Bromley PBC

Gynaecology
Guidelines

Bromley PBC
Gynaecology
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Bromley PBC Gynaecology

February 2010
Dear Colleague
We are delighted to be able to circulate copies of the Gynaecology Guidelines that have
been developed by GPs for GPs.
Please share them with your colleagues, give them a go and let us know what you think.
Guidelines can go out of date but very soon these will be made available on the new
Bromley PbC website and will be updated on a regular basis.
Many of you will know that our starting point was trying to understand the high and variable
rates of gynaecological referrals from practices to secondary care. Through our discussions
with practices it became clear that developing a set of easy to follow guidelines would be
incredibly useful. The key messages that came out of all the discussions were:

Recognising that consultant gynaecologists are surgeons and they should be seeing
patients who might need an operation. Hospital outpatient clinics are expensive.

Many GPs lack confidence in their own knowledge or skills and believe that their patients
demand a consultant opinion. In some cases this will be true, but many patients would
prefer to be managed by a GP that they trust and who offers greater accessibility and
continuity of care.

Patients cannot demand to see a particular specialist on the NHS. Community clinics of
the highest standard are a logical next step for patients who need more than their GP
but who do not immediately require a surgeons opinion.

If patients are to be referred to the right person, in the right place and at the right time,
GPs need to be supported to think clearly about their referrals and to communicate more
effectively with their patients.

Costs would be reduced and patient care enhanced if there was a shared understanding
of the management of common gynaecological conditions and a wider range of options
for investigation and treatment patients outside of the hospital outpatient clinic.

We are currently working with the PCT to establish a community Gynaecology One Stop
Service for women in Bromley and will keep you informed of developments.
Most importantly, a very big thank you to James Heathcote who led the working group and
to his team Nikki Payne, William Okonji & Seye Sodipe and of course the practices involved
in the discussions.
With very best wishes,
Yours sincerely

Neil Francis,
Chief Executive

Andrew Parson,
Clin Lead Bromley

Ruchira Paranjape,
Clin Lead Orpington

Alan Fishtal
Clin Lead Unity

Bromley PBC
Gynaecology
Introduction
Welcome to the Bromley PBC Gynae management project. We would like to introduce
you to some easy to follow, evidence based and locally referenced care pathways that
have been designed to help all GPs to deliver a first class service to their patients.
To make the most of these guidelines, please spend a few minutes looking at them to see
what is there and how they work. You will soon see that .....
The next page is a list of the pathways included.
Next comes a page that summarises the key points in a full gynae history. This is only
here as an aide memoire and if it doesnt help you, please skip past it.
Thereafter there is a common format of one page algorithm and one page notes.
All of the algorithms read from top to bottom with as few boxes and tricks in them as
possible. The small boxed numbers refer to foot notes on the second page.
Also on the second page, you will find Key Messages and Resources (usually on the
web) and these will help you find the national guidelines on which these pathways
are based, patient information and (occasionally) images to help you.

These are guidelines not rules

Follow your clinical instincts

At the end of the guidelines, you will then find information on Two Week cancer referrals
and the answers to some Frequently Asked Questions.
If you have any corrections, questions or ideas that could improve them, please let us
know by e-mailing Janet.Edmonds@bromleypct.nhs.uk .
The next stage in this project will be to expand the options available to you when
managing your patients by making existing services more accessible or commissioning
new services. As and when we are able to do this, we shall update the guidelines.
Janet Edmonds, James Heathcote, William Okonje,
Nikki Payne, Seye Sodipe
[ Bromley PCT Gynae Project team members ]

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Gynaecology
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Gynae History

6 pregnancy:
Pregnancies (G) and births (P)
Problems in pregnancy or labour
Miscarriage / TOPs / subfertility

1 presenting problem:
Any possibility of pregnancy?
Exclude cancer / STD / ectopic

7 contraception:
Contraceptive method chosen

2 periods:
( take an age-relevant history )
LMP - Last menstrual period
K - Cycle length and frequency

Unprotected SI / pregnancy?
Why? was last period normal?
Method required?
Potential contraindications

How heavy is the bleeding?

IMB - Inter-menstrual bleeding?
PCB - Postcoital bleeding?

8 sex & relationships:

Age of menarche/menopause?

Orientation and sexually active?

PMB - Postmenopausal bleeding?

In a relationship at the moment?

"How are things between you?"

3 discharge:
Colour / smell / amount
Duration
Itch / Rash?
Symptoms in partner?

9 infection:
Past history of infection or PID?
Any known contact with STD?
Higher risk = age < 25years or
... new partner in past 12 months

4 pain:
Duration, type, radiation
Precipitation or relief?
Relation to menstrual cycle?
Dyspareunia - superficial / deep?

10 general health:
Bowel problems?
Smoking/alcohol/drugs (esp iv usage)
Other medical conditions?
Drug history

5 bladder symptoms:

Gynaecological operations?
Date and result of last cervical smear

Dysuria / frequency / blood

Hesitancy / strangury
Stress or urge incontinence?

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Contents
Gynae History

Page 2

Continence problems

Pages 4-5

Problem Periods (Heavy Menstrual Bleeding)

Pages 6-7

Polycystic Ovarian Syndrome

Part 1 : Diagnosis

Pages 8-9

Polycystic Ovarian Syndrome

Part 2 : Treatment

Pages 10-11

Postmenopausal Bleeding

Pages 12-13

Prolapse

Pages 14-15

Pruritus Vulvae

Pages 16-17

Vaginal infections

Pages 18-19

Benign cervical problems

Pages 20-21

Simple Ovarian Cysts

Pages 22-23

South East London Cancer Network

information to support Gynaecology referrals

Pages 24

Frequently asked questions

Pages 25-27

Dept of GUM/HIV Services

Pages 28

Enhanced Sexual Health Services

Page 29

Continence Service

Page 30

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Continence problems
Woman presents with
bladder symptoms

Take history to define

bladder problem
1

Examine abdomen, inspect

vulva and consider PV
exam for pelvic floor
muscle tone
2

Dipstick urinalysis
+/- MSU
3

Refer Continence
Clinic and arrange
follow up
4

URGE

STRESS

= a sudden compelling desire

to urinate that is difficult to
defer

= involuntary urine leakage

on effort, exertion, sneezing
or coughing

If no better after 6 weeks, try......

