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

2. 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

3. 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

4. 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

5. 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.

7. NICE CG 44

8. 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.

10. 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 years to 1 in 2,400 women aged years.

11. 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.

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

13. 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.

14. 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

16. NICE CG 122

17. NICE CG 122

18. NICE CG 122

19. Vulval disease

20. Thank you for listening !