Gynaecology Referral Pathway for GPs to Aid Triage for Gynaecology Services in the Rotunda
For acute gynaecology (suspected torsion, acute PID, etc..) or acute early pregnancy referrals please consider discussing with Obstetrics and Gynaecology registrar on call prior to referral to ED.
All referrals for out-patient appointments can also be discussed with the Obstetrics and Gynaecology registrar as necessary.
1.General Gynaecology
2.Ambulatory Hysteroscopy
3. Adolescent Gynaecology
4. Fertility
5. Promotion of Continence
6.Perineal Clinic
7.Recurrent pregnancy loss
8. Gynaecology Ultrasound
9. Community Gynaecology/GP led clinic
| For abnormal smears please follow National Referral Guidelines for Colposcopy |
| For early pregnancy complications please follow the EPU guidelines |
| For suspected ovarian cancer see HSE Ovarian Cancer referral guidelines |
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| Problem | Helpful examination findings and results of investigations which aid with triage*
|
Urgent referral | Routine Referral | If routine consider following these appropriate steps prior to referral |
| Palpable abdomino-pelvic mass not obviously fibroids/urological or gastrointestinal
|
Bimanual and speculum examination findings
Ca 125
Pelvic Ultrasound |
Presence of ascites
Raised Ca125
Pelvic ultrasound suspicious for ovarian ca
See Ovarian Cancer referral guideline |
Not appropriate | See Ovarian Cancer referral guideline |
| Persistent symptoms suggestive of ovarian cancer in women >50
· persistent abdominal distension (women often refer to this as ‘bloating’) · feeling full (early satiety) and/or loss of appetite · pelvic or abdominal pain · increased urinary urgency and/or frequency
|
Bimanual and speculum examination findings
Consider · Ca125 · Pelvic Ultrasound
|
If either suspicious for ovarian cancer
See ovarian cancer referral guideline |
As necessary
|
If Ca 125 and pelvic ultrasound normal no indication for referral if post menopausal
If still menstruating consider routine referral |
| Post menopausal bleeding | Bimanual and speculum examination findings
|
One episode if no HRT
On HRT- unexpected or prolonged bleeding
Consider direct referral to ambulatory hysteroscopy
|
Not appropriate | |
| Suspected cervical cancer | Bimanual and speculum examination findings
Suspicious cervix on speculum examination
Smear
|
Refer colposcopy
|
Not appropriate | |
| Post-coital bleeding
Letters received cannot be triaged without smear result unless under 25 years
|
Bimanual and speculum examination findings
HVS and endocervical swabs
Smear
Transvaginal ultrasound report if done |
See colposcopy guidelines for abnormal smears
Examination suspicious for cervical/vaginal cancer refer to colposcopy |
Under 35 with normal appearing cervix on clinical exam and normal smear with negative swab results
If >35 with normal smear and normal appearance of cervix with persistent symptoms consider referral to colposcopy
|
Smear results
Swab results
Consider a transvaginal ultrasound if access |
| Intermenstrual bleeding | Risk factors for endometrial cancer
Speculum examination
Bimanual examination
Smear result
HVS and endocervical swab results
Consider pelvic ultrasound if over 35
|
Physical findings suggestive of malignancy- cervical or vaginal tumour
Abnormal pelvic ultrasound
If over 40 consider direct referral to ambulatory hysteroscopy
|
No suspicious features for malignancy/no risk factors for endometrial cancer/under 35 years and persistent symptoms | If associated with contraception try alternative
Smear result
Symptom chart |
| Heavy menstrual bleeding
(>3months duration) |
Frequency and regularity of bleeding
Bimanual and speculum examination findings
FBC
Latest smear result
Pelvic ultrasound result |
Hb <8
Abnormal ultrasound
Consider direct referral to Ambulatory hysteroscopy |
If pelvic US normal and <40 years of age consider referral to GP led clinic
