Gynaecological Guidelines

Gynaecological Guidelines
Management of Cervical Polyps
Cervical polyps are common coincidental findings in women undergoing cervical screening. In
the asymptomatic woman they are almost always benign. They consist of an overgrowth of the
endocervical columnar epithelium and are usually solitary although a small number may coexist.
More rarely a submucosal uterine fibroid on a long pedicle may be extruded through the cervical
canal.
Removal of a cervical polyp up to 2cm long by 1cm wide is a simple painless procedure requiring
little skill and is not associated with significant bleeding and can be easily done in the primary
care setting. Assuming this is a coincidental finding a vaginal speculum will already be in
place.
z If the intention was to take a cervical smear this should now be performed.
z The vaginal speculum may be replaced with a self-retaining one thus freeing
up the examiner.
z The polyp should be grasped with a polypectomy forceps and twisted several
times. The polyp can now be pulled upon and avulsed. The vaginal speculum
should be removed. Make sure to use polyp forceps rather than sponge
holding forceps
z The polyp should be placed in a specimen pot with fixative and sent to a
pathology department with a completed request form for histological
examination.
z The patient should be reassured and advised how and when she will learn
of the pathology findings.
z Patient should be warned to expect some vaginal bleeding for up to 24 h.
z In the unlikely event that the patient experiences significant discomfort or
there is difficulty, the procedure should be abandoned and the patient
referred to a gynaecologist.
Gynaecological Guidelines
Vaginal Discharge
In adolescence the cyclical hormonal surges alter the shape of the cervix so that it “pouts”
exposing the thin walled columnar, glandular epithelium. This looks red compared with the
surrounding pink cervical covering of multilayered squamous cells since the underlying
vascular tissue is being viewed through a clear window as opposed to a frosted glass one.
This has traditionally been referred to as a cervical “erosion”, a term which conjures up an
impression of pathology where none exists. This cervical eversion may be encouraged to
persist in women taking the combined oral contraceptive pill but normally with the passage
of time the exposed columnar epithelium undergoes physiological metaplastic change to a
squamous covering. A little vaginal discharge is normal consisting of desquamated cervical
and vaginal cells increasing somewhat premenstrually. Midcycle the cervical mucus is clear
and stringy facilitating the passage of sperm into the uterus. Otherwise it is thicker and
opaque acting as a barrier to the passage of bacteria beyond the vagina. Rarely cervical
eversion is associated with excessive mucous discharge warranting treatment. As metaplasia
proceeds cervical crypts become closed off resulting in multiple physiological mucus retention
cysts, Nabothian follicles. They may be yellow or pearl like in appearance and are commonly
seen when a cervical smear is being taken or on ultrasound, CT or MRI scan.
Nabothian Follicles are of no consequence and their presence does not constitute a
reason for gynaecological referral. They are not pedunculated and should not, therefore,
be confused with cervical polyps.
Gynaecological Guidelines
Vaginal Discharge – Patient Pathway
Patient presentation
Vaginal Discharge
GP
Sexual history
Examination
If full STI testing is
required refer to GUM
mucopurulent
discharge
if postmenopausal
external
pelvic
visualise cervix and
check smear is up to
date
high vaginal and
endocervical swabs
including a check for
chlamydia
review lab
results
cervical
ectropion
-ve
for infection
gynaecology
if discharge
persists or
Post coital
bleeding
+ve
review
therapy
GP
If swabs negative and
examination negative:
discharge, reassure likely physiological
refer for
consideration
of cervical
cautery. Any
suspicious
appearance;
refer
colposcopy
Gynaecological Guidelines
Check for foreign
body (eg tampon) and
remove if present
cervical
polyp
remove –
see
introductory
section for
management
of cervical
polyps
Sterilisation – Patient Pathway
Patient presentation
Patient wishes
sterilisation
GP
Discuss alternative
contraception
Vasectomy
failure rate 1 in
2000; can be
done under local
