Debra Holloway discusses common gynaecological symptoms, differential diagnosis, and treatment.

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Read this article to learn more about: 

  • Different gynaecological conditions with similar symptoms
  • The importance of accurate diagnosis of the condition and cause
  • The most appropriate treatment, which takes account of women's desired outcome
  • The negative impact of symptoms on women's quality of life.

Different gynaecological conditions can produce similar symptoms. For example, women with polycystic ovary syndrome (PCOS) may have irregular, heavy bleeding with spotting and post coital bleeding (PCB), but these symptoms could apply equally to women with a sub mucosal fibroid.

Accurate diagnosis of condition and cause is important to provide appropriate treatment, taking account of the desired outcome for women. This is particularly relevant when considering fertility issues.

This article discusses abnormal bleeding, pelvic pain, and urinary symptoms. It explores their multiple causes, diagnosis, and management. It does not cover pregnant women.

Abnormal bleeding

At any stage of a woman's reproductive life and after, abnormal bleeding is a common presentation. In August 2016, NICE updated Clinical Guideline (CG) 44 on assessment and management of heavy menstrual bleeding (HMB), which is a good source of relevant clinical guidance.1 Bleeding other than regular heavy bleeding is outside the scope of NICE CG44.

Symptoms of abnormal bleeding include:

  • variation in length and flow of menstruation
  • intermenstrual bleeding (IMB)
  • PCB1
  • Postmenopausal bleeding (PMB) 1 year after the menopause, which includes bleeding that occurs when a woman is on hormone replacement therapy.

These symptoms can occur in isolation or combination. Women may also have pain and pressure symptoms.

History

An accurate history first needs to be taken from the woman.1 It should include:

  • the length of the cycle from the first day of bleeding in one cycle to the first day of bleeding in the next
  • the amount of blood loss each day, which can be assessed by asking about frequency of pad or tampon change, the presence of clots, flooding, and if the woman is able to leave the house
  • the days of the cycle it occurs
  • any cyclical hormonal changes during the month
  • IMB: amount, pattern, timing, and if every month
  • PCB: amount, duration, frequency, timing, and if every time
  • any hormonal contraception used
  • last cervical screening and results
  • previous or current sexually transmitted infection and any discharge
  • any gynaecological operations.

Examinations

As well as an accurate history, speculum and pelvic examinations are necessary. The speculum examination assesses the cervix and can identify cervical polyps, erosion, and cancer. The pelvic examination may identify a mass that can indicate the presence of fibroids.

Investigations

A full blood count test should be carried out on all women with HMB, in parallel with any HMB treatment offered. A serum ferritin test for suspected anaemia should not be routinely carried out on women with HMB.1 If women have irregular bleeding and suspected hormonal dysfunction, tests include thyroid-stimulating hormone to investigate HMB in the absence of pathology and when there are other clinical symptoms of thyroid disease,1 follicle-stimulating hormone (FSH), luteinising hormone, and oestradiol. Oestradiol tests should not be used to diagnose the menopause and a serum FSH test should not be used to diagnose the menopause in women using combined oestrogen and progestogen contraception or high-dose progestogen.2 Consider an FSH test to diagnose the menopause only in women aged:

  • between 40–45 years with menopausal symptoms, including a change in their menstrual cycle
  • under 40 years in whom menopause is suspected.2

Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.1 It can show the presence of pathology in the endometrial cavity, fibroids, and ovarian cysts.

Dependent on age and presenting complaint, a hysteroscopy and biopsy may be needed to investigate any cavity pathology and colposcopy to investigate any cervical abnormality.

Women may present with similar symptoms that have different causes. For example, women with PCOS may have irregular, heavy bleeding with spotting and PCB, but these symptoms could apply equally to women with a sub mucosal fibroid.

Causes, symptoms, and treatments

Table 1 outlines the causes of HMB, PCB, and IMB; their symptoms; and treatments.

