General Practice: Child health, women's health and men's health in primary care

🩺 Child health, women's health and men's health in primary care. Much of the population's contact with the NHS outside illness happens here - child health surveillance, immunisation, contraception, pregnancy care, menopause and sexual health. Detailed obstetric, gynaecological and paediatric management is in those chapters; this chapter covers the primary care framework, the national programmes, and the common decisions examined in the UKMLA.
Your four questions: Is this child growing and developing normally, and are immunisations up to date? Is this woman's contraception safe for her (UKMEC)? Is there a screening, immunisation or prevention opportunity today? Is there any safeguarding concern?

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Child Health Surveillance (Healthy Child Programme)

• Delivered by health visitors, GPs, midwives and school nurses; records in the Personal Child Health Record (red book).
• Key contacts: antenatal visit (28 weeks onwards), new birth visit (10–14 days), 6–8 week check (GP), 9–12 months, 2–2½ years (with ASQ-3 developmental review), school entry (vision, hearing, height and weight via the National Child Measurement Programme at reception and Year 6).
• Newborn and Infant Physical Examination (NIPE) within 72 hours and at 6–8 weeks: eyes (red reflex - congenital cataract, retinoblastoma), heart (murmurs, femoral pulses), hips (DDH - Barlow and Ortolani; risk factors - breech, family history → hip ultrasound), testes (undescended - refer if not descended by 3 months for surgery by 6–12 months); plus weight, head circumference, feeding, maternal mood (postnatal depression).
• Newborn screening: blood spot at day 5 (sickle cell disease, cystic fibrosis, congenital hypothyroidism and six inherited metabolic diseases including PKU and MCADD), newborn hearing screening, NIPE.
• Growth: plot on UK-WHO charts; concern if crossing two centile lines (faltering growth) or weight below the 0.4th centile.
• Development red flags: not smiling by 8 weeks; not sitting unsupported by 9 months; not walking by 18 months (check CK in boys); no words by 18 months; loss of skills at any age (refer urgently); hand preference before 12 months (possible hemiplegia).

The UK Routine Immunisation Schedule

The schedule changed in July 2025 and January 2026 - always check the current UKHSA "Green Book" and schedule.

Age	Vaccines (England, from January 2026)
8 weeks	6-in-1 (DTaP/IPV/Hib/HepB); MenB; rotavirus
12 weeks	6-in-1; MenB (2nd dose moved here from 16 weeks in July 2025); rotavirus
16 weeks	6-in-1; pneumococcal (PCV) (moved here from 12 weeks in July 2025)
1 year	MMRV (MMR plus varicella, replacing MMR from January 2026); PCV booster; MenB booster - Hib/MenC is no longer given
18 months (new appointment, children born on or after 1 July 2024)	6-in-1 (4th dose); MMRV 2nd dose (moved from 3 years 4 months)
3 years 4 months	4-in-1 pre-school booster (DTaP/IPV) (and MMR/MMRV 2nd dose for older cohorts not yet given it)
12–13 years	HPV (single dose, boys and girls)
14 years	3-in-1 teenage booster (Td/IPV); MenACWY
Pregnancy	Pertussis (from 16 weeks, ideally 20–32); RSV (from 28 weeks); influenza (any stage); COVID-19 per seasonal advice
65 years and older	Influenza annually; pneumococcal; shingles (Shingrix, two doses; eligibility extended by age cohorts and to immunosuppressed adults 18+); RSV (from age 75; eligibility is being extended - check current UKHSA guidance)

• Rotavirus: first dose by 15 weeks, second by 24 weeks - do not start after 15 weeks; it is a live oral vaccine (avoid in severe combined immunodeficiency).
• Live vaccines (MMRV, rotavirus, BCG, live influenza nasal spray, yellow fever) - avoid in significant immunosuppression and pregnancy.
• Selective BCG for infants at higher risk of TB (high-incidence area or parents/grandparents from high-incidence countries), given at 28 days after SCID screening result.
• Contraindications are few: confirmed anaphylaxis to a previous dose or a component. Minor illness without fever, prematurity, eczema, asthma and egg allergy (for MMR) are not contraindications.

