Investigations of other symptoms – vaginal discharge and deep dyspareunia
Cervical screening and women with symptoms that may be associated with cervical cancer[edit source]
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.
- Women at any age with unexplained inter-menstrual bleeding, which may be suspicious for cervical cancer, require initial investigation with a co-test (HPV and LBC) 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-test (HPV and LBC)
- if the cervix is clinically normal and the co-test 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-test 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-test (HPV and LBC) 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-test.
- 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-test 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-test (HPV and LBC):
- if the co-test is abnormal she should be referred for colposcopy;
- even if the co-test is negative (no HPV detected and LBC 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-test.
- 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-testing[edit source]
- 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-test.
- Any woman with an unexplained persistent unusual vaginal discharge (especially if offensive and/or blood stained) should be investigated with a co-test, 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.