The role of the GP in gynaecology and breast health
As a GP, your role is to:
- understand the impact of gynaecological problems on a woman’s life and that some women will find these issues difficult to discuss
- opportunistically promote women’s health, such as breast and cervical screening, and during pregnancy
- manage gynaecological problems in primary care
- be aware of presentations and issues relating to women’s cancers
- be alert to safeguarding issues in relation to women’s health, including female genital mutilation (FGM)
- be aware that men may also experience breast disorders.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs
Breast
- Breast development and abnormalities of development
- Breast lumps (men and women)
- Breast skin changes
- Gynaecomastia
- Mastalgia
- Nipple changes
Pelvic
- Bleeding symptoms:
- menstrual bleeding problems such as amenorrhoea, menorrhagia, oligomenorrhoea and polymenorrhoea
- non-menstrual vaginal bleeding including intermenstrual and post-coital bleeding
- postmenopausal bleeding
- Other pelvic symptoms and signs:
- continence problems (urinary and faecal)
- pelvic and abdominal masses
- pelvic and abdominal pain
- vaginal discharge and vaginal dryness
- vaginal swellings and prolapse symptoms
- vulval pain, lump, irritation, ulceration, pigmentation, leucoplakia and other vulval skin lesions
Other
- Menopause and perimenopause physical and psychological symptoms including, but not limited to, bleeding disturbances, hot flushes, night sweats, psychological symptoms and urogenital symptoms
- Non-specific symptoms that could be consistent with ovarian cancer such as abdominal distension, ascites, bloating, early satiety, new onset irritable bowel syndrome symptoms in women over 50, urinary symptoms, weight loss.
(Urinary symptoms such as dysuria and haematuria are covered in the Renal and urology topic guide. Sexual health symptoms are covered in the Sexual health topic guide. Symptoms relating to pregnancy and reproductive health are covered in the Maternity and reproductive health topic guide.)
Common and important conditions
Breast
- Benign breast conditions including eczema, infection (mastitis, breast abscess), lumps (cysts, fibroadenoma) and mastalgia
- Breastfeeding, including common problems
- Malignant breast conditions, including carcinoma in situ, invasive ductal and lobular carcinomas, Paget’s disease of the nipple and secondary malignancy such as lymphoma, including awareness of treatment (surgery, radiotherapy, hormonal) and its complications
- Surgery (including potential complications) for breast reconstruction, breast enlargement or implants and breast reduction
Pelvic
- Bleeding problems (which may have a pelvic or extra-pelvic cause):
- amenorrhoea (primary and secondary), oligomenorrhoea, polymenorrhoea, irregular menstrual cycles and anovulatory cycles
- medication-induced bleeding problems (including secondary to hormonal contraceptives)
- menstrual problems, including menorrhagia, dysmenorrhoea (primary and secondary), dysfunctional uterine bleeding
- intermenstrual bleeding
- post-coital bleeding
- postmenopausal bleeding
- Pelvic pain
- Ovarian:
- benign ovarian swellings, including ovarian cysts and dermoid cysts
- ovarian cancer, including adenocarcinoma and teratoma
- polycystic ovary syndrome: gynaecological aspects and associated metabolic disorders such as insulin resistance and obesity, and symptoms such as acne and hirsutism
- Uterine:
- endometrial polyps, hyperplasia and cancer
- endometriosis and adenomyosis
- fibroids
- prolapse, including cystocele and rectocele
- Cervical:
- cancer, cervical intraepithelial neoplasia (CIN), dysplasia, ectropion and polyps
- Vulvo-vaginal:
- FGM, including legal aspects and cosmetic genital surgery
- malignancy, including vulval intraepithelial neoplasia (VIN) and melanoma
- skin disorders such as lichen sclerosus, psoriasis, intertrigo, pigmented lesions and genital warts
- vaginal discharge, including infectious causes such as candida, bacterial vaginosis and sexually transmitted infections (STIs). These are also covered in the Sexual health topic guide
- vulval pain with causes such as atrophic changes, Bartholin’s problems, dysesthesia and vulvodynia
- (Urinary conditions, including incontinence, are covered in the Renal and urology topic guide)
Fertility
- Infertility and subfertility – causes and investigations:
- male factors, including impaired sperm production and delivery (such as drug-induced, cystic fibrosis)
- female factors, including ovulatory disorders, tubal disorders, uterine disorders and genetic causes
- Principles of assisted conception with knowledge of associated investigations
- Recurrent miscarriage
Other
- Premenstrual disorders, including premenstrual syndrome and premenstrual dysphoric disorder
- Menopause:
- menopause and perimenopause, including premature ovarian insufficiency
- systemic symptoms such as skin changes, hot flushes and psychological symptoms
- treatment options, including hormone replacement therapy (HRT) and alternatives to HRT; role of testosterone therapy
- urogenital aspects including atrophic vaginitis
- wider health issues associated with menopause, including increased cardiovascular risk, mental health symptoms and osteoporosis
(STIs, pelvic inflammatory disease (PID), dyspareunia and pregnancy (including miscarriage and ectopic pregnancy) are covered in the Sexual health and Maternity and reproductive health topic guides. Urinary problems are covered in the Renal and urology guide.)
