North West London Referral Guidelines Gynaecology

July 2018

Version 1.1 [Published 23 July 2018]

NWL Gynaecology transformation working group

The gynaecology transformation working group was attended by gynaecology consultant leads from each NWL Trust, GP clinical leads from each NWL CCG, patient representatives and management staff from the CCGs and Trusts.

Members of the gynaecology transformation working group are:

2

Organisation Clinical / Patient Representative

Chelsea and Westminster Hospitals Dr Elizabeth Owen (Trust Clinical Lead for Transformation working group)

Hillingdon Hospital Dr Anjali Kothari, Dr Shruti Mohan

Imperial College Healthcare Trust Dr Debbie Gould, Dr Deirdre Lyons

London North West Hospitals Dr Bosko Dragovic

Central London CCG Dr Sheila Neogi,

Brent CCG Dr Shazia Sidiqqi, Dr Jahan Mahmoodi

Ealing CCG Dr Maria Waters

Hammersmith and Fulham CCG Dr James Cavanagh, Dr Clare Jarman

Hillingdon CCG Dr Bevi Dahele

Harrow CCG Dr Kaushik Karia

Hounslow CCG Dr Annabel Crowe

West London CCG Dr Puvana Rajakulendran (CCG Clinical Lead for Transformation working group)

Patient representatives Jane Watson, Nannette Spain

Facilitators Jatinder Garcha (NWL Outpatients Programme Lead)

Merav Dover (Chief Transformation Office – Collaboration of NWL Trusts)

Dr Vikram Palit (Clinical Fellow, Chelsea and Westminster Hospital)

Important notice

This guidance is intended to support general practice. The guidance has been developed after careful consideration of the information and clinical opinion available to the speciality transformation working group, including consultant and GP leads for NWL Trusts and CCGs. Whilst it has been produced with significant input from clinicians, it provides general advice only and does not replace any part of a clinician’s responsibility to assess each clinical case on its own merits, when exercising their clinical judgement. The CCG will not, therefore, accept liability for any loss, damage or inconvenience arising as a consequence of any use of or the inability to use any information in this guidance.

This guidance is not intended to be used as a performance management resource.

3

Conditions not to refer

1. Asymptomatic Polycystic Ovaries (polycystic ovaries found on ultrasound scan)

• For subfertility, refer to Fertility Clinic once basic primary care investigations are completed

• For acne and/or hirsutism not responding to primary care management, consider referral to Dermatology or Endocrinology (see PCOS guidelines on referral criteria)

2. Menorrhagia (prior to trial of Tranexamic Acid and/or NSAID, and COCP OR IUS)

3. Premenstrual Syndrome (prior to trial of COCP or IUS)

4. Psychosexual dysfunction (e.g. non-consummation)

• refer for psychosexual counselling (consider signposting to Relate 0300 100 1234, for advice or counselling, requires self-funding)

5. Labia Reduction or any other cosmetic procedure on labia, vulva or vagina.

6. Asymptomatic prolapse

4 V1.1 July 2018

5

Referral Guidelines List

1. Cervical polyps 11. Post-coital bleeding/Inter-menstrual bleeding (recurrent)

2. Chronic pelvic pain 12. Post-menopausal bleeding or bleeding on HRT

3. Dysmenorrhoea 13. Post menopausal cyst

4. Female sterilisation 14. Primary amenorrhoea

5. Heavy Menstrual Bleeding 15. Recurrent Miscarriage or second trimester miscarriage

6. Incontinence 16. Secondary amenorrhoea/Oligomenorrhoea

7. Management of lost IUD threads 17. Subfertility

8. Ovarian cysts in pre-menopausal women 18. Vaginal discharge

9. Pelvic organ prolapse 19. Vulval pathology

10. Polycystic Ovarian Syndrome

Click to return to contents page V1.1 July 2018

1. Cervical polyps: These may be found incidentally or after examination for symptoms eg PCB /IMB

<1cm wide and/or

<2cm long

Remove in

primary care if

trained to do

so or refer

Send for

histology

>2cm long and/or

>1cm wide

Pelvic USS

Refer to

Gynaecology

References

RCOG Query

bank

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

- Cervical polyp that is not

easily removed or that looks

suspicious

6

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

2. Chronic pelvic pain >6 months, cyclical or constant

1. Pelvic examination

2. Smear (if indicated)

3. STI Swabs

4. Consider non-gynae causes such as

IBS, hernias, MSK, interstial cystisis.

