneal irritation – e.g. Clot, uterine perforation). - **New acute pain:** Could indicate expelled clots or surgical complication. - **Constitutional symptoms:** weight loss, night sweats – think malignancy or systemic disease. - **Large pelvic mass:** Consider sarcoma or fibroid degeneration – urgent imaging. - **Bleeding with coagulopathy:** If known, manage with platelet/FFP as per haematology advice. ### UK-Specific Referral Criteria - **Suspected cancer:** Use NICE NG12 “Suspected cancer: recognition and referral” guidelines. Key criteria: - Endometrial cancer (2ww): **postmenopausal bleeding** in women ≥55 (urgent gynae). PMB <55: still consider urgent. Also unexplained intermenstrual bleeding in women >45. Palpable uterine mass + anaemia. - Cervical cancer (2ww): Postcoital or intermenstrual bleeding in women ≥25, or abnormal cervical cytology (see cervical screening guidelines). - Vulval cancer: Any suspicious vulval lesion (ulcer/lump) >2 weeks. - Ovarian cancer: Pelvic/abdominal mass or ascites + symptoms (bloating, satiety) – CA125 + TVUS, refer if positive. - **Gynae consult (routine):** Symptomatic fibroids (persistent pain or anaemia), HMB causing Hb<10, complex ovarian cysts, dysplastic smears. - **Primary care management:** Mild HMB + normal Hb – initial management as above. - **Menorrhagia referral:** If medical therapy fails or fibroids >5–6 cm.

### Exam-Focused Checklists - **History “5 Ps” for bleeding:** P *Pattern* (regularity, duration, flow), P *Problems* (anemia symptoms, clot passage), P *Pregnancy* (exclude), P *Pathology* (pain, discharge, systemic), P *Prophylaxis/Pfam* (HRT, contraception, FH of cancer or bleeding disorders). - **Exam “LIGHTS”:** *L*ook (pallor, BMI, thyroid), *I*nsert speculum (look for lesions, cervix, discharge), *G*ently feel (uterine size/position, adnexa), *H*emoccult stool (if anal/vaginal bleeding unclear), *T*ight cough (stress test if incontinence), *S*wabs (if infection). - **Key red flags:** Per NICE and UK referral guidance. <br> ```mermaid flowchart TD A[Acute Pelvic Pain (Woman)] --> B{Pregnancy test}; B -- Negative --> C{Severe pain?}; B -- Positive --> D[Consider ectopic/miscarriage]; C -- Yes --> E[Assess for torsion or rupture: USS pelvis;\nIV analgesia; surgical review]; C -- No --> F{Urinary/GI?}; F -- UTI/renal colic --> G[Dipstix, urine culture;\nmanage UTI/stone]; F -- GI cause likely --> H[Bloods, appendicitis evaluation]; D --> I[TVUS; follow Early Pregnancy Guideline]; E --> J[Emergency gynae involvement;\nstabilise hemodynamics]; G --> K[Antibiotics or stone management]; H --> L[GI workup (appendicitis, IBD etc.)]; ``` *Figure: Algorithm for acute pelvic pain. Always perform a pregnancy test. If positive, manage as ectopic/miscarriage (NICE NG126). If pain is severe or peritonitic, suspect adnexal torsion/rupture and admit with gynaecology input. If negative and less severe, consider UTI (test urine), urinary stones, appendicitis or other GI causes. Adapt investigations accordingly.*

```mermaid flowchart LR M[Acute Uterine Bleeding] --> N{Haemodynamically stable?} N -- No --> O[Resuscitate (IV fluids, transfuse);\nObstetric/Gynae team;\nUrgent curettage or tamponade] N -- Yes --> P[Send Hb, β-hCG, FBC;\nIV access] P --> Q{Pregnancy test positive?} Q -- Yes --> R[Consider ectopic/miscarriage;\nTVUS (Early Pregnancy Unit)\nmanage per NG126] Q -- No --> S[Begin medical therapy:\nTranexamic acid,\nNSAIDs (e.g. mefenamic acid),\nor start LNG-IUS/COCP] S --> T{Response to medical tx after 3-4 mo?} T -- Yes --> U[Continue management;\nmonitor Hb periodically] T -- No --> V[Refer to Gynae;\nImaging (TVUS/hysteroscopy);\nConsider ablation or surgery] ``` *Figure: Acute vaginal bleeding pathway. If unstable, treat as emergency. If stable, always exclude pregnancy (ectopic rule-out). Begin appropriate therapy even before full workup if no red flags. If initial medical therapy fails, investigate (TVUS, hysteroscopy) for structural causes.*

## Amenorrhoea ### Core Knowledge - **Definitions:** - *Primary amenorrhoea:* No menarche by age 15 with normal secondary sexual characteristics, or by 13 without them. - *Secondary amenorrhoea:* Absence of menses for ≥6 months in a previously cycling woman (or ≥3 cycles if history irregular). - **Pathophysiology:** Reflects failure at any level of the HPO (hypothalamic-pituitary-ovarian) axis or outflow tract. Key categories: anatomical (uterine/vaginal anomaly), ovarian (premature ovarian insufficiency, PCOS), pituitary (prolactinoma), or hypothalamic (stress, weight loss, exercise). ### Presentation and Differentials **Primary amenorrhoea:** Often presents in adolescence. If secondary sexual characteristics are absent (no breast development by 13) suspect gonadal dysgenesis (e.g. Turner’s syndrome) or pituitary/hypothalamic cause. If secondary sex is present but no menarche by 15, suspect outflow tract abnormality (Mullerian agenesis or imperforate hymen) or gonadal failure (Swyer, 17-OH defect). **Secondary amenorrhoea:** Common causes – Pregnancy first (must exclude). Then consider **PCOS** (oligo/amenorrhoea + hirsutism/obesity), **hypothalamic amenorrhoea** (anorexia, stress, exercise), **hyperprolactinaemia** (galactorrhoea, pituitary adenoma), **thyroid disease**, and **Asherman’s syndrome** (intrauterine adhesions, usually after D&C). **Red flags:** Severe headache or visual field defects (pituitary tumour), virilisation (androgen-secreting tumour), absent uterus on US (Mullerian agenesis) warrant specialist referral.