anaesthetic; few
complications
Implanted
progestogen
only device
>99% effective;
lasts 3 years;
local anaesthetic;
initial menstrual
upset; weight
gain
Intra-uterine
progestogen
only device
>99% effective;
lasts 5 years;
periods less
heavy; may
cause initial
menstrual upset
Injectable
progestogen
only
contraceptive
>99% effective;
lasts 12 weeks;
periods may be
irregular or stop;
weight gain
Oral
contraceptive
COCP >99%
effective; periods
less heavy; POP
99% effective;
compliance issues
Intra-uterine
contraceptive
device
>99% effective;
lasts 3 to 10
years depending
on type; periods
heavier and more
painful
GP/Family Planning Clinic
If decision taken
to perform
vasectomy, refer
to Urology or
Family Planning
Clinic
Patient’s attention should be drawn to the
following, which will also be discussed in
Secondary Care:
General anaesthetic – usually undertaken
laparoscopically with clips as day surgery
Age – sterilisation is performed in women < 30 yrs
only in exceptional circumstances (increased regret
rates in under 30s
Laparotomy – may be required if surgical
complications are encountered
Irreversible – difficult to reverse and NHS may not
fund reversal
Failure rate – 1/200, increased risk of ectopic with
any subsequent pregnancy
Surgical risks – greater in high-risk women (BMI,
abdominal scars, medical disorders)
Continue current contraception until after the
procedure
Periods – will be unchanged (unless on hormonal
method pre-op or an IUCD is removed)
If decision to
consider female
sterilisation
Refer for
sterilisation
Gynaecological Guidelines
Post-Menopausal Bleeding – Patient Pathway
Patient presentation
Post-menopausal
bleeding symptoms
GP
Vulvo-vaginal
examination and
speculum
Pelvic examination
Smear only if due
Normal
Persistent post-menopausal
bleeding despite negative
findings warrants direct
referral to Gynaecology on 2
week wait
Gynaecology
Cervical
polyp
On
Tamoxifen
? Cervical
carcinoma
Remove if
appropriate
Refer
Refer to
colposcopy /
rapid access /
triage / fast
track clinic
Pelvic and transvaginal
ultrasound
Gynaecology
If scan not
available
within 2
weeks
See
ultrasound
algorithm
Gynaecology
Gynaecological Guidelines
Ultrasound algorithm for the management of patients
with post-menopausal bleeding – Patient Pathway
No HRT ≥ 1 year or
continuous combined HRT
Endometrium
> 4mm
On sequential combined HRT
(or within 1 year of stopping)
Endometrium
< 4mm
Endometrium
≤ 5mm
Endometrium
> 5mm
Refer
Refer
? other
abnormal
findings
Gynaecology
Gynaecology
Yes
No
Reassure patient
but encourage
early reporting of
persistent
symptoms
Simple cyst(s)
≤ 5cm
Fibroids
Other adnexal
mass
Refer
Ca125
Gynaecology
Normal
Re-scan 4-6
months
Ca125 > 30
No Change,
reassure patient,
do further
investigations
Refer
increase in
size or
change in
morphology
Refer
Gynaecological Guidelines
Infertility – Patient Pathway
Patient presentation
Couple present with
infertility
GP
Remember:
Rubella status
Folic acid
Drug history
Cervical smear
history
Chlamydia check
If female with BMI
>30 advise weight
loss
History and
examination of both
partners
Advise regular
intercourse (2 or 3
times per week)
Do not encourage
use of temperature
charts or LH
detection kits
Advise both
partners on
smoking and
drinking
Female
Confirm ovulation
with mid-luteal
progesterone level.
No need to
measure thyroid
function or prolactin
if cycles are
regular.
Normal
results
Defer referral until
couple have been
trying to conceive
for 12 to 18 months
Gynaecology
Male
GP
Discuss results with
couple
Consider early
referral if...
Arrange for at least
one semen sample
to be sent to lab for
analysis
Abnormal
results
Female
Male
Age over 35
Amenorrhoea/oligomenorrhoea
Previous abdo/pelvic surgery
Previous PID/STD
Abnormal pelvic examination
Previous genital pathology
Previous urogenital surgery
Previous STD
Varicocoele
Significant systemic illness
Abnormal genital examination
Consider
referral to
Urology
Gynaecological Guidelines
Pelvic Pain – possible causes
Gynaecological
Primary dysmenorrhoea
z Endometriosis
z Adenomyosis
z Ovarian Cyst
z
Key Questions
z Is pain: cyclical; dysmenorrhoea; pre-menstrual; dyspareunia?
z Is menstrual cycle abnormal?
z Cyclical pain on defecation
Gastrointestinal
Inflammatory bowel disease
z Irritable bowel syndrome
z
Key Questions
z Altered bowel habit?
z PR bleeding?
z Weight loss?
z Vomiting?
