Postmenopausal Bleeding

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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

Risk Factors

The majority of the established risk factors for endometrial cancer stem from the exposure of the endometrium to estrogen unopposed by progesterone. This results in the proliferative effects of the hormone on the endometrial cells and consequently hyperplastic activity and malignancy.

Increasing age
Late menopause
Nulliparity
Obesity (and associated with diabetes)
Unopposed oestrogens
Liver cirrhosis
Polycystic Ovarian Syndrome (PCOS)
Oestrogen producing tumours
Family History
Patients with hereditary non-polyposis colorectal cancer (HNPCC), otherwise known as the Lynch (type 2) syndrome, have a 70% lifetime risk of developing colon cancer, and a 40–60% lifetime risk of endometrial cancer.
Women presenting with PMB who are also taking tamoxifen have more than a 10% risk of having uterine cancer

Out of scope

Women without a uterus 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.

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History and Examination

History

Enquire about the bleeding:
- When it started
- 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
Past medical history – especially thyroid, renal or hepatic problems
Family history
Distinguish whether bleeding is PMB or related to hormone replacement therapy (HRT) - please see Unscheduled bleeding on HRT CRG,
Enquire about:
- Duration of amenorrhea
- Use of anticoagulation agents
- Tamoxifen use
- Possible underlying disease, e.g. hypothyroidism

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.

Refer on the Urgent Suspected Gynaecological Cancer Pathway (USCP).

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-Western-2WW Gynaecology-NHS Devon.

Referral Form

Urgent Suspected Gynaecological Cancer Pathway

Evidence

NICE guidance for referrals for suspected cancer

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2015
Updated: July 2024

Referral