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Practice case P2-14 · Pelvic manikin · simulated patient

Bleeding after sex — speculum examination and cervical screening sample

A 34-year-old woman has come for an overdue cervical screening test. At the desk she mentioned that she has been bleeding after sex. A pelvic manikin is set up beside her.

Reviewed and kept current

Station family: Practical procedure on a manikin, with a simulated patient · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice. You have completed cervical sample-taker training and hold a sample-taker code. Your supervising GP is next door; a practice nurse is available as a chaperone.
Patient	Ms Zoe Hartley, 34, dental nurse
Reason for appointment	Booked for routine cervical screening — overdue. At the desk she said she has been “bleeding after sex” and asked whether the smear would “check for that”.
Records	Last cervical screening six years ago: HPV negative. Two invitations since then, not taken up. No abnormal results, colposcopy or treatment to the cervix. One vaginal birth seven years ago. No regular medication. No known allergies (no latex allergy). Urine pregnancy test today (practice nurse): negative. Last menstrual period 12 days ago.
Set-up	A pelvic manikin and a tray: disposable specula in three sizes, water-based lubricant, a cervical sampling broom, an opened liquid-based cytology vial, swabs, gloves and a request form. Examine the manikin; talk to the patient, who sits beside it. If the manikin has no cervical insert you will be told what you see. No manikin at all? Talk through every step aloud, miming with the equipment.

Your task

•

Take a brief, focused history of the bleeding — no more than two minutes.

•

Obtain consent and perform a speculum examination on the manikin, saying what you are doing and what you find.

•

If it is appropriate to do so, take the cervical screening sample.

•

Explain your findings and your working diagnosis to Ms Hartley and agree a plan. Abdominal and bimanual examination are not required.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Zoe Hartley, 34, dental nurse. You live with your seven-year-old son and have been seeing Callum for four months.
Friendly but embarrassed, and nervous about the examination — your last smear, six years ago, was uncomfortable.
You sit on a chair beside the manikin. The candidate examines the manikin, not you; you respond as though it were you.

Opening line — say this verbatim

“I’ve come for my smear — I know I’m really late with it. But I’ve been bleeding after sex and it’s frightening me. Will the smear tell us what’s wrong?”

Volunteer freely if given the space

Bright red blood after sex, most times, for about six weeks. A small amount — on the tissue and a little on the sheets. It stops within the hour.
It does not hurt.

Only if asked

Periods: regular, every 28 days, five days, not heavy. Last period 12 days ago.
Bleeding between periods: only if asked about it directly — “Now you mention it — a bit of spotting, twice this month, not after sex.” Otherwise keep it until you are invited to add anything.
No pain during or after sex, no pelvic pain, no unusual discharge, smell or itching, no urinary symptoms, no fever. No weight loss or bloating.
Contraception: condoms with Callum at first; you stopped using them about two months ago. No pill, implant, injection or coil. The pregnancy test today was negative.
Infections: you have never been tested. You do not know whether Callum has. He has no symptoms that you know of.
Smears: one, six years ago — normal. The letters since then went in a drawer: “life got busy.” No abnormal smears, no colposcopy. You think you had “the jab” at school at about 16 or 17 but are not sure.
You smoke five to ten cigarettes a day.
No medical problems, no medicines — no blood thinners or aspirin — and no allergies, including latex. No bleeding or bruising problems.

Impact on daily life — home and work (only if asked)

You have been avoiding sex for the last fortnight and making excuses to Callum; you have not told him why.
You have been searching online late at night and are not sleeping well; you are distracted at work.
You feel guilty about the missed smears and frightened, for your son’s sake, that you have left it too late.

Ideas, concerns and expectations

Idea: it could be cervical cancer — “because I didn’t go for my smears”.
Concerns: cancer; that the examination will hurt; that you may have caught something from Callum — you have not dared ask him.
Expectation: that the smear test will show what is causing the bleeding, and that you will have the answer in a few days.

Cues to deliver, timed

During consent, or as the speculum is picked up: “Last time it really hurt. Will it hurt?”
While the candidate is looking at the cervix: “Can you see anything? Is it bad?”
If nothing has been said about what the smear can and cannot show by minute 7: “So the smear will tell me why I’m bleeding?”