The Feverish Child

• NICE NG143 traffic-light system - assess colour, activity, respiratory, circulation/hydration and other features.
• Red features: pale/mottled/ashen/blue; no response to social cues, appears ill, does not wake or stay awake, weak/high-pitched cry; grunting, RR >60, chest indrawing; reduced skin turgor; age <3 months with temperature ≥38°C; non-blanching rash; bulging fontanelle; neck stiffness; status epilepticus; focal neurology or seizures → urgent face-to-face assessment by a paediatric specialist.
• Amber features: pallor reported by parent; not responding normally; reduced activity; nasal flaring; RR >50 (6–12 months) or >40 (>12 months); SpO₂ ≤95%; crackles; capillary refill ≥3 s; dry mucous membranes; poor feeding; reduced urine; age 3–6 months with temperature ≥39°C; fever ≥5 days; rigors; swelling of a limb or joint → safety-net or refer depending on context.
• Antipyretics for distress only (paracetamol or ibuprofen; consider alternating only if distress persists) - they do not prevent febrile seizures.
• Suspected meningococcal disease in primary care → benzylpenicillin IM/IV (if it will not delay transfer) and emergency transfer.
• Urine - test in unexplained fever in infants and children (NICE NG224 UTI in under 16s).

Common Child Health Problems

• Infant colic - crying >3 hours/day, >3 days/week, in a thriving baby; reassure; resolves by 3–4 months.
• GORD and cow's milk protein allergy - consider CMPA with eczema, reflux, diarrhoea, blood in stools, faltering growth; extensively hydrolysed formula; continue breastfeeding with maternal elimination of cow's milk if needed.
• Constipation - common; exclude red flags (onset from birth, delayed meconium >48 h, ribbon stools, abnormal neurology - Hirschsprung's, spinal problems); macrogol disimpaction and maintenance; behavioural support.
• Eczema - emollients (generous), stepped topical steroids; watch for eczema herpeticum (urgent).
• Bronchiolitis - under 2 years; supportive; admit if apnoea, severe respiratory distress, SpO₂ <92%, poor feeding (<50–75% usual intake).
• Croup - single dose oral dexamethasone 0.15 mg/kg.
• Otitis media - most resolve in 3 days without antibiotics; consider antibiotics if <2 years with bilateral AOM, otorrhoea, or systemically unwell.
• Safeguarding in children - bruising in a non-mobile baby, injuries inconsistent with history or development, delay in presentation, faltering growth, neglect → follow child protection procedures (see next chapter).

Contraception

Method	Failure rate with typical use (approx)	Key points
Implant (etonogestrel)	<1%	3 years; irregular bleeding; effective immediately if inserted day 1–5 of cycle
Copper IUD	<1%	5–10 years; immediate; most effective emergency contraception; heavier periods
LNG-IUS (52 mg)	<1%	Contraception up to 8 years (Mirena); reduces bleeding; endometrial protection in HRT (5 years)
Injectable (DMPA)	About 4%	Every 13 weeks; bone density loss (review at 2 years; caution <18); delayed return of fertility up to 1 year; weight gain
Combined hormonal (pill/patch/ring)	About 7–9%	Reduces dysmenorrhoea and heavy bleeding; VTE, stroke, breast cancer risks; many interactions
Progestogen-only pill (desogestrel)	About 7–9%	12-hour window (desogestrel); 3-hour for traditional POPs
Condoms	About 13–18%	Only method protecting against STIs

• UKMEC (UK Medical Eligibility Criteria): 1 - no restriction; 2 - benefits outweigh risks; 3 - risks usually outweigh benefits; 4 - unacceptable risk.
• UKMEC 4 for combined hormonal contraception: migraine with aura, age ≥35 smoking ≥15/day, BP ≥160/100, history of VTE or known thrombogenic mutation, stroke/IHD, breast cancer (current), breastfeeding and <6 weeks postpartum, not breastfeeding and <3 weeks postpartum with other VTE risk factors, major surgery with prolonged immobilisation, complicated valvular disease, severe cirrhosis, SLE with antiphospholipid antibodies.
• Enzyme-inducing drugs (rifampicin, carbamazepine, phenytoin, St John's wort): reduce efficacy of CHC, POP and implant - use copper IUD, LNG-IUS or DMPA.
• Emergency contraception: copper IUD within 5 days of UPSI (or of earliest expected ovulation) - most effective; ulipristal acetate within 120 hours (avoid hormonal contraception for 5 days after); levonorgestrel within 72 hours (double dose if BMI >26 or weight >70 kg, or on enzyme inducers).
• Under 16s: Fraser guidelines for contraception; Gillick competence for other decisions; always consider safeguarding (under 13 cannot consent to sex in law → safeguarding referral).

