Gynaecology - public patients

Essential information (Referral will be declined without this)

• General referral information
• History of:
  • Any abnormal bleeding (i.e. post-coital and intermenstrual) or abnormal discharge
  • Previous abnormal cervical screening
  • Immunosuppressive therapy
• Medical management to date
• Most recent and current cervical screening (LBC should be performed on any sample with positive oncogenic HPV)

Additional referral information (useful for processing the referral)

• BMI
• HPV vaccination history
• STI screen result endocervical swab or first catch urine for chlamydia +/- gonorrhea NAA
• History of smoking

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines
• Women who are in follow-up for pLSIL / LSIL in cytology in the previous program (pre-renewal NCSP) should have a HPV test at their next scheduled follow-up appointment
  • If oncogenic HPV is not detected, the women can return to 5-yearly screening
  • If any HPV is detected, the woman should be referred for colposcopic assessment
• A single cervical screening test may be considered for women between the ages of 20 and 24 years who experience their first sexual activity at a young age (e.g. before 14 years) who have not recieved the HPV vaccine before sexual activity commenced
• Adolescent patients with abnormal HPV should follow the same pathway as adult patients. Patients <25 years old should also have screening for STI as they are a high-risk group.
• Consider using oestrogen cream +/- liquid cytology in post-menopausal women
• Patients with positive non-16/18 but normal or LSIL on LBC would not need referral and only a repeat CST in 12 months 
• Recall women in 6-12 weeks if they have an unsatisfactory screening report
• Specific efforts should be made to provide screening for Aboriginal and Torres Strait Islander women. They should be invited and encouraged to participate in the NCSP and have a 5-yearly HPV test, as recommended for all Australian women
• Women who have been treated for HSIL (CIN2/3) do not need a post-treatment colposcopy. These women should have a co-test (HPV and LBC test) performed at 12 months after treatment, and annually thereafter, until she receives a negative co-test on two consecutive occasions, when she can return to routine 5 yearly screening. This is called ‘test of cure’.
• If, at any time post treatment, the woman has a positive oncogenic HPV (16/18) test result, she should be referred for colposcopic assessment (regardless of the reflex LBC result).
• If, at any time during Test of Cure, the woman has a LBC prediction of pHSIL/HSIL or any glandular abnormality, irrespective of HPV status, she should be referred for colposcopic assessment.

Clinical resources

• National Cervical Screening Program - Guidelines

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General referral information
• Findings of speculum examination
• Current cervical screening
• Pelvic USS (TVS preferable)

Additional referral information (useful for processing the referral)

• BMI
• HRT use

Other useful information for management (not an exhaustive list)

• Small endocervical polyps (<2cm) in premenopausal women with normal cervical screening can be avulsed and sent for histology
• Cervical polyps in post-menopausal women have a higher risk of malignancy
• Refer to Healthpathways or local guidelines

Categorisation 

Essential information (Referral will be declined without this)

• General referral information
• History of:
  • Nature of the pain – location, intermittent or persistent
  • General body muscle tensing and general or focal pelvic floor muscle tension before and during attempts at penetration
  • Medical, surgical and obstetric history
• Pelvic USS results (TVS preferable)

Additional referral information (useful for processing the referral)

• BMI
• STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhea NAA
• HVS M/C/S and viral PCR result
• Previous CST result (if within last 5 years)

Other useful information for management (not an exhaustive list)

• Advise using lubricant and adequate foreplay prior to intercourse
• Refer to Healthpathways or local guidelines.
• For superficial dyspareunia: (consider referral to women’s health physiotherapist)
  • breast feeding women – consider topical oestrogen
  • consider vaginismus and referral to a sexual medicine service
  • consider psychosocial issues and referral for counselling

Clinical resources 

• Sexual health services Queensland

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General referral information
• History of:
  • Symptoms
  • Heavy menstrual Bleeding (HMB), brief description of periods, medical management to date
  • Dragging sensation
  • Urinary frequency
• Most recent or current cervical screening
• FBC iron studies results
• Pelvic USS (TVS preferable)

