1. Gynaecological referrals from primary to secondary care Dr Fozia Malik MRCOG,DFSRH
14/11/2018

2. Referral to Gynaecology Out Patient
chronic pelvic pain
Polycystic Ovary Syndrome
Non-neoplastic epithelial disorders of the vulva
Contraception
Vaginal discharge

3. chronic pelvic pain
CPP is defined as intermittent or continuous pain of at least six months' duration felt in the lower abdomen or pelvis, NOT associated exclusively with menstruation, intercourse, pregnancy or malignancy

4. Contributory factors in CPP

5. Management of chronic pelvic pain
A careful history is required including assessment for red flag symptoms.
Examination should involve assessment for abdominal scars or localised spots of pain. Focal tenderness or pelvic floor trigger points may be detected on vaginal examination.
Investigations include swabs to screen for sexually transmitted infections, urinalysis and USS pelvis.
Therapeutic options include simple analgesics or adjuvant analgesics such as amitriptyline or gabapentin.
Hormonal treatment for ovarian suppression should be trialed before offering diagnostic laparoscopy

6. siPolycystic Ovarian Syndrome

7. siPolycystic Ovarian Syndrome Ovary Syndrome
PCOS should be diagnosed according to the Rotterdam consensus criteria
polycystic ovaries
oligo-ovulation or anovulation
clinical and/or biochemical signs of hyperandrogenism

8. siPolycystic Ovarian Syndrome

9. Risk associated with PCOS
Metabolic consequences of PCOS
Risk of developing gestational diabetes
Risk for type II diabetes
Risk of developing sleep apnoea
Risk of developing cardiovascular disease
Risk of having reduced health-related quality of life
Risks of cancer in women with PCOS

10. Strategies for reduction of risks
Exercise and weight control
It is recommended that lifestyle changes, including diet, exercise and weight loss, are initiated as the first line of treatment
Insulin-sensitising agents have not been licensed in the UK for use in patients without diabetes.

11. Non-neoplastic epithelial disorders of the vulva

12. Non-neoplastic epithelial disorders of the vulva
Vulval pruritus has a wide, differential diagnosis.
Lichen sclerosus (LS) is common and most patients respond to topical ultrapotent corticosteroids. LS not responsive to treatment might be due to hyperkeratotic disease, poor treatment compliance, contact sensitivity to steroids, or infection.
For difficult cases, the opinion of a vulval dermatologist is invaluable
Some patients with lichen sclerosus will need referral to a vulval service when they do not respond to topical steroids (or develop symptoms whilst on treatment). In these patients consider:

13. contraception

14. contraception Most methods of contraception are safe for most women.
For women with certain medical conditions, the UK Medical Eligibility Criteria provides guidance on the relative safety of each method.
Long-acting reversible contraception methods are associated with lower failure rates as they are less user-dependent than other methods.
Women requesting contraception should receive comprehensive and clear verbal and written information on all methods that are safe for them, in order to make an informed choice

15. Vaginal discharge
Careful history taking to identify symptoms, which will guide examination and tests required
Identify sites needing sampled depending on sexual practices
Confirm timing of sexual exposure to assess reliability of tests and possibility of window periods
Allow discussion of other sexual health issues (e.g. psychosexual problems)
Be mindful that this consultation may be embarrassing or uncomfortable for the patient
A non-judgemental attitude is key