### Diagnostic Approach **Initial steps:** Always perform a urine or serum β-hCG test to exclude pregnancy. Review medications (e.g. progesterone withdrawal test often not needed if amenorrhoea present). Document weight loss, eating disorder signs, or stressors. Check secondary sexual development to determine if oestrogen present. **Physical Exam:** General (BMI, signs of Cushing’s or thyroid), breast (tissue present, galactorrhoea), skin (acne, hair pattern for androgens), and pelvic exam (uterus size, vaginal patency if indicated). **Laboratory tests:** - **If suspect PCOS:** LH, FSH (LH:FSH >2), testosterone, SHBG; investigate insulin resistance (glucose, lipid profile). - **Prolactin** (high → pituitary MRI). - **Thyroid function tests.** - **Oestradiol/FSH:** High FSH/low oestradiol suggests ovarian failure/menopause (especially >40y, measure FSH twice 6–8 weeks apart). - **If outflow issue:** Pelvic ultrasound to confirm uterus, check for uterine or vaginal anomalies. - **Karyotype** in primary amenorrhoea if gonadal dysgenesis suspected (e.g. Turner’s, Mullerian agenesis). **Specialist tests:** - **Progesterone challenge:** If withdrawal bleed occurs, indicates anovulatory cycles with adequate estrogen. - **Pituitary MRI:** If prolactin >1000 mU/L or other suspicious features. - **Hysterosalpingogram or diagnostic laparoscopy** for Asherman’s or congenital anomalies.

### Management - **PCOS:** Lifestyle (weight loss ≥5–10% can restore ovulation). First-line medical: combined OCPs (e.g. ethinyloestradiol/levonorgestrel) for cycle regularisation and hirsutism control; anti-androgen (spironolactone if needed), metformin for metabolic syndrome. For fertility: ovulation induction (letrozole first-line per NICE fertility guideline, clomifene second). Monitor glucose and lipids (increased diabetes risk). - **Hyperprolactinaemia:** Dopamine agonist (cabergoline 0.5 mg once or twice weekly, or bromocriptine). Check serum prolactin after 4 weeks. MRI if adenoma. - **Hypothalamic amenorrhoea:** Correct underlying cause (weight gain, reduce exercise/stress). If fertility desired, pulsatile GnRH or gonadotrophins may be needed. - **Thyroid disorders:** Treat hypothyroidism/hyperthyroidism accordingly; menses often return to normal. - **Asherman’s syndrome:** Surgical lysis of adhesions (hysteroscopic adhesiolysis) with estrogen support post-op. - **Ovarian failure/POI:** Physiological in older women (menopause). <40y (premature ovarian insufficiency, POI): give HRT until age ~50 to maintain bone density and cardiovascular health (unless contraindicated by hormone-sensitive cancer). Discuss fertility options. - **Imperforate hymen or mullerian agenesis:** Surgical correction (hymenotomy) or multidisciplinary management for mullerian agenesis (Mayer-Rokitansky; uterus absent – fertility via surrogacy or adoption).

### Emergencies / Red Flags - **Pregnancy complications:** If amenorrhoea + pelvic pain or bleeding, act as potential ectopic/molar (see acute pelvic pain). - **Pituitary apoplexy:** Amenorrhoea with headache/vision loss – emergency MRI and steroids. - **Severe osteoporosis:** Long-term amenorrhoea in young women requires bone density assessment and consider HRT. ### Referral Criteria - **Primary amenorrhoea:** Refer all cases by age 15 (with or without secondary features) to paediatric/gynae/endocrine specialists. - **Secondary amenorrhoea:** If >6 months absent with no obvious cause, or if after 12 months ovarian failure signs (hot flushes) – refer endocrine/gynae for endocrine workup and discuss HRT if needed. - **Premature ovarian insufficiency (<40y):** Refer endocrine (immediate HRT recommended). - **Pituitary suspicion:** Amenorrhoea + visual changes/headache → urgent MRI & neuroendocrine referral. ### Exam Checklists - **Amenorrhoea history:** Last bleed, breast/pubic hair development, galactorrhoea, weight changes, exercise/stress, medications (esp. antipsychotics, OCP, steroids), family history (Turner, delayed menarche). - **Exam:** General exam (growth, dysmorphism, gynaecomastia). Tanner staging, thyroid exam, visual fields if prolactin high. Pelvic ultrasound (uterus presence, ovarian volume).

## Menstrual Disorders ### Premenstrual Syndrome (PMS) / Premenstrual Dysphoric Disorder (PMDD) - **Definition:** Cyclic physical/emotional symptoms in luteal phase. PMDD (more severe) requires ≥5 symptoms (including mood changes) affecting life, per DSM-5/NICE. - **Must know:** Diagnose by symptom diary (e.g. daily chart) over ≥2 cycles. Rule out underlying depression or anxiety. - **Presentation:** Breast tenderness, bloating, irritability, mood swings, headache. Symptoms resolve with menstruation. - **Differential:** Depression, dysthymia, bipolar (rare), thyroid, endometriosis (pain vs mood). - **Management:** First-line **SSRIs** (fluoxetine 20 mg daily in luteal phase or continuously; NICE RCOG suggests sertraline or citalopram also). If only mild, calcium/vitamin D, exercise, reduced caffeine/salt. Cognitive Behavioural Therapy is effective. Combined OCPs or GnRH analogues for severe cases. Spironolactone may help (small evidence). - **UK guidance:** RCOG Green-top 48 (2021) – confirms SSRIs as first-line for moderate/severe PMS/PMDD. ### Polycystic Ovary Syndrome (PCOS) - **Definition:** Rotterdam criteria: any 2 of (a) oligomenorrhoea/amenorrhoea, (b) clinical/biochemical hyperandrogenism, (c) polycystic ovarian morphology on US. Exclude other causes (late-onset CAH, Cushing’s). - **Presentation:** Irregular periods, hirsutism, acne, obesity, insulin resistance. - **Differential:** Thyroid dysfunction, hyperprolactinaemia, ovarian/adrenal tumour. - **Investigations:** FSH, LH (LH:FSH >2), testosterone, SHBG, fasting glucose/HbA1c, lipids, pelvic ultrasound. - **Management:** Lifestyle (weight loss often restores ovulation). Combined OCP for cycle control and hirsutism. Metformin for insulin resistance (improves cycles, prevents progression to diabetes). Spironolactone for hirsutism (after contraception). Fertility: letrozole or clomiphene. Long-term follow-up for diabetes and cardiovascular risk. (No single NICE guideline, but RCOG/Endocrine Society advice).