If the doctor summarises and asks whether you want to add anything

If bleeding between periods has not come up: “There is one more thing — I’ve had a bit of spotting between my periods as well, twice this month.”
If it has: “Should Callum get tested as well? I haven’t told him any of this.”

How to respond to the doctor

If the doctor explains each step before doing it, offers a chaperone, tells you that you can say stop at any time and keeps talking to you during the examination: you relax — “That’s better than last time.”
If the doctor starts the examination without asking your permission, or does not offer a chaperone: look uneasy — “Is it just us in here?”
If the speculum is inserted or opened roughly, or without warning: “Ow — can you stop a second?” If the doctor stops at once and checks with you before going on: “OK — carry on.”
If told plainly that there is a small polyp — a fleshy growth that is almost always harmless and a common cause of bleeding after sex — that the rest of the cervix looks healthy, and that you will be referred to have it removed and checked: relieved but still anxious — “But it could be cancer?” If that is answered honestly (very unlikely — and that is exactly why it is removed and looked at): you accept it.
If the doctor says the smear will show what is causing the bleeding, or that a normal smear means there is nothing to worry about: “Oh good — so if that’s clear, I’m fine?”
If offered a test for chlamydia and gonorrhoea: a pause — “Do you think I’ve got something?” If it is explained as routine for this symptom with a new partner: “OK. Yes.”
If the doctor says nothing can be done until the result is back: look confused — “So I just wait?”
If the doctor starts to remove the polyp: alarmed — “What are you doing? Is that safe to do here?”

Do not

Volunteer the spotting between periods, stopping condoms or your fear of an infection unless asked, or invited to add anything (apart from the timed cues).
Undress or lie on the couch — the manikin is examined; you stay seated.

Findings to give the candidate — only if asked for

This is a manikin station: give each finding as the candidate reaches that step of the examination, or asks for it. Do not offer findings for steps the candidate has not performed. (Where a separate examiner is present, the examiner reads them.)