1st line: immediate release oxybutynin
2nd line: Alternative antimuscarinic or
long acting oxybutynin

If no better after 3 months

of pelvic floor muscle
training, refer Gynae
6

If post-menopausal, consider
intravaginal oestragens
Refer Urology if not better

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Continence problems
Key messages:

Female continence problems include stress and urge incontinence and incomplete bladder
emptying.

All of the above can be referred to the continence clinic for further management, but women
with obvious prolapse or haematuria should be referred elsewhere (see below).

Foot notes:
1.

Incontinence - if and when it happens

Bladder symptoms - hesitancy or voiding problems, prolapse, urgency, frequency and
nocturia, dysuria and blood in urine
Medical, occupation and drug history - treatable causes, eg lifting, cough or constipation
O&G history - menopause status, big babies or difficult labours

2.

Refer, investigate or treat any abdominal mass (tumour, fibroids, constipation, bladder),
atrophic vaginitis or prolapse (see prolapse pathway, pages 18-19). Arrange ultrasound
scan and refer gynae if the bladder is still palpable after voiding.
NICE recommends a PV exam to assess pelvic floor muscle tone before starting pelvic floor muscle
training, but there is only low level evidence for this (see debate on link below)
http://www.continence-uk.com/journal/downloads/0102_debate.pdf

3.

Send MSU if dipstick +ve or symptoms suggest UTI. Refer all women aged > 50 with
microscopic haematuria to Urology. Refer women aged > 40 with recurrent or persisting UTI
associated with haematuria.

4.

The Bromley PCT Continence Service, 77 Addington Road, West Wickham, Kent BR4
9BG offers 16 clinics a month across Mottingham, Princes Plain, Penge, St Pauls Cray,
Orpington & Addington Road will assess women with a full range of continence issues and
refer onwards if needed. Tel: 0208 462 1255.

5.

Start with oybutynin 5mg bd or tds (2.5 mg bd in elderly). If oxybutynin isnt tolerated, try
any of the following: darifenacin, solifenacin, tolterodine, trospium or SR/patches of
oxybutynin - there is little to choose between then in terms of cost.
Estriol [ortho-gynest] 0.5mg pessary (x15) or 0.01% cream (80g) apply 1 pessary or
applicatorful every evening for 2 weeks, then twice a week and reassess every 3-6 months.

6.

Refer Gynaecology unless there is a history of past bladder surgery, radiotherapy or

complex pelvic surgery - in which case, refer Urology.

Resources:
For GPs

http://www.nice.org.uk/Guidance/CG40/NiceGuidance/pdf/English
http://www.nice.org.uk/nicemedia/pdf/word/CG40quickrefguide1006.pdf

For patients

www.nice.org.uk/CG040publicinfo
Bladder diary: http://kidney.niddk.nih.gov/kudiseases/pubs/diary/index.htm
http://www.patient.co.uk/ includes the following titles: Incontinence,
Incontinence - Picture Summary, Urinary Incontinence, Stress Incontinence,
Pelvic Floor Exercises, Incontinence / Bladder Chart
and Urge Incontinence

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Problem Periods

Patient presents with

Heavy Menstrual Bleeding

Is there Inter Menstrual or

Post Coital Bleeding
2

YES

Investigate
or refer

NO
Order Full Blood Count for
ALL women with HMB
3

Offer abdominal and

pelvic examination
[+cervical smear if due]

Is abdominal and pelvic

examination needed?
4
NO

Is the
examination
normal?

YES

NO or
(or not sure)

Arrange pelvic
ultrasound
scan
5

YES
Offer treatment. Review and consider
2nd line option. Safety net
Mirena IUS

(* - see below)

NB - take care to examine the patient first

tranexamic acid (** - see below)

NSAID (** - see below)
combined oral contraceptive
day 5-26 norethisterone
injected long-acting progestogens

Is ultrasound scan
NORMAL or
only fibroids of
<3cm diameter
YES

NO

Refer

*- irregular bleeding may last for > 6 months

**- stop if no improvement after 3 cycles
6, 7
If not
settled
Age >45 : refer for endometrial biopsy
Age <45 : consider 2nd pharmaceutical
treatment, safety net, review again
and refer if treatment fails
8

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Problem Periods = Heavy Menstrual Bleeding

[ based on NICE guideline CG44 ]
Key messages:

HMB is not itself associated with significant mortality but a hysterectomy is a major
operation, associated with significant complications in a minority of cases

In the early 1990s, at least 60% of women with HMB went on to have a hysterectomy but
this number is now decreasing rapidly

Treatment for uncomplicated HMB can safely be started in primary care without carrying out
a physical examination or any complicated investigations

All women with HMB should have an FBC but other tests (ferritin, thyroid function, hormone
levels) are not routinely indicated

Foot notes:
1. Heavy Menstrual Bleeding = excessive menstrual blood loss which interferes with the womans
physical, emotional, social and material quality of life and which can occur alone or in
combination with other symptoms.
2. A history of intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms needs
explaining. Consider (but dont assume) breakthrough bleeding or ectropion for younger
women on the pill and physical examination, ultrasound and/or referral for older women.
3. Ferritin, thyroid function and hormone levels are not routinely indicated (NICE recommendation)
4. If the history suggests HMB without structural or histological abnormality, pharmaceutical
treatment can be started without carrying out a physical examination or other investigations.
5. Specify pelvic ultrasound. There is no need for a routine abdominal scan
6. NICE guidance suggests that treatments should be considered in the following order:

7.
8.

