9.3 Common Gynaecological Presentations & Gynaecological Oncology

Common Gynaecological Presentations & Gynaecological Oncology

Gynaecological symptoms, ranging from abnormal uterine bleeding and chronic pelvic pain to suspected malignancy, are frequent reasons for consultation in primary and secondary care. Applying structured diagnostic frameworks, implementing evidence-based stepped medical therapies, and recognizing oncological red flags are fundamental to clinical practice.

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Heavy Menstrual Bleeding (Menorrhagia / HMB)

Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, emotional, social, and material quality of life. The International Federation of Gynecology and Obstetrics (FIGO) classifies the underlying aetiology using the PALM-COEIN framework:

• Structural Causes (PALM):
  • Polyp (endometrial or endocervical polyps)
  • Adenomyosis (endometrial tissue within the myometrium)
  • Leiomyoma (uterine fibroids: submucosal causing greatest bleeding, intramural, or subserosal)
  • Malignancy & hyperplasia (endometrial atypical hyperplasia and endometrial carcinoma)
• Non-Structural Causes (COEIN):
  • Coagulopathy (e.g., von Willebrand disease, immune thrombocytopenia)
  • Ovulatory dysfunction (e.g., polycystic ovary syndrome, perimenopause, thyroid disorders)
  • Endometrial primary disorders (impaired local haemostasis and prostaglandin production)
  • Iatrogenic (anticoagulants, copper intrauterine devices)
  • Not yet classified

Clinical Investigation

• Full Blood Count (FBC) & Ferritin: To identify microcytic hypochromic iron-deficiency anaemia.
• Pelvic Examination: Speculum (visualise cervix, exclude polyps or cancer) and bimanual palpation (assess uterine size, contour, and mobility).
• Pelvic Ultrasound (TVUS & Transabdominal): Indicated if the uterus is palpable abdominally, pelvic masses are suspected, or symptoms persist despite first-line pharmaceutical therapy.

Stepped Medical Management (NICE NG88)

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Endometriosis & Adenomyosis

Endometriosis

Endometriosis is characterized by the presence of functioning endometrial stroma and glands outside the uterine cavity, most commonly affecting the ovaries, uterosacral ligaments, pouch of Douglas, and pelvic peritoneum.

• Pathophysiology: Ectopic endometrial tissue undergoes cyclical proliferation, ischaemic shedding, and localized bleeding in response to ovarian oestrogen and progesterone, triggering chronic inflammation, neuroangiogenesis, and dense fibrous adhesions.
• Clinical Presentation (The Classic 4 Ds):
  1. Dysmenorrhoea: Severe, progressive cyclical pelvic pain starting days before menses.
  2. Deep Dyspareunia: Sharp pelvic pain during or following sexual intercourse.
  3. Dyschezia: Painful defecation, particularly exacerbated during menstruation.
  4. Dysuria: Cyclical urinary discomfort or hematuria.
  • Chronic non-cyclical pelvic pain and subfertility are also prominent.
• Clinical Examination: Fixed, retroverted, tender uterus; tender nodularity along the uterosacral ligaments and pouch of Douglas; enlarged tender adnexa (ovarian endometriomas / "chocolate cysts").
• Diagnostic Standard: Diagnostic laparoscopy with histological biopsy is the gold standard. Pelvic TVUS and MRI can identify endometriomas and deep infiltrating nodules but cannot exclude superficial peritoneal disease.
• Management:
  • Analgesia: First-line NSAIDs (ibuprofen, mefenamic acid) and paracetamol.
  • Hormonal Suppression: Continuous COCP, oral progestogens, or the 52 mg LNG-IUS to induce amenorrhoea. GnRH agonists with "add-back" low-dose HRT (to prevent osteoporosis and vasomotor symptoms) for refractory disease.
  • Surgical Excision: Laparoscopic excision or ablation of endometriotic lesions and adhesiolysis to restore anatomy and improve fertility.

Adenomyosis

Adenomyosis is the invasion of endometrial tissue directly into the uterine myometrium, causing myometrial hypertrophy and hyperplasia. It characteristically presents in multiparous women aged 35–50 with heavy menstrual bleeding and severe dysmenorrhoea. On examination, the uterus is symmetrically enlarged, globular, soft, and uniformly tender (unlike the irregular, firm, non-tender contours of fibroids). First-line therapy is the LNG-IUS; definitive cure is hysterectomy.

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Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is a complex metabolic and endocrine disorder characterized by chronic anovulation, androgen excess, and insulin resistance.

Rotterdam Diagnostic Criteria

Diagnosis requires the presence of at least 2 out of the following 3 criteria, after excluding other causes of hyperandrogenism (such as congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumours):

1. Oligo- or Anovulation: Menstrual cycles lasting > 35 days, fewer than 9 cycles per year, or complete amenorrhoea.
2. Clinical and/or Biochemical Hyperandrogenism:
   • Clinical: Hirsutism (excessive terminal hair growth in male-pattern distribution, evaluated by Ferriman-Gallwey score), severe persistent acne, androgenic alopecia.
   • Biochemical: Elevated total serum testosterone, elevated Free Androgen Index (FAI), or elevated androstenedione.
3. Polycystic Ovaries on Ultrasound: TVUS demonstrating ≥ 20 follicles (measuring 2–9 mm) per ovary and/or an increased ovarian volume ≥ 10 mL in either ovary.

