Post-coital bleeding (PCB) needs a sensitive history and speculum examination where appropriate. NICE NG12 (updated April 2026) recommends considering a suspected-cancer referral when the cervix appears consistent with cervical cancer, rather than referring every patient with PCB through the cancer pathway; PCB with a normal-appearing cervix should follow local urgent gynaecology/colposcopy guidance. A previous negative screening result does not exclude cancer or justify delaying referral, and symptomatic patients need clinical assessment and referral rather than an opportunistic smear. Under section 5B of the Female Genital Mutilation Act 2003 (inserted by the Serious Crime Act 2015), regulated health and social care professionals and teachers in England and Wales must report to the police (101) when a girl under 18 discloses FGM or they see physical signs of it — ideally by the end of the next working day, and within one month (Home Office mandatory reporting procedural information, 2015/2020). This is in addition to, not instead of, local safeguarding referral. The duty does not cover suspected or at-risk cases (which need safeguarding referral), or women aged 18 and over — FGM in a non-pregnant adult does not automatically require police referral unless another child is at risk; these follow the Home Office multi-agency statutory guidance on FGM (2020) and RCOG Green-top Guideline 53; FGM in any woman is recorded in the notes and in the NHS FGM Enhanced Dataset. Adult FGM should be sensitively explored in appropriate contexts (Sub-Saharan Africa, Middle East, South Asia, Southeast Asia) and specialist support offered.

The superficial/deep distinction is the primary clinical diagnostic step in dyspareunia assessment — it determines the likely anatomical level of pathology and directs investigation and referral. Deep dyspareunia in premenopausal women should prompt consideration of endometriosis — a common condition with recognised diagnostic delay — but no single symptom identifies a specific diagnosis, and the combination of dysmenorrhoea, deep dyspareunia and subfertility raises suspicion rather than confirming it. Vaginismus (genitopelvic pain/penetration disorder) is an involuntary muscle spasm of the pelvic floor that prevents penetration — it is not a voluntary response and is extremely distressing. It responds well to specialist psychosexual therapy and pelvic floor physiotherapy.

Lichen sclerosus carries a lifetime risk under 5% of vulval squamous cell carcinoma — review at about 3 months, then at 6–12 months until stable; annual review is then appropriate for stable disease. Good compliance with topical clobetasol (which suppresses chronic inflammation) reduces but does not eliminate this risk. Patients should be taught vulval self-examination and instructed to report any new lump, ulcer, or persistent sore area promptly. GSM is undertreated, although it responds well to vaginal oestrogen. Systemic HRT does not reliably treat GSM — topical vaginal oestrogen (e.g., Vagifem 10 mcg pessary, Ovestin cream) is required; systemic absorption is minimal; in patients with current or previous breast cancer, use shared decision-making with the breast-cancer team (NICE NG23).

The Q-tip test is a simple, reproducible office test for vestibulodynia — it identifies allodynia (pain from light non-painful touch) at the vestibule and maps its distribution. It is not diagnostic in isolation — it supports a diagnosis of provoked vestibulodynia once infection, dermatoses, fissures, erosions and other causes have been assessed. Transvaginal ultrasound is the most important pelvic investigation — it identifies endometriomas (ground glass cystic ovarian masses), fibroids, and pelvic fluid. A normal TV-USS does not exclude endometriosis (peritoneal deposits and adhesions are not visible on USS) — continue initial treatment and refer to gynaecology if symptoms persist, affect daily activities or treatment fails despite a normal USS. Do not request CA125 to diagnose endometriosis — it is neither sensitive nor specific.

NICE NG73 (Endometriosis, updated 2024) recommends transvaginal ultrasound for all patients with suspected endometriosis, with initial treatment in primary care; refer to general gynaecology if treatment is ineffective, not tolerated or contraindicated, symptoms affect daily activities or are persistent, or there are pelvic signs, and to a specialist endometriosis service for endometrioma, suspected deep endometriosis (bowel, bladder or ureter) or disease outside the pelvis. Specialist centres provide laparoscopic diagnosis and treatment including excision of deep infiltrating endometriosis, which has significantly better outcomes than ablation. Diagnosis of endometriosis in the UK is often delayed by years — largely because GPs and gynaecologists historically normalised dysmenorrhoea and dyspareunia in young women. Recognition that these symptoms require investigation and treatment is a key educational message. NICE NG73 also emphasises that a normal examination, ultrasound or MRI does not exclude endometriosis — clinical diagnosis and empirical treatment with the COCP or progestogens are appropriate while awaiting specialist review.

Continuous COCP (without a pill-free interval) suppresses endometrial and ectopic endometrial tissue activity by maintaining consistent progestogenic and oestrogenic suppression — the cyclical bleeding during pill-free intervals stimulates endometriosis. Continuous use is supported by NICE NG73 and the British Society for Gynaecological Endoscopy. Amitriptyline for vulvodynia works via several mechanisms: sodium channel blockade (reduces afferent C-fibre activity), noradrenaline and serotonin reuptake inhibition (modulates pain processing), and NMDA receptor blockade (reduces central sensitisation). Starting dose is 10 mg nocte with gradual titration — this reduces sedation side effects. Response is assessed at 6–8 weeks. Neuropathic agents are not universally effective and cause sedation, anticholinergic effects, dizziness, weight gain and sexual adverse effects — prescribe individually, with specialist or local guidance, and review.

Vaginal trainers (dilators) are an established part of patient-controlled graded exposure for vaginismus; NHS supply and prescribing arrangements vary, so check local arrangements before advising patients. The sensate focus programme (Masters and Johnson, 1970) remains the gold standard psychosexual therapy approach — it systematically removes performance anxiety and penetration expectation from sexual activity and rebuilds sensory intimacy. It has strong evidence across 50+ years of use. The key message for patients with vaginismus is: this is a physical condition (involuntary muscle spasm) that is treatable — it is not a reflection of desire or attraction to their partner.

Sexual activity should be non-painful and patient-controlled — penetration should not be forced or continued through pain. Fragranced and irritant products can worsen vulvodynia and lichen sclerosus; washing with water or a bland emollient soap substitute is a reasonable approach according to patient preference. Lubricants support comfortable sexual activity, and vaginal moisturisers can be used regularly for GSM but do not replace vaginal oestrogen where oestrogen deficiency is the main cause.

Endometriosis significantly reduces ovarian reserve — anti-Müllerian hormone (AMH) levels are lower in women with endometriosis compared to age-matched controls, and the reduction accelerates with each surgical intervention. Women with endometriosis who wish to conceive should be advised not to delay — referral to fertility services earlier than the conventional "after 12 months trying" guideline is appropriate. NICE NG73 specifically advises earlier referral for women with known endometriosis. Lichen sclerosus needs review at about 3 months, then 6–12 months until stable, then annual review for stable disease, with a recall system in the clinical record and self-examination education.