Additional referral information (useful for processing the referral)

• BMI

Other useful information for management (not an exhaustive list)

• If asymptomatic (e.g normal menstrual pattern, normal Hb, post menopausal) there is no need for referral
• Refer to Healthpathways or local guidelines

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information (Referral will be declined without this)

• General referral information
• Brief description of periods
• Medical management to date
• Current cervical screening
• FBC Serum ferritin results
• Pelvic USS (TVS preferable)
• Adolescent patient - Coag profile including von Willebrand's disease (vWD)

Additional referral information (useful for processing the referral)

• BMI
• TSH if symptomatic of thyroid disease
• Previous management modalities, iron utilisation if deficient.

Other useful information for management (not an exhaustive list)

• A woman with heavy menstrual bleeding is referred for early specialist review when there is a suspicion of malignancy or other significant pathology based on clinical assessment or ultrasound. Read Clinical Care Standard.
• Consider increased risk of hyperplasia or malignancy if: 
  • Endometrial thickness greater than 12mm (transvaginal USS ideally day 4-7)
  • Irregular endometrium or focal lesion
  • Weight >90kg
  • PCOS / diabetes / unopposed oestrogen
  • Age >45yrs
  • Intermenstrual or post-coital bleeding
• Medical treatment prior to or while waiting for specialist review if no suspicion of malignancy:
  • Progesterone releasing IUD
  • Tranexamic acid
  • OCP
  • NSAIDS
  • Oral progestogens

• Referral is also arranged for a woman who has not responded after six months of medical treatment.

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
  • History of:
    • Previous pregnancies, STIs and PID, surgery, endometriosis
    • Other medical conditions
  • Include the following information about partner
    • age and health, reproductive history, testicular conditions, semen analysis
  • Weight/ BMI
  • STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhea NAA 
  • FBC group and antibodies rubella IgG varicella IgG, syphillis serology, HBV/HCV/HIV serology results
  • FSH, LH (Day 2-5), prolactin, TSH if cycle prolonged and/or irregular
  • Anti-mullerian hormone (AMH)
  • Pelvic USS (TVS preferable)
  • If PCOS is suspected include the following:
    • Free androgen index (FAI) or Free Testosterone
    • Fasting blood glucose result
    • Lipids, TSH results

Infertility – additional Essential Referral Information

• Day 21 serum progesterone level (7 days before the next expected period)

First trimester RPL – additional Essential Referral Information 

• Thrombophilia screen, antiphospholipid syndrome (APS)
• Autoimmune screen
  • Coeliac serology – serum deamidated gliadin peptide (DGP), tTG Ab
  • Antinuclear antibodies (ANA) only if personal or family history indicates higher risk of autoimmune disease
• Karyotype for both parents
• Second trimester RPL – additional Essential Referral Information
  • Hysterosalpingogram (HSG) or hystero-sonogram
  • US with cervical length 

Additional referral information (useful for processing the referral)

• History of marijuana use (including partner)
• Fasting blood glucose, testosterone and free androgen index test for those likely to have PCOS
• Hysterosalpingography (HSG) or saline infusion USS (sonohysterography)

Other useful information for management (not an exhaustive list)

• IVF not available in Mater public hospitals
• Refer to HealthPathways and or local guidelines
• Treatment is as a couple and requires a partner referral
• To assess tubal patency, consider Hysterosalpingography (HSG) or saline infusion USS (sonohysterography) if history suggestive of blocked fallopian tubes
• Seminal analysis of partner (≥4 days of abstinence). Repeat in 4-6 weeks if abnormal.
• Lifestyle modification (increased activity, dietary, weight, smoking, alcohol)
  • simple moderate physical activity including structured exercise (at least 30 minutes/day) and optimising incidental exercise with weight loss and weight maintenance
  • achieve optimal weight BMI 20 – 30
  • referral to dietitian
• Infertility: folic Acid 0.5mg/day
• RPL: Definition ≥ Three (3) CONSECUTIVE miscarriages (excluding chemical miscarriages) as documented by ultrasonography or histopathologic examination. Second trimester miscarriages are considered more significant. Two (2) would be an indication for further investigation.