Examinations and procedures
- Abdominal assessment for ascites, distension and masses
- Bimanual pelvic examination
- Breast examination
- Obtaining informed consent for breast examination, vaginal examination and speculum examination, including use of chaperones where appropriate
- Speculum examination, including appropriate choice of size
- Vaginal and endocervical swabs
- Vulval examination
Investigations
- Blood tests, including CA125, full blood count and hormone profiles (including for investigation of subfertility)
- Cervical cytology tests
- Vaginal and cervical swabs
- Semen analysis
- Ultrasound – abdominal and pelvic ultrasound, including transvaginal scans
- Breast imaging, including mammography, magnetic resonance imaging (MRI) and ultrasound
- Common secondary care gynaecological investigations, including colposcopy, hysteroscopy and laparoscopy
Service issues
- Emotional and organisational support structures and techniques to deal with the psychosocial aspects of women’s health (for example, in relation to pelvic pain, menopause, and breast and gynaecological cancers)
- Human papillomavirus (HPV) vaccination programme
- Local service provision and pathways for suspected malignancy, including one-stop clinics
- Practical and legal aspects around FGM, including reporting mechanisms, safeguarding concerns and protecting girls at risk of FGM
- Safeguarding issues that may present through gynaecological concerns
Other important content
- Aftercare of women who have had gynaecological or breast surgery and radiotherapy, including long-term effects of treatment and risk of cancer recurrence
- Gynaecological issues in transgender patients. Transgender issues are covered more fully in the Sexual health and Equality, diversity and inclusion topic guides
- The physiological and hormonal changes of the menstrual cycle
- Genetic mutations related to breast and gynaecological malignancy, including BRCA, and indications for referral for genetic counselling
- Screening programmes for cervical and breast cancer, including practicalities, benefits, risks, interpretation of results, non-participation and strategies to promote uptake
- Provision of these screening programmes to the transgender population
Case discussion
Jackie Johnson is a 48-year-old woman who comes to see you about some irregular vaginal bleeding. She attends with her four-year-old granddaughter Kylie, who she is caring for because Kylie's mother is currently in prison for drug-related offences. Jackie admits she has not paid much attention to her own health lately owing to her chaotic family situation. She has been too busy caring for Kylie and visiting her daughter in prison to attend the GP surgery any earlier.
She reports having some pink-coloured vaginal discharge for around six months before more recently developing irregular vaginal bleeding, which is becoming more frequent. She has not had a cervical screening test for over 15 years and on examination you find an irregular, ulcerated area on the cervix. You explain your findings and agree with her that you will refer her to gynaecology on a suspected cancer pathway.
