Intermenstrual Bleeding Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • Intermenstrual vaginal bleeding which is defined as bleeding that occurs between normal menstruation in non-pregnant women.
  • Normal menstrual cycle can be anywhere between 21 and 35 days


Signs and Symptoms

Intermenstrual vaginal bleeding is defined as bleeding that occurs between normal menstruation in non-pregnant women. Normal menstrual cycle can be anywhere between 21 and 35 days

History and Examination

Record history
  • Frequency of occurrence
  • Any specific pattern?
  • Heavy or light spotting?

Differential Diagnoses

  • Intermenstrual bleeding can be associated with:
    • Hormonal imbalances
    • Contraception:
      • Progestogen only pill
      • Combined contraception, especially low dose
    • Intra-uterine contraception device or intra-uterine system
    • Injury
    • Foreign body
    • Infection (chlamydia is a common cause)
    • Polyps
    • Lower genital tract or uterine cancers

Red Flags


Look at cervix and vagina

  • Look for evidence of:
    • Injury
    • foreign body
    • infection
    • suspicious lesions
  • Take triple swabs (high vaginal, endocervical and chlamydia swabs)


  • Treat any identified infection
  • Remove foreign body or cervical polyp where possible
  • If no red flags consider trial of contraceptive pill or progestrogenic support (day 10 - 25) for 6 months
  • If still symptoms:
    • organise ultrasound scan
    • consider referral to Gynecology


Referral Criteria

  • If no response to primary care management and symptoms persist organise a scan

Referral Instructions

  • e-consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/ Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This Care Pathway was ratified by: The OSCAR Assurance Group
  • Date ratified: 03.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: OG2 - 03.2017
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Only the electronic version is maintained, once printed this is no longer a controlled document


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