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:
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:
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:
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.
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:
Vaginal and pelvic examinations, ultrasound, magnetic resonance imaging, and, in some cases, diagnostic laparoscopy, may be undertaken to diagnose the causes of pelvic pain.
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
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).
An assessment of the presenting complaint should be undertaken. Examinations and investigations include:16,17,clinical knowledge
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.