Examination
z
Abdominal plus pelvic, FOB, FBC, Coeliac antibodies, CRP
Musculoskeletal
Key Questions
z Pain related to position or movement?
Urological
z
Interstitial cystitis
Key Questions
z Spasmodic pain related to full or emptying of bladder?
Examination
z
Abdominal plus pelvic, check urine, exclude infection
Psychosomatic
z
Consider alongside rather than after organic causes
Key Questions
z Past history of mental health problems, depression, anxiety?
z Current life events, stress factors?
z History of medically unexplained symptoms?
Gynaecological Guidelines
Pelvic Pain – Patient Pathway
Patient presentation
Pelvic pain symptoms in
pre-menopausal woman
GP
Assessment
Is the pain (or was it initially) menstrual or
pre-menstrual?
Is it new/altered dysmenorrhoea?
Is there (or was there initially) deep
dyspareunia?
Is the menstrual cycle abnormal?
Lack of GI symptoms?
Yes
No
Exclude/treat
infection (high
vaginal and
endocervical swabs
including
Chlamydia check)
Consider
non-gynaecological
cause
Bimanual
examination
Normal
If tender or
endometriosis
suggested or
complex cyst
TVS
Normal
Arrange ultrasound
and refer as
appropriate
Uterus fixed/tender
or adnexal mass
Simple cyst
<5 cm
Fibroids
Treatment options
and
COCP or
progestogenonly
contraceptive
(oral,
injectable or
intra-uterine
and
Non-opiate
analgesia,
Paracetamol,
NSAID
Consider
psychological
factors. Antidepressants?
Review in 3
months
Gynaecological Guidelines
GP
Symptoms controlled?
Continue
Gynaecology
If symptoms
persist
Irregular Bleeding – Patient Pathway
Patient presentation
Irregular
bleeding symptoms
May be: Intermenstrual;
post-coital; more frequent,
including irregular cyclicity;
prolonged.
Is not: Oligomenorrhea;
post-menopausal bleeding.
GP
1. Exclude pregnancy
2. Bimanual examination
3. Visualise cervix, smear
only if due
4. Check for chlamydia
5. Review contraception
Post-coital
bleeding
Normal smear
and cervix
Abnormal
smear or cervix
Observe
Refer to
colposcopy
If persistent
(over 2
months)
follow
intermenstrual
bleeding arm
of this pathway
Uterus palpable abdominally:
see Abdomino-pelvic Mass
Pathway
Cervical polyp: see protocol
for management of Cervical
Polyps in the introductory
section
Inter-menstrual
bleeding
Complete 3 month
menstrual blood loss
chart
Heavy vaginal
loss over 40 yrs
old: see Heavy
Menstrual Bleed
Pathway
GP
Under 40:
Treat with oral
contraceptive or
Norethisterone 5mg tid
days 5-25 for 3 to 6
months
No improvement
Refer to
Gynaecology
Gynaecological Guidelines
Heavy irregular vaginal bleeding in women over 40 –
Patient Pathway
Patient presentation
Symptoms of heavy
irregular vaginal
bleeding in a woman
over 40 years old
Refer to Gynaecology
Gynaecological Guidelines
Abdomino-pelvic Mass
Following the menarche the first few cycles are commonly anovulatory, resulting in irregularity
and heavy menstruation. This is normal and self limiting. Thereafter, the cycles settle into a
regular ovulatory pattern with several ovarian follicles developing in any one cycle during
the proliferative phase when oestrogen is producing endometrial growth. Usually one follicle
will predominate reaching some 2-3cm in diameter before rupturing releasing the ovum.
The other follicles will shrink leaving the ruptured follicle to become the corpus luteum, an
endocrine gland with a well developed blood supply into which progesterone is secreted
directly. The progesterone prevents further growth of the endometrium preparing it for the
arrival of a fertilised ovum. If this does not happen the corpus luteum atrophies approximately
14 days later, the levels of oestrogen and progesterone fall and the endometrium is shed as
a period.
Developing ovarian follicles and the corpus luteum are visible on ultrasound examination
and are commonly referred to as cysts which indeed they are being fluid filled structures in
the former and occasionally similarly when there has been bleeding into the latter.
