Debra Holloway discusses common gynaecological symptoms, differential diagnosis, and treatment
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.
At any stage of a woman's reproductive life and after, abnormal bleeding is a common presentation. In 2018, 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)
- 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.
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.
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 and pain that may indicate other pathology.
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
In the recent 2018 guideline, hysteroscopy is suggested as the first-line investigation for bleeding and ultrasound is the first-line diagnostic tool for identifying other abnormalities such as fibroids, and the presence of pain.1 Hysteroscopy can show the presence of pathology, such as fibroids and ovarian cysts, which shows a higher sensitivity in identifying abnormalities compared with ultrasound.
Dependent on age and presenting complaint, a hysteroscopy, biopsy, and treatment 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.
|Abnormal bleeding and causes||Symptoms||Treatments|
|Intra cavity/sub mucosal fibroids||HMB, spotting, IMB, or PCB||Hysteroscopic resection3|
|Endometrial polyps||HMB,IMB, PCB||Hysteroscopic resection3|
|Adenomyosis||HMB and pain||Hormonal medication, IUS, tranexamic acid, menfametic acid, embolisation|
|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—treatment dependent on size and location||HMB, IMB, PCB||Removal myomectomy, UAE, ulipristal acetate 5 mg (not to be confused with ulipristal acetate 30 mg used for emergency contraception). See summary of product characteristics for precautions about prescribing, and the need for carrying out LFT prior to starting and during treatment courses.11|
|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|
|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; LFT=liver function test.|
In addition to gynaecological causes of pelvic pain, bowel, bladder, and musculoskeletal causes may need to be excluded.
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 NICE has published a separate guideline on endotriosis.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.
|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). See summary of product characteristics** for precautions about prescribing, and the need for carrying out LFT prior to starting and during treatment courses.|
|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 ache12,13||Conservative management, i.e. monitoring, or surgical removal12,13|
|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 acute14||Antibiotics14|
|Pelvic adhesions||Non-cyclical pain and often after operations or infections. Fixed pelvis on examination15||Surgical removal15 (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|
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:16,17,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.
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.
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).
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
- NICE. Heavy menstrual bleeding: assessment and management. Clinical Guideline 44. NICE, 2007 (updated 2018). Available at: www.nice.org.uk/cg44
- NICE. Menopause: diagnosis and management. NICE Guideline 23. NICE, 2015. Available at: www.nice.org.uk/ng23
- 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
- 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
- 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
- Endometriosis UK. Information. www.endometriosis-uk.org/information (accessed 24 February 2017)
- Endometriosis UK. Endometriosis symptoms. www.endometriosis-uk.org/endometriosis-symptoms (accessed 28 February 2017)
- NICE. Endometriosis: diagnosis and management. NICE Guideline 73. NICE, 2017. www.nice.org.uk/guidance/ng73
- NICE. Ovarian cancer: recognition and initial management. Clinical Guideline 122. NICE, 2011. Available at: www.nice.org.uk/cg122
- 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
- Gedeon Richter (UK) Ltd. Esmya 5 mg Tablets (ulipristal acetate)—summary of product characteristics. July 2018. Available at: www.medicines.org.uk/emc/product/3951/smpc
- 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
- 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
- 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
- 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
- NICE. Urinary incontinence in women: management. Clinical Guideline 171. NICE, 2013 (updated 2015). Available at: www.nice.org.uk/cg171
- NICE. Urinary incontinence in women. NICE Quality Standard 77. NICE, 2015. Available at: www.nice.org.uk/qs77