Gynaecology and Breast

Gynaecology questions in the AKT cover common conditions managed in primary care, cervical screening, breast assessment, and menopause management. Several of these have had recent guideline updates.

Menorrhagia (heavy menstrual bleeding) is defined as excessive menstrual blood loss that interferes with quality of life. NICE recommends first-line treatment with the levonorgestrel-releasing intrauterine system (Mirena). Second-line options include tranexamic acid, NSAIDs (mefenamic acid), combined oral contraceptive, or cyclical progestogens. Investigate with FBC to check for iron deficiency. Refer if treatment fails, intermenstrual or postcoital bleeding is present, or pelvic mass is found.

PCOS is diagnosed using the Rotterdam criteria: at least two of oligomenorrhoea or amenorrhoea, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. Management includes lifestyle modification (weight loss improves symptoms significantly), combined oral contraceptive for menstrual regulation and acne, metformin if glucose intolerance is present, and fertility treatment (letrozole or clomifene) if pregnancy is desired.

Endometriosis affects approximately 10% of women of reproductive age. Symptoms include cyclical pelvic pain, dysmenorrhoea, deep dyspareunia, and subfertility. NICE recommends empirical treatment with analgesia and hormonal contraceptives before referral. Laparoscopy is the gold standard for diagnosis. Treatment includes hormonal suppression (combined pill, progestogens, GnRH analogues) and surgical excision.

Menopause management has changed significantly. NICE guideline NG23 recommends offering HRT to women with vasomotor symptoms, after discussing benefits and risks. HRT reduces osteoporosis risk and improves quality of life. Women with a uterus need combined HRT (oestrogen plus progestogen). Those without a uterus can use oestrogen alone. The breast cancer risk with HRT is small and varies with type and duration. Cognitive behavioural therapy is an effective non-hormonal option for vasomotor symptoms.

Cervical screening uses HPV primary testing. Samples are tested for high-risk HPV first. If HPV positive, cytology is performed on the same sample. Screening intervals: every 3 years (ages 25-49), every 5 years (ages 50-64). Abnormal results follow a colposcopy referral pathway.

Breast lump assessment: all unexplained breast lumps in women over 30 should be referred via the 2-week wait pathway. In women under 30, refer if the lump persists after the next menstrual cycle. Triple assessment (clinical examination, imaging, biopsy) is performed in the breast clinic.