A practice in the Norwich area

5. Miss M complains about aspects of her care and treatment by the Practice between May 2022 and March 2025. Specifically, she complains the Practice did not take appropriate action to investigate and consider her ongoing menstrual symptoms (menstruating is shedding of the uterine lining resulting in bleeding from the vagina, also referred to as a period) and did not refer her for further input from a gynaecologist at the earliest opportunity.

6. Within this, Miss M also complains her symptoms were described as ‘normal’ in February 2023 and appropriate action was not taken after a possible polyp (an overgrowth of cells) was noted in January 2025. Miss M says an underlying cause for her symptoms and presentation was not considered.

7. Miss M says had the Practice taken appropriate earlier action she would have had a gynaecology referral sooner and would likely be further along in receiving appropriate care and support for her symptoms.

8. Miss M says the issues with her period cycle affect her physically and mentally on a daily basis. She is concerned that the delay in referral will have increased any issues with her fertility due to symptoms not being treated sooner. She also says her untreated symptoms have affected her work and studies.

9. Miss M would like the Practice to improve staff training on women’s health, and for it to take action to see if she can be moved to the point on the gynaecology referral waiting list that she would have been at had she been referred at the earliest opportunity. Miss M is seeking a financial remedy to recognise the impact delayed referral and the impact of these events on her daily life.

10. In April 2022, Miss M phoned 111 then attended a local hospital complaining of nausea, tingling in her hands and feet, feeling faint and menstruating through two sanitary towels per hour. The hospital prescribed Cyclizine 50mg tablets (anti-sickness medicine) and advised her to follow her symptoms up with her GP practice.

11. Miss M attended her GP practice in May 2022 and November 2022 complaining of nausea and vomiting during her period. The GP diagnosed dysmenorrhea (period pain) and menorrhagia (heavy periods), prescribing Cyclizine then later tranexamic acid 500mg tablets (medicine that slows bleeding).

12. The Practice referred Miss M for an ultrasound in November 2022, and this took place in February 2023. The results of this did not show cause for concern.

13. In September 2024, Miss M contacted 111 again complaining of heavy menstrual bleeding, vomiting, nausea and abdominal pain. The 111 practitioner prescribed anti-sickness medication and pain killers, and suggested Miss M contact her GP for a consideration of possible endometriosis (a condition where cells similar to those in the lining of the uterus grow in other parts of the body).

14. Miss M attended an appointment at Practice on 13 September 2024, and the GP referred her for blood tests and another ultrasound scan of her pelvis area. The ultrasound took place on 2 January 2025 and showed a possible polyp in Miss M’s uterus. The GP referred Miss M to gynaecology for further consideration of this on 4 February 2025.

15. Miss M attended the Practice again on two further occasions in February 2025 due to pelvic pain, pain during sexual intercourse and she raised concerns that her symptoms may be related to cancer. She asked to be moved up the gynaecology waiting list. The GPs considered and assessed Miss M’s symptoms, and it was not felt these showed indications of possible cancer. Miss M’s referral therefore remained as routine.

16. Miss M was unhappy with the care provided by the Practice and felt the referral could have been made sooner. She made a complaint to the Practice in February 2025 and received the Practice’s response in March 2025. Miss M then brought the complaint to us as she remained unhappy with the Practice’s care.

20. Before we decide whether we should conduct a detailed investigation of a complaint, we look at whether there are signs the Practice has got something wrong. We do this by comparing what should have happened to what did happen. We have done this and have not seen any indications that something has gone wrong.

Appointment in May 2022

21. Miss M phoned 111 in April 2022 and attended a minor injury centre with nausea and vomiting during her period. She attended the Practice in May 2022 with the same symptoms.

22. The GMC guidelines say doctors must provide a good standard of practice and care, including adequately assessing the patient’s condition including their history, to promptly arrange suitable advice, investigations and treatment where necessary and to refer to another practitioner when this suits the patient’s needs.

23. The NICE guidelines on endometriosis say doctors should suspect endometriosis in women presenting with one or more of the following symptoms or signs:

• chronic pelvic pain • period-related pain (dysmenorrhoea) affecting daily activities and quality of life • deep pain during or after sexual intercourse • period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements • period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine • infertility in association with 1 or more of the above.

24. Miss M did not present with any of the required symptoms for suspected endometriosis at this time.

25. Miss M was appropriately prescribed Cyclizine to manage her symptoms of nausea and vomiting during her cycle, in line with the GMC guidance around promptly arranging suitable treatment. We therefore do not see indications of failings in the Practice’s care at this time.

