Poster presented at British International Congress of Obstetrics and Gynaecology - 2007

1. Postcoital Bleeding: The Inconsistent Management Justifies The Need For
Evidence-based Guidelines
Fadi Alfhaily, Specialist Registrar in Obstetrics and Gynaecology1 & Ayman A. A. Ewies, Consultant Gynaecologist2
1 = Hinchingbrooke Health care NHS Trust 2 = The Ipswich Hospital NHS Trust
Background
• Despite the reported association between postcoital bleeding
(PCB) and significant cervical pathology, the management of
PCB is inconsistent all over the UK.
• The Department of Heath (DoH) guidelines recommended
urgent referral (within 2 weeks) for women >35 years of age
with PCB >4 weeks, and early referral (within 4-6 weeks) in all
other cases of repeated unexplained PCB.1
Objectives
To measure the variations amongst consultant gynaecologists
in the UK as regards managing women with PCB.
Methods
A questionnaire was sent to 1018 consultant gynaecologists,
using the database of The Royal College of Obstetricians and
Gynaecologists, enquiring about their opinions and the details
of practice. The response rate was 44.2%.
Results
1.Do you think that PCB is a significant clinical issue
which requires developing national guidelines for
management?
2. Does your department have clinical guidelines for
managing women with PCB?
3. Where do you usually see women with PCB?
4. Do you think that PCB is an indication for referral to
colposcopy clinic (as primary procedure)?
Yes: 30.7% No: 62.7%
5. Please state your level of agreement with DoH
guidelines :
6. What investigations do you perform for women with
PCB?
7. Do you repeat cervical smear for those with negative
smear history? If the answer is yes: please state when?
• 217 (48.2%) of the respondents take a smear:
1. 84 (18.7%) repeat it only if it was done >12 months before
the episode of PCB
2. 78 (17.3%) repeat it if it was done >6 months
3. 41 (9.1%) repeat it if it was done >3 months
Discussion
• There was a great deal of diversity between gynaecologists in
managing PCB.
• 56.7% of the respondents agree with DoH guideline for referral
despite questioning its validity by many investigators who found
that the rate of pathology was not correlated to the age, or the
duration of PCB. 2, 3
• It was previously reported that 30% of women with malignancy or
dysplasia had a negative smear before being referred with PCB.4,5
Nonetheless, <50% of the respondents repeat the smear test for
those with negative smear history, and only 15% see women with
PCB in the colposcopy clinic.
• Despite the well-reported link between infection and PCB, the
majority of the respondents do not consider testing, which may
reflect the underestimation of the importance of the problem. 6,7
Conclusion
The lack of consensus and wide variations in managing women
with PCB make it prudent to standardise the management in the
UK, and provide uniform guidelines based on the best available
evidence.
References
1. Department of Health. Referral guidelines for suspected cancer, 2000; http://www.dh.gov.uk/PublicationsAndStatistics
2. Khattab AF, Ewies AA, Appleby D, Cruickshank DJ. The outcome of referral with postcoital bleeding (PCB). J Obstet Gynaecol 2005; 25(3): 279-82.
3. Slater DN. Multifactorial audit of invasive cervical cancer: key lessons for the National Screening Programme. J Clin Pathol 1995; 48(5): 405-7.
4. Rosenthal AN, Panoskaltsis T, Smith T, Soutter WP. The frequency of significant pathology in women attending a general gynaecological service for
postcoital bleeding. BJOG 2001; 108(1): 103-6.
5. Harahap RE. Combination of cytology and colposcopy in diagnosis of cervical intraepithelial neoplasia. Cancer Detect Prev 1981; 4(1-4): 461-4.
6. Lindner LE, Geerling S, Nettum JA, Miller SL, Altman KH. Clinical characteristics of women with chlamydial cervicitis. J Reprod Med 1988; 33(8):
684-90.
7. Nher H, Lamminger C, Zimmermann J, Petzoldt D. [The value of symptoms and clinical findings in cervical Chlamydia trachomatis infection]. Hautarzt
991; 42(11): 687-91.
0%
10%
20%
30%
40%
50%
60%
70%
agree disagree unsure
77.1%
17.3%
No
Yes
No Answer
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
GGC
colposcopy
either
GUM
0%
10%
20%
30%
40%
50%
strongly agree agree unsure disagree strongly disagree
0%
10%
20%
30%
40%
50%
60%
HVS
Endocervical Swab
Chlamydia Swab
Smear
Colposcopy
Scan
H`scopy
Pipelle
All