Post Menopausal Bleeding

This guideline applies to adults aged 18 years and over.

 

• Postmenopausal bleeding (PMB) is defined as unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause.
   
• 1 in 10 women (not using HRT) experience PMB in the first year after the menopause. 
   
• Up to 80% of women will experience unscheduled bleeding or spotting in the first 6 months of combined HRT treatment.
   
• BMI over 40 and age over 65yo are significant risk factors for PMB.

 

• Bleeding persisting more than 6 months after starting continuous combined HRT (CCT) or bleeding that persists more than 2 cycles after starting sequential HRT(SCT) or heavy prolonged bleeding. 
   
• Examination findings suggestive of gynaecological cancer.

 

 

• Nature of bleeding – pink, brown, fresh
   
• Amount (spotting, same as a normal period, more than a normal period)
   
• Duration (single episode, recurrent)
   
• Parity
   
• Age of menopause
   
• Known endometrial hyperplasia
   
• Strong family history of breast, bowel or colon cancer
   
• If using HRT-type of HRT, any changes in HRT preparation
   
• Risk factors for endometrial cancer (e.g. age, obesity, breast cancer, diabetes mellitus, PCOS. Family history of endometrial cancer and Lynch syndrome)
   
• Abdominal, VE and bimanual examinations – to look for cervical, vulval or vaginal pathology and identify/assess pelvic masses

 

 

 

• No ultrasound pelvis required prior to referral. 

 

 

• In the absence of bleeding persisting more than 6 months after starting continuous combined HRT (CCT) or bleeding that persists more than 2 cycles after starting sequential HRT(SCT) or heavy prolonged bleeding: 

 

• Discuss stopping HRT for 6 weeks
  • If bleeding settles, endometrial cancer is very unlikely.  Restart HRT or consider changing HRT regimen without the need for further investigation. 
  • If bleeding continues, make 2ww referral under PMB pathway.  

 

• Change the HRT regimen

 

• Unscheduled bleeding on SCT
  • Consider poor compliance, drug interactions and malabsorption problems.
  • If the withdrawal bleeding is heavy or prolonged, increasing the dose or changing the type of progestogen or reducing the dose of oestrogen may help.
  • If bleeding occurs early in the progestogen phase, increase the dose or change the type of progestogen.
  • If spotting occurs before the withdrawal bleed, a higher oestrogen dose could be tried.
  • If there is irregular bleeding, change the regime or increase the progestogen dose.
  • In the case of painful bleeding, change the type of progestogen.

 

• Unscheduled bleeding on CCT
  • Bleeding patterns are better with lower oestrogen dose and as women get older.
  • Increase the dose or changing the type of progestogen
  • Consider an intrauterine system (e.g., Mirena).
  • If bleeding continues, consider changing to sequential HRT.

 

• If the patient experiences persistent PMB within 6 months of previous investigation for PMB, and has undergone hysteroscopy and biopsy, consider other causes:
  • HRT problems – a small amount of bleeding after inserting vaginal estrogen HRT is normal.
  • Vulvovaginal or endometrial atrophy (vaginal estrogen HRT can take up to 6 months to be effective).
  • Submucous fibroids.

 

 

Use Suspected Cancer Gynaecology Referral Form

Non-HRT users:

• PMB (unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause).
• Re-referral within 6 months of previous investigations for PMB ie “Persistent PMB”.
• Asymptomatic endometrial thickening (>/ 10 mm) or suspicious endometrium on ultrasound scan.

 

HRT Users:

• Unscheduled bleeding on HRT and >/ 65 years
• Unscheduled bleeding on HRT and BMI>/40
• Unscheduled bleeding (more than 6 months after starting/changing dose of CCT or persisting >2 cycles of SCT).  Or bleeding commencing after a period of amenorrhoea.
• Bleeding that continues for >/ 6 weeks after stopping HRT

 

Unscheduled bleeding is defined as :

• Bleeding >6 months after starting continuous combined HRT
• Heavy, frequent, a change in pattern at the end of the progestogen phase or
• Breakthrough bleeding over 2 consecutive cycles of sequential HRT

 

If outside of the above criteria:

• If the patient has persistent PMB (amount similar to a normal period) and a previous ultrasound showing endometrial thickness less than 4 mm, and no hysteroscopy or biopsy, make an urgent gynaecology referral. 
• If still bleeding after 6 months, reinvestigate using clinical judgement of risk, e.g. raised BMI, smoker, age

 

Consider using the menopause advice and guidance service kernowhealthcic.menopauseadviceandguidance@nhs.net

Do not request HRT advice from RCHT as they do not provide this.

 

 

For professionals: Post Menopausal Bleeding Service Clinical Guideline[LV3] 

                                Uterine cancer statistics | Cancer Research UK

 

For patients: Postmenopausal bleeding - NHS (www.nhs.uk)

 

 

 

 

Review date	04.01.2024
Next review date	04.01.2026
Clinical editor	Dr Melanie Schick, GP
Contributors	Miss Sophia Julian, Consultant Gynae Oncology Consultant RCHT