### Ovulatory Dysfunction and Irregular Bleeding - **Anovulatory cycles:** Common in teens and perimenopause. Manage with OCP or cyclical progestogens to induce withdrawal bleeds and protect endometrium. - **Thyroid disease:** Hyper/hypothyroid can cause irregular bleeding. Treat thyroid. - **Functional (dysfunctional) uterine bleeding:** Diagnosis of exclusion. Manage with medical therapies above (tranexamic, OCP, IUS). ### Exam-Focused Points - Chart menstrual diary (length, symptoms). - Ask: pattern of mood/pain, duration, impact on function. - For PCOS: screen for metabolic syndrome (BMI, BP, waist, glucose). - PMS/PMDD: 2 months of symptom charting and end of-day symptom scoring (Diaries like Moos questionnaire).

## Dysmenorrhoea ### Core Knowledge - **Definition:** Painful menstruation. *Primary* dysmenorrhoea: menstrual pain without pelvic pathology (common, often adolescent). *Secondary* dysmenorrhoea: pain due to pathology (endometriosis, adenomyosis, fibroids, IUD). - **Mechanism (primary):** Uterine prostaglandins cause intense cramping. - **“Must know” points:** Always exclude secondary causes if onset is late (after mid-20s), pain severity increasing, or unresponsive to usual therapy. ### Presentation and Differentials - **Primary dysmenorrhoea:** Crampy suprapubic pain starting with or just before menses, lasting 1–3 days; may radiate to back/legs; commonly starts months after menarche. No other gynae symptoms. Vital signs normal. - **Secondary causes:** Suspect if: onset after years of painless periods; pain through cycle or outside menses; dyspareunia or infertility (endometriosis); heavy menstrual bleeding (fibroids, adenomyosis); palpable uterine abnormalities; age >25 with new dysmenorrhoea. - **Endometriosis:** cyclical pain, dysmenorrhoea, dyspareunia, infertility. - **Adenomyosis:** heavy, painful periods in parous women >40; uterus enlarged, tender. - **Fibroids:** heavy bleeding + pain (usually dull), depending on fibroid location. - **PID:** lower abdo pain lasting beyond menses + discharge/fever. - **IUD pain:** usually soon after insertion. **Red flags:** Fever, pregnancy signs, non-cyclical pain, neurological symptoms (cauda equina), severe tenderness (tubo-ovarian abscess).

### Diagnostic Approach - **History:** Menstrual history (onset, duration, flow, associated symptoms), sexual history (infection risk), IUD use. Impact on activity/school/work. - **Exam:** Abdominal tenderness (normal or focal). Pelvic exam only if older, nulliparous (to allow bimanual) or suspicion of pathology. Look for adnexal masses or uterine enlargement. - **Investigations:** Generally none for primary dysmenorrhoea. If suspect secondary: pelvic ultrasound (fibroids, adnexal cysts), STI screen (if PID suspected), CA125 (if endometriosis suspected, though nonspecific). Laparoscopy only if infertility or refractory pain (definitive for endometriosis). ### Management - **First-line analgesia:** NSAIDs (ibuprofen 400–600 mg TDS or naproxen 500 mg BD, or mefenamic acid 500 mg TDS) starting 1–2 days before menses if predictable. Continue 2–3 days. Paracetamol if NSAIDs contraindicated (less effective). Combined or either analgesia can be used. - **Hormonal:** Combined OCP continuous or cyclic (e.g. 2-week active pills then break) to suppress ovulation and reduce cramps. LNG-IUS can reduce pain over time. - **Second-line:** If initial measures fail, refer for evaluation of endometriosis. GnRH analogues (e.g. goserelin) provide temporary relief (limit use to 6 months with add-back HRT). Exercise and heat therapy can help mild cases. - **NICE considerations:** Dysmenorrhoea affecting QoL should prompt evaluation (see endometriosis NG73). Do not ignore severe pain.

### Emergencies / Red Flags - **Tubo-ovarian abscess:** High fever, pelvic mass, severe pain – urgent gynaecology. - **Acute PID:** Purulent discharge, fever – admit for IV antibiotics. - **Ovarian torsion:** Sudden unilateral pain, nausea – emergency surgery. - **Appendicitis:** Differentiate via localisation, rebound. ### Referral - If pain unresponsive to first-line therapy after 3–6 months; any features of secondary cause. - Suspected endometriosis: consider **laparoscopy after failure of empirical therapy** (e.g. three cycles of OCP or progestogens). - Adolescent with severe dysmenorrhoea affecting schooling should get specialist review. ### Checklists - **Dysmenorrhoea history:** Relationship to menses (cycle day pain starts/ends), impact on life, effect of analgesics/OCP, associated GI (nausea, diarrhea) or urinary symptoms. - **Exam:** Focused pelvic (if >25yo or red flags). Note uterine size (adenomyosis = globular boggy uterus).

