Gynaecology Treatment

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.

Abnormal bleeding

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:

  • variation in length and flow of menstruation
  • intermenstrual bleeding (IMB)
  • PCB1
  • Postmenopausal bleeding (PMB) 1 year after the menopause, which includes bleeding that occurs when a woman is on hormone replacement therapy.

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:

  • the length of the cycle from the first day of bleeding in one cycle to the first day of bleeding in the next
  • the amount of blood loss each day, which can be assessed by asking about frequency of pad or tampon change, the presence of clots, flooding, and if the woman is able to leave the house
  • the days of the cycle it occurs
  • any cyclical hormonal changes during the month
  • IMB: amount, pattern, timing, and if every month
  • PCB: amount, duration, frequency, timing, and if every time
  • any hormonal contraception used
  • last cervical screening and results
  • previous or current sexually transmitted infection and any discharge
  • any gynaecological operations.


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:

  • between 40–45 years with menopausal symptoms, including a change in their menstrual cycle
  • under 40 years in whom menopause is suspected.2

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. 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.

Causes, symptoms, and treatments

Table 1 outlines the causes of HMB, PCB, and IMB; their symptoms; and treatments.

Table 1: Causes of HMB, PCB, and IMB 1,3–5,clinical knowledge
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. 

Pelvic pain

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:

  • nature of pain
  • how often and associated factors
  • any relationship to periods
  • any relationship to sex
  • any problems with passing urine or opening bowels
  • pain when passing urine or opening bowels, especially related to periods
  • what helps
  • what aggravates the pain.

Examinations and investigations

Vaginal and pelvic examinations, ultrasound, magnetic resonance imaging, and, in some cases, diagnostic laparoscopy, may be undertaken to diagnose the causes of pelvic pain.

Causes, symptoms, and treatments

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

  • abdominal distension
  • feeling full (early satiety) and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency.

Table 2 outlines causes of pelvic pain, symptoms, and treatments.

Table 2: Causes of pelvic pain, symptoms, and treatments 10–15,clinical knowledge
Condition Symptoms 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

Urinary symptoms

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).

History, examinations, and investigations

An assessment of the presenting complaint should be undertaken. Examinations and investigations include:16,17,clinical knowledge

  • abdominal examination
  • vaginal examination with Sims' speculum to look for prolapse
  • midstream urine testing for infections
  • ultrasound to look for any abdominal mass
  • bladder diary
  • urodynamic testing if indicated.


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.