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• History of abnormal bleeding / hormonal contraceptive use
• Recent co-test result (HPV and LBC)
• HVS result
• BHCG result
• STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA
• Pelvic USS (TVS preferable)
  

Additional referral information (useful for processing the referral)

• BMI

Other useful information for management (not an exhaustive list)

• Refer to local Healthpathways or local guidelines

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Medical management to date/surgical history
• History of pain and menstrual diary
• Symptoms:
  • Dysmenorrhoea
  • Deep dyspareunia
  • Dyschezia
• History of sub-fertility
• Pelvic USS results (TVS preferable) if available

Additional referral information (useful for processing the referral)

• BMI
• Menstrual diary (if available)

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Medical history - relevant family, menstrual, obstetric, contraceptive, and brief sexual history or history of STDS
• Most recent or current cervical screening
• Mirena® prescription – at Mater Hospital the referring GP does not need to provide a prescription for the device, nor is the patient required to bring the device with her to the clinic. The gynaecology clinic stocks and supplies Mirena devices according to usual PBS arrangements.

Additional referral information (useful for processing the referral)

• BMI
• Pelvic USS if lost strings, HMB or other clinical indication
• STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA

Other useful information for management (not an exhaustive list)

• Mirena® prescription to be supplied by referring GP. Patient must bring the device with her to the clinic
• For paediatric and adolescent gynaecology patients please refer to statewide paediatric and adolescent gynaecology (SPAG) services at Queensland Children's Hospital/RBWH
• Where available for the routine removal or insertion of Mirena®/progesterone releasing IUD please consider referral to True – relationships and reproductive health (formerly known as Family Planning Queensland) or a Women’s Health speciality primary care provider who may be able to provide this service in their own clinic.

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• History including pain and other symptoms
• CA125 results
• Pelvic USS (TVS preferable)

Additional referral information (useful for processing the referral)

• BMI
• Family history of breast and ovarian cancer
• ROMA score in premenopausal women with elevated CA125
• In paediatric and adolescent patients, remember to exclude germ cell tumours with markers: alpha feto protein LDH BHCG along with the other tumour markers

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines
• ROMA score in premenopausal women with elevated CA125 would be beneficial to have at the time of the referral.  However, this may incur an out-of-pocket cost to the patient.
• If cyst simple or haemorrhagic corpus luteal cyst and <5 cm repeat scan in 6 – 12 weeks
• If recurrent cysts, consider COCP or Implanon®

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Obstetric and gynaecological history
• History of:
  • Prolapse symptoms
  • Protruding lump
  • Dragging sensation
  • Difficulty with defecation (requiring manual evacuation) / micturition including incontinence
• MSU M/C/S results

Additional referral information (useful for processing the referral)

• BMI
• Previous failed or complicated prolapse surgery
• Pelvic USS (TVS preferable) if available
• Bladder diary
• Renal USS if major uterine procidenta

Other useful information for management (not an exhaustive list)

• Refer to HealthPathways and or local guidelines
• Patients with chronic pelvic pain following mesh procedures can be referred to the Queensland Pelvic Mesh Service (QPMS) for assessment, this service offers comprehensive, interdisciplinary assessment and treatment for women with complications from pelvic mesh.
  • Further information is available on the Qld Health website
  • Queensland Pelvic Mesh Service (QPMS) website
  • Clinical resources
  • QPMS Referral form
  • Patient resources
  • Consider referral to women’s health physiotherapist for the following:
    • Prolapse – consider pessary
    • Stress incontinence – physiotherapist for pelvic floor exercises and bladder retraining for 3 months prior to referral
    • Urinary urgency - exclude infection
  • Consider trial of anticholinergics
  • Treat constipation
  • Consider topical oestrogen in post-menopausal women
  • Lifestyle modification (Increased activity, dietary, weight, smoking, alcohol)
  • The ACSQHC information on stress urinary incontinence and pelvic organ prolapse