Mirena IUS provided >12months use is anticipated (NB examine the patient first)

tranexamic acid (500mg 2 tds for up to 4 days) OR mefenamic acid [500mg tds from day 1] or
naproxen [500mg stat then 250mg tds-qds prn] OR mid dose combined oral contraceptives (eg
Ovranette)

norethisterone (15mg od from days 5 to 26 of the menstrual cycle) or injected long-acting

progestogens (off license use of Implanon or [for <2 years use only] Depo-Provera).

Safety net = Say to patient: If the bleeding does not improve after a couple of periods or
other new symptoms develop that worry you, please come back and see me sooner.
A biopsy should be taken to exclude endometrial cancer or atypical hyperplasia in women
aged >45 if treatment is ineffective.

Resources:
For GPs

NICE quick reference guide: http://www.nice.org.uk/CG044quickrefguide

For patients

http://www.nice.org.uk/nicemedia/pdf/HMBUNGv9Sept08.pdf
http://www.patient.co.uk/DisplayConcepts.asp?WordId=menorrhagia&MaxResults=50&x=17&y=14

www.doctoronline.nhs.uk

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Polycystic Ovarian Syndrome

Part 1 : Diagnosis
Woman presents with possible PCOS

Confirm specific history and signs

Infertility (73%)
Infrequent periods (66%)
Obesity (35-60%)
Hirsutism / acne (48%)

Ask for family history

Check drug history

Order tests
FSH, LH, prolactin (if periods infrequent),
TSH and Free Androgen Index
(+ f.lipids and f.glucose if obese)
Pelvic ultrasound
4

Diagnosis
needs

- Infrequent ovulation

2 of 3

- Polycystic ovaries
on ultrasound scan

- Hyperandrogenism
5

Is PCOS diagnosis confirmed? 6

YES
Follow second
PCOS guideline

NO
Reassure and treat any
presenting symptoms

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Polycystic Ovarian Syndrome

Part 1 : Diagnosis
Key messages:

PCOS is diagnosed on the basis of two out three of:

a) infrequent ovulation,

b) hyperandrogenism

c) polycystic ovaries on ultrasound scan

22-33% of women have polycystic ovaries alone and have normal fertility

Foot notes:
1.

Take menstrual history and examine for BMI, hirsutism, acne, male pattern hair loss or
acanthosis nigricans (hyperkeratosis and grey-brown pigmentation in axillae, neck,
perineum, or extensor surfaces of the elbows and knuckles).

2.

A positive family history of PCOS and/or type 2 diabetes raises a womans risk of PCOS

3.

Steroids, phenytoin, minoxidil, metoclopramide and other less commonly used drugs can all
cause hirsutism http://www.turner-white.com/memberfile.php?PubCode=hp_oct08_androgenism.pdf .

4.

LH may be moderately elevated in PCOS

FSH should be normal in PCOS
TSH and prolactin to rule out other causes for amenorrhoea
Free Androgen Index [= testosterone/SHBG] is more useful than serum testosterone
Check f.glucose and f.lipids if obese to save having to do them later!

5.

Infrequent periods = a cycle of >35 days (ie less than 9 periods a year).

Polycystic ovaries = 12 or more follicles in each ovary of 29 mm diameter &/or increased

ovarian volume (>10 ml).
6.

Polycystic ovaries alone are a common finding (22-33%) in women of reproductive age and
women who just have polycystic ovaries but no other characteristics of PCOS have normal
fertility. Other diagnoses to exclude (according to the presenting symptoms) include simple
obesity, adrenal disease, androgen-secreting tumours and acromegaly.

Resources:
For GPs

http://www.cks.nhs.uk/polycystic_ovary_syndrome#242662001
( Last revised in January 2007and revision planned for 2010 )

For patients

http://www.cks.nhs.uk/patient_information_leaflet/polycystic_ovarian_syndrome
http://www.patient.co.uk/showdoc/23069147/

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Polycystic Ovarian Syndrome

Part 2 : Treatment

Woman presents with confirmed PCOS

Advise weight loss for all

overweight women
1

address the presenting

symptom (s)

Infrequent
periods

Infertility

Induce bleed with

COC pill or
progestagen 2, 3

Pre-conception advice on
diet, exercise, smoking,
folic acid & rubella.
Discuss gynae referral

Hirsutism
or acne

Metabolic
syndrome
and / or
obesity

Consider COC pill

Treat acne
3, 4
Eflornithine
Refer dermatology

Assess cardiovascular
risk, arrange oral GTT
or fasting glucose.
Discuss referral to
endocrinologist

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Polycystic Ovarian Syndrome

Part 2 : Treatment

Key messages:

All overweight women with PCOS will benefit from weight loss

PCOS is associated with metabolic syndrome, but there is no evidence-based consensus

as to how (or if) this should be treated with medication

Foot notes:
1.

All symptoms and risks of PCOS may be improved by losing excess weight

2.

It is not known whether women with PCOS are at greater risk of developing endometrial
cancer but it is considered good practice to induce a regular bleed either with a combined
pill (if contraception is needed) or with dydrogesterone 10mg bd for12 days every 1-3
months. If the woman has acne or hirsutes, consider co-cyprindiol (Dianette - NB increased
DVT risk) or Yasmin. Otherwise, any first generation pill will do e.g. Ovranette.

3.

For advice on long term use of co-cyprindiol, see

http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Patient-Safety/500652/

4.

i) Consider treatment as in foot note 2 above

ii) Treat acne as for any other woman.
iii) Consider prescribing topical eflornithine in women with facial hirsutism it has no known
serious side effects, but benefit stops on cessation, costs approximately 1 a day and there
is no long term data available.
NB If hirsutism or acne is severe or of sudden onset, test serum dehydroepiandrosterone
for adrenal tumour or congenital adrenal hyperplasia.

5.

