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Abnormal Cervix and Post Coital Bleeding

 

Introduction

PCB is defined as non-menstrual bleeding that occurs immediately after sexual intercourse. In the absence of other clinical symptoms and signs PCB rarely indicates cervical cancer and is more likely due to other common causes such as chlamydia, menstrual disorders or contraceptive/HRT issues.  

 

Normal physiological changes on the cervix do not require referral or treatment. Benign changes on the cervix include:

  • Normal physiological findings e.g. cervical ectropion, Nabothian cysts
  • Iatrogenic e.g. scarring following previous LLETZ treatment
  • Benign cervical polyps

 

In Scope:        Post-coital Bleeding and “abnormal cervix”

Not in scope: Post menopausal bleeding (PMB)

                        Heavy menstrual bleeding (HMB)  and intermenstrual bleeding  (IMB)

               
 

Red Flag Features

 

Management Optimisation

Normal Cervix - no referral needed, continue cervical screening.

Cervical Cancer- any suspicion of cancer requires a fast-track suspected cervical cancer referral

Ectropion(a normal physiological finding)- does not usually require treatment or referral.  Reassurance and written patient information can be provided.

Nabothian Cysts(a normal physiological finding)- does not usually require treatment or referral.  Reassurance and written patient information can be provided.

Post LLETZ Scar- Post LLETZ scars do not require treatment or referral. Patients who have been successfully treated for CIN simply require ongoing screening through the NHS Cervical Screening Programme and should be encouraged to engage with this.

Benign Cervical Polyp- can be left alone or removed if symptomatic or greater than 1cm.  See cervical polyps page for further information on removal. 

Prolapsed Cervical Fibroid- routine referral to general Gynaecology clinic with US pelvis.  Emergency referral is appropriate if there is significant pain/prolonged and heavy bleeding. These should not be removed in primary care due to the risk of profuse bleeding. 

Cervical Atrophy- treat with vaginal oestrogen

 

Investigations required prior to referral

  • Cervical screening if overdue or due (or due within 3 months). This can and should be done in the presence of physiological changes, cervical polyps and post LLETZ scarring
  • Chlamydia screening (whether high risk or not)



Referral instructions

Fast track suspected cervical cancer referral criteria

  • Seen in Cervical Assessment Clinic
  • Patients with a suspicious cervix i.e. examination findings (speculum and or vaginal examination) consistent with cervical cancer do not require formal colposcopy (please do not advise the patient that they will be having a colposcopy.

Complete fast track suspected gynaecology cancer referral form

 

Routine referral criteria

Benign Gynaecology Clinic

  • Cervical polyps that cannot be removed in a GP surgery (eg prolapsed fibroid polyps)
  • Unable to visualize the cervix completely owing to difficulties with examination in the presence of symptoms. Digital vaginal examination can be helpful to ensure that the cervix feels normal, even if it cannot be visualised. Checking cervical screening history is important.
  • PCB with a normal cervix once common causes eg Chlamydia infection, contraceptive cause etc have been excluded

Colposcopy clinic referral criteria

  • Abnormal cervical screening – these patients will be referred directly to the colposcopy service by the screening laboratory in Bristol
  • Difficulties taking a cervical screening test
  • Patients currently under the care of colposcopy clinic who are transferring to RCHT from another area

Referral exclusions:             

  • Isolated contact bleeding at the time of sample taking is not an indication for referral. 
  • Referrals to colposcopy with normal cervical screening.

Information to include in referral letter 

  • Describe problem and length of symptoms
  • Details of contraception or other hormonal treatment
  • HPV vaccination history if possible (for patients born after September 1990)
  • Screening history if possible (including date of last screen & result) 
  • If cervical screening is due, please advise whether or not (and if not, why not) a screening test was taken at the time of the referral
  • Examination findings (eg. normal / ectropion/cervical polyp)

 

Supporting Information

For patients

Cervical Assessment Clinic, RCHT

Following treatment of cervix

leaflet-cervical-ectopy.pdf

Cervical Polyps — Chelsea and Westminster Hospital NHS Foundation Trust

Nabothian follicle/Nabothian cyst — Chelsea and Westminster Hospital NHS Foundation Trust

References:    Cervical Assessment at RCHT V2.0 Feb 2025

                             BSCCP | Cervical images

                             Colposcopy Digital Atlas

 

Page Review Information

 

Review date

14/03/2025

Next review date

14/03/2027

Clinical editor

Dr Melanie Schick, clinical lead for gynaecology

Contributors

Miss Sophia Julian, Consultant Gynaecological Oncologist and Lead Colposcopist, RCHT