## Menopause and Genitourinary Syndrome ### Core Knowledge - **Definition:** Menopause is 12 months of amenorrhoea (no period) due to ovarian insufficiency (median UK age ~51). Perimenopause (menopausal transition) can last years with irregular cycles. - **Symptoms:** Vasomotor (hot flushes, night sweats), psychological (mood swings, low mood) and genitourinary (vaginal dryness, dyspareunia, urinary frequency). Urogenital atrophy is part of **Genitourinary Syndrome of Menopause (GSM)**. - **Diagnosis:** Clinical (age ~45–55, symptom pattern). FSH >30–40 IU/L can support diagnosis but not needed in typical age group. Measure FSH only if <45 suspect premature ovarian insufficiency. - **Must/Should:** Always consider contraception until menopause confirmed (age>50 and amenorrhoea 12m without HRT, or 2y if on HRT). Provide information on bone health and cardiovascular risk. ### Presentation and Differentials - **Vasomotor:** Sudden heat, flushing, sweating, tachycardia, then chills. Worse at night (insomnia). - **Genitourinary:** Vaginal dryness, dyspareunia, recurrent UTIs, urgency (atrophic urethritis). - **Other:** Joint pains, migraines, weight changes. - **Differential:** Thyroid disease, anxiety disorders, cardiovagal symptoms (POTS), phaeochromocytoma (rare for hot flushes).

### Diagnostic Approach - **History:** Onset/duration of symptoms; menstrual history. Smoking (lowers age of menopause). - **Examination:** BP (hypertension?), BMI, breasts (fibrocystic changes?), vulvovaginal exam if dryness/atrophy suspected (pale, thin mucosa, petechiae). - **Investigations:** Not needed for simple menopause. Check FSH/estradiol if <45 (to diagnose premature ovarian insufficiency). DEXA scan if risk factors for osteoporosis (fracture, family hx). Lipids/glucose in POI or 50+. ### Management - **Lifestyle:** Regular weight-bearing exercise, smoking cessation, limit alcohol/caffeine, cool environment, layered clothing. - **Vasomotor Relief:** - *First-line:* **HRT** (estrogen ± progestogen) for relief of hot flushes and night sweats. NICE: Offer HRT to menopausal women under 45 with symptoms (and up to around average age menopause); balance benefits/risks (Breast ca risk vs protective effects on bone). Can use oral or transdermal (patch or gel) oestrogens; add cyclic or continuous progestogen if uterus present to prevent endometrial hyperplasia. - *Progestogen choices:* Oral micronised progesterone or levonorgestrel, or progestogen-containing IUS (Mirena) if bleeding. - *Duration:* Use lowest effective dose; no fixed stop date but review annually. Discuss tapering after ~5 years if appropriate. Evidence suggests risks (breast ca, VTE) accrue with longer use. - *Alternatives:* If HRT contraindicated/unwanted, **SSRIs/SNRIs** (e.g. venlafaxine 37.5–75 mg OD) or gabapentin can modestly reduce hot flushes. Clonidine occasionally used. (NICE doesn’t prioritise non-hormonal; BMS suggests trial if HRT unsuitable.)

- **Genitourinary:** **Vaginal estrogen** (cream, pessary, or ring) is first-line for dryness, itching, dyspareunia. If HRT, systemic oestrogen also helps dryness, but local is preferred for isolated symptoms (lower systemic risk). Lubricants for intercourse and regular moisturisers for dryness. - **Bone health:** Adequate calcium/Vit D, exercise; treat osteoporosis per guidelines (bisphosphonates if indicated). - **Premature Ovarian Insufficiency (<40y):** Give HRT until at least age 45–50 for bone and CV protection, even if fertility completed (contraception still needed if ovaries functioning). Inform about fertility implications (low eggs). - **Other:** SSRIs or psychotherapy for mood swings if persistent; see psychiatry as needed. ### Emergencies / Red Flags - **VTE risk:** History of DVT/PE is a contraindication to combined HRT or BHRT. Transdermal HRT may be used in VTE risk (lower effect on clotting). - **Unexpected bleeding on HRT:** Investigate as per AUB above (exclude endometrial hyperplasia or carcinoma). - **Underlying cancer:** HRT contraindicated in current or recent breast cancer, active liver disease, undiagnosed vaginal bleeding. - **Cardiovascular:** In women >60 or with uncontrolled hypertension, consider cardiology input before HRT. - **Mental health:** New depression or anxiety severe – evaluate separately (menopause can worsen mood).

### Referral - **Specialist menopause clinics:** For complex cases (POI, severe symptoms refractory to primary care management, desire bespoke HRT). - **Gynecology/Endocrine:** Early menopause (POI) for bone health, fertility counselling, and specialist HRT guidance. - **Urology:** If prominent urinary symptoms (e.g. recurrent UTIs, severe incontinence) after basic management. ### Checklists - **Menopause history:** Symptom review (vasomotor, urogenital, mood), duration of amenorrhoea, impact on life, contraception needs, bone pain or fractures. - **Medications:** Review current HRT (type/dose). Encourage keeping up with regular screening (mammogram, smear if due up to age 64). ```mermaid flowchart TD Y[Menopausal Symptoms] --> Z{Symptoms mild or moderate?}; Z -- Mild --> AA[Lifestyle measures;\nReassure; consider CBT or relaxation]; Z -- Moderate/Severe --> AB{Any contraindications to HRT?}; AB -- No --> AC[Offer HRT (systemic oestrogen ± progestogen)]; AB -- Yes --> AD[Consider SSRIs/SNRIs (e.g. venlafaxine); or Clonidine]; AC --> AE[Review annually;\nMonitor BP, lipids;\nMammogram/Pap as per UK schedule]; AD --> AF[Manage genitourinary symptoms with local oestrogen;\nReferral if no improvement]; ``` *Figure: Menopause management. First-line for troublesome vasomotor symptoms is HRT if no contraindications. Otherwise consider non-hormonal options. Always address bone and cardiovascular health. Provide support and information (NICE NG23).*

## Atrophic Vaginitis (Genitourinary Syndrome of Menopause) - **Definition:** Vaginal mucosal thinning and dryness due to oestrogen deficiency. Presents as vaginal itching, dryness, dyspareunia, and possibly post-coital bleeding. Part of menopause symptomatology. - **Diagnosis:** Clinical – pale, thin epithelium, loss of rugae on speculum exam. pH >5 (due to reduced lactobacilli). - **Management:** First-line is **topical oestrogen** therapy (vaginal rings, tablets, or creams) to restore mucosa. Lubricants for sexual activity. Topical oestrogens have minimal systemic absorption. Rarely systemic HRT is sufficient alone. Topical progesterone not needed if no uterus or on systemic therapy. - **Differential:** Infections (candida), lichen sclerosus. Rule out STIs if risk. Vaginal cultures if discharge unusual. - **Referral:** Dermatology if suspected lichen planus, lichen sclerosus.

