Intermenstrual and postcoital bleeding — structured SAQ (15 marks)

(a) Definitions and FIGO significance (3 marks)

One mark per point. ^[1][2]

• Intermenstrual bleeding (IMB): any bleeding between regular menstrual periods.
• Postcoital bleeding (PCB): bleeding during or after sexual intercourse, separate from menstruation.
• Within FIGO System 1, both are abnormal by definition; both point to a focal lesion (cervical or endometrial polyp, CIN, cervical cancer, endometrial pathology) and are not a diagnosis in themselves. They are distinct from unscheduled bleeding on hormonal contraception (AUB-I).^[1][2]

(b) Structured assessment (5 marks)

One mark per point, maximum five. ^[2][3]

• Pregnancy test FIRST — exclude pregnancy before labelling the bleed nongestational.
• Speculum examination — visualise the cervix; inspect for ectropion, polyp, discharge, ulceration, mass. An abnormal-looking cervix triggers a suspected cancer pathway referral.
• Chlamydia and gonorrhoea NAAT — test any woman with PCB or unexplained IMB, particularly with risk factors.
• Cervical screening — HPV plus LBC co-test — perform when symptomatic even if not due; a normal result never reassures in a symptomatic woman.
• Bimanual examination — assess uterine size, mobility, tenderness, adnexal masses.^[2][3]

(c) Referral routes and triggers (4 marks)

Two marks for each route with its trigger. ^[2][4][5]

• Colposcopy — the route when the cervix is the suspect: persistent or recurrent postcoital bleeding, an abnormal cervical screen, or an abnormal-looking cervix on speculum. Recurrent or persistent PCB warrants referral regardless of the screening result.^[5]
• Hysteroscopy plus endometrial biopsy — the route when the endometrium is the suspect: persistent unexplained intermenstrual bleeding, especially in a perimenopausal woman (over 40), and any woman with endometrial pathology risk factors (obesity, PCOS, tamoxifen use, failed HMB treatment) per NICE NG88 1.3.4 and 1.3.10. In this woman — IMB for 4 months, age 44, BMI 33, PCOS — hysteroscopy plus biopsy is the indicated route.^[2][4]

(d) Why a normal screen does not reassure (3 marks)

One mark per point. ^[2][5]

• Cervical screening is a population-level test designed to detect pre-cancer in ASYMPTOMATIC women; in a symptomatic woman it is not being used in its validated context.
• A normal screen has a falsenegative rate and does not exclude high-grade CIN or early cervical cancer — colposcopy with acetic acid is the diagnostic test.
• Therefore, persistent symptoms (PCB or IMB) warrant referral for colposcopy or hysteroscopy regardless of the screen result. Reassuring the woman on the basis of a normal screen is the cardinal pitfall and a common cause of delayed cancer diagnosis.^[2][5]