Unsuccessful medical management
Consider direct referral to Ambulatory hysteroscopy if >40
If sent to ambulatory hysteroscopy patient should arrive with Mirena coil to be inserted if desired
|
FBC result
Smear up to date
Pelvic US if access
Trial medication-mefanamic acid and transexamic acid for 2 cycles
Trial OCP
Offer Mirena
|
| Dysmenorrhoea | Bimanual and speculum exam
Pelvic US results
|
Not appropriate | Consider if failed medical intervention | Try OCP or Mirena
Arrange pelvic ultrasound if access |
| Dyspareunia | Bimanual and speculum exam
HVS and endocervical swabs
|
Not appropriate | As required
If abnormal exam or potential need for laparoscopy |
Consider pelvic ultrasound if access |
| Ovarian Cysts
(Pelvic Ultrasound performed and result available) |
Bimanual and speculum examination findings
Incidental finding or not
Symptoms
Assess Risk of Malignancy (RMI)
Pelvic ultrasound result
Tumor markers if not simple cyst and pre-menopausal Ca125 Ca19.9 hCG AFP LDH If post-menopausal (any cyst) Ca125 Ca19.9 CEA |
If known cyst and symptoms of torsion refer direct to ED
Suspicious features on ultrasound; sepatations, solid components, papillary projections, ascites
High RMI refer directly to Gynae-oncology in Cancer centre (>200)
Low RMI (<200) but symptomatic |
Persistent simple cyst x2 ultrasounds at least 6 weeks apart in pre-menopausal woman
Low RMI (<200), asymptomatic, <5cm, simple appearance, unilocular, unilateral. |
If simple cyst <4cm size repeat scan after 6 weeks to exclude corpus luteal cysts in pre-menopausal woman. If repeat ultrasound normal no need for referral. |
| Fibroids | Assess menstrual loss and pressure/pain symptoms
Bimanual and speculum exam Pelvic ultrasound results
FBC |
Not appropriate | If abnormal menses and anaemia or obstructive symptoms | If asymptomatic with normal menstrual pattern, normal Hb no need for referral.
Organise annual pelvic ultrasound for surveillance |
| Incontinence/Voiding difficulty
Promotion of continence clinic |
Bimanual and speculum examination findings
FBE
Biochemistry
Medication list
MSU
Recent diabetes screening results
Flow/volume chart for 3 days prior to appointment
|
Not appropriate unless acute urinary retention due to suspected gynaecological condition | Failed response to PFE/physio
No response to 2 anticholinergics if OAB
|
Advise pelvic floor exercises
Consider physio referral
Risk factors for diabetes-consider screening
If OAB- trial oxybutinin,kentara or urispas, bladder drill
Check bladder diary-intake
Advise against caffeinated beverages especially after 6pm
Treat underlying chronic cough or constipation |
| Pelvic organ prolapse | Symptoms
?Bladder ?Bowel
Extent of prolapse/pelvic exam
Details of previous pelvic surgery
MSU
Biochemistry |
Not appropriate
*If patient has an ulcerated procidentia or complete vaginal vault prolapse with failed pessary consider referral to ED after discussion with on call Registrar |
Failed pessary
Patient unwilling to try pessary |
If asymptomatic no need for referral
Consider vaginal pessary
Consider local oestrogen therapy for post-menopausal women
Treat underlying chronic cough or constipation |
| Oligomenorrhoea/Secondary amenorrhoea | FSH/LH
Prolactin TSH Oestradiol Testosterone SHBG Pelvic ultrasound report |
Not appropriate | As required | Check for pregnancy
Do bloods,
Pelvic ultrasound if access
Check BMI
Dietary/lifestyle advice
|
| PCOS | FSH/LH
Prolactin TSH Oestradiol Testosterone SHBG Pelvic US report |
Not appropriate | Clarify why referring-abnormal bleeding or referral to fertility clinic if trying to conceive
|
Diet and lifestyle advice
Dietician referral
Consider pelvic ultrasound if access
Consider metformin and/or OCP |
| Chronic pelvic pain | Associated symptoms
Pelvic exam HVS Endocervical swabs
Pelvic US results |
Not appropriate | Abnormal findings
Not responsive to medication
Trying to conceive |
Smear UTD