WHO advises screening with fasting glucose or (ideally) oral glucose tolerance test every
3 years for all women with other risk factors (e.g. BMI > 30, South Asian, age > 40, women
who want to get pregnant or +ve FH), check BP and fasting lipids and consider cardiovas
cular risk score.

Resources:
For GPs

http://www.cks.nhs.uk/polycystic_ovary_syndrome#242662001
( Last revised in January 2007and revision planned for 2010 )

For patients

http://www.cks.nhs.uk/patient_information_leaflet/polycystic_ovarian_syndrome
http://www.patient.co.uk/showdoc/23069147/

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Postmenopausal Bleeding

Patient presents with

postmenopausal bleeding
If patient on Tamoxifen,
refer under 2 week rule 2

Offer examination
abdominal
bimanual
speculum

Have you found a treatable

cause for the bleeding?

YES

Treat and
safety net

3, 5

NO
Have you found a problem
that needs to be referred? 3

YES

4
Refer
appropriately

NO
Is patient on HRT or within
6 weeks of stopping HRT?

NO

Refer 2 2
week rule

YES
Arrange ultrasound scan for
endometrial thickness

Endometrial thickness < 3mm

- Reassure and safety net
Endometrial thickness > 3mm
- Refer 2 week rule
2, 6

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Postmenopausal Bleeding
Key messages:

Most post-menopausal bleeding should be referred under the 2 week rule

Refer all women on Tamoxifen

A simple external, abdominal and speculum examination will sometimes reveal simple,
treatable pathology (eg a atrophic vaginitis, a non-gynae cause or a cervical polyp)

Women on HRT should have endometrial thickness measured to determine whether referral
is needed

Foot notes:
1. Postmenopausal Bleeding = vaginal bleeding 12 months or more after the last period
2. Patient referral forms on http://www.selcn.nhs.uk/content/dynamic.asp?
id=629&dynamic_id=40&sn=Forms%20for%20use%20by%20Healthcare%20Professionals
3. If atrophic vaginitis, treat with estriol [Ortho-gynest] 0.5mg pessary (x15) or 0.01% cream
(80g) apply 1 pessary or applicatorful every evening for 2 weeks, then twice a week and review
after 2 months (NB progestogen not needed with such low dose).
4. If uncertain adnexal mass found, refer 2 week rule. If fibroids, follow Heavy Periods pathway
5. Safety net = Say to patient: If the bleeding continues or other new symptoms develop that
worry you, please come back and see me
6. The SIGN guideline suggests a threshold of 5mm, but some are unhappy with this and so
3mm has been chosen as the cautious option. These are however guidelines, not absolute
rules!
Resources:
For GPs
South East London Cancer Network patient referral forms and guidelines
http://www.selcn.nhs.uk/content/dynamic.asp?id=629&dynamic_id=40&sn=Forms%20for%
20use%20by%20Healthcare%20Professionals
http://www.sign.ac.uk/guidelines/fulltext/61/index.html
Patient information see: http://www.patient.co.uk/showdoc/40024599

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Prolapse

Patient presents with

possible prolapse

How severe are the

symptoms?
2

Identify treatable
risk factors
3

Dipstick urinalysis
+/- MSU
4

NO

Is abdominal examination
normal?
5

Order ultrasound
scan and/or refer
gynae

YES
YES

Is cervix visible at
the introitus?

Refer gynae

NO
Is woman young, fit
and motivated?
6

YES

Refer continence clinic

and review after 3/12 7

NO
Trial of ring pessary
+/- topical oestrogen

Refer gynae if either

Patient or GP are
unhappy

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Prolapse
Key messages:

50% of parous women have some prolapse and most are asymptomatic

Treat the symptoms, not the prolapse

Although the evidence of benefit is poor, a trial of pelvic floor muscle training and/or a ring
pessary can be tried before referring women for surgery

Foot notes:
1.

Prolapse = downward herniation of vaginal with or without uterus. Some degree of prolapse
is seen in 50% of parous women and most are asymptomatic.

2.

Ask about

Urinary frequency, urgency or incontinence

Constipation (may be cause or effect)
Bulges or lumps in the vagina, pelvic pressure, heaviness or dyspareunia
Does the patient insert her fingers in the vagina to void or defaecate?

3.

Advise weight loss if obese. Review medication and treat cough (ACE-i) and constipation.
Is the patient a carer? (lifting).

4.

Send MSU only if dipstick +ve or symptoms suggest UTI.

5.

Exclude abdominal masses. Assess prolapse using disposable Simms speculum in left
lateral position. Assess pelvis for possible ring pessary.

6.

There is no convincing evidence for either conservative treatment (Cochrane), though they
are often tried for mild to moderate prolapse. Pelvic organ prolapse surgery has a success
rate of 65% to 90%. The repeat operation rate is 30%.

7.

The Bromley PCT Continence Service, 77 Addington Road, West Wickham, Kent BR4
9BG offers 16 clinics a month across Mottingham, Princes Plain, Penge, St Pauls Cray,
Orpington & Addington Road will assess women with a full range of continence issues and
refer onwards if needed. Tel: 0208 462 1255.

8.

PbC needs to develop a local pessary service. Topical oestrogen = estriol [Ortho-gynest]
0.01% cream (80g) apply 1 applicatorful every evening twice a week as needed. See below
links for more information on ring pessaries.

Resources:
For GPs
Step-by-step approach to managing pelvic organ prolapsed and Pessary insertion
from the College of Family Physicians of Canada :
http://www.cfpc.ca/cfp/2007/Mar/vol53-mar-fpwatch-bordman.asp
http://www.cfpc.ca/cfp/2007/Mar/vol53-mar-currentpractice-practicetips.asp

Cochrane review of conservative treatment

http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003882/frame.html

For Patients
http://www.patient.co.uk/showdoc/27001324/

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Pruritus Vulvae
Patient presents with
vulval itching

What exactly is the complaint? 1

Is she otherwise well?