## Pelvic Pain ### Acute Pelvic Pain (Women of Reproductive Age) - **Urgent causes:** Ectopic pregnancy, tubo-ovarian abscess, ovarian torsion, ruptured ovarian cyst, acute appendicitis, intestinal obstruction, urinary stone, acute PID. - **Approach:** Always take pregnancy test (β-hCG). Manage per algorithm above. Observe vital signs and administer analgesia. Often requires multi-disciplinary care (ED, gynae). ### Chronic Pelvic Pain (CPP) - **Definition:** Non-cyclical pain lasting ≥6 months not exclusively related to menstruation or intercourse. Affects quality of life akin to migraine/low back pain. - **Common causes:** Endometriosis, interstitial cystitis, IBS, pelvic floor myalgia, adenomyosis, musculoskeletal (SI joint), psychological factors. Often **multifactorial**. - **Key points:** Treat as a symptom, not diagnosis. Use RCOG GTG 41 for assessment: history, pain diary, psychosocial impact. - **History:** Pain character, relation to cycle/intercourse, urinary/bowel factors, trauma history. Trauma screening (sexual abuse) is essential. - **Exam:** Comprehensive including abdominal, pelvic, MSK (pelvic tilt, spine), neurological (if radiculopathy), gait. Check for trigger points in abdominal wall (e.g. Carnett’s sign for abdominal wall pain). Look for pelvic floor spasm. - **Investigations:** Usually normal routine tests. Use targeted: ultrasound (fibroids, adenomyosis), laparoscopy if endometriosis suspected (diagnostic and possibly therapeutic), cystoscopy if bladder pain, colonoscopy if IBS suspicion. Do pregnancy tests for flank pain. - **Management:** Multidisciplinary. Start with analgesia (NSAIDs, paracetamol). Pelvic physiotherapy (biofeedback, manual therapy). Treat identifiable conditions (e.g. endometriosis – OCP/GnRH/ablation). Psychological support / CBT. Meds: tricyclics or SNRIs if neuropathic pain component. Avoid repeated surgeries without clear benefit. - **NICE guidance:** NG73 covers endometriosis; no single CPP guideline, but RCOG GTG41 is key. Consider referral to chronic pain services (NICE says pain services for chronic pain if >3 months).

### Dyspareunia (Painful Intercourse) - **Superficial:** Burning/irritation at entry. Causes: vulvodynia (vestibulodynia), vaginal dryness (atrophic), infections (yeast, BV), dermatoses (lichen sclerosus), trauma (vaginismus, scars, piercings), contraceptive irritant (spermicides, latex). - **Deep:** Pain with deep penetration. Causes: pelvic pathology (endometriosis, PID, fibroids, ovarian cysts), pelvic floor spasm, retroverted uterus, adenomyosis, IBS/IBD. - **Approach:** Take thorough sexual history (onset, lubricant use, positions). Examine vulva and vagina for dermatological lesions (lichen planus, lichen sclerosus, eczema, infections). Check for vaginal atrophy (N.B. see Menopause above). Bimanual exam to elicit deep tenderness (adnexal masses, nodularity). - **Investigations:** Swabs for STIs and yeast/BV. Consider post-coital cytology if cervicitis. Ultrasound if pelvic pathology suspected. - **Management:** Identify cause: e.g. treat infection or dermatological condition. For atrophy: vaginal oestrogen (see above). For vulvodynia: refer to specialized pain/dermatology clinics; use topical lidocaine, CBT, pelvic floor PT. For muscle spasm/vaginismus: physiotherapy. Pain from pathology: treat underlying (e.g. adhesiolysis for endometriosis). - **Referral:** Gynecology if pathology found or if no improvement with first-line (e.g. failed local treatment, suspicion of endometriosis).

## Vulval/Vaginal Symptoms & Lesions ### Common Presentations - **Itching/Burning:** Often dermatological (eczema, lichen simplex, lichen sclerosus, psoriasis), or infections (candida, scabies). - **Ulcers/Lumps:** Genital herpes (painful ulcers), syphilis (painless), HPV warts (painless papules), molluscum, Bartholin cyst (painful lump on labia). Vulval carcinoma (ulcerated or nodular lesion, usually older women, often pruritic/painful). - **Discharge:** - *Physiological:* clear/white around ovulation. - *Pathological:* Malodourous or colored suggests infection (BV: grey discharge, fishy smell; candidiasis: white curdy; trichomoniasis: frothy yellow-green; gonorrhoea: purulent; chlamydia: often minimal, may cause post-coital bleed). ### Examination - Inspect vulva: look for rash (generalised or focal), lumps (Bartholin’s cyst, fibroepithelial polyps), fissures. Check introitus for petechiae (dermatitis) or ulcers. - Speculum: inspect vagina and cervix – discharge, lesions, cervicitis, polyps, ectropion. - Bimanual: pelvic pain, masses. ### Investigations - **Swabs/cultures:** Vaginal swab for BV/pH, yeasts; swab for trichomonas, GC/Chlamydia (NAAT) if risk; cervical cytology (Pap smear) if due or abnormal lesion. - **Biopsy:** Any suspicious lesion (ulcer lasting >2 weeks, pigmented lesion on vulva). - **HIV and syphilis serology:** If ulcers or high-risk. - **Imaging:** Rarely needed (e.g. US for Gartner’s duct cyst).

