Gynecology Clinical Practice Guidelines
For general gynecological care, prioritize evidence-based screening, preventive measures, and timely specialist referral based on specific clinical presentations, with particular attention to menstrual disorders, contraception management, and menopause-related symptoms.
Initial Gynecologic Assessment
The initial gynecologic visit should include comprehensive menstrual history, sexual practices, contraception history, previous STDs, prior abnormal Pap tests, history of gynecological conditions, and current symptoms 1. A complete pelvic examination is not universally required for asymptomatic patients but is specifically indicated for persistent vaginal discharge, dysuria in sexually active patients, dysmenorrhea unresponsive to NSAIDs, amenorrhea, abnormal vaginal bleeding, and lower abdominal pain 1.
Cervical Cancer Screening
- Initiate Papanicolaou testing at age 21 years, except for immunosuppressed patients or those with HIV who should begin at the start of sexual activity 1.
- Annual mammography is strongly recommended for women aged >50 years; for women aged 40-49 years, perform individualized risk assessment 1.
Menstrual Disorders
When to Refer
Abnormal uterine bleeding unresponsive to medical therapy or associated with severe anemia requires gynecologic evaluation 2. Dysmenorrhea unresponsive to medical therapy warrants specialist referral 2.
Amenorrhea Management
- Primary amenorrhea by age 16 or secondary amenorrhea necessitates gynecologic evaluation 2.
- For secondary amenorrhea treatment, progesterone capsules may be given as a single daily dose of 400 mg at bedtime for 10 days 3.
- Oligomenorrhea requires assessment, particularly when associated with fertility concerns 2.
Common Pitfall
Do not delay referral for persistent menstrual irregularities despite initial medical management, as underlying pathology may require surgical intervention or advanced diagnostic evaluation 2.
Contraception Management
A pelvic examination is not required to prescribe most contraceptive methods, including oral contraceptives, patches, vaginal rings, implants, and medroxyprogesterone 1. This removes unnecessary barriers to contraceptive access 4.
Contraceptive Initiation Protocol
- Measure blood pressure before initiating combined hormonal contraceptives 4.
- Determine pregnancy status using clinical criteria rather than requiring universal pregnancy testing 4.
- Begin method at time of visit ("quick start") if reasonably certain patient is not pregnant 4.
- Prescribe one full year supply to reduce barriers to care 4.
- Make condoms easily available and discuss dual-method contraception for patients with or at risk of STIs 4.
Managing Unscheduled Bleeding
For unscheduled bleeding during extended or continuous combined hormonal contraceptive use, first rule out underlying gynecological problems including inconsistent use, medication interactions, cigarette smoking, STDs, pregnancy, or new pathologic uterine conditions 4. If no underlying problem is found and the woman desires treatment, advise discontinuation of combined hormonal contraceptive use for 3-4 consecutive days (not during the first 21 days of use and not more than once per month) 4.
Menopause Management
Hormone Replacement Therapy Indications
For women with early or premature menopause without contraindications, hormone replacement therapy is recommended at least until the average age of natural menopause 4. Surgery-induced menopause often leads to vasomotor symptoms that may be more severe than after natural menopause and can persist for many years 4.
HRT Formulation
- Hormone replacement therapy is based on estrogens without progesterone if hysterectomy has been performed, either as oral medication or topical 4.
- If the uterus has not been removed, the addition of progesterone to estrogen is mandatory 4.
- For postmenopausal women with a uterus taking estrogens, prescribe progesterone capsules 200 mg as a single daily dose at bedtime for 12 continuous days per 28-day cycle 3.
HRT Contraindications
Hormone treatment is contraindicated in patients with low-grade serous epithelial ovarian cancer, granulosa cell tumors, certain types of sarcoma (leiomyosarcoma and stromal sarcoma), and advanced endometrioid uterine adenocarcinoma 4. There is no evidence to contraindicate systemic or topical hormone therapy for women with cervical, vaginal, or vulvar cancers, as these tumors are not hormone-dependent 4.
Alternative Management
When hormone replacement treatment is contraindicated or for persistent hot flushes, use selective serotonin reuptake or norepinephrine reuptake inhibitors in conjunction with non-pharmacological approaches such as cognitive-based therapy, yoga, acupuncture, or auriculotherapy 4.
Osteoporosis Prevention
- Perform baseline dual absorptiometry (DEXA scan) for all patients at risk of early-induced menopause 4.
- Recommend calcium supplementation when dietary intake is insufficient to achieve 1300 mg/day, plus vitamin D, weight-bearing exercise, diet modification, and smoking cessation 4.
- Treat osteoporosis with bisphosphonates or denosumab and vitamin D 4.
Infertility
Infertility, defined as failure to conceive after 12 months of unprotected intercourse (or 6 months if age >35 years or with risk factors), requires referral to reproductive endocrinology 2. Women with a history of infertility have elevated risk of earlier surgical menopause until age 43 years but experience no differences in timing of natural menopause 5.
Pelvic Pain and Masses
Acute pelvic pain with possible ovarian torsion, ectopic pregnancy, tubo-ovarian abscess, or adnexal mass requires urgent gynecologic consultation 2. Chronic pelvic pain warrants referral for comprehensive evaluation 2.
Adnexal Mass Management
Adnexal masses require gynecologic assessment, with referral to gynecologic oncology for intermediate-risk (O-RADS 4) or high-risk (O-RADS 5) lesions 2.
Cervical Abnormalities
Abnormal Pap test results requiring colposcopy mandate gynecologic referral 2. Atypical glandular cells (AGC) on cervical cytology require colposcopy, endocervical curettage, and HPV testing 2. Adenocarcinoma in situ (AIS) should be referred to a gynecologic oncologist 2.
Cancer Survivorship Care
Follow-up Schedule
Regular follow-up visits are recommended every 3 months in the first 3 years post-treatment (every 6 months for low-risk early breast cancer), every 6 months from years 4 to 5, and annually thereafter 4. The interval can be adapted to risk of relapse and patient needs 4.
Sexual Health Assessment
All gynecologic cancer survivors should be asked about genitourinary symptoms, including vulvovaginal dryness, regardless of sexual activity 1. Post-radiation use of vaginal dilators and moisturizers is recommended 1. Topical therapy such as moisturizers, vaginal estrogens, and lubrication help improve treatment-induced vaginal dryness or pain 4.
Psychosocial Support
Special attention should be given to treatment-related effects including sexual dysfunction, early menopause, and infertility 1. Psychosocial effects may include depression, anxiety, fear of recurrence, altered body image, financial concerns, and interpersonal relationship issues 4. Patients should be referred to appropriate specialty providers (physical therapy, pelvic floor therapy, sexual therapy, psychotherapy) based on prior treatment history and assessed risk of developing late effects 4.
Cardiovascular and Metabolic Monitoring
Long-term follow-up should include monitoring for cardiovascular disease with regular blood pressure checks and assessment of cardiovascular risk factors 1. Patients should be encouraged to adopt a healthy lifestyle, exercise regularly, avoid being overweight, and minimize alcohol intake 4.
Common Pitfalls
- Failure to provide comprehensive gynecologic care that extends beyond cancer surveillance to include management of treatment-related symptoms and psychosocial support 1.
- Inadequate communication and coordination between specialists and primary care providers, which can be improved through survivorship care plans 1.
- Neglecting to address the broader dimensions of culture and context that impact implementation of follow-up strategies 4.
- Requiring preventive services (cervical cytology, breast examination, STI evaluation) as prerequisites for contraceptive care, which introduces unnecessary barriers 4.