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Post-coital and intermenstrual bleeding NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
primary and secondary care management of:
abnormal menstrual bleeding, including heavy menstrual bleeding (HMB), irregular menstrual bleeding, and intermenstrual bleeding
post-menopausal bleeding (PMB)
post-coital bleeding (PCB)
Out of scope:
primary care management of amenorrhoeaa nd criteria for referral into secondary care
non-menstrual bleeding associated with pregnancy or pregnancy loss:
premenstrual syndrome (PMS)
chronic pelvic pain
specific management of bleeding problems caused by contraceptive devices
treatment of conditions underlying HMB, such as endometriosis and adenomyosis
HMB, or menorrhagia, is excessive menstrual blood loss over several consecutive cycles which interferes with the woman's physical, emotional, social, and material quality of life
irregular menstrual bleeding is defined as between three and five episodes with fewer than three bleeding-free intervals of length 14 days or more 
oligomenorrhoea is defined as menstrual bleeding at intervals of between 35 days and 6 months 
PMB is defined as:
an episode of bleeding in a woman at least 12 months after her last menstrual period 
any breakthrough bleeding in a woman receiving cyclical hormone replacement therapy (HRT)
breakthrough bleeding after the first 6 months of continuous HRT, or after full amenorrhoea has been established 
intermenstrual bleeding is defined as bleeding between periods 
PCB is defined as bleeding that occurs after sexual intercourse 
Prevalence of HMB:
10% of reproductive-aged women have objective evidence of HMB
 National Institute for Health and Clinical Excellence (NICE), National Collaborating Centre for Women's and Children's Health. Long-acting reversible contraception: the effect and appropriate use of long-acting reversible contraception. London: Royal College of Obstetricians and Gynaecologists (RCOG) Press; 2005.
 Scottish Executive Health Department. Scottish referral guidelines for suspected cancer. Edinburgh: Scottish Executive Health Department; 2007.
 NHS Cancer Screening Programmes (NHSCSP). Colposcopy and programme management: Guidelines for the NHS Cervical Screening Programme, second edition. Sheffield: NHSCPS; 2010.
 National Institute for Health and Clinical Excellence (NICE). IPG413 Magnetic resonance image-guided transcutaneous focused ultrasound for uterine fibroids. London: NICE; 2011.
 NHS Evidence. Evidence Update on Heavy Menstrual Bleeding. London: National Institute for Health and Clinical Excellence (NICE); 2010.
 National Institute for Health and Clinical Excellence (NICE). Uterine artery embolisation for fibroids. IPG 367. London: NICE; 2010.
 Royal College of Radiologists (RCR), Royal College of Obstetricians and Gynaecologists (RCOG). Clinical recommendations on the use of uterine artery embolisation in the management of fibroids, second edition. London: RCR/RCOG; 2004.
 Royal College of Obstetricians and Gynaecologists (RCOG). Long-term consequences of polycystic ovary syndrome. London: RCOG; 2007.
Further information was provided by the following references including practice-based knowledge:
 Contributors representing the Royal College of Obstetricians and Gynaecologists (RCOG), 2013
 Gupta JK, Sinha A, Lumsden MA et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database of Systematic Reviews 2012; 5:CD005073.
 Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database of Systematic Reviews 2012; 9:CD001895.
 Oxford University Press. Oxford Medical Dictionary, 4th edition. Oxford: Oxford University Press; 2007.
 Talaulikar VS, Manyonda IT. Ulipristal acetate: a novel option for the medical management of symptomatic uterine fibroids. Adv Ther. 2012; 29:655-63.
 Hoellen F, Griesinger G, Bohlmann MK. Therapeutic drugs in the treatment of symptomatic uterine fibroids. Expert Opin Pharmacother. 2013 August epub ahead of print.
Post-coital bleeding is defined as bleeding that occurs after sexual intercourse .
Intermenstrual bleeding is defined as bleeding between periods .
Epidemiological evidence suggests that an alteration in the menstrual cycle, intermenstrual bleeding, or post-coital bleeding may be the first symptoms of gynaecological cancer and indicate the need for a pelvic examination – persistent intermenstrual bleeding requires investigation to exclude malignancy .
