Referral of patients with unscheduled vaginal bleeding

referral of patients with unscheduled bleeding

When considering this presentation - always be cognisant of the possibility of needing to exclude a gynaecological cancer via the urgent referral pathway

The following patients should be referred to the secondary care for further evaluation

• women with an abnormal looking cervix, particularly in those without a recent smear test - if cervical cancer is suspected then an urgent referral cancer referral (2 week) is indicated
  
  
• women with a cervical polyp not easily removed in the surgery or that looks suspicious - if cervical cancer is suspected then an urgent referral cancer referral (2 week) is indicated
  
  
• women with a pelvic mass associated with heavy menses and intermenstrual bleeding, because these women are likely to have fibroids - refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
  
  
• women at high risk of endometrial cancer, such as those with a family history of hormone dependent cancer, those with prolonged and irregular cycles, and women on tamoxifen
  
  
• women in whom irregular bleeding might lead to discontinuation of hormonal contraception. Such women are best referred to their local family planning centre where there will be clinics for complex contraceptive problems
  
  
• all women over 45 years with intermenstrual bleeding should have a biopsy and those under 45 with persistent symptoms or risk factors for endometrial cancer should also be referred (1)

Reference:

• (1) Lumsden MA, Gebbie A, Holland C. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ. 2013;346:f3251.
• (2) NICE (June 2015). Suspected cancer: recognition and referral