5. Important to consider psychological

impact/cause of chronic pain.

If normal, request

pelvic USS

Direct referral to

colposcopy.

Normal scan, with cyclical

pain suggestive of

endometriosis

Abnormal scan

Initial management:

1. Analgesia – NSAIDs

2. COCP

3. POP/mirena IUS

Refer to

Gynaecology

Review in 3

months

References:

RCOG. Green Top

Guideline no. 41

Management

and Refer to

GUM

Abnormal

smear

Abnormal

swabs

Symptoms

controlled

- Reassure

Symptoms

continue

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

• New pain after the

menopause

• Abnormal abdominal/pelvic

ultrasound suggestive of

endometrial cancer

• Excessive weight loss

• Persistant Post coital

bleeding if over 35 years

REFER SUSPECTED LOWER

GI CANCER

• Bleeding per rectum

• New bowel symptoms over

50 years old

7

Patient resources:

RCOG patient

information leaflet

V1.1 July 2018

3. Dysmenorrhoea

Pelvic examination

1. Check smear

2. STI swabs

If no pelvic mass:

Initial treatment:

1. NSAIDs ± paracetamol

2. Oral contraceptive pill or

mirena

References:

NICE CKS

RCOG

Hounslow Guidelines

Pelvic mass on

examination

- for urgent USS

If abnormal,

2-week

Suspected

Cancer referral

criteria

Symptoms

improved

Reassure and

continue

treatment

Patient still

symptomatic

Refer to

Gynaecology

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

- Appearance of cervix

consistent with cervical

cancer

- Persistent inter-menstrual

bleeding or post-coital

bleeding without any signs of

PID greater than 3m

- Palpable mass that is not a

fibroid and where an urgent

USS could not be arranged.

- Abnormal abdominal/pelvic

ultrasound suggestive of

endometrial cancer

Review in 6

months

If normal / benign

pelvic mass

8

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

4. Female sterilisation

Counsel and discuss alternatives

Keen for

alternatives

Vasectomy LARC

Manage in

primary care.

Refer according to

local guidelines

Still keen for

sterilisation:

Consider other

methods/counselling if

- Less than 30 yrs

- One child/ no children

- Menstrual dysfunction

Consider

counseling

Refer to

Gynecology after

a 1 month period

of reflection.

Yes No

Inform:

• General Anaesthetic – usually undertaken laparoscopically with clips as a day surgery.

• Age – sterilisation is performed in women <30 yrs only in exceptional circumstances

• Laparotomy – may be required if surgical complications are encountered.

• Irreversible – difficult to reverse and NHS may not fund reversal

• Failure rate – 1/200, increased risk of ectopic with any subsequent pregnancy

• Surgical risks – greater in high-risk women (BMI, abdominal scars, medical disorders)

• Continue current contraception until after the procedure

• Periods – will be unchanged (unless on hormonal method pre-op or an ICUD is removed)

• High incidence of regret approx 30%

9

Patient resources:

FPA patient

information leaflet

V1.1 July 2018

5. Heavy Menstrual Bleeding: (Assess effect on women rather than quantity)

with symptoms such as intermenstrual or post-coital bleeding, pelvic pain and/or pressure symptoms

Physical examination

abdo/pelvis

Normal scan,

no anaemia

Abnormal scan*/

Palpable uterus:

Investigations:

1. FBC, ferritin.

2. Check cervical smear

3. TVUS

(TFTs and hormones not routinely

required)

Start Management:

1. Levenorgesterol

releasing IUS

2. Tranexamic Acid;

NSAIDs;

3. OCP

Refer to Gynaecology if

failure of >2 medical

treatments after 6

months

>45 years with

persistent bleeding or

IMB

Refer to

Gynaecology

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

- Abnormal abdominal/pelvic

ultrasound suggestive of

endometrial cancer

- Appearance of cervix

consistent with cervical cancer

References:

NICE guideline NG88

Anaemia

Iron

supplements

Consider

*Abnormal scan:

- Sub mucosal -fibroid,

- ET greater than

12mm,

- uterus palpable or

greater than 12cm,

- endometrial polyp

10

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

6. Incontinence: Important to ascertain whether the predominant symptom is urge or stress incontinence

especially if it is a mixed picture. Sudden urgency or inability to reach the toilet on time.

Frequency and nocturia. Leaking on coughing/sneezing/exercise/rising from sitting or lifting.

Consider referral to Urology

if incontinence plus:

- Persistent bladder or

urethral pain

- Recurrent ( or persistent

unexplained UTI

Consider referral to

Neurology if incontinence

plus:

- Suspected neurological

disease.

Examination of abdomen

and pelvis

Urine dip/MSU

Initial management:

1. Lifestyle modifications: weight loss,

smoking cessation, review fluid intake,

stop caffeine.

2. Bladder diary

If no improvement after 6-12 weeks:

Refer to community continence service/woman’s health

physiotherapy.

Refer to Urogynaecology if

failure to improve after

CCS/WHP. Refer with USS

and MSU from within 3

months.

Trial of medication:

1. Oxybutynin/ tolerodine/darifenacin

2. Other agent

3. Miragebron

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

UROLOGICAL CANCER:

- >45 with unexplained visible

haematuria without UTI

- >60 with unexplained non-

visible haematuria

- Visible haematuria that

persists or recurs after

treatment of UTI

REFER SUSPECTED

GYNAECOLOGICAL CANCER

- Suspicious pelvic mass

Stress

Incontinence

Urge Incontinence /Overactive

Bladder

References:

NICE guideline CG171

No improvement after 3

months

Refer to

Gynaecology

Pelvic mass

(clinically

benign)

11

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

7. Management of lost IUD threads: (Unable to visualise threads)

1. Date of LMP

2. Pregnancy test

3. Provide emergency contraception if

necessary

Refer to Early

Pregnancy Unit

If IUD not

visible, reassure

If IUD intrauterine,

reassure and advise

they may need

removal at a later

stage in the pregnancy

depending on position.

Refer for USS

IUD correctly

positioned in

uterus

Leave in situ. When

due for removal,

attempt removal in

primary care

IUD not

visible

Pelvic/abd

oXR

IUD in

abdomen

IUD not

seen

Likely expelled.

Offer alternative

contraception.

Refer to

Gynaecology

Not pregnant Pregnant

References:

Oxfordshire CCG

guideline

If removal failed

12

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

8. Ovarian cysts in pre-menopausal women:

Simple cyst: Complex cyst

<5cm

likely functional >7cm

Request Ca 125 +

Refer Suspected

Gynaecological

Cancer

Reassure

Refer to

Gynaecology

References:

RCOG – green top

guideline no. 62

Suspicious

features

Endometrioma/

dermoid cyst

Repeat

scan at 3

months

Reassure

Persistent

and

<3-5cm

Resolved

5-7cm

Repeat

scan at 3

months

>5cm <5cm

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL

CANCER

- Abnormal abdominal/pelvic

ultrasound suggestive of

ovarian cancer

13

Patient resources:

RCOG patient

information leaflet

V1.1 July 2018

Symptoms including: - Vaginal bulging - Pelvic pressure/dragging - Bleeding/discharge/infection - Splinting/digitation - Low backache

9. Pelvic organ prolapse: the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the

uterus (cervix) or the apex/vault of the vagina (post hysterectomy)

Non-symptomatic or

incidental finding

Initial investigations:

1.Speculum examination

2. If urinary symptoms are present check

MSU

1. Refer for pelvic floor physiotherapy

2. Offer advice on lifestyle modifications (see

leaflet)

3. Trial of vaginal oestrogen cream – if atrophy

4. Consider Ring pessary insertion

If successful, continue

with conservative

treatment.

