Information for GPs

Information for GPs and Referring Doctors

The Complex Menopause clinic is open to patients in the Dublin, Wicklow and Kildare areas who have menopause disorder issues alongside co-morbidities that make it complicated to offer HRT treatment in primary care.

Patients who are suitable include people with a past or current diagnosis of:

• VTE
• Immunological Diseases including HIV
• Ischemic Heart Disease
• Stroke
• Cancer; particularly reproductive cancers
• Serious Current Liver Disease

Please complete all sections of the application form fully as we will not be able to offer an appointment to your patient without this completed form.

Thank you. 

GP Referral Letter

Ambulatory Gynaecology at The National Maternity Hospital

The Ambulatory Gynaecology clinic is located on the ground floor of the National Maternity Hospital next to the Gynecology Clinic. Women are referred in by their GPs if they have had postmenopausal bleeding. All referrals are reviewed by a Consultant and an ultrasound scan is arranged. Depending on the results of the scan, an appointment will be sent to the patient if an outpatient hysteroscopy is needed.

At the clinic, a small camera is inserted very gently through the cervix to view the inside of the womb. Sometimes a biopsy is taken. If a polyp is identified, this can either be removed on the day or a return appointment is made to remove it under local anesthetic, thus avoiding general anesthetic.

The clinic also sees women who have difficult to remove mirena coils, uterine abnormalities, infertility and endometrial polyps.

Download referral form here

Many individuals and couples face fertility challenges. The National Maternity Hospital Fertility hub is one of six fertility hubs in Ireland that provide evidence based fertility work up and management. Couples identified as requiring Assisted Reproduction (AHR) while attending the Fertility Hub, and who meet the HSE criteria for funding, are referred to one of nine fertility clinics nationwide to avail of publically funded AHR.

When referring a patient to the hub, please send your referral through Healthlink via the Gynae pathway. Please note we only accept female referrals as part of a couple. Please also note, as per the HSE criteria for referral to the fertility hub your patients must meet the following:

• Female partner aged under 43
• Male partner aged under 60
• BMI 18.5-35 for women
• Address is within the Ireland East Hospital Group (IEHG) Catchment area
• Couple are unable to conceive for 6 months (if female partner over 36) or 12 months (if female partner under 36)
• There is a known cause of infertility or a history of predisposing factors for infertility

The referral will need to include:

• Age of the patient
• The length they have been trying to conceive
• BMI
• Past medical history relevant to fertility
• A basic workup of tests including AMH, TFTs, Rubella, FBC and Chlamydia swab. Please also send on any other testing done such as pelvic ultrasounds.

Patients can view The NMH’s Fertility Hub webpage for more information on our services and the HSE webpage for access criteria for funded treatment.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a common reason for Gynaecologic referral. The majority of causes are benign, but some cases raise concerns about gynaecological cancer. It can be broadly divided into the following:

• Menorrhagia (regular heavy menstrual bleeding)
• inter-menstrual bleeding
• postmenopausal bleeding
• post coital bleeding

Menorrhagia

Women with regular heavy menstrual bleeding should initially be managed by remote communication. They should be reassured that the complaint is common and that the risk of malignancy is very low.

• History should describe the severity of the symptoms, the possibility of anaemia and the likely cause.
• If there are no significant symptoms of anaemia, medication should be prescribed with due consideration of relevant contraindications (NICE guidelines)
• Women should be referred to secondary care for further management if:
  • Bleeding is torrential and / or prolonged.
  • Bleeding is ongoing and unmanageable despite recommended oral treatments
  • Significant anaemia is suspected.

Women being referred to secondary care should have the following examination and investigations included with the referral:

• A pelvic examination
• A full blood count to diagnose anaemia.
• If locally available, a pelvic ultrasound / other recent imaging reports

Consider the following interim therapies for women being referred to secondary care:

• oral or intravenous iron infusion according to the severity of the anaemia and associated symptoms.
• Tranexamic acid and a course of high dose oral progestogens to rapidly supress acute bleeding.
• NICE recommended medical treatments that have not been used including the levonorgesterol- releasing intrauterine system.
• Gonadotrophin releasing hormone (GnRH) analogues for refractory bleeding despite use of recommended NICE medical treatments and / or in the presence of significant uterine fibroids. This is a high-tech prescription so would need to be organised in conjunction with hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established or delivery via the nasal route. Addback hormone replacement therapy (HRT) should be considered, once bleeding is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.

