Gynaecology: Pelvic Pain, Subfertility and Prevention
Obstetrics and Gynaecology — Gynaecology, NMC MBBS licence examination syllabus (Nepal Medical Council).
Gynaecology: pelvic pain, subfertility and prevention
One test comes before all the reasoning, and it is the same test every time.
Gynaecological presentations have a useful property: a small number of diagnoses account for most of the danger, and one investigation — a pregnancy test — sits in front of nearly all of them. A woman of reproductive age with abdominal pain has an ectopic pregnancy until that test is negative, no matter how confidently she reports that pregnancy is impossible.
Beyond the emergencies, much of this chapter is about conditions whose real significance lies outside the pelvis. Pelvic infection matters because of what it does to fertility years later. Polycystic ovary syndrome matters because of diabetes as much as periods. And cervical cancer matters because it is one of the few common cancers that is very largely preventable.
🩺 Where this lives: Cervical cancer is among the leading causes of cancer death in women in many low- and middle-income countries, and it is one of the most preventable. Persistent infection with high-risk human papillomavirus is a necessary cause — which is precisely why a vaccine can prevent the cancer itself and why screening works, since it detects a treatable pre-cancerous stage that exists for years before invasion. A country with effective vaccination and screening coverage sees very little of this disease. Where coverage is poor, women present with advanced, incurable cancer in their thirties and forties.
💡 A note on scope and numbers. Abnormal uterine bleeding and contraception are covered in the Antenatal Care and Gynaecology chapter and are not repeated here. This chapter gives no doses; it does not state PCOS diagnostic criteria as a fixed rule, because the required combination of features differs between guidelines; and it gives no cervical screening ages, intervals or method, because Nepal's programme is set nationally and revised. Take all of those from current national guidance.
Acute pelvic pain
The single rule worth carrying out of this chapter: do a pregnancy test in every woman of reproductive age with abdominal or pelvic pain. Not when it seems plausible — every time. Patients may not know they are pregnant, may not wish to say so in front of family, or may be certain it is impossible for reasons that turn out not to hold. A ruptured ectopic pregnancy can present as collapse with almost no external bleeding, and the diagnosis is missed most often because the possibility was never entertained.
THE THREE GYNAECOLOGICAL EMERGENCIES
ECTOPIC PREGNANCY
Positive pregnancy test with pain, with or without
bleeding. The bleeding is largely CONCEALED, so shock
can precede any visible loss. Shoulder-tip pain suggests
blood irritating the diaphragm. Rupture is a surgical
emergency: resuscitate and involve a surgeon at once.
OVARIAN TORSION
Sudden, severe, usually unilateral pain, often with
vomiting, sometimes with a known ovarian cyst. The
ovary's blood supply is twisted, so delay costs the
ovary — this is time-critical in exactly the way
testicular torsion is.
PELVIC INFLAMMATORY DISEASE
Bilateral lower abdominal pain, discharge, fever, deep
dyspareunia, cervical motion tenderness. Not immediately
life-threatening, but the long-term cost is permanent.
AND REMEMBER THE NON-GYNAECOLOGICAL CAUSES: appendicitis,
urinary tract infection and renal colic all present with
pelvic pain. The abdomen does not respect specialty
boundaries.
Pelvic inflammatory disease
💡 Exam angle: PID is the classic treat-on-suspicion diagnosis in gynaecology. Clinical diagnosis is imprecise, confirmatory testing is slow or unavailable, and the consequences of undertreatment — tubal infertility, ectopic pregnancy, chronic pelvic pain — are permanent. So the threshold to start empirical treatment is deliberately low. Note also that all three long-term consequences share one mechanism: tubal scarring. And the partner must be treated, or she will simply be reinfected.
Polycystic ovary syndrome
PCOS is routinely taught as a reproductive problem and is at least as much a metabolic one. Insulin resistance underlies much of it, and these women carry a raised long-term risk of type 2 diabetes and cardiovascular disease. Two practical consequences follow: lifestyle and weight management are genuinely first-line treatment rather than an afterthought, and prolonged amenorrhoea needs attention — unopposed oestrogen without regular shedding of the endometrium raises endometrial cancer risk, so inducing regular withdrawal bleeds is a protective measure, not a cosmetic one.
Subfertility
THE STRUCTURE OF A SUBFERTILITY ASSESSMENT
INVESTIGATE THE COUPLE, NOT THE WOMAN.
A male factor contributes in a large proportion of couples,
and SEMEN ANALYSIS is simple, cheap and non-invasive. It
should be among the FIRST tests, not the last — yet in many
settings the woman undergoes months of investigation first.