If no improvement,

refer to

Gynaecology

Consider referral to gynaecology if:

1. Recurrent prolapse after

surgical repair

2. Voiding problems

3. Recurrent UTIs or incontinence

Reassure patient and

give lifestyle advice, e.g.

weight loss, pelvic floor

exercises.

References:

Hounslow Guidelines

14

Patient resources:

RCOG patient

information leaflet

Patient.co.uk

information leaflet

V1.1 July 2018

10. Polycystic Ovarian Syndrome If 2 out of 3 of: Polycystic ovaries on scan , Oligo/amenorrhoea, Clinical or

biochemical Hyperandrogenism.

General management:

1. Lifestyle measures including weight loss

2. Modify cardiovascular risk factors

3. If BMI >25 random glucose

Acne/hirsutism

Refer to

Endocrinology

• Discuss topical hair

removal methods

• Consider COCP

such as Dianette.

• Consider Acne

treatment

Oligo/amenorrhoea:

Consider COCP or Progestogens

to ensure at least 3-4 withdrawal

bleeds per year

Review in 6/12, if no

improvement refer to

Gynaecology.

Subfertility

Refer to subfertility

clinic after 6 months

of trying to conceive

if oligomenorrhoeic or

amenorrhoeic

References:

NICE CKS PCOS

Hounslow Guidelines

Testosterone >5 Testosterone <5

Random or day 2-5

Prolactin and TFTs Check Testosterone

15

Patient resources:

RCOG patient

information leaflet

V1.1 July 2018

11. Post-coital bleeding/Inter-menstrual bleeding

(recurrent):

Initial investigations:

1. Speculum + pelvic exam

2. HVS + endocervical swab

+NAT for GC/Chlamydia

3. Smear, if due

4. Consider pregnancy test

Abnormal

smear Abnormal swabs

Normal cervix + normal

swab/smear Abnormal cervix

Direct referral to

colposcopy

Treat +/- referral to

sexual health for

contact tracing

Lesion suspicious

of cancer: irregular,

hard, friable

Refer

Suspected

Gynaecological

Cancer

Cervical

polyps Ectropion

Cervical

warts

Post coital

bleeding

Persistent

intermenstrual

bleeding

USS

Refer to

colposcopy if

not settled

after 6 months

Reassure or

consider

referral to

Gynaecology

Remove or

refer to

Gynaecology

1. Consider

switching to

lower dose

oestrogen

COCP or to

POP.

2. Treat using

silver

nitrate

cautery

Refer to

colposcopy

2-week Suspected Cancer referral

criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

- Abnormal looking cervix

- Cervical polyp that is not easily

removed or that looks suspicious

- Pelvic mass on examination

- Women >45 with persistent symptoms

and high risk of endometrial cancer.

No NICE guidelines

If persistent refer to

Gynaecology

USS

Normal Normal Abnormal inc

ET > 12mm

Refer to

Gynaecology

16

Patient resources:

NHS patient

information leaflet

V1.1 July 2018

12. Post-menopausal bleeding or bleeding on HRT: (>1year after last menses)

Continuous combined HRT

(if started >1 year after LMP):

Not on HRT

1. Clinical examination

2. Check Smear history

3. Urgent TVUSS

Consider changing HRT. Review

at 3 months and if persistent, refer

to Gynaecology.