Table 1: Causes of HMB, PCB, and IMB1,3–5,clinical knowledge
Abnormal bleeding and causesSymptomsTreatments
HMB
Intra cavity/sub mucosal fibroids HMB, spotting, IMB, or PCB Hysteroscopic resection3
Endometrial polyps HMB,IMB, PCB Hysteroscopic resection3
IUCD/medroxyprogesterone acetate injection Irregular bleeding, HMB Change contraception
PCOS HMB, irregular, spotting, or continuous bleeding Depends on patient's needs. Can use hormones to control cycle if patient does not want to get pregnant
Hyperplasia HMB, irregular, spotting, or continuous bleeding Treatment with progestogens, LNG-IUS4
Endometritis HMB, irregular, spotting, or continuous bleeding Treatment with antibiotics
Cancer HMB, IMB, PCB, discharge Referral to gynaecology oncology team for hysterectomy
No cause found HMB, IMB, PCB Treatment with tranexamic acid, NSAIDs (e.g. mefenamic acid), LNG-IUS
Fibroids HMB, IMB, PCB Removal myomectomy, UAE, ulipristal acetate 5 mg (not to be confused with ulipristal acetate 30 mg used for emergency contraception)
PCB
Cervical polyps IMB, PCB Removal
Cervical ectopy IMB, PCB Can be treated with cold coagulation
Sexually transmitted infection IMB, PCB Treatment in accordance with guidelines5
Vaginal atrophy PMB, pain with sex Vaginal oestrogens
Endometrial polyps IMB, PCB Resection
Cervical cancer IMB, PCB Referral to gynaecology oncology team
IMB
Cervical and endometrial polyps IMB, PCB Removal
Submucosal fibroids HMB, IMB, PCB Hysteroscopic resection
Cervical and endometrial cancer HMB, IMB,PCB, PMB Referral to gynaecology oncology team
HMB=heavy menstrual bleeding; IMB=intermenstrual bleeding; IUCD=intrauterine contraceptive device; LNG-IUS=levonorgestrel intrauterine system; NSAID=non-steroidal anti-inflammatory drug; PCB=postcoital bleeding; PCOS=polycystic ovary syndrome; UAE=uterine artery embolisation

Pelvic pain

In addition to gynaecological causes of pelvic pain, bowel, bladder, and musculoskeletal causes may need to be excluded.

History

The initial assessment should establish if the pain is related to the menstrual cycle or not. Keeping a diary may be useful if there is doubt.

Specific questions to ask include the following:

  • nature of pain
  • how often and associated factors
  • any relationship to periods
  • any relationship to sex
  • any problems with passing urine or opening bowels
  • pain when passing urine or opening bowels, especially related to periods
  • what helps
  • what aggravates the pain.

Examinations and investigations

Vaginal and pelvic examinations, ultrasound, magnetic resonance imaging, and, in some cases, diagnostic laparoscopy, may be undertaken to diagnose the causes of pelvic pain.

Causes, symptoms, and treatments

Endometriosis is one of the most common causes of pelvic pain in women. It typically causes pain before, and just after, periods and with sexual intercourse. Some women also have non-cyclical pain. On average, it takes 7.5 years from onset of symptoms to receive a diagnosis.6 There can also be pain when passing urine and defecating.7 The NICE guidance on Endometriosis: diagnosis and management is expected in the second half of 2017.8

Women who present with ascites and/or a pelvic or abdominal mass, which is not uterine fibroids, should be referred urgently for suspected ovarian cancer. Perform tests in primary care if women, especially if they are aged 50 years or older, report any of the following symptoms on a persistent or frequent basis, particularly more than 12 times per month:9

  • abdominal distension
  • feeling full (early satiety) and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency.

Table 2 outlines causes of pelvic pain, symptoms, and treatments.

 
Table 2: Causes of pelvic pain, symptoms, and treatments10–14,clinical knowledge
ConditionSymptomsTreatments
Endometriosis Cyclical pelvic pain, worse before and just after periods. Deep dyspareunia. Infertility10 Laparoscopy and removal, hormonal contraceptives, or analgesia10
Fibroids Pain and pressure, which may be acute if torsion of pedunculated fibroid or degeneration Surgical, UAE, hormonal contraceptives, or ulipristal acetate 5 mg (not to be confused with ulipristal acetate 30 mg used in emergency contraception)
Ovarian cyst Unilateral or bilateral pain, which can be sudden and acute if cyst ruptures and spills into the pelvic cavity. Acute with vomiting if torsion. Can be ongoing ache11,12 Conservative management, i.e. monitoring, or surgical removal11,12
Prolapse Back ache, lump in vagina, pressure, or pulling Pelvic floor exercises, pessaries, or surgery
Pelvic infections Vaginal discharge, pyrexia, generalised abdominal pain, and cervical excitation if acute13 Antibiotics13
Pelvic adhesions Non-cyclical pain and often after operations or infections. Fixed pelvis on examination14 Surgical removal14 (caution as adhesions may reform), reassurance, and analgesia
Misplaced IUCD/IUD Pain and bleeding, may be worse with intercourse, seen on scan Replace
Non-gynaecological causes General pain, not related to cycle, can be referred Referral to GI, urology, or pain clinics
GI=gastrointestinal; IUCD/IUD=intrauterine contraceptive device/intrauterine device; UAE=uterine artery embolisation
 

Urinary symptoms

Many women can be affected by urinary symptoms to a greater or lesser degree at different times in their lives. Symptoms can include pain when passing urine, difficulties starting the urine stream, difficulties with flow, frequency of passing urine, or problems holding urine (e.g. stress incontinence).

