Postmenopausal Bleeding Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Postmenopausal Bleeding (PMB) whcih is defined as an episode of bleeding in a woman at least 12 months after her last period
  • 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

This guidance does not cover:

  • Women without a uterus do not need to be referred via PMB 2ww guideline and can be referred routinely if necessary.

Assessment

Postmenopausal (PMB) 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

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 hormone replacement therapy (HRT)
    • Urinary and gastrointestinal tract source

Red Flags

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

Investigations

  • 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
  • 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

  • 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 Instructions

  • e-consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This Care Pathway was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 03.2019
  • Ref No: OG4 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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