City and Hackney Irregular Bleeding Referral Pathway

History Establish nature of bleeding: Menstrual, Inter-menstrual or postcoital, prolonged/irregular/frequent bleeding  Current method of contraception and duration of use  Risk of STI or pregnancy  Cervical screening history  Other symptoms suggestive of underlying cause (e.g. abdominal or , , heavy bleeding)

Examination and Investigation Abdominal Exam: Palpate for a pelvic mass  : Bimanual and speculum examination. Assess for cervical ectropion and cervical - a typical polyp protrudes for the cervical os and is surrounded by normal cervix. It has a fleshy consistency and may bleed on contact. Nabothian cysts are cystic swellings on the cervix and are benign.  Cervical carcinoma presents with hard mass on cervix, extending to and into the pelvis: it may be friable on examination.  Take relevant STI and MCS swabs and only conduct smear test if due.  or in women who are >40 years refer for Pelvic Ultrasound Scan to rule out endometrial pathology after three cycles.

Red flag symptoms Red flag signs and management  Post Menopausal bleeding  Suspicious lesion on cervix not a polyp/  Weight loss ectropion/: refer to  Recent change in bowel habit > 50 years colposcopy 2WW  Persistent intermenstrual bleeding in  Pelvic mass which is not a fibroid or women over 45 lasting 6 weeks after benign : refer to stopping HRT or COCP and normal VE 2WW

Management in the absence of: red flag symptoms and signs, abnormal cytology or pathology detected at USS  In presence of a normal cervix, swabs and US scan consider use of Levonorgestrel-releasing intrauterine system (LNG-IUS), Combined Oral Contraceptives, Depo Provera.  Refer to Community or Hospital Gynaecology if persistent or these treatments are not appropriate/acceptable

Specialist Referral – Community Gynaecology  In presence of a cervical polyp and normal cervical cytology and normal ultrasound scan refer to Community Gynaecology for polypectomy

Specialist Referral – Hospital Gynaecology Services  Abnormal cervical cytology refer to Colposcopy as per NHSCSP standards  Refer women with irregular bleeding and pelvic pathology e.g. on scan to Gynaecology for consideration of outpatient hysteroscopy  Persistent bleeding from ectropion – refer to Gynae as may need cautery  Refer women over 45 years with irregular bleeding

Click here for patient information from NHS Choices

Authors: Anita Coutinho (GP Lead), Sandra Watson (Consultant Gynaecologist & Obstetrician), Dr Priyanka Patel, November 2017 Review: November 2019