History

• Duration and type of bleeding
• Type of HRT and compliance/adherence
• Date of starting HRT
• Date of any change in HRT preparation
• Date of last natural period
• Assess individual risk factors (see below)

Assess risk factors for endometrial cancer including:

MAJOR risk factors – any of:

• BMI 40 or more
• Unopposed oestrogen for more than 6 months (in women with a uterus)
• Sequential HRT for more than 5 years when started after age 45
• Inadequate progestogen for more than 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 less than 10 days/month
• Micronised progesterone for less than 12 days/month
• Expired LNG-IUD

Tamoxifen use

Possible underlying disease, e.g. liver cirrhosis, oestrogen producing tumour

Examination

• Bimanual examination
• Speculum examination (and where relevant, initial investigations such as cervical screening, lower genital tract swabs)
• Body-Mass Index (BMI).

Postmenopausal bleeding in women who are not on HRT – see Postmenopausal Bleeding (not on HRT) CRG and refer on Urgent Suspected Cancer Pathway on referral form here

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.

Unscheduled bleeding on HRT - see Risk Factors in ‘Assessment’ and flow chart here. Refer on Urgent Suspected Cancer Pathway if one major or 3 or more minor risk factors.

Offer an Urgent TV USS if:

Unscheduled bleeding on HRT and any one of:

• First bleed more than 6 months after starting HRT
• Bleeding continuing more than 3 months after adjustments of HRT in absence of other risk factors
• On HRT and bleeding is prolonged or heavy

OR

Unscheduled bleeding on HRT and any two of:

• BMI 30-39
• Diabetes
• PCOS (or anovulatory cycles)
• Unopposed oestrogen 3-6 months
• Inadequate progestogen* 6-12 months
• Expired LNG-IUD

USS are expected to be performed within 6 weeks. Abnormal findings will be managed as per the flowchart here.

Gynae USCP (2ww) referrals required as a result of scan result will be made by secondary care internally.

Full Blood Count (FBC) – an up-to-date FBC should be requested to inform primary care management. Obtaining this should not delay appropriate referrals.

For management of menopause please see Devon Formulary guidance:

Guidance on the management of menopause - South & West

Optimisation of modifiable risk factors can reduce episodes of unscheduled bleeding on HRT and endometrial risk.

It may be helpful to think about management in two distinct ways,

1. What treatments should I consider to reduce the likelihood of further bleeding?

2. Does this person need referral to exclude the possibility of cancer?

1. Reducing the likelihood of unscheduled bleeding on HRT

In women who have a low risk of endometrial cancer (see Risk Factors in ‘Assessment’ and flow chart here), GPs are supported by the recent BMS guidance to make changes to the HRT regime prior to referral.

1. Assess adherence and understanding of how to use the prescribed preparation including dose and duration of progestogen – for example, would a combined patch or pill reduce administration errors when compared to a separate oestrogen and progestogen component.

2. Offer women a 52 mg LNG-IUD; this preparation reduces episodes of unscheduled bleeding when compared to all other preparations.

3. Oral preparations provide higher rates of amenorrhoea when compared to transdermal preparations and could be offered, if there are no risk factors for thrombosis, as a) a first-line therapy or b) to women who have recurrent unscheduled bleeding with transdermal preparations.

4. Offer vaginal oestrogens if there are atrophic findings on examination.

2. When to refer via Gynaecology USCP to exclude cancer

Postmenopausal bleeding in women who are not on HRT – see Postmenopausal Bleeding (not on HRT) CRG

Unscheduled bleeding on HRT - see Risk Factors in ‘Assessment’ and flow chart here. Refer on Urgent Suspected Cancer Pathway if one major or 3 or more minor risk factors.

Options:

1. Refer via Gynaecology USCP to exclude cancer:

• Postmenopausal bleeding in women who are not on HRT – see Postmenopausal Bleeding (not on HRT) CRG
• Unscheduled bleeding on HRT - see Risk Factors in ‘Assessment’ and flow chart here. Refer on Urgent Suspected Cancer Pathway if one major or 3 or more minor risk factors.

2. Refer for Urgent TV USS those patients outlined in the flow chart here:

• USS are expected to be performed within 6 weeks.
• Gynae USCP (2ww) referrals required as a result of scan result will be made by secondary care internally.
  

3. Devon Menopause Service:

• See CRG here for referral criteria

Referral Instructions

e-Referral Service Selection

Specialty: Gynaecology

Clinic Type: Unexplained bleeding on HRT USS request

Service: DRSS-Western-Gynaecology-Unexplained bleeding on HRT USS request-Devon ICB-15N

Referral Form

Unscheduled Bleeding on HRT Urgent Trans-vaginal Ultrasound Scan Request Form

GP Information

British Menopause Society - Progestogens and endometrial protection

NICE - Hormone replacement therapy (HRT)

BMS Guidance on the management of unscheduled bleeding on HRT

NICE Guidance on the recognition and referral of cancers

Pathway Group

This guideline has been signed off by NHS Devon

Publication date: March 2025