Inspection: vulva and vagina normal; no discharge and no blood in the vagina. Cervix: pink and healthy. A smooth, red, fleshy polyp about 8 mm long hangs from the cervical canal on a narrow stalk; its base cannot be seen. It bleeds slightly when the broom touches it; the cervix itself is not friable and does not bleed when touched. No ulcer; no irregular, hard or crumbling area; no abnormal vessels; no offensive discharge. The broom can be seated in the canal beside the polyp and makes a full 360-degree sweep. Only if asked: pulse 72, BP 118/74, temperature 36.6 °C.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Two-minute history: pattern and amount of bleeding; bleeding between periods, pain, discharge; last period and pregnancy; contraception; new partner and infection risk; screening history Red flags (intermenstrual bleeding, persistent discharge, pelvic pain, weight loss); ICE — fears cancer, expects the smear to explain it; impact on her relationship, sleep and work Before examining: explains, gains consent, offers a chaperone, “tell me to stop”; latex allergy; vial in date and open; right speculum; privacy and cover Technique: vulva inspected; speculum lubricated, inserted gently side-on; whole cervix seen and described; broom 5 turns clockwise, fixed in the vial at once, vial labelled; blades apart on withdrawal	☐	☐	☐	☐	/4
2 · Clinical management skills Decides correctly, and says why, that the screening sample is appropriate — overdue, cervix not suspicious, full sweep possible; request form records the last period, the bleeding and the polyp Summary and check, then the working diagnosis: a benign-looking cervical polyp; why cancer is unlikely but must be excluded; infection possible — chlamydia and gonorrhoea swab offered Says plainly that screening is not a test for bleeding: gynaecology referral for removal and histology whatever the result; supervising GP told; does not try to remove it Safety-net: bleeding soaking a pad an hour, or with faintness, severe pain or fever → NHS 111 / emergency department; offensive discharge or heavier bleeding → appointment that week · Follow-up: swab result and referral check in 1–2 weeks; a normal screening result does not cancel the referral	☐	☐	☐	☐	/4
3 · Interpersonal skills Acknowledges her embarrassment and the painful previous smear; no criticism of the missed invitations Talks to her throughout the examination; warns before each step; would stop if asked Answers “is it cancer?” honestly — very unlikely, and being checked — without false reassurance Plain words (“a small fleshy growth”); checks what she has understood about the smear and the referral	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Introduces self, confirms identity and why she has come; a focused two-minute history — onset, frequency and amount of bleeding after sex; bleeding between periods; pain during sex, pelvic pain, discharge; last menstrual period and the pregnancy test; contraception; a new partner and infection risk; previous screening and colposcopy; smoking Red flags: intermenstrual bleeding, persistent or offensive discharge, pelvic pain, weight loss, heavy bleeding; a bleeding tendency or anticoagulants ICE: fears cervical cancer because she missed her smears; worried about an infection; expects the smear to explain the bleeding Impact on daily living: avoiding sex and not telling her partner, poor sleep, distracted at work, guilt Preparation: explains what the examination involves and why; gains consent and says she can stop it at any time; offers a chaperone and notes the answer; checks for latex allergy; privacy, a cover sheet, an empty bladder; washes hands and puts on gloves; checks that the vial is in date and open and that the broom and the right size of speculum are to hand Technique: inspects the vulva; lubricates the speculum sparingly, avoiding the tip; inserts it gently, side-on and directed downwards, then opens it until the whole cervix is seen; describes the cervix, the polyp and the absence of suspicious features; withdraws with the blades apart until clear of the cervix, then lets them close; leaves her covered, disposes of the equipment, washes hands Sampling technique (once the decision to sample is made): central bristles in the canal, broom rotated five times clockwise with pencil pressure; fixed at once — pushed to the bottom of the vial at least ten times — before the speculum comes out; vial labelled with her name and date of birth and checked against the form	Interprets what is seen: a smooth, stalked polyp in the cervical canal with a healthy cervix around it — no ulcer, no irregular or crumbling area, no abnormal vessels — so there is no clinical suspicion of malignancy Decides about the sample correctly and says why: she is overdue for routine screening, the cervix is not suspicious and the broom can make a full 360-degree sweep — so the sample is taken. (Had the cervix looked malignant: no sample, and an urgent suspected-cancer referral) Completes the request form with what the laboratory needs: the last period, the bleeding after sex and the polyp Offers a vulvovaginal swab for chlamydia and gonorrhoea — self-taken if she prefers; any swab taken through the speculum follows the screening sample Summarises and checks whether she wants to add anything Working diagnosis with justified differentials: a cervical polyp — a benign-looking fleshy growth — is the likely cause of the bleeding after sex. Cervical cancer is very unlikely because the rest of the cervix looks healthy, but the polyp has to be removed and examined, and bleeding between periods as well means she should see a gynaecologist whatever the screening result. An ectropion was not seen; chlamydial infection of the cervix is possible with a new partner and no condoms, and is being tested for; pregnancy has been excluded Says plainly that cervical screening is not a test for symptoms: a normal result will not explain the bleeding and does not cancel the referral Plan: gynaecology referral made today — it does not wait for the screening or swab results — for removal and histology of the polyp and assessment of the bleeding. Not the suspected-cancer pathway (the cervix does not look malignant and the bleeding has a visible benign