Occasionally ovulation does not take place and the lead follicle continues to grow in diameter.
In an asymptomatic woman with functioning ovaries the coincidental finding of ovarian
cysts up to 5cm in diameter does not warrant gynaecological referral.
Gynaecological Guidelines
Abdomino-pelvic Mass – Patient Pathway
Patient presentation
Abdomino-pelvic mass palpable or
found on ultrasound scan
Arrange
USS/TVS
GP
Adnexal/ovarian
cause. Check
Ca125
Assessment
Abnormal
Ca125 >30
Normal Ca125 <30
Fibroid on scan
Minimal or
no
symptoms
< 5cm in
diameter
GP
Partly cystic,
partly solid or
multilocular or
irregular
Unilateral or bilateral, cystic,
unilocular, smooth, regular
Menorrhagia
or pressure
symptoms
≥ 5cm in
diameter
If pain
present
Follow-up
scan in 4-6
months
Suspect
endometrioma
or
complications
to simple
ovarian cyst
Minimal or no
symptoms:
Pre-menopausal
with Ca125 <
30Ku/l
Especially if
ascites present
and/or Ca125
> 30Lu/l
Suspect simple
or functional
ovarian cyst
Suspect
ovarian cancer
regardless of
symptoms or
size
<5cm in
diameter
Reassure
≥ 5cm in
diameter
Urgent referral
2 weeks
Normal
finding
Refer to Gynaecology
Gynaecological Guidelines
Gynaecology
Six month’s history of secondary amenorrhoea – Patient
Pathway
Patient presentation
6 months history of secondary
amenorrhoea symptoms
GP
Exclude pregnancy
Assess:
History
Menstrual, sexual, contraceptive, medical,
drugs, psychiatric (including eating
disorders), diet, recent weight loss, stress,
travel, exercise
Check BMI
Blood tests
Wishes for pregnancy
For all:
FBC, TFT, FSH, LH, Oestradiol,
Prolactin, Free Androgen Index
(FAI), Testosterone, Sex hormone
binding globulin (SHBG)
Examination
BMI, hirsutism, severe acne
See overleaf for action
on results
Refer to Infertility
Pathway
Gynaecological Guidelines
Six month’s history of secondary amenorrhoea – Action
on results
All normal
Raised FSH and
LH
Reassure, offer
review in 3
months
Consider
menopause
Low FSH, LH,
low oestradiol,
raised prolactin
If PCOs
suspected, ie
raised LH/FSH
ratio, hirsuitism
and FAI >6
Weight loss if necessary. Consider
cosmetic advice for hirsuitism
If amenorrhoea
persists, repeat
all tests and
refer
Prolactin > 1000
? Prolactinoma.
Refer to
endocrinology
Gynaecology
Prolactin < 1000
TVS to confirm
PCOS
Repeat prolactin
(if 400-1000) and
give COCP
Needs
contraception:
COCP, POP or
intra-uterine or
implanted
progestogen-only
device
Hirsuitism/acne:
cyprotone and
ethinyloestradiol
combination or
COCP
Re-assess in 12
months
Amenorrhoea
Gynaecology
Gynaecological Guidelines
Care pathway for heavy menstrual bleeding
Patient presentation
Woman presenting
with HMB
TakeGP
history
Take full blood count
No structural or histological
abnormality suspected
Structural or histological
abnormality possible
Physical examination
Pharmaceutical
treatment (see table 1)
No abnormality/fibroids
<3cm diameter
Consider second
pharmaceutical
treatment if first
fails
Consider endometrial
biopsy for persistent intermenstrual bleeding, and in
women >45, treatment
failure or ineffective
Uterus is palpable
abdominally or pelvic
mass
Consider imaging,
first-line transvaginal
ultrasound
Consider physical
examination
Provide information to woman and
discuss treatment options
Severe impact on quality of
life, no desire to conceive,
normal uterus, ± small
fibroids (<3cm diameter)
Other treatments have
failed, are contraindicated
or declined
Severe impact on quality of
life
Fibroids (>3cm diameter)
Desire for amenorrhoea
Fully informed women
requests it
No desire to retain uterus
and fertility
Endometrial ablation
(see table 2)
Hysterectomy (see table 2)
(don’t remove healthy
ovaries)
Myomectomy
(see table 2)
Uterine artery
embolisation
(see table 2)
Gynaecological Guidelines
Pharmaceutical treatments proven to reduce menstrual bleeding1
Table 1
Discuss hormonal and non-hormonal options and provide time and support to help the
women decide which is the best option for her.