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• History of/to:
  • Pain, severity and duration, cyclical nature, dysmenorrhea
  • Differentiate from GI pain
  • Previous sexual abuse, PID
  • Medical management to date
• Most recent or current cervical screening
• HVS result
• STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhea NAA
• MSU M/C/S result
• Pelvic USS (TVS preferable) if available

Additional referral information (useful for processing the referral)

• BMI

Other useful information for management (not an exhaustive list)

• Refer to local Healthpathways or local guidelines
• Medical management
  • Important to exclude cyclical bladder, bowel symptoms
  • Treat infection if present
  • Simple analgesia
  • Suppress menstrual cycle with oral contraceptive pill / implanon® / depo-provera / mirena®
  • Treat dysmenorrhoea with NSAIDS or COCP

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Pelvic ultrasound (incl. TVS)
• Day 21 Progesterone (D21P)
• SHBG results
• Free Testosterone (FAI), DHEA-S results
• Fasting blood glucose results
• Lipids, TSH results

If problems with sub fertility:

• History of:
  • Previous pregnancies, STDs and PID, surgery, endometriosis
  • Other medical conditions
• Include the following information about partner
  • Age and health, reproductive history, testicular conditions
• Weight/ BMI
• FBC Group and antibodies Rubella IgG Varicella IgG, Syphilis Serology, HBV/HCV/HIV serology results
• Day 21 serum progesterone level (7 days before the next expected period)
• FSH, LH (Day 2-5), Prolactin, TSH if cycle prolonged and/or irregular
• STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhea NAA
• Partner semen analysis result
• Pelvic USS (TVS preferable on day 5-10)

Additional referral information (useful for processing the referral)

• Ensure BMI sent as essential information above

Other useful information for management (not an exhaustive list)

• Psychological features need to be screened for, acknowledged, discussed and counselling considered, to improve quality of life in PCOS and to facilitate effective and sustainable lifestyle change  consideration of depression and/or anxiety and appropriate management
• Emphasis on healthy lifestyle, with targeted medical therapy where indicated
• Lifestyle modification (increased activity, dietary, weight, smoking, alcohol)
  • Simple moderate physical activity including structured exercise (at least 30 minutes/day) and optimising incidental exercise assists with weight loss and weight maintenance
  • Achieve optimal weight BMI 20 – 30
  • Referral to dietitian

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Findings of speculum examination
• Recent co-test result (HPV and LBC)
• HVS result
• Sexual health history
• STI screen result - endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA

Additional referral information (useful for processing the referral)

• BMI
• Pelvic USS (TVS preferable)
• Contraceptive use

Other useful information for management (not an exhaustive list)

• Refer to local Healthpathways or local guidelines
• Pre-menopausal women who have a single episode of post-coital bleeding and a clinically normal cervix do not need to be reported if oncogenic HPV is not detected and LBC is negative

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• History of HRT use
• Recent co-test result (HPV and LBC)
• Pelvic USS (TVS preferable)

Additional referral information (useful for processing the referral)

• BMI

Other useful information for management (not an exhaustive list)

• Refer to local Healthpathways or local guidelines
• Postmenopausal women with an incidental finding on pelvic ultrasound of a regular endometrial thickness of less than 11mm and having no episodes of postmenopausal bleeding would only need a repeat ultrasound and referral if developing vaginal bleeding