>3 months use and

persistent bleeding

Refer Suspected

Gynaecological

Cancer

Sequential HRT:

>6 months use with

irregular and

persistent bleeding

Urgent

TVUSS

Endometrial

Thickness

<5mm

Endometrial

Thickness >5mm or

irregular

Refer Suspected

Gynaecological

Cancer

On HRT

Endometrial

Thickness

<5mm

Endometrial

Thickness >5mm or

irregular

2-week Suspected

Cancer referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL

CANCER

- Post-menopausal

bleeding not on HRT

- Post-menopausal

bleeding on HRT over

6m with ET >5mm

References:

NICE CKS suspected

gynaecological cancers

17

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

13. Post menopausal cysts: >1year after LMP

Refer to Gynaecology

Simple, unilocular, no solid

components

<5cm

Ca125

<35

Ca125

>35

Repeat

USS in 4

months

>5cm <5cm

Reassure

Complex, multi-locular,

separate solid component.

Do Ca125

Refer via 2-week wait

cancer pathway

>5cm

References:

RCOG green top guideline

no. 34

Ca125

<35

Ca125

>35

18

Patient resources:

NHS patient

information leaflet

V1.1 July 2018

14. Primary amenorrhoea: No secondary sexual characteristics by age 14

No menses by age 16

Initial investigations:

1. BMI

2. TFTs FSH LH

3. Prolactin

Abnormality suspected:

Symptoms suggestive of androgen excess

Suspected genital tract anomaly, anorexia

nervosa or chromosomal abnormality

Refer to Endocrinology

Refer to Gynaecology

References:

NICE CKS primary

amenorrhoea

Abnormal blood

test:

Abnormal

Prolactin or TFTs

Abdominal/pelvic USS

KUB

19

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

15. Recurrent Miscarriage or second trimester miscarriage: Do not refer if >42 or with 2 or more children in this relationship

>3 consecutive first trimester

miscarriages: 1 or more second trimester miscarriages:

Investigations:

1. TFTs, HbA1c, Hb electrophoresis

2. APL antibodies + anti-cardiolipin

3. Rubella status

4. USS pelvis

Refer to secondary

care (as per local

services)

References:

RCOG – green top

guideline no. 17

Add in Thrombophilia

screen (Factor V Leiden,

Protein S, prothrombin

gene)

20

Patient resources:

RCOG patient

information leaflet

V1.1 July 2018

16. Secondary amenorrhoea/Oligomenorrhoea: Defined as <4 menses per year or absence of menstruation for 6 months.

If Subfertility then see Subfertility guidelines

Initial investigations:

1. Pregnancy test

2. BMI

3. TFTs

4. Random FSH/LH

5. Prolactin

Abnormal

TFTs

Low FSH/ LH with

low BMI or Normal

bloods and high

exercise.

Prolactin >1000 on

two occasions

(N.B. 800-1000

likely due to

stress/PCOS)

FSH >20 x2

Secondary investigations:

1. Pelvic USS

2. If signs of

hyperandrogenism check

Testosterone

Testosterone >5 Normal

- USS adrenals

- 5-hydroxytestosterone

- DHEA androstenedione

and refer to

Endocrinology

Refer to

Gynaecology

Review

medication and

refer to

Endocrinology

Age <40:

Refer to

Gynaecology

References:

NICE CKS Secondary

Amenorrhoea

Age 40-50:

Discuss trial

of HRT

Abnormal results Normal results

Symptoms in keeping with

PCOS + raised BMI

Follow PCOS

pathway

- Reassurance and

psychological support

- Encourage to gain

weight or reduce

exercise to increase

body fat.

