REMEDY : BNSSG referral pathways

Cervical Conditions

Checked: 09-11-2018 by vicky.ryan Next Review: 08-11-2019

Introduction

Please refer to this presentation of cervical images (powerpoint), compiled by Caroline Overton, Consultant Gynaecologist, UHBristol.

The presentation provides a useful introduction to a range of cervical conditions including images of:

  • The normal cervix
  • Cervical cancer
  • Cervical ectropion
  • Nabothian follicles
  • Atrophic cervix
  • Benign cervical polyps
  • Cervical warts

Cervical Polyps

Smaller benign cervical polyps can often be managed in primary care. Refer to the guidelines on the management of cervical polyps in primary care (PDF).

Guidelines published by Dr Tim Percival (GP, Student Health Service), Dr Nicola McGuinness (GP, The Family Practice), Phil Smith (Consultant Gynaecologist, North Bristol NHS Trust) and Caroline Overton (Consultant Gynaecologist, UHBristol).

If there is any suspicion of malignancy then a 2WW referral should be made.

If a clinician does not feel comfortable removing a polyp in primary care then referral to gynaecology should be made via e-referral. Patients with a cervical polyp should not be referred directly to colposcopy.

Cervical Smears

Cervical smears are usually taken in primary care as part of the cervical screening program. This is available to women aged 25 to 64 in England. Women aged 25 to 49 receive invitations every 3 years and women aged 50 to 64 receive invitations every 5 years.

Patients who need follow up following an abnormal smear are referred directly to colposcopy clinics by the laboratory (outside of e-referral).

If a smear is difficult and cannot be taken in primary care then a referral to a general gynaecology clinic can be made via e-referral.

Post coital and inter-mentrual bleeding

Please see below advice on management of abnormal bleeding from Amit Patel, Gynaecological oncology consultant, UBHT (updated 20.3.15).

England changed the starting cervical screening age to 25 in 2012. This change was made as there are only a very small number of cervical cancers in patients aged under 25 and a huge number of patients under 25 will have an abnormal smear due to recent onset of sexual activity. Most of these women will clear HPV by age of 25. However young women (<25yrs) with symptoms need assessment to avoid missing cancer as they are now not screened. DoH therefore issued guidance which I think is a good guide on decision making (and also makes good sense for women of any age).

Post Coital Bleeding:

All patients with post coital bleeding should have a pelvic examination including an examination of the cervix.

Any age: if on examination the cervix appears SUSPICIOUS of cancer then the patient should be referred via 2WW pathway.

Any age: if on examination the cervix is either NORMAL  or there is an abnormality that is NOT SUSPICIOUS of cancer, then common reasons of symptoms should be explored/treated which in many cases relate to infection and hormonal contraceptives. The majority of these women do not have cancer. If no satisfactory explanation can be found, they should be referred to gynaecology clinic.

Women over 25yrs of age with  a negative previous smear history within the last three years are very unlikely to have a cervical cancer.

Intermenstrual Bleeding or Heavy Menstrual Bleeding:

If women have IMB or irregular periods, pathology is more likely to be related to the uterus and endometrium and not the cervix. If their cervix is not suspicious, they should be referred to general gynaecology clinic. US scan of pelvis is helpful in this group of women.

Post Menopausal Bleeding:

Please refer via 2WW if criteria are met

 

 

Referral

Gynaecology Referral:

Referrals for patients with cervical conditions that cannot be managed in primary care should be sent to gynaecology via eRS.

Colposcopy Referral:

The colposcopy service is under high demand at present and is mainly designed to see patients referred via the cervical screening program* (not via eRS). Referrals for colposcopy should therefore only be made where this is specifically indicated and referral to gynaecology is usually preferable in most cases (for example abnormal bleeding, ectropion, polyps should all be referred to gynaecology and not colposcopy). If referral to colposcopy clinic is indicated then this can be done in the following ways:

NBT: via eRS to a Referral Assessment Service (RAS). Referrals that are not appropriate may therefore be returned or triaged to alternative clinics. Please see the attached for comprehensive advice on how to refer GP information - Colposcopy referrals

UHB: eRS not available. These referrals are usually made directly as a result of an abnormal cervical smear via the smear program.

 

*Some GP’s are sending duplicate referrals for smear results when the laboratory has already referred directly. The colposcopy team have sent the referrals back with advice. GP’s do not need to separately refer when the laboratory directly refers. Almost all the women have been seen already and so it proves that the direct laboratory referral system works more efficiently than waiting for a GP referral.

If there is any suspicion of cancer on examination of the cervix then a 2WW referral should be made - see Red Fag section below.

Red Flags

If the appearance of the cervix on examination is suspicious for cervical cancer then refer via 2WW using the proforma.

For persistent post-coital bleeding in a woman under 35 years of age who on examination does not have a cervix that is suspicious for cancer,  then swab first to exclude infection and consider an urgent referral to gynaecology.