‘Red Flags’ in Gynaecology Andrew Sizer Clinical Director for Gynaecology

What is a ‘red flag’ symptom ? …alert signs and symptoms that indicate a more serious underlying pathology – GP Online ‘Red Flags: 10 symptoms you can’t ignore’ – ABC News "Red flag" indicates symptoms that are particularly worrisome for a serious illness - UCSD School of Medicine

Red Flags - Gynaecology Condition Symptoms Ovarian cyst torsion/accident Severe pelvic pain associated with hypovolaemic shock Endometrial carcinoma Abnormal uterine bleeding, especially PMB Ovarian carcinoma Non-specific symptoms of abdominal distension, pain, abnormal bleeding, weight loss Cervical carcinoma IMB, PCB, PMB, offensive vaginal discharge PID PV discharge, pelvic pain, fever, abnormal bleeding

Amenorrhoea Pregnancy Menopause Medication Lifestyle - exercise/stress Genetic abnormalities, such as Turner syndrome Kallman syndrome Sheehan's syndrome Ovarian or adrenal malignancy Imperforate hymen Cushing's syndrome Polycystic ovary syndrome Hypothyroidism

Amenorrhoea Always consider pregnancy. A pregnancy in a very young person could be a red flag for child protection. A relatively uncommon cause for primary amenorrhoea is an imperforate hymen, with blood collecting in the vagina (haematocolpos). Ask about medication (certain drugs can raise prolactin levels, leading to amenorrhoea), lifestyle (excessive exercise, stress, significant weight loss) and check if a recent pregnancy test or pelvic ultrasound has been requested or carried out. Ask about sense of smell (Kallman syndrome) or galactorrhoea (hyperprolactinaemia). Prolactin can be raised without drugs. If found, referral to an endocrinologist may be necessary, as pituitary prolactinomas are commonly found in this group.

NICE CG 44

Post-menopausal bleeding Post-menopausal bleeding (PMB) is defined as genital tract bleeding that recurs in a menopausal woman at least one year after cessation of cycles. Endometrial cancer is present in approximately 10% of patients referred with PMB.

Post-coital bleeding A systematic review identified that the risk of a woman in the community presenting with postcoital bleeding having cervical cancer ranges from 1 in 44,000 at age 20-24 years to 1 in 2,400 women aged 45-54 years.

Post-coital bleeding A full pelvic examination will establish whether there are any polyps, discharge or any obvious sites of bleeding in the lower genital tract.

Post-coital bleeding Possible causes Cervical ectropion. Cervical or endometrial polyps. Chlamydia. Atrophic vaginitis. Gynaecological malignancy. Trauma.

Post-coital bleeding Atrophic vaginitis In menopausal or postmenopausal women atrophic vaginitis may cause postcoital bleeding as the vagina is not sufficiently lubricated due to reduced mucosal secretions. Coupled with an increased pH and thinning epithelium, this can lead to painful intercourse and bleeding. Women with atrophic vaginitis may also experience vulval itching or burning. Estrogen preparations are an effective treatment.

Post-coital bleeding Chlamydia rates have been steadily increasing since the mid-1990s and chlamydia is now the most commonly diagnosed STI. Young people are particularly at risk. In females, chlamydia does not often present with any symptoms so it is important for young women to be aware of the risk even if they do not have any symptoms. If symptoms are present, they may include postcoital bleeding as well as altered vaginal discharge, lower abdominal pain or dysuria. If left untreated, chlamydia can cause pelvic inflammatory disease

NICE CG 122

NICE CG 122

NICE CG 122

Vulval disease

Thank you for listening ! Andrew.Sizer@sath.nhs.uk