Preconception and Early Pregnancy Care

• Folic acid 400 micrograms daily from before conception until 12 weeks; 5 mg if higher risk: previous NTD, family history, diabetes, antiepileptic drugs, BMI ≥30, sickle cell disease/thalassaemia, coeliac disease.
• Vitamin D 10 micrograms daily in pregnancy and breastfeeding.
• Medication review: stop or switch teratogens - valproate, topiramate, isotretinoin, methotrexate, warfarin, ACE inhibitors/ARBs, statins, lithium (specialist advice).
• Lifestyle: stop smoking (offer carbon monoxide testing and referral), no alcohol, weight, optimise diabetes (HbA1c <48 mmol/mol where safely achievable) and epilepsy control.
• Booking with a midwife by 10 weeks; dating scan 11–14 weeks with combined screening (Down's, Edwards' and Patau's syndromes); anomaly scan 18–20+6 weeks; infectious disease screening (HIV, hepatitis B, syphilis); haemoglobinopathy screening.
• Pregnancy of unknown location / bleeding / pain in early pregnancy - same-day early pregnancy assessment unit if pain, or bleeding with pregnancy ≥6 weeks; suspected ectopic (pain, shoulder-tip pain, collapse) → emergency.
• Hyperemesis gravidarum - PUQE score; antiemetics (cyclizine, prochlorperazine, promethazine first line; ondansetron second line); admit if unable to keep fluids down or ketonuria with weight loss.

Menopause and HRT

• Diagnosis (NICE NG23): clinical in women aged over 45 with typical symptoms - no FSH test needed. Consider FSH under 45 (two levels 4–6 weeks apart for premature ovarian insufficiency under 40).
• HRT: oestrogen with progestogen if a uterus is present (LNG-IUS, cyclical or continuous combined). Transdermal oestrogen does not increase VTE risk - preferred if BMI >30, VTE risk factors or migraine.
• Risks: breast cancer (combined HRT - small increase with duration, falling after stopping); VTE (oral); stroke (oral); endometrial cancer with unopposed oestrogen. Benefits: vasomotor and genitourinary symptoms, mood, sleep, bone protection. Under 60, benefits usually outweigh risks.
• Vaginal oestrogen for genitourinary syndrome of menopause - safe long term, and no progestogen is needed.
• Premature ovarian insufficiency (<40): HRT or CHC until at least the average age of menopause (51).
• Non-hormonal options: CBT (vasomotor symptoms and mood), SSRIs/SNRIs, clonidine, gabapentin, fezolinetant (specialist/licensed options vary).
• Contraception - continue until age 55, or 1 year after last period (over 50) / 2 years (under 50) if not on hormones.

Menstrual Problems in Primary Care

• Heavy menstrual bleeding (NICE NG88): FBC; if no structural cause suspected → LNG-IUS first line; otherwise tranexamic acid, NSAIDs, combined hormonal contraception, cyclical progestogen. Ultrasound if suspected fibroids or examination abnormal; hysteroscopy if risk factors for endometrial pathology.
• Intermenstrual or postcoital bleeding - examine cervix, STI testing, check cervical screening; refer if cervix looks suspicious.
• Postmenopausal bleeding (≥12 months after last period) - suspected cancer pathway (age 55+), or direct-access transvaginal ultrasound per local pathway.
• Amenorrhoea - pregnancy test first; then weight/exercise, PCOS, hyperprolactinaemia, thyroid, premature ovarian insufficiency.
• PCOS (Rotterdam: 2 of 3 - oligo/anovulation, hyperandrogenism, polycystic ovaries on ultrasound): lifestyle, CHC for cycle control, endometrial protection, screen for diabetes and cardiovascular risk.
• Endometriosis (NICE NG73) - average diagnostic delay of 8 years; analgesia and hormonal treatment; refer if severe, persistent or fertility concerns.

Sexual Health in Primary Care

• Sexual history: partners (gender, number, dates), type of sex, condom use, previous STIs, contraception, HIV/PrEP, drugs (chemsex), sex work, consent and coercion.
• Testing: NAAT for chlamydia and gonorrhoea (vulvovaginal self-swab in women; first-void urine in men; pharyngeal and rectal swabs as indicated), HIV, syphilis, hepatitis B/C serology for higher-risk groups.
• Chlamydia: doxycycline 100 mg twice daily for 7 days (azithromycin if pregnant); partner notification; test of cure if pregnant.
• Gonorrhoea: ceftriaxone 1 g IM single dose - refer to GUM (resistance; culture before treatment; partner notification).
• HIV testing - offer to anyone with an indicator condition (e.g. TB, lymphoma, recurrent pneumonia, unexplained weight loss or lymphadenopathy, shingles in under-50s) and in high-prevalence areas (opt-out testing). Post-exposure prophylaxis (PEP) within 72 hours; PrEP via sexual health services.
• Mpox, syphilis and gonorrhoea are rising - have a low threshold for referral.