- Consider COCP if

oestrogen low for bone

protection

Manage

accordingly

21

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

17. Subfertility: If >42 or more than 1 living children in this relationship, check local hospital

guidelines

Regular sexual intercourse for 6 months PLUS:

- >36 years old

- Significant PID or known tubal disease

- Amenorrhoea/significant oligomenorrhea

- Significant oligospermia

Regular sexual intercourse for 1 year:

Initial investigations:

1. Check Smear

2. Rubella status

3. Chlamydia screen

4. Semen analysis (if abnormal,

repeat)

5. Measure BMI

Regular cycle

(between 21-40):

Irregular cycle

(6/52-4/12):

Secondary investigations

1. Day 2-4 FSH

2. Progesterone 7 days

prior to period

Refer to subfertility

clinic

Secondary

investigations:

1. Day 2-4 FSH/LH

2. TFTs

3. Prolactin

References:

NICE CKS Infertility

N.B. Same sex couples, see

PPWT guidance

If BMI <19 or >30 advise

patient to aim for BMI 20-

30 as outside this will not

receive intervention

If repeat semen analysis

shows < 5million refer to

Andrology

22

Patient resources:

Patient UK

information leaflet

V1.1 July 2018

18 Vaginal discharge

Initial assessments:

1. Pelvic examination and Speculum

2. Smear, if due

3. HVS, endocervical swab and chlamydia + gonorrhoea swabs

N.B. if features of infection, start empirical antibiotics.

Cervical

polyp

Refer to

cervical

polyp

guideline

Cervical

ectropion

Negative infection

screen

Positive infection

screen

Refer to Gynaecology If

persistent discharge or

post-coital bleeding.

Bacterial

vaginosis

1. Chlamydia

2. Gonorrhoea

3. Trichomonas

Start

treatment

and refer

to GUM.

Treat in

Primary

Care

Normal cervix

Negative infection

screen

USS if

discharge is

persistent

Reassure,

likely

physiological

Refer to

Gynaecology

Normal Abnormal

References:

NICE CKS

BASHH Guidelines -

Management of

Vulvovaginal Candidiasis

1. Reassure

2. Consider switching

to lower dose

oestrogen COCP

or to POP.

3. Consider Treat

using silver nitrate

cautery

Candida

Acute Recurrent

Lifestyle advice

cotton underwear,

avoid soaps and

perfumes, etc

Lifestyle advice

cotton

underwear, avoid

soaps and

perfumes, etc

Abnorma

l Vulva

Refer to

vulval

pathology

guideline

Treat in

Primary

Care

Induction and

Maintenance

regime*

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL CANCER

• Abnormal Cervix

• Pyometra

* TREATMENT REGIME RECURRENT THRUSH Induction Fluconazole Capsule 150mg every 72 hours x 3 doses Maintenance Fluconazole* Capsule 150mg once a week for 6 months

23

Patient resources:

NHS information

leaflet

V1.1 July 2018

19. Vulval pathology: Full history and examination, looking for signs of eczema or other

dermatological conditions

What is the predominant

symptom?

Pain/discomfort? Itching

Normal skin,

anatomy and

mucosa

Atrophic

vaginitis/

vulval

mucosa

Any other

vulval

abnormality

Vulvodynia

Consider

amitryptiline

Topical

oestrogen or

Vagifem

Abnormal appearance of skin

- Suggest emollient + substitute Thrush

Treat with

canesten or

fluconazole.

Treat with

dermovate.

If no improvement after 3 months,

refer to Gynaecology clinic

2-week Suspected Cancer

referral criteria:

REFER SUSPECTED

GYNAECOLOGICAL

CANCER

• Unexplained lump

• Ulceration

• Persistent symptoms >3m

References:

NICE CKS

Hounslow Guidelines

Lifestyle advice - Avoid soap,

bubble bath, shampoo, perfumes,

personal deodorants, wet wipes,

detergents, textile dyes, fabric

conditioners, tight fitting clothes

and sanitary wear.

Lichen

Sclerosus/

Planus

Seborrhoeic

dermatitis +

psoriasis, Lichen

Simplex or Contact

Dermatitis

Moderately potent

Topical

Corticosteriods Refer to vulval

clinic

Refer to

Gynaecology

24

Patient resources:

RCOG patient

information leaflet

V1.1 July 2018