NB: Be aware that in the rare cases of cervical cancer which occur in women under the age of 25 years, delays in diagnosis are relatively common – the cardinal symptom of cervical cancer in this age group is post-coital bleeding .
Take a thorough history to include :
the woman's concerns
possibility of pregnancy and pregnancy history
menstrual cycle history, including:
last menstrual period
age at menarche
length of cycle
duration of menstruation
variability of cycle
any intermenstrual bleeding
if using hormonal contraception, also ask about bleeding pattern prior to treatment commencement
presence of additional symptoms that may suggest possible underlying pathology, such as:
pelvic pain and pressure symptoms
current contraceptive method (including duration of use and compliance)
medical conditions that may affect the absorption of orally-administered hormones
current medications that may interact with contraceptive method
cervical screening history (check if participating in a National Cervical Screening Programme)
risk of sexually-transmitted infections
recommended for all women who present with post-coital bleeding 
should include bimanual examination if there is pain, dyspareunia, or abnormal vaginal discharge 
can be performed:
either in primary care or at a genito-urinary medicine (GUM) clinic
If the cervix appears abnormal/suspicious upon speculum examination, refer urgently for 2 week wait
The following alarm symptoms may be the first symptoms of cancer and indicate the need for a pelvic examination and/or biopsy:
sudden increase in blood loss 
bulky uterus palpable abdominally (size more than a 10 week pregnancy) [5,6]
pelvic mass 
an unexplained vulval lump or vulval bleeding due to ulceration 
pelvic pain, tenderness, or pressure symptoms 
severe anaemia 
Cervical and endometrial cancers are rare in women of reproductive age who are using hormonal contraception or who do not have risk factors .
Risk factors for cervical and endometrial cancers include:
unopposed oestrogen treatments [2,5]
age 45 years and over 
family history 
abnormal smear result 
tamoxifen use [2,5]
polycystic ovary syndrome (PCOS) [2,5]
If there is any suspicion of underlying cancer the woman should be seen within 2 weeks [5,6].
benign uterine tumours composed of muscle and connective tissue with a thin covering capsule
most common tumour found in the female reproductive system
three different subtypes:
submucosal (most likely type to give rise to irregular or heavy menstrual bleeding)
occasionally present with symptoms similar to those associated with uterine cancer, such as:
intermenstrual or postcoital bleeding
bulky uterus (size greater than a 10 week pregnancy)
pelvic pain or tenderness
offer immediate referral to a specialist if:
fibroids are palpable abdominally
intra-cavity fibroids are present
uterine length as measured at ultrasound or hysteroscopy is greater than 12 cm
2WW referral forms are available as EMIS templates
Consider the following potential causes:
cervical ectropion 
pelvic inflammatory disease (PID) 
endometrial polyps 
endometrial hyperplasia 
hormonal contraception 
ectopic pregnancy 
adenomyosis (more common in parous women) 
cancers of the cervix or endometrium :
very rare in women of reproductive age who are using hormonal contraception or who do not have risk factors
risk factors include obesity, polycystic ovarian syndrome (PCOS), tamoxifen use, or unopposed oestrogen therapy
sexually transmitted infection (STI) :
Chlamydia trachomatis is the most common bacterial STI in the UK and chlamydial infection is a likely cause of post-coital bleeding 
risk factors for STIs include:
younger than age 25 years
a new sexual partner; or
more than one partner in the last year
Woman with post-coital bleeding should be referred for an ultrasound .
Upon speculum examination, if :
the cervix appears:
consider a pregnancy test (where appropriate)
consider cervical swabs in general practice or refer to family planning or genito-urinary medicine (GUM) clinic
abnormal/suspicious, refer urgently for 2 week wait gynaecology appointment
there is a benign lesion, eg cervical polyp, a routine gynaecological referral will suffice
A cervical screen can be taken if due or overdue .
