Women's health in primary care

Women’s health in primary care is a life-course practice rather than a set of isolated reproductive consultations. Menstrual health, contraception, fertility intentions, pregnancy, menopause, cardiovascular and bone health, sexual wellbeing, mental health and cancer prevention interact. Use inclusive language: some women do not have a cervix or uterus, and some trans men and non-binary people require cervical, contraceptive or pregnancy care. Ask which language and examination arrangements the person prefers.

Create psychological and physical safety. Offer time alone when a partner or relative attends, use a professional interpreter and explain confidentiality and its limits. Ask permission before sensitive questions or examination. Reproductive coercion may present as repeated emergency contraception, hidden contraception, pressured pregnancy or partner interference. Respond without blame, assess immediate danger and follow safeguarding or specialist pathways with the person.

Triage first. Severe or sudden pelvic pain, syncope, shoulder-tip pain, peritonism or haemodynamic disturbance in anyone who could be pregnant raises ectopic pregnancy or haemorrhage. Fever, systemic illness and pelvic tenderness may indicate severe infection. Sudden unilateral pain with vomiting can be torsion. Postpartum heavy bleeding, headache with neurological features, chest pain or breathlessness needs urgent assessment. Stable presentation does not remove the need for timely suspected-cancer referral where criteria are met.

Menstrual history should establish cycle timing, duration, volume, intermenstrual or postcoital bleeding, pain, pregnancy possibility, contraception and impact on life. Ask about anaemia symptoms, medication, bleeding tendency, thyroid features, androgen excess, weight change and family history. The examination and investigations should answer a hypothesis, not be automatic. A pregnancy test is essential when pregnancy is possible, but early negative testing cannot exclude an ectopic pregnancy.

Heavy menstrual bleeding is defined by impact on physical, social, emotional or material quality of life, not a measured volume threshold. Check full blood count and tailor further tests and imaging to history and examination under current NICE guidance. Discuss options by the person’s priorities, need for contraception, pathology and contraindications. Do not prescribe from a memorised hierarchy without checking pregnancy possibility, interactions and current recommendations.

Contraception begins with reproductive intention: whether pregnancy is desired, how important avoidance is, preferred bleeding pattern, privacy, control and willingness for procedures. Explain typical-use effectiveness and non-contraceptive effects. Apply current FSRH UKMEC categories to the individual. A UKMEC category 4 means an unacceptable health risk for that method; category 3 usually means risk outweighs benefit and warrants specialist judgement or another method. It is not a global prohibition on all contraception.

For combined hormonal contraception, measure blood pressure and assess migraine with aura, smoking, age, BMI, venous and arterial thrombosis risks, cardiovascular disease, postpartum status and interacting medicines. For progestogen-only and intrauterine methods, assess their method-specific issues rather than copying combined-method contraindications. Long-acting reversible methods should be offered but never coerced. Provide switching, missed-method and follow-up advice from current FSRH guidance.

Emergency contraception is time-sensitive and method-specific. Establish unprotected intercourse dates across the cycle, usual cycle, other exposures, current contraception, medicines, breastfeeding and safeguarding. The copper intrauterine device is the most effective emergency method when eligible and can provide ongoing contraception; oral options vary by timing and interactions. Use current FSRH guidance or expert support rather than inventing a universal tablet regimen. Arrange pregnancy testing at the appropriate interval and an ongoing method plan.

Preconception care addresses folic acid according to individual risk, medicines and teratogenicity, immunisation, long-term disease control, smoking, alcohol, mental health, weight and genetic or obstetric history. Do not stop essential medicine abruptly because pregnancy is contemplated; review benefit and risk and obtain specialist advice when needed. Ask about pregnancy intention during potentially teratogenic prescribing and document a safe plan without making contraception a condition of care.

In otherwise healthy people aged 45 or over, recent vasomotor symptoms with cycle change support perimenopause without routine laboratory testing. Menopause is identified after at least 12 months without periods when hormonal contraception is not being used; after hysterectomy, use the type and combination of symptoms. Hormonal treatment can obscure the picture. Consider alternative explanations for atypical symptoms. FSH may help at ages 40–45 with symptoms and cycle change, or under 40 when premature ovarian insufficiency is suspected; it should not be used to identify menopause during combined hormonal contraception or high-dose progestogen treatment.

HRT decisions are individual. Explain expected symptom benefit, uncertainties, route-specific risks and alternatives. Confirm whether a uterus is present because systemic oestrogen ordinarily needs progestogen endometrial protection. Transdermal and oral routes have different thrombotic profiles. Vaginal oestrogen treats genitourinary symptoms with minimal systemic absorption and may be used long term when appropriate. Unexplained bleeding, cancer history or thrombosis risk requires precise assessment rather than a blanket statement that all HRT is contraindicated.

Bleeding after menopause is a symptom, not a screening question, and requires prompt investigation through the appropriate pathway. Unscheduled bleeding on HRT needs assessment based on timing, preparation, adherence, risk factors and current guidance. Cervical screening does not investigate postcoital bleeding or a visible cervical lesion; perform appropriate examination and refer based on findings even if screening is up to date.

Prevention includes invitation to the correct national screening programmes based on current eligibility and anatomy, cardiovascular risk assessment, vaccination, bone-health discussion and domestic-abuse support. Screening policy changes, so check the current nation-specific programme. Explain benefits, limitations and possible downstream tests. Respect informed decline and keep symptoms distinct from screening eligibility.

Close with shared actions and safety netting. Record pregnancy possibility, relevant UKMEC factors, decisions and alternatives, consent, examination findings and who will follow results. Give explicit advice for worsening pain, heavy bleeding, collapse, fever or new pregnancy symptoms. Arrange accessible follow-up after starting a method or HRT when clinically needed and provide a route for earlier review.