Appointment in November 2022

26. Miss M next attended the Practice in November 2022 and reported symptoms of heavy, painful periods that were getting worse. She said she had these symptoms since she was 11 or 12 years old. These symptoms would meet the criteria for suspecting endometriosis.

27. The NICE guidelines say a transvaginal ultrasound scan should be offered to all women or people with suspected endometriosis, even if pelvic or abdominal examination is normal.

28. The guidance also includes details around medication for women and people with suspected or confirmed endometriosis. It says over the counter pain killers are an appropriate starting point for pain management and hormonal treatment such as the contraceptive pill should be offered.

29. We can see the GP referred Miss M for a pelvic ultrasound scan, which is in line with standards and guidance for suspected endometriosis.

30. The records show the GP also considered hormonal treatment, with Miss M saying she had side effects when she previously tried the progesterone only contraceptive pill and that she was not keen to consider other hormonal contraceptives due to her previous experience with the contraceptive pill.

31. The combined contraceptive pill (containing different hormones) was also considered however Miss M has a family history of breast cancer.

32. The UKMEC guidelines say the risk of using the combined contraceptive pill in someone with a family history of breast cancer and who has potential of having a genetic mutation increasing their risk of breast cancer, outweighs the benefits of the contraceptive pill.

33. It was therefore in line with guidance not to manage Miss M’s symptoms with hormonal treatment such as the contraceptive or combined contraceptive pill.

34. Overall, we consider the Practice acted in line with the NICE guidelines and referred Miss M for further investigations into suspected endometriosis. We therefore do not see indications of failings.

Ultrasound scan February 2023

35. Miss M had her pelvic ultrasound scan in February 2023. The results of this were available to the Practice on 10 February 2023, and the report conclusion said: ‘normal pelvic ultrasound examination.’ This information was shared with Miss M.

36. The NICE guidelines say a referral to gynaecology should be made if the initial treatment is not effective, the patient has symptoms which are having a detrimental impact on day to day living, they have persistent symptoms or recurrent symptoms of endometriosis, or they have pelvic signs of endometriosis, but deeper endometriosis is not suspected.

37. Our adviser explains Miss M did not meet these criteria at this time. The treatment of pain killers and anti-sickness medication appeared to be effective and Miss M did not revisit the Practice with any concerns about this until September 2024. Miss M also did not report any symptoms suggestive of persistent or recurrent endometriosis during this time.

38. We therefore do not see indications to suggest Miss M should have been referred to gynaecology at this time.

Appointment in September 2024

39. Miss M phoned 111 in September 2024 asking for Cyclizine medicine as she was having heavy bleeding, vomiting, nausea and stomach pain during her period. She attended the Practice on 13 September 2024 with the same symptoms.

40. The Practice arranged for Miss M to have blood tests and prescribed her Naproxen for her pain.

41. The decision to prescribe this medication was in line with NICE guidelines on endometriosis, as over the counter pain killers were not providing enough relief.

42. Our adviser says that while blood tests are not specifically mentioned in the NICE guidelines on endometriosis, it was appropriate to arrange these to investigate the heavy bleeding described. This is in line with GMC guidelines to arrange suitable advice, investigations and treatment for patients.

43. The blood test results showed a slightly raised testosterone level (a hormone imbalance).

44. In line with the GMC guidelines, the Practice arranged for Miss M to have another pelvic ultrasound investigation, to investigate possible reasons for her raised testosterone levels. This was also in line with the NICE guidelines on endometriosis to refer for an ultrasound scan when one of the symptom criteria is met. Due to the time passed between the first ultrasound in January 2023, it was appropriate to consider the investigation pathway for suspected endometriosis in line with Miss M’s further symptoms.

45. We therefore do not see indications of failings in this part of Miss M’s care from the Practice.

Ultrasound scan January 2025

46. Miss M’s second pelvic ultrasound scan took place on 2 January 2025. The results of this showed that Miss M had a polyp in her uterus.

47. A request was sent to Miss M on 8 January 2025 to make a routine appointment, and this took place on 1 February 2025. The Practice made Miss M aware of the ultrasound findings during this appointment and made a referral to gynaecology on 4 February 2025.

48. We consider this was in line with the GMC guidelines, which says to refer patients to another practitioner when this suits the patient’s needs and the NICE guidelines on endometriosis, which say to refer to gynaecology when there are further, persistent symptoms ongoing.

