postcoital bleeding (criteria for urgent referral)

Last edited 05/2020 and last reviewed 10/2022

Gynaecological cancers

Symptoms suggestive of Ovarian cancer

• refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
  
  
• carry out tests in primary care (see below) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis - particularly more than 12 times per month:
  • persistent abdominal distension (women often refer to this as 'bloating')
  • feeling full (early satiety) and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
    
    
• consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit
  
  
• carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS)[2], because IBS rarely presents for the first time in women of this age

Tests in primary care for possible ovarian cancer:

• measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer
• if serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
• if the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation
• for any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:
  • assess her carefully for other clinical causes of her symptoms and investigate if appropriate
  • if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent

Symptoms suggestive of Endometrial cancer

• refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)
  
  
• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 with post-menopausal bleeding

A direct access ultrasound scan to assess for endometrial cancer should be considered in women aged 55 and over with:

• unexplained symptoms of vaginal discharge who:
  • are presenting with these symptoms for the first time or
  • have thrombocytosis
  • or report haematuria,
• or visible haematuria and:
  • low haemoglobin levels or
  • thrombocytosis
  • or high blood glucose levels

In the full guideline (1) the CDG states "Based on their clinical experience they considered that whilst ultrasound is an investigation commonly used to diagnose endometrial cancer in secondary care, it could have value as an investigation in primary care to determine if a suspected cancer pathway referral was needed."

Cervical cancer

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer
  
  

• information regarding urgent referral for post-coital bleeding (2,3)

  • NHS Cancer Screening Programme document "Colposcopy and Programme Management" (2010) (3) says:
    • women presenting with symptoms of cervical cancer - such as postcoital bleeding (particularly in women over 40 years), intermenstrual bleeding and persistent vaginal discharge - should be referred for gynaecological examination and onward referral for colposcopy if cancer is suspected
      • examination should be performed by a gynaecologist experienced in the management of cervical disease (such as a cancer lead gynaecologist)
      • they should be seen urgently, within two weeks of referral
        
        
  • extracts from the 2019 Scottish referral guidelines are:
    • cervical cancer
      • majority of cases (80%) are diagnosed on speculum examination and up to 40% are screen detected. Typical symptoms include vaginal discharge, postmenopausal bleeding, postcoital bleeding and persistent intermenstrual bleeding. A cytology test is not required before referral, and a previous negative result is not a reason to delay referral.
    • guidelines for urgent referral:
      • any woman with clinical features (vaginal discharge, postmenopausal, postcoital and persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix
        

Suspected Vulval cancer

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding

Suspected Vaginal cancer

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina

Reference:

• NICE (June 2015). Suspected cancer: recognition and referral
• NHS Cancer Screening Programme. Colposcopy and Programme Management. Guidelines for the NHS Cervical Screening Programme. Second edition. 2010.
• Scottish Executive Scottish Referral Guidelines for Suspected Cancer. 2019