Who not to refer to gynaecology clinic

exp date isn't null, but text field is

Listed below are clinical situations where referral to gynaecology outpatients will NOT usually be advised:

Contraception Issues

Reversal of sterilisation - No longer done on NHS. Do not refer.

Contraception - All referrals for insertion and removals of IUCD’s and Mirena IUS for contraceptive purposes, and other contraceptive advice. These should all be referred to FP & SH Dept or to a GP colleague. 

Sterilisation request - Long Acting Reversible Contraceptive (LARC) should be offered first to all women requesting sterilisation. If BMI >30, advise weight loss first, and other effective contraceptive if acceptable to patient. It is rarely justifiable to carry out laparoscopic sterilisation if BMI >30. All patients will be assessed at HSH first and then directly listed unless surgical issues in which case will be seen at GOPD.

Bleeding Issues

Menorrhagia - prior to full clinical assessment and a minimum of three months trial of adequate recommended treatment. See Menorrhagia Guideline and Heavy Menstrual Bleeding (CG44)

Menorrhagia --do not refer for pelvic ultrasound unless a pelvic mass is found on examination. Do not worry if endometrium is up to 20mm unless has IMB or PCB, this can be normal pre-menstrually

Post-coital bleeding (PCB)
—prior to full clinical assessment including examination, infection screen (PCB is a symptom in 39% patients with Chlamydia ( in under 30s)) and cervical cytology if indicated. Although PCB is a cardinal sign of cervical neoplasia, most cases are not malignant. Only refer if:

Abnormal smear—refer to colposcopy

  • Clinically suspicious cervix—refer to gynaecology clinic urgently
  • Persistent symptoms—refer to gynaecology first and they will refer onwards for colposcopy as required
  • All Abnormal smear—refer to colposcopy

Asymptomatic (ie no history of postmenopausal bleeding) thickened endometrium on scan in postmenopausal patient carried out for other medical conditions—unless endometrial measurement 10mm or more or suspicious features noted.

SOGC Clinical Practice Guideline
Contact bleeding at time of cervical sampling may often occur and is not an indication for referral in the absence of other symptoms or abnormal result.

Prolapse and Bladder Issues

Asymptomatic utero-vaginal prolapse detected during attendance for smear or IUCD insertion. Advise weight loss if high BMI and /or pelvic floor exercises.

Urinary incontinence — advise diet and lifestyle measures. We are happy to see all patients and we try to see them at a dedicated uro-gynaecology type clinic.  Consider if first line referral should be first to physiotherapy if problem is clearly of genuine stress incontinence only from history or if co-morbidities mean that surgery is unlikely to be offered. See Bladder Matters with information in Health Professionals’ area on indications for early referral and treatment options.

Routine change of ring pessary —once size of ring established, routine 6 -9 monthly change should rarely need hospital appointment. Only the portex ones are disposed off at each change, the shelf and pink flexible pessaries should be washed and replaced.

Odds and Ends!

Nabothian cysts on the cervix with normal smear-just leave alone

Mid-cycle LIF or RIF pain, short duration, patient not on contraceptive pill. This is a normal ovulatory event.

Ovarian cysts less than 5cm in a pre-menopausal patients especially if picked up on a scan for non gynaecological condition and if described as “thin walled” and believed to contain simple fluid or blood.

Asymptomatic small fibroids picked up as above.

Scan for diagnosing Polycystic Ovarian Syndrome - scan is not required if already have clinical and biochemical features.

Vaginal discharge in Young women – best seen at Highland Sexual Health where they do ‘near patient’ testing.

Labial reduction surgery – No longer offered on NHS unless history of trauma or major asymmetry. Psychological assessment may be required.

Asymptomatic cervical polyps – if patient has no irregular bleeding and this is found routinely at smear testing no action is required.

Infertility Issues

Please follow infertility guideline . Please get result of seminal analysis before referral, it is not acceptable to refer before! Please note that there is no upper age limit for being seen at the clinic but that there will be no NHS funding for IVF after age 42.

 See Subfertility Guideline

Editorial Information

Last reviewed: 31 July 2017

Next review: 31 July 2018

Version: 3

Approved By: Due for review by high-uhb.tam@nhs.net