Dipstick urinalysis +/- MSU 3

Inspect the vulva

YES

Is infection or infestation
suspected??
4

Treat or refer
GU medicine

NO
YES

Are any suspicious

localised lesions seen ?

Refer 5

NO
YES

Have you made a

firm diagnosis?

Treat appropriately 6

NO
Nothing abnormal seen
= pruritus vulvae

Remove irritants (see list)

Treat with Antihistamines

and 1% Hydrocortisone
for 2-4 weeks

Review

If not settled, refer for firm

diagnosis to dermatology

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Pruritus Vulvae
Key messages:

If you dont look, you wont make a diagnosis

Just looking may enable you to treat the patient and make her better

Lichen sclerosus may respond to a four week trial of potent steroids

Uncertain lesions in older women and warts in postmenopausal women

need a tissue diagnosis

Foot notes:
1.

Symptom enquiry

Is this pain, itch, discharge, bleeding or dyspareunia?

Is there anything to see swelling, a rash or a localized lesion?

Is she depressed (important question in pruritus vulvae)

What treatment has been tried and for how long?

2.

Does she have any skin condition (eg psoriasis) or systemic illness (see foot note 9)?

3.

Send MSU only if dipstick +ve or symptoms suggest UTI.

4.

Look carefully in good light and if discharge seen or STD possible, take HVS, endocervical
and/or Chlamydia swabs.

5.

If malignancy or pre-malignancy suspected, refer gynaecology or dermatology.

Uncertain lesions in older women (including warts in postmenopausal women) should

be referred for tissue diagnosis.

Bartholins cysts are routine but refer abscesses as an emergency

Refer suspicious (?melanoma) pigmented lesions to the dermatologists under the 2

week rule and ulcers or lumps that could be cancerous urgently.

6.

For a useful review of the subject, see Management of common vulval conditions (Medical
Journal of Australia (2003) http://www.mja.com.au/public/issues/178_08_210403/wel10498_fm.html

7.

Remove sources of irritants see http://www.patient.co.uk/showdoc/23069006/

8.

Consider blood tests for pruritus or if systemic disease suspected (full blood count, ESR/
CRP, U&E, thyroid function and fasting glucose) before referring to dermatologist

Resources:
For GPs

The NHS Clinical Knowledge Summaries http://cks.library.nhs.uk/pruritus_vulvae

For Patients

http://www.patient.co.uk/showdoc/23069006/

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Vaginal infections
Patient presents with a vaginal
discharge ? infection

Ask about discharge and

associated symptoms
1

Is patient at HIGH RISK of

Sexually Transmitted Disease?
i.e. Age <25 years or
New partner in <12 months 2

YES

Refer
GUM 3

NO
Consider empirical treatment
only if either typical BV
or thrush and safety net 4

Are speculum
and PV exam
both normal?

NO
Refer GUM, Gynae
or enhanced sexual
health clinic
3, 5

YES
Is there a mucopurulent discharge?

YES

NO
Take swabs

Consider empirical treatment for

BV or thrush but NOT for GC or
Chlamydia. Then safety net 4, 7

Treat swab results, safety net

or refer GUM / gynae

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Vaginal infections
Key messages:

Assess the risk of STD before treating vaginal discharge

Low risk, clinically obvious bacterial vaginosis or thrush can be safely treated without swabs
or examination

Chlamydia and Trichomonas infections require contact tracing

Foot notes:
1.
Ask about a) Discharge - colour, consistency, volume or odour b) Itch, soreness, dysuria,
pelvic pain, irregular bleeding and c) Foreign body eg retained tampon
2.

Women are considered at increased risk at age < 25 years or if they have had a new sexual
partner in the last 12 months, but use your local knowledge of the patient and practice
population and refer to a GUM clinic if unsure.

3.

Beckenham clinic: http://www.bromleyhospitals.nhs.uk/referrers/clinical-services/sexual-health

Other London clinics (NB gay mens site) http://www.gmfa.org.uk/sex/clinics/index#londonclinics

4.

Bacterial vaginosis (BV) is the commonest cause of discharge and produces a fishysmelling discharge, not associated with itching or soreness. Treat if simple BV predicted
and risk of STI is low (metronidazole 400mg bd for 7 days or see foot note 6 below.)
Thrush produces a white odourless discharge that may be associated with itching and
superficial soreness. Treat if simple thrush predicted and risk of STI is low (e.g. clotrimazole
10% cream + applicator [5g] or pessary [500mg] stat or 200mg pessary nocte x 3 or fluconazole [150mg] orally stat). Treat the sexual partner only if s/he is symptomatic.
Safety net = Say to patient: If the discharge doesnt settle within a week or comes back
after treatment or if other symptoms worry you, please come and see me again

5.

Pelvic exam for cervical motion or adnexal tenderness (suggests PID) or abnormal masses
(suggests gynae malignancy). NB also retained tampons not always visible with speculum

6.

High vaginal swab (HVS in all cases) - swab discharge from the lateral vaginal wall and
posterior fornix
Endocervical swab ( if STD or PID suspected) - clean the cervical os with a large sterile
swab, then insert a new swab into the endocervix and rotate 360 degrees
Chlamydia swab - if sexually active and age < 25

7.

Refer Trichomonas vaginalis (TV) (fishy-smelling, frothy, yellow-green discharge +/- itch,
soreness, dysuria) and Gonorrhoea to GUM (see 3 above) as both need contact tracing.

8.

See Management of Infection Guidance for Primary Care http://www.hpa.org.uk/webw/

HPAweb&Page&HPAwebAutoListName/Page/1197637041219

Resources:
For GPs
NHS Clinical Knowledge Summaries http://www.cks.nhs.uk/candida_female_genital/
management/quick_answers/scenario_uncomplicated_infection#-284072
HPA Guidance see foot note 8 above

For Patients
Thrush: http://www.patient.co.uk/showdoc/23068842/
Bacterial vaginosis: http://www.patient.co.uk/showdoc/23068687/
Trichomonas: http://www.patient.co.uk/showdoc/23068844/

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Benign Cervical Problems

A) Ectropion

Does the patient complain

of excessive discharge
or bleeding?