First line
Second
line
First line
How it works
ra
nt
Co
on Imp
a
f
c
e
tiv rtili t
ty
e?
?
ce
p
Potential unwanted outcomes
experienced by some woment4
Levonorgestrel-releasing
intrauterine system
(LNG-IUS)2, 3
Common: Indigestion; diarrhoea
Rare: Worsening of asthma in sensitive indivduals; peptic ulcer with
possible bleeding and peritonitis
Less common: Indigestion; diarrhoea; headache
Common: Irregular bleeding that may last for over 6 months; hormone
A device which slowly releases progestogen
related problems such as breast tenderness, acne or headaches (if present)
and prevents proliferation of the endometrium
Yes No
are minor and transitory.
Less common: Amenorrhoea
A physical examination is needed before
Rare: Uterine perforation at time of insertion
fitting
No
Oral antifibronolyctic tablets
No
No
Yes No
No
Oral tablets that prevent proliferation of the
endometrium
Common: Weight gain; bloating; breast tenderness; headaches; acne
Yes No (usually minor or transient)
Rare: Depression
Oral tablets that reduce production of
prostaglandin
Tranexamic acid
(non-hormonal)
Can be used in parallel with
investigations. If no
improvement stop treatment
after 3 cycles
Non-steroidal anti-inflammatory
drugs (NSAIDs)
(non-hormonal)
Can be used in parallel with
investigations. If no
improvement stop treatment
after 3 cycles
Oral tablets that prevent proliferation of the
endometrium
Common: Weight gain; irregular bleeding; amenorrhoea; premenstrual-like
Yes No syndrome (bloating,breast tenderness, fluid retention)
Less common: Loss of bone density
Common: Mood change; headache; nausea; fluid retention; breast
tenderness
Very Rare: DVT; stroke; heart attack
Intramuscular injection that prevents
proliferation of the endometrium
Preferred over tranexamic acid
in dysmenorrhoea
Combined oral contraceptives3
Injected progestogen2, 3
Injection that stops production of oestrogen
and progesterone
Third line Oral progestogen
(norethisterone)3
Gonadtrophin-releasing
hormone (Gn-RH analogue)
The evidence for effectiveness can be found in the full guideline
Other
1
Check the Summary of Product Characteristics for current licenced indications. Informed consent is needed when using outside licensed indications
Common: Menopausal-like syndrome (hot flushes, increased sweating,
vaginal dryness)
No Less common: Osteoporosis, particularly trabecular bone with use longer
than 6 months
2
See WHO ‘Pharmaceutical eligibility criteria for contraceptive use’ (WHOMEC), www.ffprhc.org.uk/admin/uploads/298_200506.pdf
No
3
Common: 1 in 100 chance; less common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance
If used for more than 6 months
add-back HRT therapy is
recommended
4
Gynaecological Guidelines
Continued overleaf
Surgical removal
of the fibroids
using a
hysteroscope
Hysteroscopic
myomectomy
Fertility is
potentially
retained
Fertility is
potentially
retained
Small particles are
injected into the
blood vessels that
take blood to the
uterus. The blood
supply to the
fibroids is blocked,
causing them to
shrink
Uterine artery
embolisation
(UAE)
Fibroids (>3cm
diameter) +
severe impact on
quality of life
Consider as first
line if there are
other significant
symptoms, pain or
pressure
Recommended for
women who want
to retain uterus +/avoid surgery
Fibroids (>3 cm
diameter) +
Severe impact on
quality of life
Recommended for
women who want
to retain uterus
Yes
How it works
Endometrial
Destroys the
ablation
womb lining
Second generation
impedance
controlled
bipolar radio
frequency
balloon thermal
microwave
free fluid thermal
First generation
rollerball
transcervical
resection of
endometrium
Type of surgery
Severe impact on
quality of life + no
desire to conceive
+ normal uterus
+/- small fibroids
(<3cm diameter)
Consider as first
line only after full
discussion of risks
and benefits
Preferable to
hysterectomy if
uterus no bigger
than 10-week
pregnancy
Indication
Impact
on future
fertility?