That is a clinical error and, where infertility is blamed
on women socially, an injustice as well.
THREE QUESTIONS ABOUT THE FEMALE PARTNER:
IS SHE OVULATING? A regular cycle is suggestive;
confirm biochemically where needed.
ARE THE TUBES OPEN? Tubal damage from previous infection
is a major and PREVENTABLE cause —
which links directly back to PID.
IS THE UTERUS NORMAL? Structural assessment.
ALSO ADDRESS, FOR BOTH PARTNERS:
Smoking, alcohol, weight, and timing of intercourse
FOLIC ACID before conception, to prevent neural tube
defects — start before pregnancy, not after it is
confirmed
AND TREAT THE COUPLE WITH CARE. Infertility carries heavy
social consequences in many communities, and the
consultation is rarely only a medical one.
Menopause
🔍 What matters clinically
What it isPermanent cessation of menstruation from loss of ovarian follicular activity, diagnosed retrospectively after a period of amenorrhoea. Symptoms arise from falling oestrogen.
SymptomsVasomotor symptoms — hot flushes and night sweats — sleep disturbance, mood change, and urogenital atrophy causing dryness, dyspareunia and urinary symptoms. Urogenital symptoms do not improve with time and often respond well to local treatment.
The long-term issueOestrogen is protective of bone, so accelerated bone loss follows, raising osteoporosis and fracture risk. Address calcium, vitamin D, weight-bearing exercise and smoking.
Hormone therapyEffective for vasomotor symptoms. The balance of benefit and risk depends on age, time since menopause, the preparation used and individual risk factors, and guidance has changed over time — so it is an individualised decision taken against current national guidance rather than a blanket rule.
The red flagPOST-MENOPAUSAL BLEEDING is endometrial carcinoma until proven otherwise and requires urgent investigation — never attribute it to atrophy or hormone therapy before malignancy has been excluded.
Cervical cancer prevention
💡 Exam angle: the examinable logic is the causal chain. Persistent high-risk HPV infection is a necessary cause of cervical cancer; it produces a pre-cancerous stage that persists for years; that stage is detectable and treatable. Therefore vaccination (primary prevention) prevents the infection, and screening (secondary prevention) catches the pre-cancer — the two are complementary, and neither replaces the other. Vaccination is most effective when given before exposure.
Clinical reasoning: four presentations
🔍 Case 1 — "I can't be pregnant"
PresentationA 24-year-old has severe left iliac fossa pain and light vaginal bleeding. She states firmly that pregnancy is impossible. She becomes pale and faint, with shoulder-tip pain. No pregnancy test has been done.
ErrorAccepting the history in place of the test.
ReasoningThis is a ruptured ectopic pregnancy until excluded. Bleeding is concealed, so shock precedes visible loss, and shoulder-tip pain reflects diaphragmatic irritation by blood.
AnswerPregnancy test immediately, resuscitate, and involve surgery and gynaecology urgently. Do a pregnancy test in every woman of reproductive age with pelvic pain.
🔍 Case 2 — the woman investigated alone
PresentationA couple have been unable to conceive for two years. Over eight months the woman has had extensive hormonal and imaging investigation. Her husband has not been tested, and the family attribute the problem to her.
OmissionSemen analysis.
ReasoningA male factor contributes in a large proportion of couples, and semen analysis is simple, cheap and non-invasive. Investigating only the woman is clinically wrong and delays diagnosis for months.
AnswerArrange semen analysis now, alongside assessment of ovulation, tubal patency and the uterus. Frame the assessment explicitly as one of the couple, which also matters given the social consequences she is carrying.
🔍 Case 3 — bleeding after the menopause
PresentationA 58-year-old, five years post-menopausal, has a single episode of light vaginal bleeding. She is well. It is attributed to vaginal atrophy and she is offered a moisturiser.
TrapA benign explanation that is common and plausible.
ReasoningPost-menopausal bleeding is endometrial carcinoma until proven otherwise. Atrophy is indeed the commonest cause, but it is a diagnosis of exclusion — and a single light episode does not lower the risk.
AnswerUrgent referral for investigation including endometrial assessment. Exclude malignancy first, then attribute to something benign.
🔍 Case 4 — irregular periods and weight gain
PresentationA 27-year-old has very infrequent periods, acne and hirsutism, and has gained weight. PCOS is diagnosed and she is told it only matters when she wants to conceive.
Two omissionsMetabolic risk, and the endometrium.