Refer to Colposcopy
Clinic for cautery

YES

NO
Is she on the combined pill,
with up to date smears and
otherwise well?
YES
Reassure

B) Nabothian follicles

Reassure

C) Endocervical polyps
Symptomatic
or large?
YES

NO

If up to date with smears,

twist off with sponge forceps

Send polyp to histology

Arrange u/s scan

Reassure

Refer gynae

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Benign Cervical Problems

Key messages:

See On-line pictures for GPs in resources below.

Most young women (particularly if they are taking the combined oral contraceptive pill) have
an ectropion ( also known as a cervical erosion ).

Nabothian follicles are always benign.

Incidental cervical polyps can safely be removed in primary care but (to be safe) always
send histology and arrange a check ultrasound scan.

Foot notes:
1.

Most young women, particularly if they are taking the combined oral contraceptive pill, have
a cervical erosion (ectropion) which may be observed during routine pelvic examination. If
there are no symptoms, there is no reason to offer treatment. Women experiencing a heavy
discharge or postcoital bleeding may be referred to the Colposcopy Clinic for cautery.

2.

Nabothian follicles (or cysts) are mucus-filled lumps on the surface of the cervix. They are
typically small, smooth and rounded. They may be multiple but are always benign.

3.

Endocervical polyps are most usually found in the fourth to sixth decade of life. They are
cherry red, single or multiple and appear as a pedunculated lesion on a stalk of varying
length.
Large, symptomatic endocervical polyps should be referred for further evaluation.
Small, asymptomatic polyps protruding from the cervical os may safely be removed, but
check histology and follow up with ultrasound to ensure that the problem has been fully
treated.

Resources:
On-line pictures for GPs:
Various cervical problems :
http://www.gfmer.ch/Books/Cervical_cancer_modules/Unaided_visual_inspection_atlas.htm

Nabothian follicles:
http://pennhealth.com/encyclopedia/em_PrintArticle.aspx?gcid=001514&ptid=1
http://farm4.static.flickr.com/3136/2857638949_d43b9d8379.jpg?v=0
Leaflet for patients:
Uterine Cervix and Common Cervical Abnormalities (good but very technical)
http://www.patient.co.uk/showdoc/40024690/

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Simple Ovarian Cysts

Patient is found to have

an ovarian cyst
Ask about symptoms
and red flags
2

Check family
history
3

Order trans-vaginal
ultrasound scan
if not already done

Is the cyst complex or

>5cm diameter?

YES

Refer
2 week rule 6

NO

Is the patient
pre- menopausal?

NO
4

For post-menopausal women

only, order CA 125 and
save serum
5

YES
Is CA 125 normal?

Reassure and repeat

scan after 6 weeks

YES

NO
Refer
2 week rule

Refer if not settled

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Simple Ovarian Cysts

Key messages:

Simple ovarian cysts are usually benign

Ovarian cancer usually presents too late after non-specific symptoms

A family history of ovarian and/or breast cancer raises an individuals risk

The malignant potential of an ovarian cyst can safely be assessed in primary care using
ultrasound scans and (for post-menopausal women only) CA125 measurement

Foot notes:
1.

Ovarian cysts are a common finding on clinical and ultrasound examination. Most simple
cysts are benign but ovarian cancer is fourth commonest cause of death from cancer in
women and most cases are diagnosed late.

2.

Look for symptoms and red flags : irregular menstrual bleeding (inter-menstrual, mid-cycle
or post-coital); non-specific symptoms including abdominal pain and bloating; changes in
bowel habit, urinary and/or pelvic symptoms.

3.

Most cases of epithelial ovarian cancer are sporadic but a family history of ovarian and/or
breast cancer increases the risk
(SIGN guideline link http://www.sign.ac.uk/guidelines/fulltext/75/section2.html)

4.

Ovarian cancer is rare age <30, increasing with age and reaching its maximum in the sixth
decade. The risk of malignancy can be calculated using ultrasound features, menopausal
status and CA125 levels

5.

CA125 is a glycoprotein antigen and elevated concentrations of CA125 are associated with
malignant tumours of the pancreas, breast, lung, colon and ovary. Approximately 80% of
patients with advanced ovarian cancer have elevated concentrations of CA125. A maximum
of only 50% of patients with clinically detectable stage I disease have elevated CA125
levels. Despite its poor sensitivity and specificity, CA125 is most useful for detecting and
monitoring tumours of the ovary. Ask the lab to save serum in case other antigens are
wanted later.

6.

South East London Cancer Network patient referral forms and guidelines
http://www.selcn.nhs.uk/content/dynamic.asp?id=629&dynamic_id=40&sn=Forms%20for%20use%
20by%20Healthcare%20Professionals

Resources:
For GPs
Scottish Intercollegiate Network (SIGN) guideline
http://www.sign.ac.uk/guidelines/fulltext/75/section1.html

RCOG guideline Ovarian cysts in postmenopausal women (2003)

http://www.cgmh.org.tw/intr/intr5/c6700/Guideline/GYN%20Guideline/OVARIAN%20CYSTS%
20IN%20POSTMENOPAUSAL%20WOMEN%20Guideline.pdf

For patients
http://www.patient.co.uk/showdoc/27000666/

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South East London Cancer Network

Information to support Gynaecology referrals
Refer urgently patients:

With clinical features suggestive of cervical cancer on examination. A smear test is not required before referral, and a previous negative result should not delay referral.
With an unexplained vulval lump.
Not on HRT with postmenopausal bleeding.
On HRT with persistent or unexplained postmenopausal bleeding after cessation of HRT for
6 weeks.
Taking tamoxifen with post menopausal bleeding.
With vulval bleeding due to ulceration.
With a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids
or not of gastrointestinal or urological origin. Obtain Ca125, Ca199 and CEA markers.

