HNY Policy and Pathway Repository - North Yorkshire and York

Vaginal bleeding (other than post coital) at any time in the cycle other than during normal menstruation.

• Postmenopausal Bleeding (PMB) i.e. bleeding >12 months after last period. PMB pathway
• Suspicious cervix on examination. Refer USC
• Persistent Intermenstrual bleeding (IMB) if >40 or other risk factors for endometrial cancer. (eg obesity, PCOS, unopposed oestrogen, tamoxifen) refer urgently and request USS

• If more than 3 episodes of IMB; organize examination and swabs
• Remember chlamydia in under 25s.
• If any abnormality on pelvic examination: pelvic mass- organise USS.
• If swabs and examination are normal- trial of treatment: Mirena/COCP/ POP for 3 months.
• If women already on hormonal contraception unscheduled bleeding is common with all forms of hormonal contraception during the first 3 months of use, consider trialling a different hormonal preparation after this time
• Failure to respond to standard therapy - consider referral for hysteroscopy

Indications for referral

• Failure to response to the above therapies
   

Information to include in referral letter

• Describe problem and length of symptoms.
• Current Contraception
• Smear history (including last smear & result) the patient will still be seen without this but if you can retrieve it automatically it speeds up the consultation. Do not perform smear outside of screening programme.
• Relevant past medical/surgical history
• Current regular medication
• BMI/smoking status
• Speculum findings (e.g. normal/ectropion/ cervicitis/cervical polyp)
• Swab results - VVS or ECS if sexually active or signs/symptoms of PID
• USS result
• Treatments tried so far

Patient information leaflets/ PDAs

NHS leaflet: What causes bleeding between periods?

References

NICE Guideline Heavy Menstrual Bleeding: assessment and management (NG 88)

NICE Guideline: Suspected cancer: recognition and referral (NG12)

Joint RCOG, BSGE and BGCS guidance for the management of abnormal uterine bleeding in the evolving Coronavirus (CQVID-19) pandemic

• York and Scarborough Teaching Hospitals