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Management of women with intermenstrual bleeding, postcoital bleeding or a "suspicious cervix"

(12 Apr 2021)

CervicalCheck and the National Women and Infants Health Programme (NWIHP) are working together to maximise capacity in colposcopy and gynaecology services to ensure that women are seen at the right place, by the right person, at the right time.

The introduction of primary HPV screening is anticipated to lead to at least a 40% increase in the number of new referrals to colposcopy from years 2 to 5 of the new programme.  This issue has been recognised by both CervicalCheck and the NWIHP. Creating new capacity at colposcopy clinics by investing in additional trained colposcopists has been prioritised but will take time and will not be finalised prior to year 2 of the HPV programme.

In order to ensure that colposcopy clinics will be able to cope with the anticipated number of referrals in the near future, steps are being taken to maximise capacity at colposcopy clinics for screen detected abnormalities.  It is essential that women who screen positive are seen within the programme standard waiting times (i.e. all women should be seen within 8 weeks). 

A joint decision has been made by the senior management teams at NWIHP and CervicalCheck to refer all patients with clinical symptoms to the gynaecology service (not colposcopy) from March 2021. Gynaecology clinics will then be able to prioritise referrals based on clinical need and urgency to be seen.  We believe that this will result in more holistic, women-centred care which will ensure that women will see the right person with the appropriate expertise, at the right time in the right clinical setting.  In this context NWIHP has invested in the establishment of ambulatory gynaecology clinics, to ensure there is an appropriate referral route for these women. By the end of 2021 there will be a minimum of 10 additional clinics established around the country.

National guidance and advice on clinical management and prioritisation of patients remains unchanged and is in place to support national consistency in the management of patients.  Local operational procedures will need to be developed to ensure efficient and clear pathways for referral.

CervicalCheck and NWIHP are taking the following steps which should enhance this process:

  • A. The CervicalCheck laboratory referral form issued to primary care will no longer have a tick box for suspicious cervix referrals. CervicalCheck is for people who are well with no symptoms.  If a GP is genuinely very concerned about a possible cervical cancer, they should contact senior clinical staff in their local clinic for advice and/or referral to gynaecology. 
  • B. The CervicalCheck programme will facilitate electronic referral from primary care to Colposcopy for screen-positive referrals. This has been completed and awaits implementation by HSE. 
  • C. From March 2021, all clinical referrals should be referred primarily to gynaecology clinics and not to colposcopy clinics. Any referrals that are sent to colposcopy clinics will be triaged and forwarded to the local gynaecology service for management.  This means the referral will be directed to the right clinic and GPs will not need to make an additional referral.
  • D. CervicalCheck are engaging with primary care sample takers to improve education regarding recognition and management of clinical symptoms and the recognition of a clinically ‘suspicious cervix’.
  • E. A new electronic referral, specifically for gynaecology, is currently being developed by Primary Care, NWIHP and The Institute of Obstetrics. This new form includes specific conditions that warrant urgent referral, including the suspicion of cancer. 

Although we recognise that different Hospital Groups will deal with this operationally in different ways, it is essential that several steps are taken by each Colposcopy Clinic to ensure that whilst patients are not seen in colposcopy, they are still are seen promptly and appropriately assessed to ensure their safety.

CervicalCheck and NWIHP recommend the following steps are taken by Colposcopy Leads to ensure timely patient- centred care

  1. Lead Colposcopists should engage with their local management team to determine that the funds devolved to them have been utilised for creating additional capacity.
  2. Local operational guidelines should be developed with primary care to ensure referrals are appropriate and a policy for the management of inappropriate referrals should be in place.
  3. A local operational policy should be drawn up to adequately deal with clinical referrals in conjunction with Gynaecology colleagues including a pathway to ensure letters are triaged in a single place by a suitably qualified clinician who will act on behalf of the colposcopy and gynae teams. Triage should include time frames for urgent and non-urgent gynaecology referrals to be seen. 
  4. There should be agreement between colposcopy and gynaecology services to ensure patients are seen in the right place by the right person in a timely manner. There should be suitable training in place if anyone other than consultant grade physician is seeing these patients.

Monitoring and audit of referrals should be put in place to ensure the quality and safety of this process. Our key objective is to provide high quality care for women with appropriate assessment, investigation and treatment of symptoms such as post-coital bleeding, intermenstrual bleeding and a finding of a clinically suspicious cervix. 

 

Dr Peter McKenna

Dr Nóirín Russell

Dr John Price

Ms Gráinne Gleeson 

Is cuid den tSeirbhís Náisiúnta Scagthástála é CervicalCheck
Bosca Oifig Phoist 161, Luimneach
Saorghlao 1800 45 45 55
CervicalCheck is part of the National Cancer Screening Service
PO Box 161 Limerick
Freephone 1800 45 45 55

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Is cuid den Rannóg Sláinte agus Folláine i bhFeidhmeannacht na Seirbhíse Sláinte í an tSeirbhís Náisiúnta Scagthástála. Cuimsíonn sí BreastCheck – An Clár Náisiúnta Scagthástála Cíoch, CervicalCheck – An Clár Náisiúnta Scagthástála Ceirbheacs, BowelScreen – An Clár Náisiúnta Scagthástála Putóige agus Diabetic RetinaScreen – An Clár Náisiúnta Scagthástála Reitiní do Dhiaibéitigh.

The National Screening Service is part of the Health and Wellbeing Division of the Health Service Executive. It encompasses BreastCheck – The National Breast Screening Programme, CervicalCheck – The National Cervical Screening Programme, BowelScreen – The National Bowel Screening Programme and Diabetic RetinaScreen – The National Diabetic Retinal Screening Programme.