Menstrual suppression-OCP, depot provera, implanon, Mirena
Consider pelvic ultrasound if access
|
| Primary amenorrhoea | Refer Adolescent Gynae if <18
Secondary sexual characteristics FSH/LH TSH Prolactin
|
Refer Adolescent Gynae if <18
|
Check pregnancy
Consider pelvic ultrasound if access |
|
| Permanent Contraception | For consideration of surgical sterilisation
-Alternatives tried -Suitability for surgery
|
Not appropriate | Consider referral to GP led clinic for Mirena insertion | Try Mirena/depot/implanon
Discuss vasectomy |
| Vulval pathology | Symptoms
Examination
Smear history Drug/medication history
Exclude STD Exclude UTI |
Ulcerated lesion in postmenopausal woman
Suspected cancer
Bartholin’s cyst in post menopausal woman
*Acute, painful enlargement of Bartholin’s gland may require referral to ED
|
No features of malignancy/pre-menopausal woman
Failed medical therapy
Bartholin’s gland cyst |
Emollients
Mild steroid cream-short course
Smear UTD |
| Vaginal Discharge | Physical examination
Smear UTD
HVS and endocervical swabs
|
Suspected cancer (postmenopausal women with no signs of atrophy and other causes excluded) | Chronic discharge
|
Treat underlying infection
Reassurance if investigations negative |
| Menopause
(Complex medical complications, premature menopause, surgical menopause) |
Menopause symptoms
Medical complications (CVD, Breast cancer, significant family history of breast ca, stroke, VTE)
|
Not appropriate | Consider referral to GP led clinic for general menopause consultation if not premature menopause or complicated medical history
If <40 with elevated FSH
Surgical menopause
|
If over 45 with menopause symptoms for management in primary care unless medical complications
If 40-45 consider referral if not responsive to treatment |
| Infertility Clinic | Bimanual and speculum examination findings
HVS Endocervical swabs Day 2-3 FSH/LH D21 progesterone (if 28 day cycle) Prolactin AMH level Rubella status
Semen analysis |
Over 38 and trying to conceive >6months | Under 38
Trying to conceive >12months |
Lifestyle and dietary advice
Weight loss
Smoking cessation
Pattern of sexual intercourse
|
| Perineal Clinic | Nil | In general determined prior to discharge
(3rd and 4th degree tears)
Infected perineum may need referral to the ED |
Persistent, perineal pain after episiotomy or 2nd degree tear
Previous FGM for evaluation
|
Outrule infection
Trial of topical instilagel treatment |
| Adolescent Gynaecology Clinic
(<18)
NO infertility |
Pelvic exam not necessary
See individual presenting complaints |
See individual presenting complaints | As necessary | Diet and lifestyle
For heavy or painful periods consider trial OCP |
| Recurrent pregnancy loss Clinic | >3 miscarriages
> 2 late miscarriages
No investigations necessary |
>2 miscarriages over 38 years of age | All other referrals | Not necessary |
| Ambulatory Hysteroscopy Clinic
Please ensure patient has the IUCD with them for insertion on attendance
|
Bimanual and speculum examination findings
See individual presenting complaints
Smear result |
Post menopausal bleeding
Abnormal uterine bleeding with anaemia (Hb <8)
Abnormal endometrium on ultrasound
|
Heavy menstrual bleeding
Failed medical management
For IMB and PCB see individual complaints |
Regular, heavy menstrual bleeding, no IMB or PCB in women under 45 years of age with normal pelvic exam consider referral to GP led clinic for Mirena
|
| Community Gynaecology/GP led clinic | Regular, heavy menstrual bleeding, no IMB or PCB in women under 45 years of age
Failed/Difficult IUCD insertion
Missing IUCD threads
Menopause consultation in women >45 with no complicated medical history |
Not appropriate | All should be routine | Please ensure patient has the IUCD with them for insertion on attendance |
* Helpful information from examination
If never sexually active consider early ultrasound. Pelvic exam can be deferred to Gynae OPD