Cervical Conditions

Introduction

Please also refer to Remedy guidance on Abnormal Vaginal Bleeding.

Please refer to this presentation of cervical images (powerpoint), compiled by Caroline Overton, former Consultant Gynaecologist, UHBristol, and this link to a reference guide for cervical conditions http://www.cytology-training.co.uk/wp-content/uploads/2016/11/Cervix_chart.pdf

These resources provide a useful introduction to a range of cervical conditions including images of:

• The normal cervix
• Cervical cancer
• Cervical ectropion
• Nabothian follicles
• Atrophic cervix
• Benign cervical polyps
• Cervical warts

Cervical Polyps

Symptomatic polyps

Clinical Knowledge Summaries Guideline on Cervical Cancer and HPV (Sept 2020) explains that premenopausal women should be referred to gynaecology or GUM if they have persistent IMB, PCB or blood-stained vaginal discharge AND

• Polyp, ectropion, cervicitis or warts
• Infection has been excluded or treated but bleeding has continued for 6-8 weeks after treatment.

See also the Abnormal vaginal bleeding page.

Asymptomatic polyps

If a polyp is found as an incidental finding without any symptoms (eg at smear test) then referral is not necessary unless the GP is concerned by its appearance. This referral should be to general gynaecology clinic via eRS and not colposcopy.

If there is any suspicion of malignancy then a Gynaecology 2WW referral should be made.

If a GP is happy to remove a benign polyp and send for histology then this is acceptable if they feel confident to do so.

Cervical Smears

Please see the Cervical Cancer Screening page of Remedy.

Post coital and inter-mentrual bleeding

Post Coital Bleeding:

All patients with post coital bleeding should have a pelvic examination including an examination of the cervix.

Any age: if on examination the cervix appears SUSPICIOUS of cancer then the patient should be referred via Urgent Suspected Cancer (2WW) pathway.

Any age: if on examination, the cervix is either NORMAL or there is an abnormality that is NOT SUSPICIOUS of cancer, then common reasons of symptoms should be explored/treated which in many cases relate to infection and hormonal contraceptives. The majority of these women do not have cancer. If no satisfactory explanation can be found, they have persistent PCB (>3/12) and sexually transmitted infection has been excluded, they should be referred to an URGENT gynaecology clinic.

(Please include smear history or do smear at time of referral if this is overdue. Please also include results of recent swabs to exclude sexually transmitted infection) 

Women over 25yrs of age with a negative previous smear history within the last three years are very unlikely to have a cervical cancer.

Intermenstrual Bleeding or Heavy Menstrual Bleeding:

If women have IMB or irregular periods, pathology is more likely to be related to the uterus and endometrium and not the cervix. If their cervix is not suspicious, they should be referred for a pelvic USS and then managed according to the findings of this scan.

Post Menopausal Bleeding

Please see the Abnormal Vaginal Bleeding page for Post Menopausal Bleeding, including bleeding whilst on HRT.

Please see Gynaecology Urgent Suspected Cancer (2WW) Referral

Ectropion

Consider Referral

Women aged 35 or under with abnormal bleeding or discharge who have an in-date smear where an ectropion is visualised on speculum examination which does not have suspicious features then consider other causes (COC or infection). However have a low threshold for referral or request gynaecology advice and guidance if you have any concerns.

Do not Refer

Women who are asymptomatic and have an ectropion visualised during a routine examination and a negative in-date cervical smear do not need referral.

Red Flags

If the appearance of the cervix on examination is suspicious for cervical cancer then refer via Urgent Suspected Cancer (2WW) using the proforma.

For women with evolving / worsening symptoms such as post-coital bleeding consider re-examination and expediting referral from routine to urgent gynaecology or 2WW as needed.

Referral

Gynaecology Referral:

Referrals for patients with cervical conditions that cannot be managed in primary care should be sent to gynaecology via eRS.

Colposcopy Referral:

The colposcopy service is under high demand at present and is mainly designed to see patients referred via the cervical screening program* (not via eRS). Referrals for colposcopy should therefore only be made where this is specifically indicated and referral to gynaecology is usually preferable in most cases (for example abnormal bleeding, ectropion, polyps should all be referred to gynaecology and not colposcopy). If referral to colposcopy clinic is indicated then this can be done in the following ways:

NBT: via eRS to a Referral Assessment Service (RAS). Referrals that are not appropriate may therefore be returned or triaged to alternative clinics. Please see the attached for comprehensive advice on how to refer GP information - Colposcopy referrals

UHBW: via eRS to a Referral Assessment Service (RAS). These referrals are usually made directly as a result of an abnormal cervical smear via the smear program.

*Some GP’s are sending duplicate referrals for smear results when the laboratory has already referred directly. The colposcopy team have sent the referrals back with advice. GP’s do not need to separately refer when the laboratory directly refers. Almost all the women have been seen already and so it proves that the direct laboratory referral system works more efficiently than waiting for a GP referral.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.