### Management - **Infections:** - *Candida:* Fluconazole 150 mg PO once (BNF). Topical azole (clotrimazole cream 500 mg) if systemic contraindicated. - *Bacterial vaginosis:* Metronidazole 400 mg BD x5 days or 2 g PO single dose. - *Trichomoniasis:* Metronidazole 2 g PO once (or tinidazole). Treat partner. - *Chlamydia:* Doxycycline 100 mg BD x7 days (or azithro 1 g stat + 500 mg for 2 days) and test-of-cure after 3 weeks. - *Gonorrhoea:* As per UKHSA (ceftriaxone IM + azithro). - **Bartholin’s cyst/abscess:** If small & asymptomatic, observe. If painful abscess: incision & drainage. Marsupialisation for recurrent. - **Dermatoses (vulva):** - *Lichen sclerosus:* High-potency steroid ointment (clobetasol propionate 0.05% once daily for 6–12w then maintenance) and emollients. Long-term follow-up (vulvar cancer risk). - *Eczema/Contact dermatitis:* Topical steroids (betamethasone 0.1% cream) and avoid irritants. - *Lichen planus:* Refer (often requires potent steroids and immunosuppressants). - **HPV warts:** Podophyllotoxin cream or imiquimod cream self-administered. Cryotherapy in clinic. - **Vulval cancer:** Urgent biopsy and referral. (Do not delay with topical treatments.) ### Referral Criteria - Any **suspected malignancy** (vulval or vaginal): urgent Gynae-oncology referral. - Persistent symptoms >4 weeks despite treatment (especially itching, discharge). - Dyspareunia or vaginal discharge not explained by simple infection. - Recurrent Candida (≥4/year): consider diabetes, immunosuppression. ### Checklists - **Vulva exam:** Look carefully at skin color, papules, ulcers, rashes. Check for methyl blue dye/pelvic examination if needed to delineate lesions. - **Investigations:** BV (whiff test, clue cells), yeast (pH normal, hyphae on microscopy), trich (+ve amines, flagellates on wet mount).

## Pelvic Organ Prolapse ### Core Knowledge - **Definition:** Descent of pelvic organs into/through the vagina due to weakness of pelvic support. Uterine prolapse is one form; others include cystocele (bladder), rectocele (rectum) and enterocele (small bowel). - **Grading (Baden-Walker simplified):** 1st degree: descent halfway to hymen; 2nd: to hymen; 3rd: outside hymen; 4th: complete procidentia. (POP-Q staging is more detailed). - **Symptoms:** Sensation of vaginal bulge or pressure, heaviness, seeing/feeling a lump at vagina. Often worse on standing/at end of day. Can cause urinary (incomplete emptying, stress incontinence), bowel (constipation, incomplete evacuation), or sexual dysfunction. Up to 40% of older women have some prolapse on exam (many asymptomatic). - **Risk factors:** Vaginal childbirth (multiparity), age, obesity, chronic cough, constipation, hysterectomy, connective tissue disorders. ### Diagnostic Approach - **History:** Ask about bulge sensation, difficulty inserting tampons, urinary or bowel symptoms, sexual function. Note obstetric history, family history of prolapse. - **Examination:** Supine speculum exam in lithotomy: have patient strain or stand if possible, to visualize prolapse. Identify compartment(s) involved: anterior (cystocele), apical (uterine or vault), posterior (rectocele). Cough stress test for SUI. Pelvic floor muscle strength (Oxford scale). - **Measurement:** Simpler grades (mild/moderate vs severe). No further tests needed usually unless surgical planning (urodynamics if incontinence, defecography if complex bowel symptoms).

### Management - **Conservative:** First-line for mild prolapse. - *Pelvic floor muscle training (PFMT):* Strong evidence; NICE NG123 recommends supervised PFMT for at least 3 months before considering surgery. - *Lifestyle:* Weight loss if BMI >30, avoid heavy lifting, treat constipation. - *Pessary:* Vaginal pessary (ring or shelf) inserted in clinic for symptomatic relief; change/review every 3–6 months. Good for those unfit for surgery or awaiting surgery. - **Surgical:** For bothersome moderate-severe prolapse. Options: - *Cystocele repair (anterior colporrhaphy)*, uterine suspension (sacrospinous hysteropexy), vaginal hysterectomy with vault repair, sacrocolpopexy (abdominal/mesh). - *Rectocele repair (posterior colporrhaphy)*. - *Mesh:* Little use now for primary repair due to complications; synthetic mesh only in specialist cases. - *Collagen injections:* Experimental. - *Colpocleisis:* (vaginal closure) for very elderly/not sexually active. - **Follow-up:** Many recur; counsel accordingly. PFMT should continue post-op. ### Emergencies / Red Flags - **Urinary retention:** If prolapse causes bladder outlet obstruction, treat with catheterisation and urgent gynae review. - **Urogenital fistula:** (constant incontinence) – rare, usually after surgery/radiation – refer urogynae. ### Referral - **GP/Outpatient:** All symptomatic prolapse should see specialist gynaecology. - **Urgent:** If prolapse with urinary retention or infection, or ulceration of prolapsed tissue. ### Checklists - **Exam:** Ask patient to strain/squat to quantify descent. Note any stress incontinence (leak on cough). Examine perineum and anal sphincter (defects?). - **Symptoms:** Differentiate urinary symptoms (urge, stress, obstructive), bowel (incontinence vs evacuation), sexual (pain). Use validated tools (PFDI questionnaire).

