Post-menopausal bleeding and endometrial cancer (Guidelines)

Patients may be female or trans-male. They may present with persistent vaginal discharge or with vaginal bleeding. Some patients may not be clear where the bleeding is actually coming from (ie per urethra, per vaginum, per rectum).

Patients should be confirmed to be at least 12 consecutive months amenorrhoeic. If they are on HRT, they should have been on the same regime and dose for 6 consecutive months before considering referral to the service.  

All patients MUST be examined before considering referral to the service. Please ensure that bleeding has been confirmed to be per vaginum to ensure referral to the appropriate speciality. If the patient cannot be examined, please explain the reasons for this on the referral.  

The gynaecology department will review the referral and request an urgent pelvic Ultrasound scan at that point. The gynaecology department will review the scan report and triage to urgent appointment for biopsy or discharge to GP, as appropriate.

If there is further bleeding more than 6 months after scan and /or review at Raigmore, please refer to PMB clinic with this information and the Gynaecology department will triage the referral to urgent Outpatient Hysteroscopy for further investigation.

If bleeding in post-menopausal person, using HRT, persistent vaginal discharge or concerns regarding unopposed oestrogen use / poor compliance with oral or vaginal progesterone on HRT, refer to PMB service through SCI Gateway.

Essential information to be provided with the referral to Raigmore Hospital:

• HRT use / history of use
• If patient requires assistance such as hoist, interpreter etc, please make this clear on the referral form.
• 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 Sx or FHx of this / Lynch Syndrome
• Tamoxifen Use (or SERM eg Raloxifene) 

NB:  Incomplete referrals will be returned. Appointments cannot be allocated until all information is provided. Refer peri-menopausal bleeding irregularities (<12 consecutive months of amenorrhoea) via menstrual disturbance pathway, NOT through PMB.

Asymptomatic women / Incidental finding of thickened endometrium:

This is a common finding when investigating for other reasons. 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

70-80% 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).

Ultrasound scan will be requested as part of active clinical triage of referral (ACTR). Gynaecologist requesting scan will review result once available and triage to urgent outpatient apt for biopsy or discharge to GP as appropriate.

Patients with an abnormal exam, should be referred to the general Fast Track clinc where they can be reviewed with the scan findings.

If the endometrium is thicker than expected, a pipelle biopsy should be taken. Where this is impossible, or the results found to be inadequate for diagnosis, a further referral to outpatient hysteroscopy may be required (and will be made by the clinician at the time).

If a polyp is suggested from the scan, the patient should be reviewed at outpatient hysteroscopy where it may be possible to remove the polyp at the same time.

Concerns over delay in biopsy appointment: please contact the Gynaecology department