cause) but urgent rather than routine: she also bleeds between periods, the base of the polyp cannot be seen and she is years out of date with screening. Confirms the route with the supervising GP before she leaves (a colposcopy or suspected-cancer clinic is equally acceptable if the GP or local policy prefers it) and tells her roughly when to expect the appointment; does not attempt to remove the polyp; condoms until the swab result is back; stop-smoking support offered Safety-net: bleeding that soaks a pad in an hour or comes with clots, faintness, severe lower abdominal pain or fever → NHS 111 or the emergency department the same day; an offensive discharge, pain during sex, or bleeding that becomes heavier or more frequent before the clinic appointment → ring the practice for an appointment that week; a missed period → pregnancy test and contact the practice. Follow-up: a telephone appointment with the F2 or her usual GP in one to two weeks with the chlamydia and gonorrhoea result and to confirm that the gynaecology referral has been accepted; the screening result comes by letter or the NHS App within a few weeks — she is told now that a normal result does not cancel the referral, and that the sample may need repeating after three months if blood makes it inadequate; she rings the practice if she has heard nothing from the hospital within two weeks; Callum can test at any time through a sexual health clinic and must be tested and treated if her swab is positive; contraception — she is using none — is raised at the same call.	Acknowledges that she is embarrassed and that the last smear hurt; says what will be different this time No criticism of the missed invitations — glad that she has come Talks to her throughout the examination, looking at her as well as the manikin; warns before each step; would stop if asked Answers “can you see anything?” and “is it cancer?” honestly and at once — no false reassurance, no alarm Raises the infection test without embarrassment or assumption Plain language (“a small fleshy growth on a stalk”); asks her to say back what the smear can and cannot tell her, and what happens next
3	Safe, consented, competent examination with the cervix seen and described, a correctly taken and fixed sample, and a history covering the bleeding and her screening record; chaperone offered (even if only after her prompt); one of the latex and vial checks, infection risk, smoking or the impact on her life missing.	Right decision about the sample, with the reason; polyp named and explained; referral arranged; says — even if only when she asks — that the result will not explain the bleeding; one of the infection swab, the request-form details or a specific follow-up missing. A reasoned decision not to sample today (“in doubt — refer, and screen three months after treatment”), with a firm plan for the overdue test, is also acceptable at this mark.	Kind and clear; consent and dignity good; one cue missed, or understanding checked only with “is that OK?”.
2	Examination completed but clumsy or largely silent; consent or chaperone cursory; sample taken with faults (too few rotations, delayed fixing, unlabelled vial); history either too long (so the examination is rushed) or too thin (no question about bleeding between periods, pregnancy or a new partner); findings not clearly described.	Sample taken with no reason given for doing so; findings described but no clear diagnosis or differentials; plan is to “wait for the result”; safety-net generic.	Technically focused — talks to the manikin, not the patient; her fear of pain or of cancer acknowledged late or briefly; some jargon.
1	No real consent and no chaperone offer; speculum inserted without explanation; cervix never properly seen; no relevant history. Or unsafe: examines without consent; hurts her and carries on when asked to stop; or takes a sample without looking at the cervix.	No sample although it was appropriate, with no reason given; or no explanation of the findings; no referral, safety-net or follow-up. Or unsafe: tells her the smear will show whether the bleeding is serious, or that a normal result means nothing more need be done; attempts to remove the polyp; or takes the sample after describing the cervix as looking like cancer.	Silent examination; brusque; her questions brushed aside. Or unsafe: judgemental about the missed smears or her partner; dismissive of pain; ignores a request to stop.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Starts the examination with no history at all — or goes back to history questions while the speculum is in place; findings, sample and explanation come in no recognisable order.
2 · Issues	Key issues or priorities not recognised	Treats it as a routine smear and ignores the bleeding — or as a bleeding history and ignores that she was last screened six years ago and is about three years overdue; never grasps that the station turns on ‘screening is not a test for symptoms’.
3 · Time	Poor time management	History overruns; the sample is taken as the bell goes; no explanation, no referral and no safety-net.
4 · Findings	Abnormal findings or results, or their implications, not identified	Sees, or is told of, a smooth stalked polyp with a healthy cervix and cannot say what it means; does not use the negative pregnancy test, the 12-day-old period or the six-year gap on the page; does not recognise bleeding between periods as a reason for referral.
5 · Examination	Physical examination or use of instruments not competent	No consent or chaperone offer; vial not checked, wrong speculum; lubricant on the tip; speculum forced in or not far enough, so the cervix is never seen; broom turned once, or anticlockwise; sample left unfixed while the speculum comes out; vial unlabelled; blades closed on the cervix on the way out.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“It all looks fine” — the polyp is not named; or “this looks like cancer” of a benign-looking polyp; cannot say why infection and ectropion are alternatives, or why cancer is unlikely but still has to be excluded.
