Postcoital Bleeding (893)

Cervical

• Ectopy
• Cervicitis
• STI
• Condyloma
• Carcinoma (rarely)

Vaginal/Vulval

• Trauma
• Vaginitis
• Tumours (rarely)
• Vulval Dermatoses

Uterine

• Endometrial polyp
• Dysfunctional Uterine Bleeding (DUB)
• Endometritis
• Endometrial Hyperplasia/malignancy

Iatrogenic

• IUCD/IUS
• Following smear or treatment to the cervix
• Hormonal contraception

The following aspects should be covered in the history:

• nature and timing of bleeding
• menstrual history
• smear/colposcopy history
• contraception history
• sexual history for STI where appropriate
• medical History e.g. bleeding diathesis, diabetes
• medication e.g. anticoagulants, antibiotics with secondary candidiasis
• dyspareunia

• Bimanual examination
• Speculum examination
• HVS
• STI screen where appropriate (Chlamydia and gonococcus)
• Cervical smear if due
• Urgent colposcopy referral in the event of clinical suspicion of cervical malignancy
• If no lower genital tract cause found, consider TVS in women over the age of 40

• Women with PCB should be referred to Colposcopy as ‘URGENT: Suspicious of cancer’ and seen within 10 working days if the appearance of the cervix on speculum examination is suspicious of or consistent with cervical cancer.
• Women with PCB with abnormal cervical screening should be referred to Colposcopy as per usual colposcopy protocols. Those in whom screening is absent or overdue should have a cervical smear and be referred based on the smear result and clinical examination findings.
• Women with persistent PCB aged less than 40yrs with a normal smear history and normal speculum examination should have a self-obtained vulvovaginal swab for chlamydia and gonorrhea NAAT testing and, where appropriate, treatment for genital tract infection.
  Consideration should be given to a change of hormonal contraceptive if relevant. A therapeutic trial of Relactagel (PV for one week after menses and repeated for 2 months) should also be considered. If these measures are ineffective, patients can be referred as ‘Routine’ for further assessment to gynaecology / colposcopy depending on local service provision.
• Women over 40 should be referred as urgent and seen within secondary care services within 14 days (gynaecology / coloposcopy).
• Patients are invited to participate in the national cervical screening programme from the age of 25. PCB is not an indication for a cervical smear in those aged less than 25.

Differences in age cut off and referral times in these recommendations compared to the RCOG / BSGE Abnormal Uterine Bleeding Covid Guideline should be noted. Differences are due to the current GGC service structure and Scottish Government treatment time targets which differ from the UK system.

• Treat infection
• Remove endocervical polyps
• Consider change of contraceptive formulation or method
• Consider Relactagel®/Balance Activ® gel to acidify vagina. This should be used after menses,nightly for 1 week and repeated for 2 months. (NB contra-indicated if patient or partner has shellfish allergy).
• Topical oestrogen preparations in the presence of atrophic vaginitis e.g oestradiol pessary (Vagirux® or Vagifem®) or Orthogynest® cream
• Endometrial assessment in women over 40 in whom the above measures have failed.