01 Postmenopausal bleeding – think of endometrial cancer.
02 Unscheduled bleeding on HRT – think of endometrial cancer.
03 Postcoital bleeding could be cervical cancer, even with a‘normal’ smear.
04 Pelvic discomfort, abdominal distention and dyspepsia could be symptoms of ovarian cancer.
05 Consider pregnancy, even if the possibility is denied.
06 Abdominal or pelvic pain in a woman of reproductive years – exclude ectopic pregnancy.
07 Abdominal pain, with a negative pregnancy test, could be ovarian cyst rupture.
08 ‘Being wet all the time’ may signify a urogenital fistula.
09 Vulval ulceration or bleeding may be neoplasm.
10 Enlarging ‘fibroids’ – exclude cancer.


1 Endometrial cancer
Unpredictable vaginal bleeding 12 months after the menopause may herald endometrial cancer. In women over 55, approximately 1 in 8 with postmenopausal bleeding have an underlying malignancy, two-thirds of which are endometrial. The other third comprises vulval, cervical, ovarian or bowel cancers. Prompt referral to a specialist for examination, transvaginal scan and biopsy are required. Early hysterectomy for endometrial cancers has a high cure rate.

Action: Refer urgently to gynaecology.

2 Endometrial cancer on HRT
Women taking HRT can develop endometrial cancer. Unscheduled or irregular vaginal bleeding must not be presumed to be caused by the hormone replacement.

Action: Refer urgently to gynaecology.

3 Cervical cancer
Menstrual irregularities are common, but postcoital bleeding is suspicious – it could be due to cervical cancer. Regular (3–5-year) cervical cytology smears are recommended in all women aged 25–65 to screen for precancer changes, but a recent ‘normal smear’ does not exclude the possibility. Speculum examination and targeted biopsy are required for diagnosis. Early treatment of cervical cancers has a high cure rate.

Action: Perform a speculum examination. If cervix looks suspicious, refer urgently to gynaecology, otherwise within 4–6 weeks.

4 Ovarian cancer
Ovarian cancer is often silent in its early stages, with presentation delayed until abdominal metastases have occurred. However, in retrospect, women frequently give a history of pelvic discomfort for a considerable time before referral. This may have been labelled ‘irritable bowel syndrome’. At a later stage, symptoms may be due to the mass, ascites and effect of widespread peritoneal metastases. Abdominal distension and dyspepsia may be reported. There may be personal or family history of associated breast or ovarian cancer in 5% – usually, however, there is no risk factor. A pelvic/abdominal mass and ascites may be found on examination. Transabdominal and transvaginal ultrasound scan is the first-line investigation. Early diagnosis may have no impact on survival but may improve quality of life.

Action: Consider pelvic ultrasound in cases of pelvic discomfort. If mass or ascites present, refer urgently to gynaecology.

5 Pregnancy
The medical care of all women of reproductive age must include the possibility of pregnancy. Never was the maxim ‘If
you don’t consider it, you won’t diagnose it’ more true. Vehement denial of the possibility of pregnancy is not reliable.
Urinary pregnancy testing is quick and accurate, and should be carried out if there is any doubt.

Action: Do a urinary pregnancy test.

6 Ectopic pregnancy
Ectopic pregnancy is common – rarely, it can be life-threatening. It must be considered in all females of reproductive age with pelvic or abdominal pain. There may be a history of pelvic infection, subfertility or assisted reproduction. Pain may be one-sided and associated with syncope or shoulder tip pain. Menstruation may be delayed or irregular, but do not be misled by a history of ‘normal’ periods in recent weeks, as vaginal bleeding and a tubal ectopic can coexist. Examination reveals pelvic tenderness and a closed cervical os. Catastrophic tubal rupture will cause massive intraperitoneal blood loss. Pregnancy tests must be carried out and, if positive, an ectopic must be excluded. Primary investigations include transvaginal scan andquantitative serum bhCG. Treatment includes salpingectomy or methotrexate therapy. Some cases will resolve spontaneously during monitoring.

Action: Do a urinary pregnancy test. If positive, refer immediately to gynaecology.

7 Ovarian cyst rupture
In a woman with lower abdominal pain, with a negative pregnancy test, gynaecological causes must still be considered.
Ovarian/paraovarian cyst accident may present acutely because of cyst rupture, haemorrhage or torsion. Cysts may be
physiological (e.g. corpus luteum), pathological such as ovarian tumour (e.g. teratoma or cystadenoma), ruptured/infected endometriotic cyst, or paraovarian (tubal). An ovarian mass may be difficult to palpate due to acute abdominal or pelvic tenderness. Ultrasound scan is the investigation of choice and serum CA125 should be estimated with ovarian tumours to determine risk of malignancy. Laparoscopy or laparotomy is considered depending on symptoms and scan findings. The cyst is normally removed but sometimes oophorectomy is required if it is non-viable.

Action: Refer urgently to gynaecology, immediately if symptoms are severe.

8 Urogenital fistula
If a woman complains of ‘being wet all the time’, consider a urogenital fistula and do not just attribute it to incontinence or UTI. Frequently, there is a history of recent surgery or radiation. Fistulae may run from the ureter or bladder to the vagina. GI fistulae may present as a smelly discharge, especially in elderly women.

Action: Refer urgently to gynaecology.

9 Vulval dysplasia
Vulval dysplasias are more common after the menopause. Skin changes may represent lichen sclerosis or intraepithelialneoplasia. Severe skin changes such as ulceration, contact bleeding and exophytic growth may indicate vulval cancer. All vulval abnormalities should be considered for local biopsy. Early surgical intervention can improve symptom control and prognosis.
Action: Refer to gynaecology, urgently if changes look suspicious.

10 Sarcomatous change in fibroids
Fibroids are almost always benign. However, they can undergo sarcomatous change, or may coexist with a developing ovarian mass. If the symptoms are changing, or the mass appears to be enlarging, additional pathology should be excluded.

Action: Refer urgently to gynaecology.