Reason for referral |
Criteria |
Mandatory information to include on referral |
Menstrual |
Heavy menstrual bleeding |
CBC, ferritin, TSH and prolactin. If personal and/or family history of a bleeding disorder, add: PTT, INR, von Willebrand antigen and activity factor and factor VIII |
Start patient on iron therapy. Patient must complete a menstrual calendar (paper or phone app) and bring it to their appointment. |
Secondary Amenorrhea/ Oligomenorrhea/ Irregular menses |
CBC, Bhcg, FSH, LH, E2, prolactin, TSH If inflammatory acne or a Ferriman-Gallwey score over 4 or a family history of PCOS, add: DHEAS, androstenedione, testosterone profile (total and free testosterone, SHBG), androstenedione and 17-OHP |
Provide age of menarche. If the patient has not menstruated in 3 months (and pregnancy has been ruled out), consider providing them with medroxyprogesterone acetate 10mg qhs x 10 doses to take (diagnostic and therapeutic). Patient must complete a menstrual calendar (paper or phone app) and bring it to their appointment. |
Primary amenorrhea |
As for secondary amenorrhea, but add an abdo-pelvic ultrasound (report must comment on kidneys, uterus, and ovaries) |
Must provide growth charts and indicate Tanner staging (breast and pubic hair). Indicate if cyclic abdominal pain. |
Menstrual suppression |
No investigations needed to triage. |
Must indicate if patient is pre- or post-menarchal. If the patient is pre-menarchal, must indicate their Tanner stage (for breast and pubic hair)
|
Dysmenorrhea |
Pelvic ultrasound |
Ensure patient is taking NSAIDs and acetaminophen pre-emptively (1-2 days prior to menses), regularly and at correct doses throughout menses. Constipation is often associated with this condition. Please ensure stools are Bristol type 4: Constipation - CHEO |
Vulvovaginal issues |
Vulvovaginitis |
Vaginal culture and sensitivity (for pre-menarchal patients: only if abnormal discharge or very erythematous introitus) If sexually active, NAAT for Chlamydia and gonorrhea (first void urine, vaginal or cervical) |
Please provide the patient/family with the following handout and review vulvar hygiene with them. Constipation is often associated with this condition. Please ensure stools are Bristol type 4: Constipation - CHEO |
Labial adhesions |
No investigations needed to triage. |
Please provide the patient/family with the following handouts and review vulvar hygiene with them: Vulvovaginitis - CHEO
Indicate if patient is having culture-proven recurrent urinary tract infections.
Constipation is often associated with this condition. Please ensure stools are Bristol type 4: Constipation - CHEO
|
Prepubertal vaginal bleeding |
No investigations needed to triage. |
Must provide growth charts and indicate Tanner staging (breast and pubic hair). |
Labial hypertrophy |
No investigations needed. |
Please note that only under exceptional circumstances do we accept referrals for this condition. Labioplasty is not a procedure covered by OHIP. Labia minora growth continues throughout puberty and up to age 18. Often the growth is asymmetrical but eventually catches up. Reassurance is needed and normalizing examination is important. Please review the following handout with your patient:
And provide them with the following websites:
|
Vulvodynia / Inability to insert tampons |
No investigations needed to triage. |
Recommend referral to Pelvic Floor Physiotherapy while awaiting consultation. |
Contraception Please note that we do not accept referrals for routine contraception |
Insertion of Nexplanon or intra-uterine device in patients 16yo or older |
No investigations needed to triage. |
N/A |
Insertion of intra-uterine device in patients less than 16yo |
No investigations needed to triage. |
|
Complex contraception |
No investigations needed to triage. |
Please indicate the medical condition/medication that is contra-indicated. Please indicate any contraception that has been tried thus far and why it was discontinued. |
Ovarian cysts |
Simple cyst of less < 5cm or hemorrhagic cyst of <3cm |
No investigations needed |
No referral is needed. Repeat US in 6-8 weeks. |
Simple cyst >5cm or hemorrhagic cyst >3cm |
Pelvic ultrasound |
Repeat pelvic ultrasound 6-8 weeks after the first one. Cysts are often physiological and resolve on their own. Only if the cyst is persistent on the 2nd ultrasound should a referral to Gynecology be sent. Please include growth charts or at minimum the patient’s BMI. |
Complex cyst |
Pelvic ultrasound LDH, serum hcg, AFP and CA-125 |
|
Any other type of cyst |
Pelvic ultrasound |
|
Mullerian anomalies |
Incidental finding of mullerian anomaly in pre-pubertal patient |
Abdo-pelvic ultrasound |
Please provide patient’s Tanner stage (breast and pubic hair). |
Non-obstructive mullerian anomaly |
Abdo-pelvic ultrasound |
|
Obstructive mullerian anomaly |
Abdo-pelvic ultrasound |
This is an urgent referral. Suggest calling the gynecologist on-call during the day to discuss whether menstrual suppression or other imaging is appropriate. |