Bleeding on HRT

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Background

Unscheduled vaginal bleeding with HRT is relatively common and is statistically unlikely to be associated with cancer.

The incidence of endometrial cancer amongst women with post-menopausal bleeding (bleeding over 12 months following cessation of periods) may be as high as 1:10.

The finding of cancer in women who experience unscheduled bleeding on HRT is lower than 1:200.

There is no increased risk of endometrial cancer from HRT unless unopposed oestrogen is used in a woman with an intact uterus.

Investigation carries a risk of iatrogenic injury, both physical and emotional, and this needs to be taken into consideration when discussing management and referral with women.

Women within 12m of the menopause (or aged under 55 when uncertain) should use a sequential form of HRT. Women more than 12m from the menopause or aged over 54 may also choose to take sequential HRT. They will be expected to have a regular bleed (scheduled bleeding). Absence of a regular bleed is acceptable provided they are getting an adequate dose of progestogen for endometrial protection.

Women more than 12m from the menopause or aged over 54 may choose to use continuous combined HRT. Bleeding persisting more than 6 months after starting continuous combined HRT is unscheduled and requires action, either a change of HRT or referral for investigation.

Please see Formulary guidance on prescribing: Guidance on the management of menopause

Scope

Unscheduled bleeding on HRT

Out of Scope

Postmenopausal bleeding in women who are not on HRT

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History

Duration of bleeding
Type of HRT
Date of starting HRT
Date of any change in HRT preparation
Date of last natural period
Family history of endometrial hyperplasia, endometrial cancer or Lynch Syndrome
Other known risk factors e.g. obesity, diabetes, PCOS, Tamoxifen

Examination

Bimanual examination
Speculum examination

Abnormal examination findings

Family history of endometrial hyperplasia, endometrial cancer or Lynch Syndrome

Investigations will usually be performed in secondary care.

Please note it is helpful to remove an IUS or IUD before a transvaginal ultrasound scan as these interfere with accurate measurement of endometrial thickness.

Discuss with the patient the option of stopping HRT, temporarily or permanently, where this is acceptable. If bleeding continues for more than 4 weeks following cessation of HRT, please refer into Gynaecology.

Bleeding which clearly follows a missed pill can usually be ignored.

Bleeding within 6 months of starting HRT is common and does not usually require referral.

Bleeding within 6 months of a change in HRT is common and does not usually require referral

Consider switching to a sequential formulation for women aged over 55 with bleeding on continuous combined HRT. If bleeding continues to be irregular, please refer to Gynaecology.

Referral Criteria

Refer on 2ww Suspected Gynaecological Cancer pathway women with:

Unscheduled bleeding persisting after 6 months of starting HRT
Unscheduled bleeding persisting after 6 months following a change in HRT prescription
Bleeding persisting more than 4 weeks after stopping HRT

Unscheduled bleeding in women on HRT with a family history of endometrial hyperplasia, endometrial cancer or Lynch Syndrome. A recent FBC would be useful.

Referral Instructions

e-Referral Service Selection

Specialty: 2WW

Clinic Type: 2WW Gynaecology

Service: DRSS-South Devon & Torbay-2WW Gynaecology-NHS Devon, DRSS-South Devon & Torbay-2WW Post-Menopausal Bleeding-Gynaecology Department-NHS Devon

Referral Form

DRSS Referral Form

GP Information

British Menopause Society - Progestogens and endometrial protection

NICE - Hormone replacement therapy (HRT)

Pathway Group

This guideline has been signed off by NHS Devon

Publication date: August 23

Updated: May 2024

Referral