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 Hormone Replacement Therapy (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 guideline, can be referred routinely if necessary

Assessment

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 HRT
    • Urinary and gastrointestinal tract source

Red Flags

  • High BMI
  • Tamoxifen
  • Previous polycystic ovarian syndrome
  • Diabetes
  • Family history

Investigations

  • An abdominal examination and bi-manual 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

Management

  • 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

Referral Criteria

Refer to 2ww Gynaecology
  • If patient not on HRT
  • If patient on HRT
    • Stop HRT for 6 weeks and review patient, if bleeding has not stopped refer

Referral Instructions

Referrals to 2ww Gynaecology
  • e-Referral Service selection:
    • Specialty: 2ww
    • Clinic Type: 2ww Gynaecology
    • Service: Two Week Wait Post Menopausal Bleeding-Gynaecology Department-RDE-RH8

Referral Forms

2ww Gynaecology

Supporting Information

Evidence

NICE guidance for referrals for suspected cancer

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NHS Devon CCG.

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

 

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