Postmenopausal Bleeding


  • Any bleeding defined as postmenopausal bleeding (PMB)
  • PMB caused by uterine cancer
  • Bleeding in women on hormone replacement therapy (HRT)
  • PMB is defined as an episode of bleeding in a women at least 12 months after her last period
  • PMB is any breakthrough bleeding in a woman receiving cyclical HRT, or breakthrough bleeding while receiving continuous HRT (after first 6 months, or after full amenorrhoea has been established)
  • PMB should be considered as a sign of uterine cancer until the diagnosis is excluded

Out of scope

  • Dysmenorrhoea
  • Menorrhagia
  • Non-menstrual bleeding in premenopausal women


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

  • 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
  • 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 Forms

Gynaecology 2ww referral form

Supporting Information

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

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


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