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Duration of amenorrhoea (i.e. >6 months)
• Weight/ BMI
• BHCG results
• FSH LH prolactin oestradiol TSH results
• TAS-TVS USS may not be appropriate in non-sexually active females, therefore important to seek early advice from statewide paediatric and adolescent gynaecology (SPAG) services

Additional referral information (useful for processing the referral)

• BMI
• Renal USS 

Other useful information for management (not an exhaustive list)

• Primary amenorrhoea – is defined as the absence of menses at age 16 years in the presence of normal growth and secondary sexual characteristics and 14 in the absence of secondary sexual characteristics
• Secondary amenorrhoea – absence of menses for more than six months after the onset of menses
• Refer to Statewide Paediatric and Adolescent Gynaecology Services (SPAG) services at Queensland Children's Hospital/RBWH
• Address excessive exercise or dieting
• If BMI is greater than 30, manage weight loss
• Address any significant stress or anxiety
• Review medications if relevant (e.g. antipsychotics, metoclopramide)
• Cyclical abdominal pain in adolescent with primary amenorrhoea might be indication of imperforate hymen

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• History of:
  • Pain, swelling
  • Pruritus
  • Dyspareunia
  • Localised lesions (pigmented or non-pigmented lesions)
  • STIs or other vaginal infections
  • Local trauma
• Elicit onset, duration and course of presenting symptoms
• Date of last menstrual period
• Medical management to date
• Cervical screening if referral for warts

Additional referral information (useful for processing the referral)

• BMI
• Vulva ulcers – swab M/C/S and viral PCR result
• Vulval rashes – scraping, swaps or biopsy (as appropriate)
• STI screen result -endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA (as appropriate)
• Syphillis HIV serology (as appropriate)

Other useful information for management (not an exhaustive list)

• For or paediatric and adolescent gynaecology patients, please refer to Statewide paediatric and adolescent gynaecology (SPAG) services at Queensland Children's Hospital/RBWH
  • <14 years refer to Queensland Children's Hospital
  • >14 years refer to RBWH or local adolescent gyane service
• Antibiotic treatment of Bartholins cyst is of no value.
• In women where a vulval cancer is strongly suspected on examination, urgent referral should not await biopsy
• Vulval cancers may present as unexplained lumps, bleeding from ulceration or pain.
• Vulval cancer may also present with pruritus or pain. For a patient who presents with these symptoms and where cancer is not immediately suspected, it is reasonable to use a period of ‘treat, watch and wait’ as a method of management. However, this should include active follow-up until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Confirmation that the Implanon is insitu
• Ultrasound +/- X-ray prior to referral 

Additional referral information (useful for processing the referral)

• No additional referral information

Other useful information for management (not an exhaustive list)

• Refer to local Healthpathways or local guidelines
• In some facilities, the referral maybe referred to the Medical Imaging Department where the procedure is performed under ultrasound guidance (or alternative imaging) by interventional radiologist, or this can be managed in True clinic (with experienced practitioners removing deep but palpable implants)
• Non-palpable implant should be located.  If palpation of the Implanon implant is not successful, an ultrasound may be arranged for definitive localisation. MRI, X-ray, and CT scan provide further tools for implant localisation.

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

Essential information (Referral will be declined without this)

• General referral information
• Relevant condition information
• Relevant pathology and imaging reports

Categorisation
Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access. 

The following conditions are not routinely provided at Mater Hospital Brisbane:

• Elective cosmetic surgery e.g. labiaplasty
  • NB labial hypertrophy in paediatric and adolescent patients: refer to Statewide Paediatric and Adolescent Gynaecology Services (SPAG) at QCH/RBWH.
• Tubal ligation (including reversal of tubal ligation)
  • Termination of pregnancy
• Contraception
  • Contraceptive Advice
  • Contraception e.g. Implanon
  • Routine Mirena®/ progesterone-releasing IUD insertion for contraception
  • Elective Termination of Pregnancy
• Screening Pap Smears
• Primary menopausal care
• Postnatal check-up
• IVF services