Synopsis
Localise bleeding between periods or after sex, exclude pregnancy and infection, identify cervical and endometrial warning features, and route persistent symptoms to direct examination, hysteroscopy or urgent cancer assessment.
- Clarify whether blood is vaginal, cervical, uterine, urinary or rectal; timing noticed after sex does not prove the cervix is the source.
- Ask last normal period, pregnancy possibility, contraception and adherence, pain, discharge, sexual exposure, trauma, menopause status, anticoagulants and cervical screening history.
- Offer a pregnancy test whenever pregnancy is possible and interpret an early negative result cautiously; a positive result with symptoms requires pregnancy-location assessment.
- Speculum examination is the key initial localisation test when bleeding persists or cervical disease is possible: inspect vulva, vaginal walls and the entire visible cervix with consent and a chaperone.
- Take chlamydia and gonorrhoea NAAT from appropriate exposure sites when cervicitis risk exists; infection can be asymptomatic and treatment must include partner and reinfection planning.
- Cervical ectropion and polyps are common benign explanations, but a benign-looking finding should not override persistent symptoms, an abnormal cervix or endometrial risk.
- Cervical screening prevents cancer in asymptomatic populations; it is not a diagnostic test for postcoital bleeding and a negative result does not clear a suspicious lesion.
- Persistent intermenstrual bleeding or risk factors for endometrial pathology make outpatient hysteroscopy the NICE-prioritised investigation, with selected biopsy during the procedure.
- Unscheduled bleeding can occur after hormonal contraception starts or changes, but check pregnancy, correct use, interactions, STI risk and cervical screening before attributing it to the method.
- Give a clear review interval and urgent triggers; recurrent bleeding after an initially normal examination requires reassessment rather than repeated empirical treatment.
Key red flags
Positive or uncertain pregnancy testing with unilateral pain, shoulder-tip pain, syncope or bleeding requires urgent ectopic pregnancy assessment.
A visibly irregular, ulcerated, friable or bleeding cervical lesion needs suspected-cancer referral even when cervical screening is current.
Postmenopausal bleeding, persistent intermenstrual bleeding with endometrial risk, or blood-stained discharge requires urgent endometrial evaluation.
Pelvic pain, fever, purulent discharge, cervical motion tenderness or systemic illness suggests pelvic inflammatory disease or abscess and prompts timely treatment.
Bleeding with genital injury, non-consensual sex, reproductive coercion or a controlling companion requires trauma-informed clinical and safeguarding support.
Easy bruising, mucosal bleeding or heavy periods from menarche suggests a systemic bleeding disorder rather than an isolated cervical cause.
Irregular, ulcerated, nodular, friable or spontaneously bleeding tissue requires urgent diagnostic referral rather than screening reassurance.
Investigation priorities
Detect pregnancy-related bleeding and prevent unsafe endometrial investigation or prescribing.
Management branches
Bleeding is reported between periods or after penetrative sex.
- Clarify source, timing, recurrence, amount, pain, discharge, menopause, contraception, medicine exposure and consensual sexual context in privacy.
- Offer pregnancy testing and relevant STI NAAT, then perform consented external and speculum examination when bleeding persists or cervical disease is possible.
- Treat urgent pregnancy, infection, injury or suspicious-cervix findings and assign a review point for results and recurrence.