HNY Policy and Pathway Repository - York

• Non-menstrual bleeding that occurs after sexual intercourse.
• Post-coital bleeding is predominantly cervical in origin.
• Main causes are:
  • Cervical ectropion (34%).
  • Cervical polyp (5-13%).
  • Cervicitis (STIs - usually chlamydia) (2%).
  • CIN (7-17%).
  • Cervical cancer (0.65--4%).
• Rare causes include syphilis, herpes simplex, vaginal atrophy, vaginal cancer, pelvic organ prolapse, endometrial cancer, endometriosis, trauma.
• No specific cause is identified in 50% of cases.

• Postmenopausal Bleeding (PMB) i.e. bleeding >12 months after last period over age 55.
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer (new NICE recommendation for 2015).

• History, including sexual health history. Think Chlamydia under age 25.
• Routine examination and swabs (remember increased risk of chlamydia if aged < 25 or change of sexual partner).
• Perform smear ONLY if due.
• If an ectropion is found- consider change in contraception as ectropions are commonly hormone-induced.
  • Note ROUTINE CRYOTHERAPY for treatment of an ectropion is not routinely performed as high risk of recurrence and risk of scarring
• If find cervical polyp, see guidance
• Consider USS if normal appearance of cervix, to exclude endometrial pathology.

Indications for referral

• If PCB > 6 months or bleeding is particularly heavy.
• Cervical pathology- 2ww for suspicious features, routine referral for large polyp, ectropion present or childbirth related superficial trauma/ scarring.
• Consider early referral in women over age 40
   

Information to include in referral letter

• Describe problem (cycle, quantify e.g. pad usage, duration) and effect on quality of life / activities of daily living
• FBC and USS results 
• Current contraception
• Smear history (including last smear & result) the patient will still be seen without this but if you include it automatically, this will speed up the appointment.
• Treatment options please include what has been tried and whether it has been effective
   

Investigations prior to referral

• Chlamydia screening (better taken as ECS when presenting with PCB).
• High Vaginal Swab
• Pelvic USS
• Smear test (only if due)

Patient information leaflets/ PDAs

• Intermenstrual and postcoital bleeding on patient.co.uk website
   

References

• NICE Guideline Aug 2016 Heavy Menstrual Bleeding
• https://www.gp-update.co.uk/SM4/Mutable/Uploads/pdf_file/Post-coital_bleeding.pdf 
• BMJ 2013;346:3251