History

• Frequency of occurrence
• Any specific pattern
• Heavy or light spotting
• Date of last smear

Examination

• Speculum and pelvic examination
• Visualize vulva, cervix and vagina
• Look for injury, foreign body, infection
• Take swabs:
  • one high vaginal swab (HVS e swab from posterior fornix and vaginal wall)
  • one vulvo-vaginal swab (VVS NAAT swab which is a multicollect kit) rub along vaginal wall, labia and introitus for 15s – specify gonococcus (GC) and chlamydia (CT) on form)
  • If symptoms and signs are compatible with GC or CT then an endocervical swab (ECS with e swab into the endocervix and rotated 360°) should be done in addition to the above HVS and VVS. Specify GC/CT on the request.

• Check smear is up to date and obtain if due.

Differential Diagnoses

Inter-menstrual bleeding can be associated with:

• Infection (chlamydia is a common cause)
• Hormonal imbalances
• Contraception:
  • Progestogen only pill
  • Combined contraception, especially low dose

• Intra-uterine contraception device or intra-uterine system
• Injury
• Foreign body
• Polyps

• Postmenopausal Bleeding (PMB) – see Postmenopausal Bleeding - South & West
• Suspicious lesions on cervix or vagina – refer on the Urgent Suspected Cancer Pathway (USCP) Gynaecology - South & West 

• Recurrent IMB if over 40 years:
  • that persists for longer than 6 months with no obvious cause, or 
  • if other risk factors for endometrial pathology (see below)

- request transvaginal ultrasound and refer urgently to gynaecology outlining the risk factors.

Risk factors for endometrial pathology:

• BMI over 40
• Family History/genetic predisposition (Lynch/Cowden syndrome)
• Unopposed oestrogen
• PCOS
• Diabetes
• Tamoxifen

Smear (only if due as part of national screening program).

Swabs – see examination.

• Treat any identified infection
• Where possible remove foreign body or cervical polyp and send to histology
•  If under 35 and no red flags consider trial of contraceptive pill or progestogenic support e.g. LNG-IUS, POP, luteal phase progesterone for 6 months – please see Contraception Guidance - South & West
• If over 35 years without red flags, refer for a transvaginal ultrasound
• If no response to primary care management, or management is unable to be undertaken in general practice, and symptoms persist, refer routinely to gynaecology.

Referral Criteria

Routine:
If no response to primary care management, or management is unable to be undertaken in general practice, and symptoms persist, refer routinely to gynaecology

Urgent:

• Recurrent IMB if over 40 years:
  • that persists for longer than 6 months with no obvious cause, or
  • if other risk factors for endometrial pathology (see below)

- request transvaginal ultrasound and refer urgently to gynaecology outlining the risk factors.

Risk factors for endometrial pathology:

• BMI over 40
• Family History/genetic predisposition (Lynch/Cowden syndrome)
• Unopposed oestrogen
• PCOS
• Diabetes
• Tamoxifen

Urgent Suspected Cancer Pathway:

• Suspicious lesions on cervix or vagina
  See Urgent Suspected Cancer Pathway (USCP) Gynaecology - South & West

Referral Instructions

e-Referral service selection:

• Specialty: Gynaecology
• Clinic Type: Not otherwise specified
• Service: DRSS-Western-Gynaecology-Devon ICB-15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: November 2018

Updated: November 2024