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 pelvic pain, dyspareunia, heavy bleeding)
Examination and Investigation Abdominal Exam: Palpate for a pelvic mass Pelvic examination: Bimanual and speculum examination. Assess cervix for cervical ectropion and cervical polyp - 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 vagina and into the pelvis: it may be friable on examination. Take relevant STI and MCS swabs and only conduct smear test if due. Intermenstrual bleeding 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/Nabothian cyst: 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 ovarian cyst: refer to stopping HRT or COCP and normal VE gynaecology 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. endometrial polyp 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