Testing for sexually transmitted infection (STI) :
abnormal bleeding may be a presenting symptom of Chlamydia trachomatis
genital examination not generally required if there are no risk factors for STIs
a self-obtained low vaginal swab (SOLVS) (if available locally) or a first-void urine (FVU) sample can be tested, if a speculum examination is not being performed
Levonorgestrel intrauterine system (LNG-IUS) users with pain, discharge, or lost threads (in addition to bleeding) require investigation to exclude expulsion, perforation, or infection
Local administrative information
WAHT run a Radiology Open Access Clinic at Weston General Hospital, with 20 slots for rapid access Trans-vaginal scan. The clinic runs Tuesday morning and Wednesday afternoon. When the GP refers the patient using the Open Access Gynae (OAG) request form, the patient is instructed to ring appointments and is then given a specific time within one of the designated clinics at which to attend
They will not accept referrals for women with post-menopausal bleeding as they feel most will be 2WW. For the small isolated post-menopausal bleeds that don’t warrant 2WW referral they recommend an abdominal ultrasound combined with TVS to give more information.
For other indications, if a TVS is requested and the sonographer considers a transabdominal (TA) scan is required this will be arranged but may require a second appointment as a full bladder is required
Women presenting with symptoms of cervical cancer, such as post-coital bleeding (particularly in women over age 40 years), intermenstrual bleeding, and persistent vaginal discharge should be urgently referred for gynaecological 2 week wait examination and onward referral for colposcopy if cancer is suspected [17,18].
2WW referral forms are available as EMIS templates
urgently if post-coital bleeding (PCB) persists for more than 4 weeks in women age over 35 years 
if findings from speculum examination are abnormal, refer appropriately to a gynaecologist or oncologist 
if there is any suspicion of underlying cancer, the woman should be seen within 2 weeks 
if findings are normal, but symptoms include pain, dyspareunia, and/or heavy bleeding, or patient is age 45 years and over, consider referral for further assessment (eg ultrasound, biopsy, hysteroscopy) 
Those referred for investigation in secondary care for PCB include patients :
with features suggestive of underlying pathology, such as:
a bulky uterus palpable abdominally (size more than a 10 week pregnancy)
a pelvic mass
significant change in blood loss
pelvic pain, tenderness or pressure feeling
Local administrative information
Bristol Sexual Health Centre
Appointments: 0117 3426900.
This is a single point of information telephone line for all of our clinics so when you speak to us please say which clinic you would like to attend. (The appointment line is open Monday to Thursday 9am to 7pm, Fridays 9am to 1pm, Saturdays 9.30am to 12.30pm).
Advice line: 0117 342 6944.
Monday: 9am to 4pm, Tuesday: 9am to 4pm, Wednesday: 9am to 12 midday, Thursday: 9am to
4pm, Friday: 9am to 12 midday. Doors open at 8am.
Saturday: 9am to 12 midday (reduced service). Doors open at 8.45am.
Walk-in spaces are limited and these sessions are often busy so we now operate a ticket system during these times and you may be given a ticket to return at a later time in the day.
Weston Integrated Sexual Health (WISH)
Appointments are available in the mornings and we have a Walk In and Wait service available with the Specialist Nurses in the afternoons and evenings. PLEASE BE AWARE THAT DURING BUSY WALK IN SESSIONS THE WAIT TO BE SEEN CAN BE A WHILE.
How do I make an appointment?
To make an appointment call: 01934 881234 during the opening times below. There is an answer phone if you ring at other times, we will get back to you as soon as possible if you leave a message.
9.00 am - 5.15 pm
Tuesday 9.00 am - 7.15 pm
Wednesday 9.00 am - 12.30 pm and 3.00 pm - 7.15 pm
Thursday 8.30 am - 12.30 pm
Friday 8.30 am - 12.30 pm
SATURDAY (AS OF JUNE 2014) 08:45- 12:45 APPOINTMENT ONLY-NO WALK INS WILL BE TAKEN - FIRST AND THIRD SATURDAY OF EVERY MONTH ONLY Please contact reception to make an appointment on 01934 881234
Weston Area Health Trust
Weston General Hospital
Tel: 01934 881234
Refer on standard RSS referral form which is available as an EMIS template