49. We do not consider the delay from 2 January to 4 February 2025 to be as significant as to be an indication of a failing. Within this, we note the Practice did make contact with Miss M on 8 January 2025 to advise her to make an appointment to see them to discuss her scan results. We do not see indications to suggest this referral should have been made urgently.

Appointments in February and March 2025

50. Miss M attended the Practice on 19 and 28 February 2025 with pelvic pain, pain during sex, and concerns that she may have cancer.

51. On 19 February 2025, the GP recorded a detailed history, noting the effects of her symptoms on her daily life, and her cancer concerns. They examined Miss M, took a swab test to check for any genital and urinary conditions, and tested her urine. The GP also prescribed co-codamol (a strong painkiller) to help with her pain. We consider these actions in line with the GMC guidelines as an appropriate examination and investigations took place, and appropriate medication was prescribed.

52. On 28 February 2025, Miss M attended a further appointment, and her cancer concerns were noted again. Her swab test and urine test results were available on this date and showed no cause for concern.

53. Miss M noted she would like her referral to gynaecology to be expediated due to her concerns about possible cancer. The GP checked for any symptoms which could be related to cancer, such as unexplained weight loss, fatigue or changes in bowel habits, in line with the NICE guidelines on ‘Suspected cancer: recognition and referral’. Miss M was not noted to have any of these symptoms.

54. This guidance also recommends a physical examination, to check if there is any swelling or mass. In line with this, the GP examined Miss M’s abdomen and did not note any concerns. They were not able to perform an internal examination, as Miss M was understandably anxious and upset during this, so this was arranged for 8 March 2025. This examination also did not highlight any areas of concern which could suggest cancer.

55. Overall, we have not seen indications to suggest Miss M’s gynaecology referral should have been expedited at this time. We can see the GP took her concerns seriously and her symptoms were considered in line with the NICE guidelines around suspected cancer. Miss M did not have symptoms suggestive of cancer at this time.

56. We can see the GP also offered Miss M hormone-releasing coil (a contraceptive device placed into the uterus) in the appointment on 28 February 2025. This can be an appropriate treatment for painful and or heavy periods whether or not endometriosis is present, in line with the NICE endometriosis guidelines.

57. We appreciate how worried Miss M was during this period and understand her wanting reassurance around her care and the Practice’s actions. We can reassure her this period of care was in line with standards and guidance, and we do not see indications of failings.

Symptoms being described as ‘normal for women’

58. Miss M says a GP from the Practice described her symptoms as ‘normal for women’ in February 2023. She says this caused her to feel upset and dismissed. We do not doubt the distress these events caused Miss M.

59. The Practice records show a GP spoke with Miss M about her ultrasound results in February 2023. There is no mention of Miss M being told her symptoms are ‘normal for women’. There is a record saying Miss M was advised her ultrasound scan was normal, which is in line with the report sent to the Practice.

60. We therefore have two conflicting accounts of this conversation. We have carefully considered if we are able to reach a view about what was likely said at this time.

61. We can there was some confusion when this concern was raised to the Practice, and it was not clear when this comment was made. Therefore, the Practice’s response did not fully address this.

62. We have considered whether to refer this back to the Practice to see if it would be able to add anything further to this concern. Sadly, due to the time since the events, we consider it is unlikely the Practice would be able to add anything further than what was noted in the records. This is because it is unlikely that the GP would be able to recollect an appointment from 2023.

63. Due to the above, as we would also be unlikely to reach a conclusion about what was discussed in 2023. We therefore have not reached a view about this concern.

Conclusion

64. We hope this statement clearly explains our reasoning behind our decision, and Miss M can see how we have balanced the available evidence and used independent advice to come to this conclusion.

1. Miss M complains about the care and treatment provided by a GP practice in Norfolk (the Practice), between May 2022 and March 2025. She says the Practice did not appropriately consider her gynaecological symptoms and did not make prompt referrals to the gynaecology team (specialists who focus on the health of the female reproductive system).

2. Miss M says this has meant she has suffered longer than needed with pain and she is now on a long waiting list for a gynaecology appointment. We are very sorry to hear this and appreciate Miss M’s concerns about the impact of this delay on any treatment she may need, and any impact this may have on her fertility.

3. We have carefully considered Miss M’s concerns and have not seen indications of failings in the care and treatment provided by the Practice. We can see the Practice appropriately considered and explored Miss M’s symptoms and arranged appropriate tests. We can also see Miss M was appropriately referred to gynaecology following the results of an ultrasound scan.

4. We hope our explanation provides some reassurance to Miss M as we appreciate the sensitive and distressing nature of her concerns.