Inter-menstrual bleeding

Scope

Inter-menstrual vaginal bleeding is defined as bleeding that occurs between normal menstruation in non-pregnant women. Normal menstrual cycle can be anywhere between 21 and 35 days.

Out of Scope

Assessment

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

Red Flags

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

Investigations

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

Management

  • 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

Referral Criteria

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

Referral Instructions

e-Referral service selection:

  • Specialty: Gynaecology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-Northern-Gynaecology- Devon CCG - 15N

Referral Forms

DRSS Referral Form

Supporting Information

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication date: November 2018

Updated: June 2019

 

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