7 · Management	Management plan not reflecting current best practice	“We’ll wait for the smear result”; no gynaecology referral; tries to twist the polyp off; no chlamydia test despite a new partner and no condoms; nothing about heavy bleeding or pain; no plan for the results and no follow-up.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“You really should have come for your smears”; examines in silence; ignores “last time it really hurt”.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “will the smear tell us what’s wrong?” in her first sentence — the misunderstanding the whole station turns on; never invites her to add anything, so the spotting between periods stays hidden.
10 · Language	Language or explanations not understandable; understanding not checked	“There’s an endocervical polyp with contact bleeding; I’ve taken LBC for hrHPV and a vulvovaginal NAAT and I’ll refer you to gynae” — no plain-English version, and she leaves believing the smear will give the answer.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Cervical screening is a screening test, not a diagnostic test, and a normal result can falsely reassure. People with abnormal bleeding (after sex, between periods, after the menopause), persistent discharge or pelvic pain should be referred for investigation without waiting for the screening result (NHS England cervical sample taker training, Topics 7 and 8, updated September 2026).
An unscheduled (“extra”) sample is not part of the programme (NICE CKS Cervical screening, 2026), and NHS England programme guidance (2025) says that people presenting with symptoms of cervical cancer “are not suitable candidates for screening”: the test must never be used to investigate symptoms or to decide about referral. Here the sample is defensible only because she is overdue for routine screening, the cervix is not suspicious and a full sweep is possible; it is taken alongside the referral, never instead of it. If in doubt, do not sample: refer, and screen three months after treatment. In England screening is now offered every five years from 25 to 64.
Polyps (NHS England Topic 8): a sample may be taken as long as the polyp does not prevent full 360-degree coverage; if in doubt, refer and sample three months after treatment. Small ectocervical polyps with a visible base and no symptoms need no referral; large, symptomatic or endocervical polyps whose base cannot be seen should be referred for a gynaecological opinion — they are usually benign.
Clinical suspicion of malignancy — an enlarged, irregular, friable cervix that crumbles or bleeds freely, often with an offensive watery discharge: do not take a sample (England); refer urgently on the suspected cancer pathway (NHS England Topic 8; NICE NG12 rec 1.5.16). NICE CKS adds: suspect cervical cancer when bleeding after sex or between periods persists and is not explained by infection or another cause — and do not delay referral because a previous screening result was normal. If her bleeding persists once the polyp and any infection have been dealt with it is “unexplained”, and CKS then advises a suspected-cancer referral.
Technique (NHS England Topic 8): a little water-based, carbomer-free lubricant, avoiding the tip of the speculum; insert side-on, directed downwards; central bristles of the sampling broom (Cervex-Brush) in the canal, rotated five times clockwise with pencil pressure; fix at once — push the broom to the bottom of the vial at least ten times — before the speculum is removed; withdraw with the blades apart until the cervix is clear; label the vial with name and date of birth and check it against the form.
Do not take a screening sample during menstruation, in pregnancy or within three months of giving birth, within 12 weeks of a miscarriage or termination, or when a discharge or infection is present — treat first. Slight bleeding during sampling is common: send the sample and warn that it may be reported as inadequate; an inadequate sample is repeated after no less than three months.
Bleeding after sex — causes: cervical ectropion, cervical polyp, cervicitis (most often Chlamydia trachomatis, less often gonorrhoea), unscheduled bleeding on hormonal contraception, and — uncommonly — cervical cancer (NICE CKS Cervical cancer and HPV, 2025). Test for chlamydia and gonorrhoea with a vulvovaginal NAAT swab — the sample of choice, self-taken if she prefers (NICE CKS Chlamydia, 2026). Any swab taken through the speculum follows the screening sample; a self-taken swab can be done at any point. With a new partner and no previous tests, offer HIV and syphilis blood tests too (BASHH).
Consent and chaperones: explain the examination, obtain and record consent, offer a chaperone whatever your own gender, and record whether it was accepted or declined (GMC, Intimate examinations and chaperones; NHS England Topic 8). Let her choose the position — dorsal or left lateral — and give privacy to undress and a cover sheet.
Everyone who takes cervical samples must be trained and competent. An F2 would tell the supervising GP about the polyp the same day and would not attempt to remove it.

Where candidates lose marks at this station

“The smear will tell us what’s causing the bleeding.”
No chaperone offered; no “tell me to stop at any time”.
Sampling before the cervix has been properly seen and described.
The broom turned once — or the sample left unfixed while the speculum comes out.
“We’ll wait for the result” — no referral for a symptomatic polyp.
Forgetting the chlamydia swab in a woman with a new partner.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Obstetrics and gynaecology · Sexual health · Cancer
Domain 3 · Clinical and professional capabilities	Performing procedures safely · History, examination and differential diagnosis · Capacity, consent and confidentiality · Investigations: request, interpret, act · Communication with patients, relatives and carers
Domain 5 · Patient presentations	Abnormal vaginal bleeding
Domain 6 · Conditions	Cervical screening (human papilloma virus) · Cervical cancer · Chlamydia
Station family	Practical procedures and prescribing — Practical procedure on a manikin, with a simulated patient

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-14

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-14-bleeding-after-sex-speculum-examination

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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