Post-menopausal bleeding and endometrial cancer (Guidelines)

What's new / Latest updates

21/05/25:

Added: If patient using HRT: Please refer to the Unscheduled bleeding on HRT guideline. Do NOT refer to PMB Service.
Referral information split into Essential and Useful referral information.

Audience

Highland HSCP
Primary Care.
Adults only

Consider referral to the service for:

Post-Menopausal Bleeding: vaginal bleeding in woman with > 12 consecutive months of amenorrhoea?
Persistent vaginal discharge in a woman with > 12 consecutive months of amenorrhoea

When NOT to refer to the service:

If patient using HRT: Please refer to the Unscheduled bleeding on HRT guideline. Do NOT refer to PMB Service.
Peri-menopausal bleeding irregularities (<12 consecutive months of amenorrhoea). Refer via menstrual disturbance pathway, NOT through PMB.

Referral pathway

Is there a significant clinical concern or abnormal finding on examination? Please document all examination findings on referral.

⇓

Refer to PMB Service via SCI Gateway

⇓

Referral will be vetted by Gynaecology and urgent USS requested at time of triage of referral.
Gynaecology will review USS report then write to patient and GP if discharged.
If patient needs biopsy, will be appointed urgently.
GP and patient will be informed of biopsy results in due course.

⇓

If there is recurrent bleeding more than 6 months after investigations at Raigmore, or persistent bleeding within 6 months of review: refer via SCI Gateway to PMB service stating same. Patient will then be vetted to urgent Outpatient Hysteroscopy Clinic

Referral information to be provided:

Incomplete referrals will be returned. Appointments cannot be allocated until all information is provided.

Essential referral information:

Up-to-date cervical smear history
Parity
History of PCOS / Chronic anovulation
Abdominal and speculum examination findings: palpable mass, cervical mass / ulcer, atrophy?
Current BMI and BP
Current use of any anticoagulant medications
Diabetes
HNPCC (Lynch Syndrome): Sx or FHx of this
Tamoxifen Use (or SERM eg Raloxifene)
(70 to 80% of women using Tamoxifen will have a thickened appearance of the endometrium on scan. They DO NOT require further investigation unless there is also bleeding reported, in which case, refer for Outpatient Hysteroscopy).

Useful referral information:

If patient requires assistance such as hoist, interpreter etc, please make this clear on the referral form.

All patients MUST be examined in primary care BEFORE considering referral to Raigmore Hospital.

If the patient cannot be examined, please state this and the specific reason(s) why on the referral so that appropriate measures can be taken at Raigmore Hospital.

Asymptomatic women / Incidental finding of thickened endometrium:

This is a common finding when investigating for other reasons. Also, see note above re tamoxifen.

If there is no PMB: refer as routine for ultrasound scan.

If TV USS confirms thickened endometrium or fluid in the cavity: then refer as follows (remember to state if any PV bleeding or not):

Thin endometrium with fluid in the cavity: Refer to PMB USC for pipelle biopsy
Thickened endometrium >10mm: Refer to Outpatient Hysteroscopy

Patient information

NHS Inform: Post-menopausal bleeding
Consider vaginal oestrogen for vulvo-vaginal atrophy
MySelf-Management

Abbreviations

HNPCC: -Hereditary nonpolyposis colon cancer (Lynch Syndrome)
HRT: Hormone replacement therapy
FHx: Family history
OPH: Outpatient hysteroscopy service
PCOS: Polycystic ovary syndrome
PMB: Post-menopausal bleeding
PV: per vagina
SCI gateway: Online referral platform
SERM: Selective estrogen receptor modulator
Sx: Social history
TV: Trans-vaginal
USS: Ultrasound scan