If a woman presents with symptoms at any age, whether or not she has been vaccinated against HPV, the symptoms should be investigated.

In the early stages of cervical cancer, there may be no symptoms at all. If symptoms occur, they commonly include:

• postcoital bleeding
• intermenstrual bleeding
• postmenopausal bleeding
• dyspareunia
• unusual or watery vaginal discharge.

Symptoms of advanced cervical cancer include:

• pelvic pain
• extreme fatigue
• kidney failure
• leg pain or swelling
• lower back pain.

At the time of specialist referral, an assessment informed by signs and symptoms, including a physical examination, co-test (simultaneous HPV and LBC tests), and blood tests (FBE) should occur. If the cervix appears abnormal (suspicious for cancer) on physical examination consider direct referral to a specialist gynaecological oncologist who is part of a multidisciplinary team. Where there is not an obvious cancer the flowchart should guide management.