ReasoningPCOS carries a raised long-term risk of type 2 diabetes and cardiovascular disease, so metabolic assessment and lifestyle management are part of treatment. Prolonged amenorrhoea also leaves the endometrium under unopposed oestrogen, raising endometrial cancer risk.
AnswerExclude thyroid disease and hyperprolactinaemia, assess metabolic risk, support weight and lifestyle change, and ensure regular withdrawal bleeding per guidance. Discuss fertility when relevant — but it is not the only issue.
Commonly confused
Confusion
The distinction
Why it matters
History vs pregnancy test
Always test, whatever she says
Ectopic pregnancy is missed by not considering it.
Ectopic bleeding vs visible loss
The bleeding is concealed
Shock can precede any external bleeding.
Torsion vs other pelvic pain
Sudden, severe, unilateral, with vomiting
Delay costs the ovary.
Confirming PID vs treating it
Treat on suspicion
The consequences of delay are permanent.
PCOS as reproductive vs metabolic
Insulin resistance and diabetes risk
Changes what you screen for and advise.
Amenorrhoea in PCOS as harmless
Unopposed oestrogen affects the endometrium
Regular bleeds are protective.
Investigating the woman vs the couple
Semen analysis is early, cheap and simple
Months are lost, and blame misplaced.
Post-menopausal bleeding as atrophy
Malignancy is excluded first
Atrophy is a diagnosis of exclusion.
Rapid revision
MUST-KNOW FACTS
1. PREGNANCY TEST in EVERY woman of reproductive age with pelvic pain.
2. Ectopic pregnancy until proven otherwise — regardless of the history.
3. Ectopic bleeding is CONCEALED; shock precedes visible loss.
4. Shoulder-tip pain suggests blood irritating the diaphragm.
5. Ruptured ectopic: resuscitate and involve a surgeon immediately.
6. OVARIAN TORSION: sudden severe unilateral pain with vomiting.
7. Torsion is time-critical — delay costs the ovary.
8. PID: bilateral pain, discharge, fever, cervical motion tenderness.
9. TREAT PID ON SUSPICION — do not wait for confirmation.
10. PID consequences: INFERTILITY, ECTOPIC risk, chronic pelvic pain.
11. All three follow from TUBAL SCARRING.
12. Treat the PARTNER or she will be reinfected.
13. Also consider appendicitis, urinary infection and renal colic.
14. PCOS: irregular cycles, androgen excess, ovarian appearance.
15. PCOS is a DIAGNOSIS OF EXCLUSION — check thyroid and prolactin.
16. Criteria differ between guidelines — use the current national one.
17. PCOS is METABOLIC: insulin resistance and TYPE 2 DIABETES risk.
18. Lifestyle and weight management are first-line treatment.
19. Prolonged amenorrhoea → unopposed oestrogen → ENDOMETRIAL CANCER risk.
20. Induce regular withdrawal bleeds as protection.
21. SUBFERTILITY: investigate the COUPLE.
22. SEMEN ANALYSIS early — simple, cheap, non-invasive.
23. Female assessment: ovulation, tubal patency, uterine structure.
24. Tubal damage from previous infection is a major preventable cause.
25. FOLIC ACID before conception, not after.
26. Menopause symptoms: vasomotor, sleep, mood, urogenital atrophy.
27. Urogenital atrophy does not improve with time.
28. Oestrogen loss accelerates bone loss — OSTEOPOROSIS risk.
29. Hormone therapy is an individualised decision under current guidance.
30. POST-MENOPAUSAL BLEEDING = endometrial carcinoma until excluded.
31. Persistent high-risk HPV is a NECESSARY cause of cervical cancer.
32. HPV VACCINATION is primary prevention — best before exposure.
33. SCREENING is secondary prevention — it detects a treatable pre-cancer.
34. POST-COITAL BLEEDING needs cervical assessment, not reassurance.
35. Screening ages, intervals and method follow the national programme.
💡 Exam angle: three habits answer most gynaecology questions. Do the pregnancy test. Treat PID on suspicion rather than waiting. And exclude malignancy before accepting a benign explanation for bleeding — whether post-menopausal or post-coital.
Syllabus points
Why the pregnancy test comes first
Ectopic pregnancy and concealed bleeding
Ovarian torsion as a time-critical diagnosis
Pelvic inflammatory disease and treating on suspicion
Tubal scarring and its three consequences
PCOS features and exclusions
PCOS as a metabolic condition
Amenorrhoea and endometrial cancer risk
Assessing subfertility in the couple
Why semen analysis comes early
Menopause, symptoms and osteoporosis
Post-menopausal bleeding as a red flag
HPV, vaccination and cervical screening
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