Investigations of other symptoms – vaginal discharge and deep dyspareunia

From Clinical Guidelines Wiki


Cervical screening and women with symptoms that may be associated with cervical cancer

The Cervical Screening Test (CST) is for asymptomatic women, aged 25–74, who are participating in the National Cervical Screening Program. Women with symptoms suggestive of cervical cancer require diagnostic testing at any age and not ‘cervical screening’.

The vast majority of symptomatic women, especially younger women, will NOT have cervical cancer and benign gynaecological causes are far more common.

Young women with post coital bleeding are far more likely to have a benign cause eg: Chlamydia infection or bleeding related to hormonal contraception.

Abnormal vaginal bleeding is the most common symptom of cervical cancer and is covered in detail in Investigation of abnormal vaginal bleeding.

Briefly:

  • Women at any age with unexplained inter-menstrual bleeding, which may be suspicious for cervical cancer, require initial investigation with a co-testHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.) and referral for gynaecological assessment.
  • Pre-menopausal women at any age with a single episode of post-coital bleeding should be investigated with a co-testHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.)
    • if the cervix is clinically normal and the co-testHPV test and LBC both requested and performed on a cervical sample. is negative, then she should be advised that no further investigation is necessary
    • BUT if the post coital bleeding recurs or is persistent regardless of the co-testHPV test and LBC both requested and performed on a cervical sample. result, she should be referred for gynaecological assessment that should include colposcopy.
  • Any bleeding in a post-menopausal woman (including post-coital bleeding) should be investigated with tests, including a co-testHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.) and referral for gynaecological assessment.


The following circumstances do not require co- testing or referral for colposcopy:
a) Breakthrough or irregular bleeding due to hormonal contraception
b) Contact bleeding at time of obtaining a routine cervical screening test sample
c) Heavy regular periods (heavy menstrual bleeding)
d) Irregular bleeding due to an sexually transmitted infection (STI), eg. chlamydia.

In the absence of bleeding, vaginal discharge and/or deep dyspareunia, may very rarely be the initial presentation of cervical cancer.


Co-testing is not indicated in the vast majority of women presenting with vaginal discharge and/or dyspareunia as almost all will have benign gynaecological disease and cervical cancer in these women is very uncommon. If due for cervical screening then a routine CST would be most appropriate rather than a co-testHPV test and LBC both requested and performed on a cervical sample..


  • Vaginal discharge and/or deep dyspareunia are commonly due to benign gynaecological conditions and should be investigated appropriately and if necessary referred for gynaecological assessment.

If due for cervical screening, then a routine CST would be most appropriate rather than a co-testHPV test and LBC both requested and performed on a cervical sample. for these women.


  • Unexplained persistent unusual vaginal discharge, especially if offensive and blood stained, may be associated with a cervical cancer and should be investigated by clinical examination of the cervix and a co-testHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.):
    • if the co-testHPV test and LBC both requested and performed on a cervical sample. is abnormal she should be referred for colposcopy;
    • even if the co-testHPV test and LBC both requested and performed on a cervical sample. is negative (no HPV detectedWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory. and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. normal), referral for gynaecological assessment should be considered;
    • if a CST was recently performed with a low risk result, consider referral for gynaecological assessment without a co-testHPV test and LBC both requested and performed on a cervical sample..
  • The investigation of unexplained persistent deep dyspareunia (in the absence of bleeding or discharge) should include a CST if due for routine screening and referral for gynaecological assessment should be considered.

Women who present for a routine Cervical Screening Test (CST) and are discovered on questioning to have vaginal discharge or deep dyspareunia, should in the first instance have a CST.

Summary: symptomatic women and co-testingHPV test and LBC both requested and performed on a cervical sample.

  • Women at any age with unexplained abnormal vaginal bleeding (post coital, unexplained inter-menstrual or any post-menopausal bleeding) suspicious for cervical cancer should have a co-testHPV test and LBC both requested and performed on a cervical sample..
  • Any woman with an unexplained persistent unusual vaginal discharge (especially if offensive and/or blood stained) should be investigated with a co-testHPV test and LBC both requested and performed on a cervical sample., and subsequent referral for gynaecological assessment.
  • Any woman with unexplained persistent deep dyspareunia, should have a CST if due, and referral for gynaecological assessment should be considered.

Persistence of any unexplained gynaecological symptoms should always warrant further investigation and referral as appropriate.