Discuss impact on fertility
Consider pretreatment with
Gn-RH analogue
Following with a first
generation ablation technique
is appropriate
Discuss impact on fertility
Discuss impact on fertility
Use second generation
technique in women with no
structural or histological
abnormality
Advise use of effective
contraception following this
procedure
Other considerations
Less common: Adhesions (which may lead to
pain and/or impaired fertility); need for additional
surgery; perforation; recurrence of fibroids;
infection
Rare: Haemorrhage
Common: Persisent vaginal discharge;
post-embolisation syndrome (pain, nausea,
vomiting, fever – not involving hospitalisation)
Less common: Need for additional surgery;
premature ovarian failure particularly in women
>45; haematoma
Rare: Haemorrhage; non-target embolisation
causing tissue necrosis; infection causing
septicaemia
Common: Vaginal discharge; increased period
pain or cramping (even if no further bleeding);
need for additional surgery
Less common: Infection
Rare: perforation (very rare with second
generation techniques.
Potential unwanted outcomes
experienced by some woment5
Table 2
Surgical and radiological treatment options for women whose
quality of life is severely impacted
Provide information to the woman before her outpatient appointment.
Gynaecological Guidelines
Table 2 (cont) Surgical and radiological treatment options for
women whose quality of life is severely impacted
Provide information to the woman before her outpatient appointment.
5
Indication
Fibroids (>3cm
diameter) +
Severe impact on
quality of life
Fibroids (>3cm
diameter) +
Severe impact on
quality of life
Not first line,
solely for HMB.
Consider when:
Other
treatments have
failed,
contraindicated
or declined
Desire for
amenorrhoea
Fully informed
woman
requests it
No desire to
retain uterus or
fertility
Type of surgery
Myomectomy
Hysterectomy
Decide route
based on
individual
assessment
First line: vaginal
Second line:
abdominal
Do not remove
healthy ovaries
Hysterectomy
Decide route
based on
individual
assessment
First line: vaginal
Second line:
abdominal
Consider
laparoscopic
vaginal
hysterectomy in
morbidly obese/
oophorectomy
Do not remove
healthy ovaries
Discuss impact on fertility
Consider pretreatment with
Gn-RH analogue
Other considerations
Fertility is
potentially
retained
Impact
on future
fertility?
Surgical removal
of the fibroids
Yes
Discuss impact on sexual
feelings, fertility, bladder
function, psychology
Discuss complications,
expectations, alternatives
Consider pretreatment with
Gn-RH analogue
Discuss increased risk in
women with fibroids
Discuss total and subtotal
methods in abdominal surgery
If considering oophorectomy,
discuss impact on wellbeing
If concerned discuss risks and
benefits with woman. offer
genetic counselling
How it works
Surgical removal
of the uterus
Ovaries may also
be removed
(oophorectomy)
Yes
Surgical removal
of the uterus
Ovaries may also
be removed
(oophorectomy)
Discuss impact on sexual
feelings, fertility, bladder
function, psychology
Discuss complications,
expectations, alternatives
Consider pretreatment with
Gn-RH analogue
Discuss increased risk in
women with fibroids
Discuss total and subtotal
methods in abdominal surgery
If considering oophorectomy,
discuss impact on wellbeing
If concerned discuss risks and
benefits with woman. offer
genetic counselling
Common: 1 in 100 chance; less common: 1 in 1000 chance; rare: 1 in 10,000 chance; very rare: 1 in 100,000 chance
Potential unwanted outcomes
experienced by some woment5
Less common: Vaginal discharge; increased
period pain or cramping (even if no further
bleeding); need for additional surgery; recurrence
of fibroids; infection. Rare: Haemorrhage
Common: Infection
Less common: Intraoperative haemorrhage;
damage to other abdominal organs eg urinary
tract or bowel; urinary tract dysfunction – frequent
passing of urine or incontinence
Rare: Thrombosis (DVT and clot on lung
Very rare: Death
With oophorectomy at time of hysterectomy
Common: Menopausal-like sumptoms
Common: Infection
Less common: Intraoperative haemorrhage;
damage to other abdominal organs eg urinary
tract or bowel; urinary tract dysfunction – frequent
passing of urine or incontinence
Rare: Thrombosis (DVT and clot on lung
Very rare: Death
With oophorectomy at time of hysterectomy
Common: Menopausal-like sumptoms
Gynaecological Guidelines