History, examinations, and investigations

An assessment of the presenting complaint should be undertaken. Examinations and investigations include:15,16,clinical knowledge

  • abdominal examination
  • vaginal examination with Sims' speculum to look for prolapse
  • midstream urine testing for infections
  • ultrasound to look for any abdominal mass
  • bladder diary
  • urodynamic testing if indicated.

Causes

Prolapse, generally anterior, is the most common cause of urinary symptoms. Other causes range from simple infections that can be treated easily, to pressure from fibroids, and bladder conditions.

Treatments

The treatments for urinary symptoms depend on the cause. For example, an infection can be treated with antibiotics, while a prolapse can be treated with pelvic floor exercises, support such as ring pessaries, and surgery. If the cause is related to a mass, such as a fibroid, then it requires surgical removal or the bulk reduced by uterine artery embolisation or ulipristal acetate 5 mg, as illustrated in Table 1 (not to be confused with ulipristal acetate 30 mg used in emergency contraception).

Summary

When seeing and assessing women with gynaecology problems it is important to remember that there may be many causes to one presenting complaint. Establishing the correct cause can help to direct treatment and resolve the symptoms. Although guidance is important, some complaints will span different guidelines so having an in-depth knowledge and taking a good clinical history are of paramount importance. 

Box 1: Case study

Now that you have completed the article, read the case study below and consider what treatments might be appropriate for this patient.

A 43-year-old woman presents with a history of IMB and HMB, pain around her cycle and difficulty in passing urine before her period. Examination finds no evidence of prolapse,a normal cervix, and a bulky uterus. An ultrasound confirms the presence of fibroids. Consider what treatment(s) might be appropriate, then check what you have recommended with the suggested answer.

HMB=heavy menstrual bleeding; IMB=intermenstrual bleeding

Suggested answer for case study

Treatments would include removal of intra cavity fibroids and other fibroids, a myomectomy and UAE, or a trial of ulipristal acetate 5 mg (not to be confused with ulipristal acetate 30 mg used in emergency contraception). The bleeding treated in isolation would not help with the bulk symptoms.

UAE=uterine artery embolisation

References

  1. NICE. Heavy menstrual bleeding: assessment and management. Clinical Guideline 44. NICE, 2007 (updated 2016). Available at: www.nice.org.uk/cg44
  2. NICE. Menopause: diagnosis and management. NICE Guideline 23. NICE, 2015. Available at: www.nice.org.uk/ng23
  3. Royal College of Obstetricians and Gynaecologists, British Society for Gynaecological Endoscopy. Best practice in outpatient hysteroscopy (green-top guideline 59). RCOG, 2011. Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg59
  4. Royal College of Obstetricians and Gynaecologists, British Society for Gynaecological Endoscopy. Management of endometrial hyperplasia (green-top guideline 67). RCOG, 2016 (updated 2017). Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg67
  5. British Association for Sexual Health and HIV. Standards for the management of sexually transmitted infections (STIs). BASHH, 2014. Available at: www.bashh.org/documents/Standards%20for%20the%20management%20of%20STIs%202014%20FINAL%20WEB.pdf
  6. Endometriosis UK. Information. www.endometriosis-uk.org/information (accessed 24 February 2017)
  7. Endometriosis UK. Endometriosis symptoms. www.endometriosis-uk.org/endometriosis-symptoms (accessed 28 February 2017)
  8. NICE. Endometriosis: diagnosis and management. NICE Guideline in development. NICE, July 2015. www.nice.org.uk/guidance/GID-CGWAVE0737 (accessed 24 February 2017)
  9. NICE. Ovarian cancer: recognition and initial management. Clinical Guideline 122. NICE, 2011. Available at: www.nice.org.uk/cg122
  10. European Society of Human Reproduction and Embryology. Management of women with endometriosis. ESHRE, 2013. Available at: www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
  11. Royal College of Obstetricians and Gynaecologists. The management of ovarian cysts in postmenopausal women (green-top guideline 34). RCOG, 2016 (updated 2017). Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg34
  12. Royal College of Obstetricians and Gynaecologists, British Society for Gynaecological Endoscopy. Management of suspected ovarian cysts in premenopausal women (green-top guideline 62). RCOG, 2011. Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg62
  13. British Association for Sexual Health and HIV. UK National guideline for the management of pelvic inflammatory disease. BASHH, 2011. Available at: www.bashh.org/documents/3572.pdf
  14. Royal College of Obstetricians and Gynaecologists. The initial management of chronic pain (green-top guideline 41). RCOG, 2011. Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg41
  15. NICE. Urinary incontinence in women: management. Clinical Guideline 171. NICE, 2013 (updated 2015). Available at: www.nice.org.uk/cg171
  16. NICE. Urinary incontinence in women. NICE Quality Standard 77. NICE, 2015. Available at: www.nice.org.uk/qs77