Metabolic & Oncological Considerations

• Insulin Resistance: Present in up to 70% of women with PCOS regardless of BMI; compensatory hyperinsulinaemia stimulates ovarian theca cells to produce excess androgens and suppresses hepatic sex hormone-binding globulin (SHBG) synthesis, magnifying free testosterone levels.
• Endometrial Protection: Chronic anovulation leads to continuous, unopposed oestrogen stimulation of the endometrium without luteal progesterone production. This dramatically elevates the risk of endometrial hyperplasia and endometrial carcinoma. Women with amenorrhoea or oligomenorrhoea must be induced to have at least 3 to 4 withdrawal bleeds per year.

Clinical Management

• Lifestyle & Weight Reduction: Foundational first-line for all overweight patients. A 5–10% body weight reduction improves insulin sensitivity, restores regular ovulatory cycles, and reduces androgen levels.
• Endometrial Protection & Menstrual Regulation: Combined oral contraceptive pill (particularly preparations with anti-androgenic progestogens such as co-cyprindiol / Dianette, or drospirenone / Yasmin), cyclical oral progestogens (medroxyprogesterone 10 mg for 14 days every 1–3 months), or the LNG-IUS.
• Metabolic Management: Metformin improves peripheral insulin sensitivity and glucose tolerance.
• Subfertility: Weight optimisation is paramount; Letrozole (aromatase inhibitor) is the first-line ovulation-inducing agent, with clomifene citrate as an alternative.

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Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease is an ascending polymicrobial infection of the upper female genital tract involving the endometrium, fallopian tubes, ovaries, and pelvic peritoneum.

• Aetiology: Sexually transmitted pathogens predominate, led by Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium, frequently complicated by endogenous anaerobic and facultative vaginal flora.
• Clinical Presentation: Bilateral lower abdominal/pelvic pain, abnormal or purulent vaginal discharge, deep dyspareunia, abnormal post-coital or intermenstrual bleeding, and pyrexia (> 38°C).
• Physical Examination: Cervical motion tenderness (the "chandelier sign"), bilateral adnexal tenderness, and uterine tenderness on bimanual examination.
• Clinical Diagnostic Approach: A low threshold for empirical treatment is mandatory. Awaiting laboratory swab results is dangerous; untreated or delayed treatment rapidly causes irreversible tubal damage.
• Long-Term Complications: Tubal-factor subfertility (12% after 1 episode, rising to > 50% after 3 episodes), ectopic pregnancy (6-fold increased risk), chronic pelvic pain, tubo-ovarian abscess, and Fitz-Hugh-Curtis syndrome (perihepatitis causing right upper quadrant pain and "violin-string" fibrous adhesions between the liver capsule and anterior abdominal wall).

First-Line Outpatient Antimicrobial Regimen (BASHH Guidelines)

1. Intramuscular Ceftriaxone 1 g stat (single IM injection with 1% lidocaine) — ensures potent bactericidal coverage against N. gonorrhoeae.
2. Oral Doxycycline 100 mg twice daily for 14 days — provides reliable intracellular coverage against C. trachomatis and M. genitalium.
3. Oral Metronidazole 400 mg twice daily for 14 days — treats anaerobic bacteria and concurrent bacterial vaginosis.

• Partner Management: Contact tracing and empirical treatment of all sexual partners within the preceding 60 days. Sexual abstinence is advised until both patient and partner complete treatment.

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Gynaecological Oncology Red Flags & Suspected Cancer Referrals

NICE NG12 uses the suspected cancer pathway (formerly called the "2-week wait"; NHS England now measures a 28-day faster diagnosis standard):

NHS Cervical Screening Programme Protocol

• Recall Intervals: Since 1 July 2025 in England (2020 in Scotland, 2022 in Wales), people aged 25–64 who test hrHPV-negative are recalled every 5 years (previously 3-yearly for ages 25–49).
• Primary Screening Modality: High-risk Human Papillomavirus (hrHPV) testing on liquid-based cytology samples.
• Clinical Pathway:
  1. hrHPV Negative: Return to routine 5-yearly recall.
  2. hrHPV Positive with Normal Cytology: Repeat HPV test in 12 months. If hrHPV remains positive at 12 months with normal cytology, repeat at 24 months. If hrHPV remains positive at 24 months, refer directly for colposcopy.
  3. hrHPV Positive with Abnormal Cytology (Borderline, Low-grade, or High-grade Dyskaryosis): Direct urgent referral for colposcopy.

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Other Gynaecological Presentations

• Cervical ectropion: columnar epithelium visible on the ectocervix, common in pregnancy, adolescence and with the combined pill; it can cause discharge and post-coital bleeding. Confirm cervical screening is up to date and exclude infection and cancer; treatment (for example cryotherapy) is only for troublesome symptoms.
• Ovarian torsion: sudden severe unilateral lower abdominal pain with nausea and vomiting, often with an ovarian cyst or mass (including in pregnancy or after ovarian stimulation). Doppler ultrasound can show normal flow, so clinical suspicion leads to urgent laparoscopy to untwist and preserve the ovary.