Consider an urgent referral for patients with persistent inter-menstrual bleeding and negative pelvic
examination.
Investigations in Primary Care:

A full pelvic examination, including speculum examination of the cervix, is recommended for
patients presenting with any of the following:
alterations in the menstrual cycle

intermenstrual bleeding

postcoital bleeding

postmenopausal bleeding

vaginal discharge.
Carry out an abdominal palpation, and consider a pelvic examination, in patients with vague, nonspecific, unexplained abdominal symptoms such as
bloating

constipation

abdominal pain

back pain

urinary symptoms.
In patients with vulval pruritus or pain, a period of treat, watch and wait is reasonable. Active follow
-up is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the
referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about
cancer.
Patient information and support:

Consider the information and support needs of patients and the people who care for them while they
are waiting for the referral appointment. Resources for GPs to use are available from the Cancer
Network on 020 7593 0160, or visit our website www.selcn.nhs.uk.
Approved by the South East London Cancer Network in November 2006.
For comments or additional copies contact the Network on Tel 020 7188 7090
Fax 020 7188 7020, or visit our website: www.selcn.nhs.uk.

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Frequently Asked Questions

General
Are these guidelines referenced?
Wherever possible, these guidelines are referenced to NICE, to the South London Cancer Network or to the NHS Clinical Knowledge and the reference used is generally included under
Resources for GPs on the second page. The guidelines never knowingly contradict national
guidance and are written with clinical safety in mind, not cost saving.

Ultrasound
Should GPs order a Ultrasound and then refer to gynae or should they just refer to gynae if
they think that will be the outcome anyway?
If a patient needs an ultrasound, get it done in advance of the outpatient appointment - the result
will be helpful to the next doctor and it shouldnt be repeated. If you are sure that the patient will
need a referral, then make the referral and order the ultrasound. If you are not sure, then order
the ultrasound and then make your decision.
Does the PCT get charged for both the USS and the gynae referral?
Ultrasound scans at the PRUH are currently under a block contract and therefore not charged for
separately. In the future, ultrasound scan at the PRUH (or at Pickhurst Surgery) are likely to be
billed separately.

Benign Cervical problems

Does a practice need to be approved to undertake minor surgery to twist off a cervical
polyp?
No. This is a low risk procedure, commonly undertaken in the outpatient clinic setting.
Can you leave a cervical polyp alone if it is small and asymptomatic?
Yes, but you would have to talk with the patient and manage the very small (<1/200) risk of that
polyp becoming malignant. http://www.mdconsult.com/das/pdxmd/body/155430867-2/0?type=med&eid=9-u1.0_1_mt_5092001

Do you really need to order an ultrasound scan after removing a cervical polyp?
No according to the advice of the Scottish NHS sponsored Gynaecology Patient Pathways http://
www.pathways.scot.nhs.uk/polyps.htm In the older woman, however, ultrasound is probably sensible however as 57% of postmenopausal women will be found to have an endometrial polyp.

Continence problems
Why do the guidelines not insist on a pelvic examination before treatment?
Many GPs and many patients are uncomfortable about performing a pelvic examination and if the
guideline were to suggest it in every case, this would have to be based on evidence that examination was helpful. The NICE clinical guideline CG 40 states expert opinion concludes that symptomatic categorisation of urinary incontinence based on reports from the woman and history taking
is sufficiently reliable to inform initial, non-invasive treatment decisions ie you can safely treat
and monitor what happens if there are no obvious concerns.

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What is the cost of a continence clinic referral?

The community continence clinic is part of the PCT Community Provider Unit and therefore under
a block contract. In time it should become a part of Bromley Healthcare and GPs will have the opportunity to help shape the service to deliver what patients need of it. It currently has capacity
and could be expanded if the need increases.
Can GPs try medical management options before referring to the continence clinic?
Yes, if that is what they and/or the patient wants to do but the clinic offers the opportunity for a
more detailed assessment and more education than most GPs could provide.
Which anticholinergic drug is best for overactive bladder symptoms?
The Cochrane Database of Systematic Reviews Plain language summary states: The review
found that there are several anticholinergic drugs prescribed for adults with overactive bladder
symptoms. The two most studied drugs are oxybutynin and tolterodine. These two drugs have
similar effects, but on average those taking oxybutynin were more likely to withdraw from the
studies because of adverse effects, mainly dry mouth. However, both drugs can give dry mouth,
and this problem is less likely if an extended release formulation of either drug is used.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Drug-Class-Focused-Reviews/498336/

Heavy periods
Why not check the thyroid function and ferritin level?
NICE guideline CG44 specifically states that serum ferritin, female hormone testing and thyroid
function tests are not recommended in investigating women with heavy menstrual bleeding.
Do all women need with heavy menstrual bleeding need a pelvic examination?
NICE guideline CG44 states If the history suggests HMB without structural or histological abnormality, pharmaceutical treatment can be started without carrying out a physical examination or
other investigations at initial consultation in primary care, unless the treatment chosen is
levonorgestrel-releasing intrauterine system (LNG-IUS).

Simple ovarian cysts

Why does the guideline suggest that GPs ask the lab to save serum for post-menopausal
women when requesting a CA 125?
This is normal practice in the hospital where C19-9 and CEA are used in pelvic masses of uncertain origin to rule out a bowel, rather than a gynae origin.

Polycystic Ovarian Syndrome (Parts 1 & 2)

How common is Polycystic Ovarian Syndrome (PCOS)?
Research studies of women who had an ultrasound scan of their ovaries found that up to 1 in 4
young women have polycystic ovaries and many of these women were healthy, ovulated normally, and did not have high levels of male hormones.
It is thought that perhaps 1 in 10 women have polycystic ovary syndrome.
Where can I find out more about the patho-physiology of PCOS?
There is an excellent, medical school style powerpoint presentation from Professor Stephen Atkin, Head of Academic Endocrinology at Hull York Medical School on the internet, but the date of
preparation is not stated:
http://www.pcos-uk.org.uk/Documents/PCOS%20Management%20Options%20-%20Steve%20Atkin.pdf

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Is there any place for a GP to commence metformin?

