History

• Contraception and any changes
• Possibility of pregnancy
• Any dyspareunia?
• Smear history

Examination

• Speculum and pelvic examination
• Visualize vulva, cervix and vagina
• Look for injury, foreign body, infection
• Take swabs. One high vaginal swab (HVS e swab from posterior fornix and vaginal wall) and one vulvo-vaginal swab (VVS NAAT swab which is a multicollect kit) rub along vaginal wall, labia and introitus for 15s – specify gonococcus (GC) and chlamydia (CT) on form)
• If symptoms and signs are compatible with GC or CT then an endocervical swab (ECS with e swab into the endocervix and rotated 360°) should be done in addition to the above HVS and VVS. Specify GC/GC on the request.
• Check smear is up to date and obtain if due

Differential Diagnosis

Include:

• Menstrual irregularity
• Infection
• Intermenstrual bleeding
• Trauma, abuse
• Foreign bodies
• Cervical polyps
• Cervicitis
• Vaginal atrophy
• Vulval skin issues
• Endometrial polyps
• Cervical Cancer
• Vulval, vaginal and endometrial cancer

If the cervix appears/feels abnormal/suspicious upon speculum examination, refer via the Urgent Suspected Cancer Pathway (USCP) for colposcopy.

Cervical cancers are rare in women of reproductive age.

Risk factors for cervical cancers include:

• HPV
• Previous abnormal smear result
• Multiple sexual partners
• Smoking

Cervical smear if due

Swabs – see examination

Consider pregnancy test

Consider TVUSS for persistent symptoms where no obvious cause has been found

Abnormal and suspicious looking cervix – refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP) - colposcopy

Abnormal and suspicious looking vagina or vulva – refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP)

Abnormal swabs – treat as per guidelines and refer as necessary to sexual health services. Genital tract infections - North & East. For Devon please see "Devon Sexual Health"

Cervical warts – refer to colposcopy, routine.

Foreign body – if possible, a foreign body may be removed by an appropriately trained clinician, Refer routinely to gynaecology if persistent and troublesome symptoms persist after management in primary care, with a no suspicious findings on assessment

Cervical polyp – refer routinely to gynaecology if persistent and troublesome symptoms persist after management in primary care, with no suspicious findings on assessment

Cervical ectropion – reassure, consider treatment if symptoms persist beyond 6 months. A change in method of contraception may resolve symptoms. If treatment is needed, refer routinely to Gynaecology or consider treatment in general practice if there is an appropriately trained and skilled clinician willing to undertake the procedure. The 75% silver nitrate caustic applicators are easy to use and long enough to reach the cervix. No anaesthetic or cleaning is required. Simply remove a caustic applicator from the pack and dab against the ectropion. Frequently more than one stick will be required. A colour change will be obvious where the area has been treated. Warn the patient regarding the risk of recurrence and inform them that the vaginal discharge will change over the next few days. Tampons and sex should be avoided initially. Refer routinely to gynaecology if persistent and troublesome symptoms persist after management in primary care, with no suspicious findings on assessment.

Normal cervix/vagina/vulva, normal swabs and normal smear result – reassure. If symptoms are persistent and troublesome – refer for TVUSS and to gynaecology as routine.

Approximately, 50% of women presenting to primary care with postcoital bleeding will have no obvious underlying cause. These women can be reassured that 60% of women experience a spontaneous resolution of symptoms within 6 months.

Referral Criteria

• Urgent Suspected Cancer Pathway (USCP) to colposcopy should be used for an abnormal and suspicious looking cervix (pathology will initiate actions following an abnormal smear test) Gynaecology Urgent Suspected Cancer Pathway (USCP) - North & East
• USCP to gynaecology if abnormal and suspicious looking mass in/at entrance to vagina or vulva. Gynaecology Urgent Suspected Cancer Pathway (USCP) - North & East
• Routine referral to gynaecology if persistent and troublesome symptoms persist after management in primary care, with a no suspicious findings on assessment.

Referral Instructions

For referral to Urgent Suspected Cancer Pathway (USCP):

e-Referral service selection:

• Specialty: 2WW
• Clinic Type: 2WW Gynaecology
• Service: 2WW Gynaecology - NDHCT - NDDH - RBZ

For referral to Gynaecology, refer via e-Referral service:

e-Referral service selection:

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

Referral Forms

DRSS Referral Form

Suspected Gynaecological cancer referral form - No merge fields

Patient Information

• What causes a woman to bleed after sex? - NHS (www.nhs.uk)

Pathway Group

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

Publication date: November 2018

Updated: December 24