Referral

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Gynaecology

Key Messages

GPs can refer a patient they suspect of having cancer for rapid assessment. Suspected cancer pathways are now measured against the ‘Faster Diagnosis Standard’ (FDS), in which the patient is expected to be given a diagnosis within 28 days.

GPs must send the referral within 24 hours of the decision to refer.

Please use the referral forms listed on this page to ensure appropriateness. They have been agreed by the Peninsula Cancer Alliance.

Unscheduled bleeding on HRT is very rarely (1-1.5%) associated with cancer. Please see separate guideline here

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  • A full pelvic examination, including speculum examination of the cervix, is an important part of the required assessment for patients presenting with any of the following:
    • alterations in the menstrual cycle
    • Intermenstrual bleeding
    • postcoital bleeding
    • postmenopausal bleeding
    • vaginal discharge.
  • Ovarian cancer is difficult to diagnose. Carry out an abdominal palpation and consider pelvic examination where appropriate in patients with vague, non-specific, unexplained abdominal symptoms such as:
    • bloating
    • constipation
    • abdominal pain
    • back pain
    • urinary symptoms

If considering referral for possible ovarian cancer, please include the following blood tests: CA125, FBC, Ferritin, LFT, Renal, and ideally if under the age of 40 please also include LDH, B-HCG and aFP.

Please note that CA125 may be elevated if taken during menstruation. Consider repeating the test if this is the case.

  • In patients with vulval pruritus or pain, a period of ‘treat, watch and wait’ is reasonable. Active follow-up is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.

Referral Criteria

Ovarian cancer

a. Physical examination identifies ascites and/or a pelvic or abdominal mass (not obviously fibroids)
b. Abdominal symptoms and an elevated CA125
Please include CA125, FBC, Ferritin, LFT, Renal, and ideally if under the age of 40 please also include LDH, B-HCG and aFP.

Endometrial cancer

Not taking HRT - women with an intact uterus with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)

Taking HRT - unscheduled bleeding with concern of endometrial cancer:

Risk factors for endometrial cancer include:

MAJOR risk factors – any of:
• BMI 40 or more
• Unopposed oestrogen more than 6 months in women with a uterus
• sHRT more than 5 years when started over age 45
• Inadequate progestogen more than 12 months*
• Familial risk (Lynch/Cowden syndrome)

MINOR risk factors: 3 of:
• BMI 30-39
• Diabetes
• PCOS or other causes of anovulatory cycles
• Unopposed oestrogen 3-6 months
• Inadequate progestogen 6-12 months*

*Inadequate progestogen includes:

  • Tricycling HRT (quarterly progestogen)
  • Norethisterone or Medroxyprogesterone acetate for less than 10 days/month
  • Micronised progesterone for less than 12 days/month
  • Expired LNG-IUS


TVUS findings:

  • Endometrial thickness of greater than 4mm on continuous combined HRT
  • Endometrial thickness of greater than 7mm on sequential combined HRT

Other unscheduled bleeding on HRT with GP cancer concern (outside of guidelines)

Unscheduled bleeding on HRT is very rarely (1-1.5%) associated with cancer. Please see separate guideline here.

Please consider an up-to-date FBC prior to referral

Cervical cancer

  • Appearance on cervical examination is consistent with cervical cancer

Vulval cancer

  • Unexplained vulval lump, ulceration or bleeding that is suspicious for malignancy

Vaginal cancer

  • Unexplained palpable mass in or at the entrance of the vagina that is suspicious for malignancy

Referral instructions

The GP should: use e-Referral Service to book an appointment or send the referral.

Please ensure you include:

  • The patient's NHS number
  • Tell the patient that this is an urgent referral and should be safety netted appropriately

e-Referral selection:

  • Specialty: 2WW
  • Clinic Type: 2WW Gynaecology
  • Service selection: Suspected Cancer-Gynaecology-Derriford-RK9

Referral Form

Suspected Gynaecological cancer referral form - No merge fields

This form also has been made available on Ardens for EMIS and SystmOne:

EMIS - 2WW - DCCG - Gynaecology Cancer Suspected

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