## Urinary Incontinence (UI) ### Core Knowledge - **Types of UI:** - *Stress UI (SUI):* Leakage on effort (cough, sneeze, exercise). - *Urge UI (Overactive bladder):* Sudden strong urge, leakage before reaching toilet. - *Mixed:* Features of both. - *Overflow:* (rare in women) usually from high residuals. - **Prevalence:** Very common in older women (up to 50% some leakage) and postpartum. Not a normal ageing change – should be managed. ### Presentation and Differentials - **Ask:** Onset, amount of leakage, triggers, nocturia, urgency frequency, voiding symptoms (hesitancy, dribbling). Pad usage and fluid intake. Medication review (diuretics, caffeine). - **Differential:** UTIs (can cause frequency/urgency), pelvic organ prolapse (causing obstructive voiding or SUI), neurological disorders (stroke, MS, spinal cord), fistula (continuous leak), diuretics. - **Red flags:** Haematuria (refer for cancer evaluation), severe voiding dysfunction (large post-void residual suggests obstruction or neuro problem). ### Diagnostic Approach - **Examination:** BMI, abdomen (bladder distension), neurological exam (sacral reflexes), perineal inspection. Pelvic exam: note prolapse. Stress test: supine cough with bladder filled (250ml) and bearing down; observe leakage. Assess pelvic floor muscle strength (Oxford Scale 0–5). - **Basic tests:** Urinalysis (dipstick for infection or glycosuria). **Bladder diary** for frequency/volume over 3 days. - **Special tests:** Post-void residual (bladder scan, if voiding difficulty). Urodynamics *only* if surgical planning or mixed uncertain diagnosis (NICE says do not do routine cystometry before first surgery).

### Management - **Conservative first:** Advice on fluid intake (avoid excessive caffeine/alcohol). Weight loss if BMI>30. Manage constipation. Smoking cessation (coughing causes stress leaks). - **Pelvic Floor Muscle Training (PFMT):** First-line for SUI or mixed UI. NICE: supervised PFMT ≥3 months (at least 8 contractions 3×/day) before other interventions. Can be taught in GP physiotherapy or by specialist. - **Bladder training:** For urge UI – timed voiding, delay techniques (urge inhibition), encourage to double-void. - **Medication:** - *Stress UI:* No specific drugs (duloxetine can help but not NICE approved for UI). - *Urge UI (OAB):* Oxybutynin 2.5–5 mg TDS (or long-acting 5–10 mg OD), tolterodine, or newer mirabegron 25–50 mg OD (β3-agonist; NICE-approved in OAB). Contraindications: urinary retention, uncontrolled narrow-angle glaucoma. Monitor for dry mouth, constipation (anticholinergics), BP changes (mirabegron). - **Devices:** Continence pessary or urethral plugs (specialist use). - **Absorbents:** Pads or panty liners – symptom aid, not treatment, and help with self-esteem. - **Surgery:** - *Mid-urethral sling (TVT):* For SUI if PFMT fails. NICE endorses mesh tapes as effective with low complication rates (until recent controversies; still recommended where expertise exists). - *Colposuspension (Burch):* Open abdominal alternative (long-term cure rate ~90%). - *Bulking agents:* Urethral injection (silicone, collagen) can be tried for some SUI. - *Botulinum toxin:* Into detrusor for refractory OAB (specialist). - **NICE NG123:** Emphasises PFMT first, followed by pharmacotherapy for OAB, surgery only after conservative fail.

### Referral - **Urgent:** Haematuria or suspected fistula (constant wetness). - **Routine:** Significant SUI unresponsive to PFMT; complicated OAB (neurological disease, previous pelvic surgery); prolapse with retention or recurrent UTIs. - **Surgery referral:** If >3 months PFMT unsuccessful for SUI or if patient is highly motivated for cure. ### Checklists - **UI history:** Onset, pattern (stress vs urge), pad count, impact. Fluid diary. Meds/substances (caffeine, alcohol). Neurological symptoms (diabetes, MS, stroke). - **Examination:** Cough stress test (with about 300mL bladder volume). Evaluate pelvic organ prolapse. Rectal exam if fecal incontinence/coexistent bowel symptoms.

## Investigations & Referral Pathways - **Laboratory:** Pregnancy test for AUB and pelvic pain (universal first step). FBC in heavy bleeding, Hb for anaemia. FSH/oestradiol in amenorrhoea (if >40). TFTs and prolactin when indicated. Urine dipstick in pelvic pain or incontinence. STI screens (chlamydia/gonorrhoea) if discharge or at-risk. - **Imaging:** TVUS is first-line for most AUB, pelvic pain, suspected adnexal masses. MRI pelvis for complex cases (fibroids, adenomyosis, malignancy staging). - **Endoscopy:** Hysteroscopy for endometrial assessment (especially PMB or fibroids), laparoscopy for chronic pain or infertility, colposcopy for abnormal cervix smear. - **Referral (UK/NICE):** - *2-week wait (suspected cancer):* PMB (≥55y), cervical symptoms (bleeding/abnormal smear), suspicious vulvar lesions, complex adnexal mass + CA125/ascites. - *Routine gynae:* Endometrial thickening on US without PMB, failed medical therapy for HMB, persistent heavy/prolonged bleeding causing anemia, postmenopausal HRT bleed. - *CASES block:* Per user instruction, cases content to be addressed with case handbook.