Men's Health

• Men use primary care less and present later; opportunistic health checks matter.
• LUTS (NICE CG97): frequency, nocturia, hesitancy, poor stream; examine abdomen and prostate, urinalysis, U&E, PSA after counselling; frequency–volume chart. Treatment: lifestyle, alpha-blocker (tamsulosin) for moderate–severe voiding symptoms, 5-alpha reductase inhibitor (finasteride) if prostate is estimated >30 g or PSA >1.4; antimuscarinic or mirabegron for storage symptoms.
• Prostate cancer: no national population screening. In 2026 the UK NSC recommended targeted screening for men aged 45–61 with a BRCA2 variant and a family history of cancer (PSA every 2 years); it recommended against screening all men, Black men or men with only a family history. Men over 50 may request a PSA test after informed counselling.
• Erectile dysfunction - a marker of cardiovascular disease: check BP, lipids, HbA1c, testosterone (morning) if low libido; PDE-5 inhibitors (contraindicated with nitrates and nicorandil).
• Testicular lump - suspected cancer referral if non-painful testicular enlargement or change; ultrasound if uncertain; teach self-examination (age 15–45 peak).
• AAA screening - men in their 65th year; one ultrasound (see the Public Health chapter).
• Mental health and suicide - suicide is the biggest killer of men under 50 in the UK; ask directly about suicidal thoughts.

At a Glance

Topic	Remember
6–8 week check	Red reflex, heart, hips, testes, growth, maternal mood
Immunisation changes	MenB 2nd dose at 12 weeks; PCV at 16 weeks; MMRV from Jan 2026; new 18-month visit
Feverish child	NICE traffic-light; red features → paediatric assessment
CHC UKMEC 4	Migraine with aura; ≥35 smoking ≥15/day; VTE; BP ≥160/100
Emergency contraception	Cu-IUD best; ulipristal 120 h; LNG 72 h
Folic acid	400 micrograms (5 mg if high risk) until 12 weeks
Menopause	Clinical diagnosis over 45; transdermal oestrogen - no VTE increase

Spot the Answer

• A woman of 34 with migraine with aura wants the combined pill. → UKMEC 4 - offer a progestogen-only method, LARC or copper IUD.
• A baby at the 6–8 week check has an absent red reflex. → Urgent ophthalmology referral (cataract, retinoblastoma).
• A 14-week-old has missed the first rotavirus dose. → Can still have the first dose (must be before 15 weeks) - give today.
• A 50-year-old with hot flushes and irregular periods asks for an FSH test. → Not needed - diagnose clinically.
• A man on rifampicin wants his partner's pill to be reliable. → Not relevant to her pill (it is the user's drug that matters) - but if she starts an enzyme inducer, switch to Cu-IUD, LNG-IUS or DMPA.

Exam-style Scenarios

• Scenario. A 15-year-old asks for the contraceptive pill and does not want her parents told. Her partner is 16.
  Answer: Assess Gillick competence and the Fraser criteria (understands advice, cannot be persuaded to tell parents, likely to have sex anyway, health would suffer without contraception, in her best interests). Assess for exploitation or coercion (age gap, power imbalance, CSE risk). Provide contraception (consider LARC), condoms and STI testing, and keep confidentiality unless there is a safeguarding risk.
• Scenario. A 6-month-old has temperature 38.5°C, is irritable but consolable, feeding reduced, capillary refill 2 seconds, no rash, RR 48.
  Answer: Amber features (age, reduced feeding) - test urine, consider an alternative source, and either refer for paediatric assessment or provide a clear safety net with a review within a defined time, depending on overall assessment and parental confidence.
• Scenario. A 53-year-old woman with a uterus and BMI 34 asks about HRT for severe vasomotor symptoms.
  Answer: Offer transdermal oestradiol (no increased VTE risk) plus a progestogen (LNG-IUS or oral micronised progesterone), explain breast cancer risk in absolute terms, and review at 3 months.

Key Points

• The 6–8 week check screens eyes, heart, hips and testes.
• The immunisation schedule changed in 2025–26: MMRV, an 18-month appointment, and moved MenB and PCV doses.
• Use UKMEC for every contraception decision; Cu-IUD is the most effective emergency contraception.
• Menopause is a clinical diagnosis over 45; transdermal oestrogen avoids VTE risk.
• Men present late - use every contact for opportunistic health checks and mental health.

Guidelines and Further Reading

• UKHSA: Immunisation against infectious disease (the Green Book); Routine childhood immunisation schedule (from January 2026)
• NICE NG143: Fever in under 5s; NICE NG224: UTI in under 16s
• FSRH: UK Medical Eligibility Criteria for Contraceptive Use (UKMEC); FSRH emergency contraception guideline
• NICE NG23: Menopause - identification and management (updated 2024)
• NICE NG88: Heavy menstrual bleeding; NICE NG73: Endometriosis
• NICE CG97: Lower urinary tract symptoms in men
• UK National Screening Committee: prostate cancer screening recommendation (2026)
• BASHH national guidelines (chlamydia, gonorrhoea, HIV testing)