Take a good history including:



• hormone therapy including OCP

• recurrence of bleeding

• previous abnormal pap smears

• smoking

• multiple partners



Do a detailed gynaecological examination including a pap smear and bimanual exam.


• look for cervical or vaginal abnormalities eg polyps, ectropion

• assess uterine size

• assess for adnexal masses

• take a pap smear



If examination is normal do a transvaginal ultrasound to assess the thickness of the endometrium. the size of the uterus and adnexae.

If the endometrium is thickened or polypoid they will need a biopsy.

Recurrent intermenstrual bleeding without an obvious cause needs referral even though they are most likely normal. Organise an ultrasound and pap smear before referral.

Repeat the pap smear even if there was a normal one performed within recommended times.

The presence of a fibroid on US scan does not exclude malignancy. Fibroids are more likely to cause menorrhagia and dysmenorrhoea rather than intermenstrual bleeding.

If there is a cervical abnormality the specialist with perform a graded curette, or cervical biopsy and a uterine curette. If adnexal or uterine disease is suspected, then they may also need a laparoscopy.

Endometrial biopsy in the rooms without need for anaesthesia is possible but as it has a false negative rate, if the problem persists, then full hysteroscopy and curettage is needed.