History and Examination

History

• Frequency of occurrence
• Any specific pattern
• Heavy or light spotting
• Date of last cervical smear

Examination

• Visualize cervix and vagina
• Look for injury, foreign body, infection
• Take triple swabs, high vaginal, endocervical and chlamydia

Differential Diagnoses

Inter-menstrual bleeding can be associated with:

• Infection (chlamydia is a common cause)
• Hormonal imbalances
• Contraception:
  • Progestogen only pill
  • Combined contraception, especially low dose
• Intra-uterine contraception device or intra-uterine system
• Injury
• Foreign body
• Polyps
• Lower genital tract or uterine cancers

• Postmenopausal bleeding
• Risk factors for endometrial pathology e.g. diabetes, obesity, tamoxifen treatment, family history, polycystic ovary syndrome
• Suspicious lesions on cervix or vagina

• Smear if due as part of national screening programme
• Triple swabs (high vaginal swab, endocervical swab, chlamydia)

• Treat any identified infection
• Where possible remove foreign body or cervical polyp and send to histology
• If under 35 and no red flags consider trial of contraceptive pill or progestrogenic support eg LNG-IUS, POP, luteal phase progesterone for 6 months
• If over 35 years without red flags, refer for an ultrasound
• If treatment is unsucessful
  • Organise ultrasound scan
  • Consider referral to Gynecology

Formulary Chapter 7.3 - Contraceptives

Referral Criteria

If no response to primary care management and symptoms persist, refer to gynaecology.

Referral Instructions

For referrals to Gynaecology

e-Referral service selection:

• Specialty: Gynaecology
• Clinic Type: Not otherwise specified
• Service: DRSS-Eastern-Gynaecology-Devon ICB- 15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of the NHS Devon.

Publication date: November 2018

Updated: June 2019