History and Examination

History

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

Examination

• Visualize cervix and vagina
• Look for injury, foreign body, infection
• Take triple swabs, high vaginal, endocervical and chlamydia

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
• Lower genital tract or uterine cancers

• Postmenopausal bleeding
• Risk factors for endometrial pathology e.g. diabetes, obesity, tamoxifen treatment, family history, polycystic ovary syndrome
• Suspicious lesions on cervix or vagina

• Smear if due as part of national screening programme
• Triple swabs (high vaginal swab, endocervical swab, chlamydia)

• 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 progestrogenic support eg LNG-IUS, POP, luteal phase progesterone for 6 months
• If over 35 years without red flags, refer for an ultrasound
• If treatment is unsucessful
  • Organise ultrasound scan
  • Consider referral to Gynecology

Formulary Chapter 7.3 - Contraceptives

Referral Criteria

If no response to primary care management and symptoms persist, refer to gynaecology.

"All routine referrals have been changed to telephone consultation where possible and if required can attend the department for examination and further investigation."

Referral Instructions

e-Referral service selection:

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

Referral Forms

DRSS Referral Form

Pathway Group

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

Publication date: November 2018

Updated: June 2019