Intermenstrual Bleeding

Women with IMB should initially be managed by remote communication. Women should be reassured that IMB is common and symptoms often spontaneously resolve and that underlying cancer is rare.

A relevant clinical history should describe the severity of the symptoms and enquire about the likely cause:

• Cervical smear history
• Use of hormonal preparations
• Pregnancy should be excluded
• Likelihood of STI

Where the likelihood of sexually transmitted infection or genital tract cancer is considered negligible, then management options to discuss include:

• Reassurance.
• Observation with phone follow up to see if the IMB subsides.
• Change in hormonal contraceptives in current users.
• Trial of hormonal contraceptives in non-users.

Women should be asked to come for a pelvic examination, preferably in primary care, if:

• There is a risk of sexually transmitted infection (take genital tract swabs).
• Cervical cancer is suspected because of associated post-coital bleeding and / or offensive vaginal discharge.

Women should be referred to secondary care for further investigation of IMB if:

• Cervical cancer is suspected on pelvic examination.
• Endometrial cancer is suspected because of persistent IMB (i.e. occurring for at least 3 consecutive months) in women over 40 years who are not using hormonal contraceptives.

Post-menopausal bleeding

Referrals for PMB will be triaged urgently and an individualised plan of action made taking into account additional risk factors for malignancy, and whether hospital attendance should be deferred for COVID vulnerable individuals eg., those cocooning, or currently in self-isolation.

Women presenting with postmenopausal bleeding will firstly have a pelvic ultrasound to determine endometrial thickness. The scan report is reviewed by a consultant and a decision is then made regarding the need for hysteroscopy / tissue sampling. It would be helpful to include information such as smear history, HRT use, pelvic examination findings and BMI. If for any reason you feel the patient would not be suitable for a transvaginal scan or outpatient hysteroscopy please let us know.

Post coital bleeding

Women with PCB should initially be managed by remote communication. If they have an in-date negative cervical screening test, a cervical cancer is extremely unlikely and patients should be reassured.

Women with PCB who do not have an in-date negative cervical screening test need to be seen for a speculum examination and for a smear to be taken.

If they have any risk factors for a sexually transmitted disease, they should have genital tract swabs taken or referred to a Sexual Health Clinic for further investigation and management.

Ovarian Cysts

Referrals for ovarian cysts will be triaged according to symptomatology and risk of malignancy. Lesions suspicious for ovarian cancer will be managed urgently by the Gynaecology Oncology Specialists.

CA125 and transvaginal ultrasound scan findings should be included in referrals, as well as significant personal or family history (ovarian, bowel or breast cancer).

The RMI score (malignancy risk index) is calculated based on the serum CA 125 value, menopausal status (M), and evaluation of ultrasound (U).

 RMI = U x M x s-CA 125

In general, lesions with RMI > 200 have a high index of suspicion for cancer.

Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months.

Urogynaecology

Referral to the Urogynaecology clinic is by healthmail or letter. Please note all referral letters are triaged by a Consultant and appointments offered accordingly. Unfortunately, due to significant demand on the service there is quite a long waiting list for appointments.

The majority of patients referred into the clinic present with non-urgent conditions such as prolapse and or incontinence. When women are offered an appointment for the clinic they are also invited to an online /in-person physiotherapy information session which includes advice on managing symptoms, guidance on pelvic floor exercises and helpful lifestyle changes. We encourage women to attend this session to gain some insight into conservative measures which can help symptoms.

 Engagement with pelvic floor physiotherapy is helpful for women with pelvic floor disorders such as prolapse and urinary incontinence. If possible, please refer women with pelvic floor issues to a pelvic health physiotherapist locally while they wait for their appointment in the clinic. Lifestyle changes which can be useful for women with prolapse/urinary incontinence include: weight reduction, smoking cessation, cutting down on caffeinated and fizzy drinks, management of constipation.

 For postnatal women who have attended  the National Maternity Hospital the hospital offers a virtual class“ Healthy Bodies after Birth” which takes place every Friday morning online-  email njordan@nmh.ie for the link.