Jackie is diagnosed with a stage 1b cervical squamous carcinoma. She has a hysterectomy and subsequent chemoradiotherapy. At a subsequent GP review Jackie describes how the hospital admission, post-operative recovery period and subsequent daily outpatient visits for radiotherapy make it even more difficult for her to look after her granddaughter. Jackie is not keen on any further help at home as she fears social services will take her granddaughter away, but she agrees that you could ask the health visitors to see what support they can offer.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do I feel when a patient’s neglect of their own health may have contributed to a condition? For example, in this case Jackie is a smoker and has not attended for cervical screening? |
An ethical approach This is about practicing ethically with integrity and respect for equality and diversity. | What ethical dilemmas does this case present? What tensions do I see between the scientific, political and patient-centred aspects of cervical screening? What safeguarding concerns are raised by this scenario? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How would I negotiate with a patient who is reluctant to accept help I feel is needed from social services or other agencies? How good am I at explaining the risks and benefits of a screening test to my patients? What about explaining the results of abnormal smear tests to a patient? What communication strategies can I employ when ‘breaking bad news’ in a situation such as this? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What are the risk factors in Jackie’s history that might suggest a diagnosis of malignancy? What factors (for example, patient, doctor, clinical findings, guidelines) would influence which further investigations to perform and the urgency of these investigations in a woman presenting with vaginal bleeding? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How confident am I in carrying out a speculum examination and a smear test, and being able to differentiate between a healthy cervix, common minor changes or serious pathologies? What other examinations and procedures could I consider performing in general practice? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | If Jackie’s cervix had been normal, what would have been my next step? How do I make decisions about whether a child is safe? Who could I speak to for further advice? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | Do I know the ‘red flag’ symptoms that require urgent referral for suspected gynaecological cancer? Abnormal cervical cytology and cervical cancer are often related to sexually transmitted HPV– how do I explore the risk of other STIs, including human immunodeficiency virus (HIV), in this case? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | When supporting a patient with a serious illness how do I appropriately introduce ongoing health promotion and advice? What steps would I take to understand the impact of this illness on the patient’s family? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What are the local arrangements for administering the HPV vaccine? What systems are in place to identify vulnerable families in the practice where I work? Do I have a good awareness of other agencies that might be helpful in this case? How might we be able to support Jackie as she cares for her granddaughter? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What is my plan for maintaining and updating my knowledge base in women’s health? How do I ensure that my cervical smear taking skills are adequate? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What is the protocol in my practice for calling, recalling and following up patients who attend and do not attend (DNA) for smears? How does the practice record the family relationships? What are the potential safeguarding issues related to record-keeping in this family? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | As the GP for more than one generation of a family, how do I balance their health and social care needs? In patients who are diagnosed with cancer, how do I acknowledge their fears and concerns in the consultation? How could we increase cervical smear uptake? What are the barriers to increased uptake? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What relevant social care assistance and support groups are available to patients in my area? How do we deliver primary care services to ‘chaotic’ and marginalised groups in society? How does the ‘inverse care law’ apply? |
How to learn this area of practice
Work-based learning
GP registrars should take the opportunity to attend outpatient clinics in specialties directly relevant to this area of health, such as general and emergency gynaecology clinics, one-stop clinics for suspected cancer, and breast clinics and community gynaecology clinics.
Self-directed learning
There are many online and clinical courses for GP registrars on breast and gynaecological health issues to supplement their local programmes and to ensure that those GP registrars who have not passed through a hospital-based placement in breast surgery or gynaecology are made aware of current management of these problems. You can find eLearning module(s) relevant to this topic guide at eLearning for healthcare and on the RCGP eLearning website.
The RCGP Women’s Health Library is a collection of educational resources and guidelines relevant to GPs and developed in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG) and Faculty of Sexual and Reproductive Healthcare (FSRH). The RCGP also offers a women’s health toolkit.
The RCOG offers the DRCOG diploma examination particularly aimed at GPs. Details are on its website. Other organisations providing useful online resources in this area include the Primary Care Women’s Health Forum, the British Menopause Society and Menopause Matters.
Learning with other healthcare professionals
Gynaecological and breast health problems, by their nature, are often exemplars of teamwork across agencies. Joint sessions with nursing colleagues provide you with multidisciplinary opportunities for learning about the wider aspects of these areas of healthcare provision, in both primary and secondary care. You should also find it fruitful to consider and discuss the roles of the various individuals who represent the many professional and non-professional groups involved in these areas of healthcare.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Symptom management through reproductive stages, for example, menopause, fertility and menstrual issues
- Recognition of red flag breast and gynaecological symptoms
- Differential diagnosis of pelvic pain
Simulated Consultation Assessment (SCA)
- A woman has a breast lump (silicone model provided for the examination)
- A woman from Somalia with a history of FGM has concerns about family pressure to submit her daughter to the same
- Phone call: a young woman wants to discuss her cervical smear result, which shows borderline dyskaryosis (HPV negative)
Workplace-based Assessment (WPBA)
- Observation of a pelvic examination for a woman with unexplained vaginal bleeding
- Consultation Observation Tool (COT) on an 80-year-old patient who ends the consultation saying she is bleeding
- Case-based Discussion (CbD) about a private gynaecologist’s request that you prescribe high-dose oestrogen preparations when you disagree with the consultant’s diagnosis and management plan
- Statutory clinical observation and procedural skills (CEPS) assessment of female genital examination