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Referral
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Postmenopausal Bleeding (no HRT)
Key Messages
Postmenopausal Bleeding (PMB) is defined as an episode of bleeding in a woman at least 12 months after her last period. PMB should be considered as a sign of uterine cancer until the diagnosis is excluded.
Common causes include vaginal atrophy, benign focal lesions (polyps, fibroids) and the bleeding may also arise from the vulva, vagina, cervix, fallopian tubes or ovaries.
- If patient not on HRT refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP)
- If patient on HRT – please see Unscheduled bleeding on HRT CRG
Referral should not be delayed if a separate appointment is needed for an examination.
Referral may be made following a telephone consultation or when the problem has been reported by another health professional within the primary care team.
Out of scope
Women without a uterus and a normal examination do not need to be referred via PMB USCP but can be referred routinely if necessary.
Women on HRT – please see Unscheduled bleeding on HRT CRG
Distinguish whether bleeding is postmenopausal (PMB) or related to hormone replacement therapy (HRT) - please see Unscheduled bleeding on HRT CRG
History
- When bleeding started and duration of amenorrhoea
- Nature of the bleeding – timing, quantity, duration
- Precipitating events, e.g. trauma, post coital
- Origin of bleeding (consider urinary tract, vulva, or rectum)
- Associated symptoms – pain, unplanned weight loss, fever, bowel, or bladder symptoms
- Risk factors for endometrial cancer, which include:
MAJOR risk factors – any of:
- BMI 40 or more
- Unopposed oestrogen >6 months (in women with a uterus)
- Sequential HRT > 5 years when started after age 45
- Inadequate progestogen >12 months*
- Familial risk (Lynch/Cowden syndrome)
MINOR risk factors - 3 or more of:
- BMI 30-39
- Diabetes
- PCOS (or other causes of anovulatory cycles)
- Unopposed oestrogen 3-6 months
- Inadequate progestogen 6-12 months*
*Inadequate progestogen includes:
- Tricycling HRT (quarterly progestogen)
- Norethisterone or Medroxyprogesterone acetate for <10 days/month
- Micronised progesterone for <12 days/month
- Expired LNG-IUS
Tamoxifen use
Possible underlying disease, e.g. liver cirrhosis, oestrogen producing tumour
Examination
- An abdominal examination and bimanual palpation of the pelvic area
- A speculum examination of the vagina and cervix
- Assess for:
- Size of uterus
- Any palpable abdominal pelvic masses
- Tenderness
- Discharge
Look for signs of systemic disease, e.g. bruising for coagulopathy, weight loss
Differential Diagnoses
While bleeding from the genital area is normally from a uterine source, other anatomical sources should be considered.
Causes of postmenopausal bleeding (PMB) include:
- Cancers
- Benign growths, e.g. polyps or fibroids
- Vaginal or endometrial atrophy
- Endometrial hyperplasia
- Breakthrough bleeding in relation to hormone replacement therapy (HRT)
- Urinary and gastrointestinal tract source
- High BMI
- Tamoxifen
- Previous polycystic ovarian syndrome
- Diabetes
- Family history
If a referral is made via the USCP to PMB clinic an ultrasound will be done as part of this assessment, no USS should be requested separately.
Referral Criteria
- If patient not on HRT refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP)
- If patient on HRT – please see Unscheduled bleeding on HRT CRG
Referral Instructions
Refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP)
- The GP should use e-Referral Service to refer.
- Specialty: 2ww
- Clinic Type: 2ww Gynaecology
- Service: DRSS-South Devon & Torbay-Gynaecology- Devon ICB - 15N
Referral Form
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: March 2025
