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guideline (postcoital bleeding, urgent referral)

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Gynaecological cancers

Symptoms suggestive of Ovarian cancer

  • refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)

  • carry out tests in primary care (see below) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis - particularly more than 12 times per month:
    • persistent abdominal distension (women often refer to this as 'bloating')
    • feeling full (early satiety) and/or loss of appetite
    • pelvic or abdominal pain
    • increased urinary urgency and/or frequency

  • consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit

  • carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS)[2], because IBS rarely presents for the first time in women of this age

Tests in primary care for possible ovarian cancer:

  • measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer
  • if serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
  • if the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation
  • for any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:
    • assess her carefully for other clinical causes of her symptoms and investigate if appropriate
    • if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent

Symptoms suggestive of Endometrial cancer

  • refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)

  • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 with post-menopausal bleeding

A direct access ultrasound scan to assess for endometrial cancer should be considered in women aged 55 and over with:

  • unexplained symptoms of vaginal discharge who:
    • are presenting with these symptoms for the first time or
    • have thrombocytosis
    • or report haematuria,
  • or visible haematuria and:
    • low haemoglobin levels or
    • thrombocytosis
    • or high blood glucose levels

Cervical cancer

  • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer

  • information regarding urgent referral for post-coital bleeding (2,3)

    • NHS Cancer Screening Programme document "Colposcopy and Programme Management" (2010) (3) says:
      • women presenting with symptoms of cervical cancer - such as postcoital bleeding (particularly in women over 40 years), intermenstrual bleeding and persistent vaginal discharge - should be referred for gynaecological examination and onward referral for colposcopy if cancer is suspected
        • examination should be performed by a gynaecologist experienced in the management of cervical disease (such as a cancer lead gynaecologist)
        • they should be seen urgently, within two weeks of referral

    • extracts from the 2007 Scottish referral guidelines are:
      • cervical cancer
        • typical symptoms are postmenopausal, postcoital and persistent intermenstrual bleeding
        • usually (80%) diagnosed on speculum examination
      • guidelines for urgent referral:
        • Postcoital bleeding (PCB) age > 35 years that persists for more than 4 weeks
      • key points
        • women with abnormal vaginal bleeding should have a speculum examination at presentation to identify local causes of bleeding. A woman presenting with this symptom who has negative cytology has a greatly reduced risk of cervical cancer but the risk is not entirely eliminated
        • with clinical features suggestive of cervical cancer on examination. A smear test is not required before referral, and a previous negative result should not delay referral (more detailed criteria regarding urgent referral for PCB are outlined below)
        • consider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examination

Suspected Vulval cancer

  • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding

Suspected Vaginal cancer

  • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina

Reference:

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General Practice Notebook
General Practice Notebook
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