This information is sourced from the Royal College of Obstetricians and Gynaecologists (RCOG):

Women should initially be managed by remote communication

Heavy Menstrual Bleeding (HMB)

• Women should be reassured that the risk of malignancy is negligible
• A history should elucidate the severity of the symptoms, the possibility of anaemia and the likely cause
• If there are no symptoms of anaemia, or if present anaemia is likely to be mild, oral medication should be prescribed after exclusion of contraindications

Women should be referred to secondary care for further management of HMB if:

• The HMB is torrential and / or prolonged
• Ongoing HMB that has been resistant to NICE recommended oral treatments and is considered unmanageable by the woman
• Severe anaemia is suspected
• Considered unmanageable by the woman
• Associated with significant risk factors for endometrial disease (atypical hyperplasia or cancer) e.g. morbid obesity (BMI >/= 40), obesity (BMI >/= 35) in women over 40 years of age, Lynch syndrome

Intermenstrual Bleeding (IMB)

Women age 40 or over with persistent IMB (> 3 consecutive months who are not using hormonal contraceptives) should be referred to secondary care and seen within 30 days

Women under age 40, or women age 40 or over who are using hormonal contraceptives, with persistent IMB (> 3 consecutive months) should be referred to secondary care and may be seen beyond 30 days. If resources for assessment in hospital are limited then consider:

• Women should be reassured that IMB is common, symptoms often spontaneously resolve, and underlying cancer is rare
• Take a clinical history to determine symptom severity and the likely cause
• Pregnancy should be excluded

Where the likelihood of sexually transmitted infection or genital tract cancer is considered negligible, then management options to discuss include:

• Reassurance
• Phone follow up to see if the IMB subsides
• Change in hormonal contraceptives in current users
• Trial of hormonal contraceptives in non-users

Women should only be asked to come for a pelvic examination, preferably in primary care, if:

• There is a risk of sexually transmitted infection (take genital tract swabs)
• Cervical cancer is suspected because of associated post-coital bleeding and / or offensive vaginal discharge

Women should be referred to secondary care for further investigation if:

• Cervical cancer is suspected on pelvic examination
• Endometrial cancer is suspected because of persistent IMB (i.e. occurring for at least 3 consecutive months) in women over 40 years of age who are not using hormonal contraceptives

Postmenopausal bleeding (PMB)

• PMB is a red flag symptom because 5 – 10% of women will have endometrial cancer
• Clinical management of PMB should be focused on identifying cancer

Women with PMB should initially be managed by remote communication to:

• Confirm the symptom
• Be informed that a 2 week wait referral to secondary care will be made
• Determine if they have any symptoms of Covid-19. Women who have suspected or confirmed Covid-19 will not be seen in secondary care until they are no longer infectious (14 days from the onset of symptoms)
• This risk of viral transmission from hospital assessment for Covid-19 vulnerable / shielding patients’ needs to be balanced against the risk of delay in diagnosis of a gynaecological cancer on a case by case basis
• This risk needs to be balanced against the risk of delay in diagnosis or exclusion of a gynaecological cancer on a case by case basis

Post coital bleeding (PCB)

• Reassure women that cervical cancer is extremely unlikely if they have an in-date negative cervical screening test
•  If risk factors for an STI exist, they should be seen in primary care or a Sexual Health Clinic for further investigation and management
• Women who do not have an in-date negative cervical screening test need to be seen for a speculum examination to exclude cervical cancer and for a smear to be taken; depending on local circumstances, this could be in primary or secondary care

Women with PCB should be referred to secondary care and seen within 14 days if:

• The appearance of the cervix is consistent with cervical cancer
• They are aged 35 years or under with abnormal, absent or overdue cervical screening
• They are aged >35 years, regardless of smear history

Women with PCB aged <35 years, should be referred to secondary care and seen within 42 days