## Key Tables **Differential Diagnoses** | Presentation | Top Differentials | |-------------------------|--------------------------------------------------------------------------------------------------------------------------------| | **Heavy/Prolonged Bleeding** | Fibroids, adenomyosis, endometrial polyps, coagulopathy, thyroid disease, endometrial hyperplasia/carcinoma (esp. >45y), anovulatory cycles. | | **Intermenstrual Bleeding** | Cervical polyp/cancer, endometrial polyp, hormonal withdrawal bleed, PID, bleeding diathesis. | | **Postcoital Bleeding** | Cervical ectropion or polyp, cervical dysplasia/cancer, atrophic vaginitis, infection (chlamydia). | | **Amenorrhoea (secondary)** | Pregnancy, PCOS, prolactinoma, hypothalamic amenorrhoea (athlete, stress), Asherman’s, thyroid disease. | | **Dysmenorrhoea (secondary)** | Endometriosis, adenomyosis, fibroids, PID, ovarian cysts, IUD. | | **Dyspareunia** | Vulvar atrophy, vulvodynia (vestibulitis), vaginismus, pelvic pathology (endo, adhesions), infections (vaginitis), lichen sclerosus. | | **Pelvic Organ Prolapse** | (Bulge symptom is usually prolapse) – distinguish from hernia (rare). | | **Urinary Incontinence** | SUI (weak pelvic floor), UUI (detrusor overactivity), mixed. Rule out UTI, overflow (diabetes, MS). |

**Investigations** (select examples) | Condition | First-line Tests | Indication/Notes | Timeline / Follow-up | |---------------------------|--------------------------------------------------|---------------------------------------------------------------------|----------------------------------------| | **Heavy Bleeding (HMB)** | FBC, β-hCG, coag screen (if history), TVUS | Assess anaemia, exclude pregnancy, screen clotting disorders | Repeat FBC post-treatment; ultrasound if pathology suspected | | **Dysmenorrhoea** | (None routine for primary) | If red flags → pelvic US (fibroids/adenomyosis), STI swabs (if discharge) | Consider laparoscopy for endometriosis if refractory | | **Amenorrhoea** | β-hCG, FSH/LH, prolactin, TFTs, pelvic US | Pregnancy test, ovarian reserve vs pituitary cause, thyroid | Endocrine follow-up if abnormal; refer if diagnostic uncertainty | | **PMB** | β-hCG, TVUS (endometrial thickness), hysteroscopy biopsy | Exclude pregnancy, assess endometrium (thin <4mm usually benign) | Urgent referral if ≥55y; if TVUS inconclusive, hysteroscopy | | **Pelvic Pain (acute)** | β-hCG, TVUS, FBC, CRP, MSU | Exclude ectopic, evaluate inflammatory markers, UTI or PID | If suspect PID, test swabs, consider CT/US; follow-up per diagnosis | | **Vulvovaginal symptoms** | Swabs (GC/Chlamydia, culture, pH), biopsy (if lesion) | Identify infection or pathology (cancer), pH for BV | Test-of-cure STI swabs; refer for positive biopsy | | **UI / Prolapse** | Bladder diary, MSU, uroflow or PVR scan, cough stress test | Identify type; exclude infection; measure residual if voiding issue | If incontinence persists, urodynamics before surgery (if criteria) |

**First-line Treatments** | Condition | Treatment & Dose (UK) | Contraindications / Monitoring | |----------------------------------|------------------------------------------------------|-------------------------------------------------------| | **Heavy bleeding (HMB)** | Tranexamic acid 1–1.5 g PO TDS (max 4d); NSAIDs (mefenamic acid 500 mg TDS); Levonorgestrel-IUS (Mirena); COCP (e.g. Ethinyloestradiol 30 µg + LNG 150 µg) | TXA: VTE history, thrombosis – monitor for thrombotic signs; NSAIDs: peptic ulcer, asthma – give PPI if needed; IUS: uterine cavity <10 cm, no infection – monitor expulsion, bleeding pattern; OCP: smoker>35y contraindication, check BP, lipids. | | **Dysmenorrhoea** | Ibuprofen 400–600 mg TDS or mefenamic acid 500 mg TDS (days1–3); COCP continuous; Paracetamol 1 g QDS if NSAIDs CI | NSAIDs: gastric ulcer, renal impairment – co-prescribe PPI for ulcer risk; COCP: migraine with aura contraindicated – BP monitoring; check adherence. | | **PCOS** | COCP (as above) + Metformin 500–850 mg BD (if IR); Spironolactone 50–100 mg BD (if needed, with contraception) | Metformin: GI upset (start low, titrate); Spironolactone: renal impairment, hyperK (monitor K+, creatinine). | | **PMS/PMDD** | Fluoxetine 20 mg OD (luteal phase or continuous) | SSRIs: Nausea (take after meal); sexual dysfunction; suicidal risk (monitor mood). | | **Amenorrhoea (POI)** | HRT: e.g. Oestradiol transdermal 50–100 µg/day + oral progesterone 200 mg daily days15–28 | HRT: see Menopause. Monitor BP, lipids, breast exams yearly. | | **Vaginal atrophy** | Vaginal oestrogen cream 1 g twice weekly (estriol) | CI: undiagnosed vaginal bleeding (investigate); local effect minimal systemic risk. | | **Dyspareunia (atrophy)** | Same as vaginal atrophy | Ensure compliance; if no uterus, give oestrogen alone. | | **Infections (candida)** | Fluconazole 150 mg PO once | E.g. in hepatic failure avoid; if <18yrs, topical clotrimazole preferred. | | **Stress UI** | PFMT (supervised, 3–6 mo) | Contra: pelvic pain (may need analgetics first); encourage regular exercise. | | **Urge UI (OAB)** | Oxybutynin 2.5–5 mg TDS (or tolterodine 2 mg BD) | Anticholinergics: narrow-angle glaucoma, urinary retention CI; monitor for dry mouth, constipation; consider mirabegron if intolerant (monitor BP). | | **Mixed UI** | PFMT (as above) + bladder training (timed voids) | Tailor to predominant symptom. | | **Prolapse (conservative)** | PFMT (as for SUI); Pessary (ring with support) | Pessary: check for erosion every 3–6 months. | | **Prolapse (surgical)** | *If indicated* – e.g. Vaginal hysterectomy + uterosacral ligaments | Surgical: standard pre-op workup, inform consent on prolapse recurrence, mesh risk. | **Note:** Doses given are standard; adjust for renal/hepatic function and patient comorbidities. Always check BNF/NICE for drug contraindications and up-to-date monitoring guidelines (e.g. HRT: yearly review; anticholinergics: monitor cognition in elderly). <hr> **Sources:** UK NICE guidelines and Royal College guidance have been used wherever possible. Key references include NICE NG88 (AUB), NICE NG23 (Menopause), NICE NG126 (Pregnancy complications), NICE NG123 (Incontinence/Prolapse), and RCOG Green-top guidelines (e.g. PMS, chronic pelvic pain). All UK BNF and NICE standards (2024/25) have informed drug regimens and referrals.