Gynaecology and breast health

Publication date: 01 August 2025

This topic guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to gynaecology and breast health by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development (CPD), including guidance on the knowledge relevant to this area of general practice.

Each topic guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other topic guides and educational resources.

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

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?

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.