PCOS is not a licensed use for metformin, but some specialists do use it. A leaflet from the Royal
Berkshire Hospital for women being prescribed it off license is available on the internet: http://
www.royalberkshire.nhs.uk/pdf/Metformin_PCOS_oct08.pdf

Are GPs allowed to prescribe eflornithine?

Yes, though it is expensive (300 a year and for life?) and its long term safety has not been established.

Vulval infections
What is the best treatment for recurrent Bacterial vaginosis?
A BMJ review suggests using oral or vaginal preparations of metronidazole and clindamycin, 80
90% of women will have an initial response to treatment but 1530% will get a recurrence within 3
months and different organisms respond better to one or other treatment.
In trials comparing treatments, cure rates for metronidazole 400 mg or 500 mg twice daily for 7
days have been equivalent to clindamycin vaginal cream daily for 37 days, and to metronidazole
vaginal gel once or twice per day for 5 days.31 It is not known whether or not women with recurrent BV benefit from longer courses of current treatment but there is some evidence that vaginal
lactate tablets or acidic vaginal gel in combination with antibiotic treatment may be more effective.
Sexually Transmitted Infections 2004;80:8-11; doi:10.1136/sti.2002.002733
Copyright 2004 by the BMJ Publishing Group Ltd.

Should I take endocervical swabs or an HVS?

The recent User Guide to Pathology for General Practitioners suggests:
Genital swabs.

Separate swabs MUST be collected for Chlamydia (Contact Serology laboratory

Ext.64250)

A separate form must be completed for Chlamydia investigations.

High vaginal swabs are routinely screened for:

Trichomonas vaginalis

Candida

Beta haemolytic streptococci

Staphylococcus aureus
If screening for sexually transmitted disease is required, please send Urethral and / or cervical
swabs. High vaginal swabs are NOT routinely screened for Neisseria gonorrhoea.

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Department of GUM/HIV
at the Beckenham Beacon
379 Croydon Road BR3 3QL Tel: 01689 866659
Dr Barbara Vonau and Dr Caroline Dimian (South London Healthcare NHS Trust)
Screening/testing, treatment and care for patients with sexually transmitted infections and HIV

Opening times for walk in GU services :

Monday

9.00-11.30

14.00-16.30

Tuesday

12.00-14.30

16.00-18.00 (Young persons, 13-20 only)

Wednesday

9.00-11.30

Thursday

12.00-2.30

16.00-18.30

Friday

9.00-11.30

We offer telephone advice to GPs regarding STI issues and HIV.

We offer testing and onward referral for Hepatitis B and C for further assessment and treatment.

All first time attenders are offered and recommended to have an HIV test. Routine results
are back in 3 weeks, more urgent tests can be obtained with liaison with the laboratory usually within 48 hours.

We give out condoms and advice on contraceptive methods.

We offer pregnancy tests and emergency contraception but not routine contraceptive services or cervical screening as a routine (signpost to Contraceptive services and primary
care).

Some doctors but not all will see patients for TOP onward referral within Bromley.

We see survivors (male and female) of sexual assault for Screening and treatment of sexually transmitted infections and HIV but no forensic service (please signpost to the Haven).

There are 2 (adult) HIV clinics a week with Consultant delivered care. We link in with antenatal Services to diagnose HIV and prevent Mother to child transmission. We advice and
consult with Bromley NHS trust inpatient services for those diagnosed with HIV as inpatients in conjunction with the admitting medical team and offer outpatient follow up for those
diagnosed as inpatients. There are comprehensive links with Specialty HIV units at Kings
College Hospital and St Thomas/Guys for those patients with complex HIV presentations or
treatment issues. Community liaison and specialist support is provided by HIV Nurse Specialists who are based within the GUM department. We have a service user group for HIV
patients. HIV patients who wish to transfer their care do not need to go to the walk in but are
encouraged to contact the CNS service directly for initial assessment and facilitation of
transfer. GP referrals for people requiring HIV treatment and care are also organised
through the CNS service.

(October 2009)

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Enhanced Sexual Health Services

From April 2010 a number of GP surgeries will be offering Enhanced Sexual Health Services to
both registered and non-registered patients, including complex contraception, insertion and removal of IUS/IDU/SDI and basic level GUM.
This service will (but do not currently) also cover Mirena IUS for women meeting the conditions
specified in this local gynaecology guideline.

Two practices currently provide Sexual Health Services

to non-registered patients:
Dr Mary Bateman
Eden Park Surgery,
194 Croydon Road,
Beckenham,
Kent
BR3 4DQ
Dr O Sodipe
Addington Road Health Centre,
Stanley House,
77 Addington Road,
West Wickham,
Kent
BR4 9BG

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The Continence Service

Addington Road Health Centre,77 Addington Road,
West Wickham, Kent, BR4 9BG
Direct Line 0208 462 1255

There are 15 nurse-led adult continence clinics per month across the borough.
Clinics offer

Digital Vaginal Examination

Digital rectal exam (not prostate)
Electrical stimulation
Vaginal cones
Bladder scans
Flow rate

Intermittent self catheterization

Rectal irrigation
Pelvic floor exercises

Fluid correction
Bladder retraining
Medication
Nocturia
Appliances and equipment

And teach

And advise on

Clinic nurses will also refer on to Urologists and Gynaecologists for further investigations
and treatment, as needed and unless the GP asks otherwise.

Referrals should be made by letter and include a medical and drug history.
All patients are sent a three day fluid chart to complete before their appointment.

Rachel Corney
Continence Service Lead / Nurse Specialist
Bromley Primary Care NHS Trust

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