All women with postmenopausal bleeding should be referred urgently. Endometrial cancer is present in approximately 10% of cases. First-line investigation is a transvaginal ultrasound scan. A normal TVUS is reassuring, and if examination is normal further investigation is not required, providing the bleeding has stopped. There is no evidence to indicate whether different patterns of postmenopausal bleeding such as one-off bleeding or more frequent bleeds are more likely to be associated with malignancy.

Rates of delivery by caesarean section (CS) have steadily risen from 10% of all deliveries in the 1980s to a current figure of around 23.8%. Approximately 75% of CS are emergency procedures and only 25% are elective planned deliveries. When deciding whether to offer CS, it is important to consider the psychological implications for the patient as well as the physical and mental sequelae in future pregnancies. The updated NICE guideline helps clinicians to be consistent in the management of patients requesting and having a CS.

Pelvic inflammatory disease (PID) typically results from ascending infection through the endocervix, from the lower to the upper genital tract. This leads to inflammation of the endometrium, uterus, fallopian tubes, adnexal structures or pelvic peritoneum. It is extremely common and accounts for one in 60 GP consultations by women under the age of 45 years. PID may cause significant short- and long-term morbidity. Whereas most patients are asymptomatic, others may present acutely unwell with pelvic peritonitis and septicaemia. The long-term effects of PID include chronic pelvic pain, subfertility and ectopic pregnancy. However, there may also be substantial psychological morbidity in the form of guilt, isolation, and stigma associated with the diagnosis.  Although PID may occur following pelvic surgery, after instrumentation of the uterus and even in the puerperium, the most common cause is sexually transmitted infection (STI).

At least one in four women will develop one or more fibroids during their lifetime. They are most common in women aged 30-50 years and can run in families. Patients often have multiple fibroids, although some women have just one. Fibroids are three times more common in women of Afro-Caribbean descent than Caucasian women. Risk factors for the development of fibroids are:age; nulliparity; race; family history; obesity. There appears to be a decreased risk in smokers. Fibroids may be found during a routine examination or by chance during a scan for some other reason. On bimanual examination the uterus appears irregular in outline. An ultrasound scan can confirm the diagnosis. If the uterus is >12 weeks in size and/or palpable abdominally, an abdominal scan should be requested. Uterine length in centimetres is equivalent to weeks in size i.e. a 12 cm uterus is equivalent to a 12-week uterus. Women with menorrhagia and fibroids >12 cm and/or a palpable uterus should be referred to a specialist for further opinion.

Premature menopause can mean the end of fertility. The condition affects 1% of women under the age of 40, 1 in 1,000 under the age of 30 and 1 in 10,000 under the age of 20. In the UK, each year, 110,000 women will experience premature menopause between the ages of 12 and 40.3

Approximately 1 in 4 couples will see their GP for infertility problems. infertility is thus a very common condition with around 1 in 7 couples of reproductive age being diagnosed as infertile. Fertility is a couple issue. A detailed history should be taken, for both the woman and the man, including duration of infertility, any coital problems, previous conceptions, and frequency of intercourse. There is a comprehensive guideline from NICE on the assessment and treatment of fertility problems.² This suggests that, unless there are confounding factors (see above), couples should not be referred for further investigation if they have been trying for a child for less than a year. In these cases, couples should be encouraged to keep trying. The NICE guideline states that overall half of couples will conceive within 6 months of trying, 85% within 12 months and 92% within 2 years. In some cases, particularly when the woman is older (>35 years of age) earlier referral (www.hfea.gov.uk) shows the average success rates depend on female age with live birth rates in patients over 40 being very low. The use of donor gametes is a successful treatment although following legislative changes protecting anonymity gamete donors are in limited supply. There are variations in overall success rates of IVF/ICSI between different clinics (all are listed on the HFEA website) but overall these are not significant.

Pelvic pain is a common symptom that accounts for a large proportion of consultations in primary care. There is a steady monthly incidence and prevalence of 1.58/1,000 and 21.5/1,000 respectively.Chronic pelvic pain presents as frequently as migraine or low back pain and needs to be managed appropriately and effectively.