Signs and Symptoms

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 and require urgent referral

History and Examination

History

• Enquire about the bleeding:
  • when it started
  • nature of the bleeding – timing, quantity, duration
  • precipitating events, e.g. trauma, postcoital
  • 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 postmenopausal (PMB) or that related to hormone replacement therapy (HRT), enquire about:
  • duration of amenorrhoea
  • 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

Examination

• Look for signs of systemic disease, e.g. bruising for coagulopathy, weight loss
• An abdominal examination and bimanual 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

Differential Diagnoses

• While bleeding from the genital area is normally from a uterine source, other anatomical sources should be considered
• Causes of postmenopausal bleeding (PMB) include:
  • cancers
  • benign growths, e.g.. polyps or fibroids
  • vaginal or endometrial atrophy
  • endometrial hyperplasia
  • breakthrough bleeding in relation to hormone replacement therapy (HRT)
  • iatrogenic

If patient is on HRT:

• stop HRT for 6 weeks and review patient.
• bleeding stopped – review HRT prescriptions

If patient is not on HRT or still bleeding after stopping HRT for 6 weeks:

• consider referral 2ww Gynaecology.

Transvaginal ultrasound is required.

• If a referral is made via the 2 week wait process the ultrasound will be done at this time.

Referral Criteria

Refer to 2ww Gynaecology

• If patient:
  • is not on HRT or
  • still bleeding after stopping HRT for 6 weeks

Referral Instructions

For referral to 2WW Gynaecology

• Choose and Book service selection:
  • Specialty: 2WW
  • Clinic Type: 2WW Gynaecology
  • Service: 2WW Gynaecology-NDHCT-NDDH

Referral Form

Gynaecology 2ww referral form

This guideline has been signed off on behalf of NHS Devon.

Publication date: April 2015