Abnormal Vaginal Bleeding

Overview

If there is uncertainty about management of any woman with abnormal bleeding then please consider using Gynaecology Advice and Guidance.

Heavy/irregular Menstrual Bleeding – on HRT

See Unscheduled bleeding on HRT.

Heavy Menstrual Bleeding - not on HRT

Information on the assessment and management of menorrhagia is available on CKS Assessment | Diagnosis | Menorrhagia | CKS | NICE

Emergency referral

Women should be referred as an emergency to secondary care for further management if the HMB is torrential and / or prolonged and either severe anaemia is suspected or there are symptoms suggestive of haemodynamic compromise.

Emergency Gynaecology (Remedy BNSSG ICB)

Urgent referral

Consider urgent referral  if:

• bleeding is associated with significant risk factors for endometrial disease (atypical hyperplasia or cancer) e.g. morbid obesity (BMI >/= 40), obesity (BMI >/= 35) in women over 40 years of age, women with anovulatory cycles or known Lynch/Cowden syndrome.
• significant anaemia not responding to oral iron replacement.

Routine referral

Consider routine referral if:

• bleeding has not responded to oral treatment or hormonal IUD and surgical management is being considered.

Please note that hysterectomy for menorrhagia is not routinely funded unless criteria are met.

Intermenstrual Bleeding - not on HRT

Women should be reassured that Intermenstrual Bleeding (IMB) is common and symptoms often spontaneously resolve and that underlying cancer is rare. Initial assessment should include:

• A relevant clinical history should be taken to elucidate the severity of the symptoms and the likely cause.
• Smear history - cervical cancer is extremely unlikely if there is an in-date negative cervical screening test.
• Pregnancy should be excluded.
• Genital tract infection should be excluded (self swabs can be taken if possible)
• A vaginal examination should be performed in primary care to exclude cervical pathology. Women who do not have an in-date negative cervical screening test should also have a smear taken.

Urgent Suspected Cancer (USC) Referral

If there is concerning appearance of the cervix (even if smear is normal) then refer via Gynaecology USC.

Routine and Urgent Referral Please request TVUSS at the time of referral. If USS suggests abnormally thickened endometrium please adjust referral as advised by radiology.

Routine Referral

Women 40 years of age or over with persistent IMB (> 3 consecutive months who are not using hormonal contraceptives) and no individual risk factors for endometrial hyperplasia with normal appearance of the cervix, no history suggestive of pregnancy and up to date smear and swab history, refer women to gynaecology clinic (not colposcopy) routinely.

Urgent Referral

Women of any age - with persistent IMB and risk factors for endometrial hyperplasia (1 major risk factor or 3 minor risk factors, see table below) refer as URGENT referral - within 6 weeks - to general gynaecology.

Advice and Guidance.

Top Tips:

If persisting IMB and bleeding is intermittent (e.g 1-2 times per week) with no hyperplasia risk factors and normal swab / smear history offer combined hormonal contraception (if < 50, no ectropion or VTE risk factors) or a progestogen only pill and review in 3 months. If bleeding improving, review in a further 3 months. If bleeding worsening before 6 months or not improving at 6 months, please request TVUSS and seek advice and guidance.

If under 40, above investigations are normal and bleeding is intermittent (eg 1-2 times per week) start combined hormonal contraception (if no ectropion) or progestogen and review in 6months. If bleeding continues please request TVUSS then seek advice and guidance.

At any age, if examination/smear/swabs/pregnancy test are normal, the woman has not recently started hormonal contraception and bleeding is continuous/daily, especially if associated with watery vaginal discharge, please request TVUSS and then use advice and guidance

For women over 40 who are using hormonal contraception with persisting IMB for >3 consecutive months, a normal cervix, please request routine TVUSS and then use A and G.

If using depo provera and atrophic changes on examination, a trial of 3 months vaginal oestrogen can be very effective. Similarly if breastfeeding, vaginal oestrogen can be helpful.

Management options to discuss include:

• Reassurance
• Observation with phone follow up to see if the IMB subsides.
• Change to hormonal contraceptives in current users (eg consider increasing oestrogen component of COCP, switch to more androgenic progestogen, consider LNG-IUD more information can be found here: CEU-Unscheduledbleeding)
• Trial of hormonal contraceptives in non-users.
• Routine referral if advised by A and G.

Post Coital Bleeding

Please see the Cervical Conditions page of Remedy

Ectropion

Please see the Cervical Conditions page of Remedy

Post Menopausal Bleeding - not on HRT

Post-menopausal bleeding (PMB) = bleeding >12months after menstruation has stopped because of the menopause, in women who are not taking taking hormones.

Causes of PMB

1. Atrophic endometritis and vaginitis ( 60 – 80%)
2. Exogenous oestrogens (15-25%)
3. Endometrial cancer (10%)
4. Endometrial or cervical polyp (2-12%)
5. Endometrial hyperplasia (5-10%)
6. Cervical cancer (1-2%)
7. Vulval cancer (<1%),

For women taking HRT, please see unscheduled bleeding with HRT

For women not taking HRT:

Risk factors for endometrial cancer

• Obesity
• Exposure to unopposed oestrogens
• Nulliparity
• PCOS
• Lynch/Cowden syndrome
• Diabetes

Clinical Assessment

Clinical assessment should involve a thorough history to assess symptoms and suitability for ongoing investigations or treatment followed by examination.

Women should be examined in primary care, cervical screening test taken if overdue and referred via Gynae USC pathway. Please note the change to pathways Jan 2025- if referring to NBT please request USC ultrasound scan at the time of referral, UHBW will now arrange the scan when they receive the USC referral.

Ultrasound scan (ideally this should be transvaginal scan if tolerated) for patients not on HRT

The appearance of the endometrium on USS should be interpreted in accordance to the patient’s hormone status. For postmenopausal women (not on HRT) the endometrial thickness should measure up to 4mm. Women with an endometrium ≥4mm require endometrial sampling +/- hysteroscopy and should be being seen in urgent suspicion cancer clinic (ie. USC referral should have already been done).

Please note women with a thickened endometrium on USS may be triaged straight to out-patient hysteroscopy.

Post Menopausal Bleeding - on HRT

See Unscheduled Bleeding in Patients on HRT

Urgent Suspected Cancer Referrals

Indications for USC referrals see Gynaecology - USC  page

Abnormal vaginal bleeding in transgender people

Incidental finding of thickened ET >5mm this is not normal and needs referral to gynaecology.

Please see information on Gender Identity

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.