Referral

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Postmenopausal Bleeding

Scope

Postmenopausal Bleeding (PMB) is defined as an episode of bleeding in a woman at least 12 months after her last period

  • If patient not on HRT refer to 2ww Gynaecology
  • If patient on HRT Stop HRT for 6 weeks and review patient
    • If bleeding stopped after 6 weeks review HRT prescription
    • If bleeding not stopped after 6 weeks refer to 2ww Gynaecology
Definitions
  • PMB would also include any breakthrough bleeding in a woman on continuous HRT after first 6 months, or after full amenorrhea has been established
  • PMB should be considered as a sign of uterine cancer until the diagnosis is excluded
Pre-investigation risk factors
  • Main risk factors are age and HRT use
  • 1% risk of cancer for those on combined HRT with PMB
  • 0.1% risk of cancer for patients under age 50 years with PMB
  • 1.5% risk of cancer for patients over age 60 years with PMB
  • 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 2ww guideline, can be referred routinely if necessary.

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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 (could this be arising from 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 HRT, enquire about:
    • Duration of amenorrhea
    • Compliance with HRT regimen
    • Possible HRT drug interaction or malabsorption
    • Whether bleeding occurs in progestogen phase or oestrogen phase of HRT cycle
    • Use of anticoagulation agents
    • Tamoxifen use
    • Possible underlying disease, e.g. hypothyroidism
  • Look for signs of systemic disease, e.g. bruising for coagulopathy, weight loss
Examination
  • Pelvic and speculum examination

Differential Diagnoses

  • While bleeding from the genital area is normally from a uterine source, other anatomical sources should be considered
  • Causes of 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

  • 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
  • If a referral is made via the 2 week wait process an ultrasound will be done as part of this assessment

  • If patient not on HRT refer to 2ww Gynaecology
  • If patient on HRT Stop HRT for 6 weeks and review patient
    • If Bleeding stopped after 6 weeks review HRT prescription
    • If Bleeding not stopped after 6 weeks refer to 2ww Gynaecology

Referral Criteria

  • If patient not on HRT refer to 2ww Gynaecology
  • If patient on HRT Stop HRT for 6 weeks and review patient
    • If Bleeding stopped after 6 weeks review HRT prescription
    • If Bleeding not stopped after 6 weeks refer to 2ww Gynaecology

Referral Instructions

For referrals to 2ww Gynaecology
  • Please refer via DRSS using the e-Referral Service
    • Specialty: 2ww
    • Clinic Type: 2ww Gynaecology
    • Service: DRSS-Western-2WW Gynaecology-NHS Devon.

Referral Form

2ww Gynaecology

Evidence

NICE guidance for referrals for suspected cancer

Pathway Group

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

Publication date: 03 February 2015
(This guideline is currently under review)

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