Additionally women who deliver in the National Maternity Hospital can self-refer to the physiotherapy service in the hospital within the first 6 months following delivery- contact physio@nmh.ie

Scan the QR code below for more patient information leaflets and videos from the Pelvic Floor Centre on prolapse and stress urinary incontinence

     videos leaflets

Some other useful guidelines for managing prolapse and urinary incontinence are included below

http://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/assessment-and-management-of-stress-urinary-incontinence.pdf

http://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/diagnosis-and-management-of-pelvic-organ-prolapse.pdf

https://www.nice.org.uk/guidance/ng123

Recurring 1st Trimester / 2nd Trimester Miscarriage

• Patients attending NMH who are diagnosed with a 3rd consecutive early miscarriage or a second trimester loss will be automatically referred for timed investigations and subsequent remote clinic review by Dr Allen.
• Referrals from GPs will be triaged and patients fulfilling the criteria will be contacted by the bereavement liaison midwife team. Arrangements will be made for blood and ultrasound investigations to take place, and for subsequent clinic review to occur remotely.
• Patients who have previously attended this clinic will already have a care plan for future pregnancy. In the event of a positive pregnancy test, they should follow the advice in their plan to contact the bereavement liaison midwife team who will arrange early pregnancy assessment, any necessary additional prescriptions, and first trimester surveillance with Dr Allen in the antenatal out-patient clinic.
• It is not possible at present to provide a second opinion on tests performed in other units.

Chronic Pelvic Pain

The multifactorial nature of CPP makes it difficult to triage but as a general rule patients presenting for the first time in later life and those with atypical symptoms normally warrant hospital referral.

Women should be offered appropriate analgesia to control their pain even if no other therapeutic manoeuvres are yet to be initiated.

Known or suspected cases of endometriosis:

Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis. Options for management for suspected but unconfirmed cases while awaiting Gynaecology assessment include the following:

• Continuous course of combined oral contraceptive eg tricyling for 3/12, for patients without contraindications.
•  progesterone-only pill
• oral progestogens daily
• Some patients get relief with insertion of levonorgesterol- releasing intrauterine system.
• Gonadotrophin releasing hormone (GnRH) analogues for management of severe pain despite medical treatments in conjunction with remote hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established. Addback hormone replacement therapy (HRT) should be considered, once pain is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.

Irritable bowel syndrome

www.bsg.org.uk provides guidance on management of IBS and may be useful in elucidating and alleviating symptoms of pelvic pain in patients with a normal gynaecologic examination.

Women with IBS should be offered a trial with antispasmodics. Women with IBS should be encouraged to amend their diet to attempt to control symptoms.

• Certain symptoms are considered ‘red flag’ and should be highlighted in referrals for CPP
• Bleeding per rectum
• New bowel symptoms over 50 years of age
• New pain after the menopause
• Pelvic mass
• Suicidal ideation
• Excessive weight loss
• Irregular vaginal bleeding over 40 years of age
• Postcoital bleeding

Suspected Pelvic Inflammatory Disease

All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs). Suitable samples to screen for infection, particularly Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of PID.

If PID is suspected clinically, this condition is best managed in conjunction with a genitourinary medicine service in order that up-to-date microbiological advice and contact tracing can be arranged.

Adolescent Gynaecology

While serious gynaecological pathology in childhood and adolesence is rare, we appreciate that gynaecological symptoms can cause significant distress, in particular to those students studying for upcoming examinations.

In so far as possible we are offering telephone consultations with parents and young women.

Urgent referrals will be reviewed and it may be possible to offer advice remotely.

The majority of adolescents attending our clinics do so because of menstrual problems. Menstrual problems are very common in adolescents and are mostly related to anovulatory cycles.

We would recommend continuing current treatments such as the Combined Oral Contraceptive pill if the treatment is working well.

It is helpful to keep a menstrual/symptom diary/app.

Helpful regimens for menstrual problems include:

Non-steroidal anti-inflammatory drugs:

Ibuprofen 10mg/kg max 400mg TDS, or Mefenamic acid 500mg TDS >12 years.
Decrease in blood loss by approximately 20% as evidenced by Cochrane

Emphasize the importance of early commencement of regular analgesia.

Tranexamic Acid1g QDS (500mg QDS if <50 kg)   — 40-50% ↓in menstrual flow v placebo Cochrane

Hormonal management:
Cyclical progesterone is particularly helpful for younger girls who do not need contraception.
Norethisterone 5 mg BD-TDS Day Day 14- 28
Duphaston 10 mg bd daily Day 14-28 – continue x 6/12
Medroxyprogesterone Acetate
2.5-10 mg od Day 14- 28

30mcg COCP usually gives better cycle control than 20 mcg Pills. Extended use/back to back COCP is particularly effective for management of cyclical symptoms. Breakthrough bleeding may occur when taking the pill in this manner. A 4-day break may be necessary if there is breakthrough bleeding for more than 4 days.

LARCS may be appropriate for some adolescents.

See britspag.org for useful  patient information leaflets on common adolescent gynaecological conditions.