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Abnormal vaginal bleeding

Checked: 23-08-2023 by 3 Vicky Ryan Next Review: 23-08-2025


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

Heavy Menstrual Bleeding

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 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

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 (2WW) Referral

If there is concerning appearance of the cervix then refer via Gynaecology 2WW.

Routine Referral

Refer women to gynaecology clinic (not colposcopy) if they are 40 years of age or over with persistent IMB (> 3 consecutive months who are not using hormonal contraceptives) and no concerning appearances of the cervix. Also request TVUSS at the time of referral. If USS suggests abnormally thickened endometrium or patient has risk factors for hyperplasia (BMI >35) then expedite to URGENT referral to general gynaecology.

Advice and Guidance.

Consider advice and guidance  for women with persistent IMB (>3 consecutive months) and no concerning appearances of the cervix who are:

  • under 40 years of age
  • 40 years of age or over who are using hormonal contraceptives

Please request routine TV USS prior to requesting A and G

Management options to discuss include:

  • Reassurance
  • Observation with phone follow up to see if the IMB subsides.
  • Change in hormonal contraceptives in current users. 
  • 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


Please see the Cervical Conditions page of Remedy

Post Menopausal Bleeding

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

Causes of PMB

Endometrial cancer


Endometrial or cervical polyp


Endometrial hyperplasia


Atrophic endometritis and vaginitis


Exogenous oestrogens


Cervical cancer


Vulval cancer



Risk Factors for Endometrial Cancer

  • Obesity
  • Unopposed oestrogens
  • Nulliparity
  • PCOS
  • Lynch syndrome

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 for 2WW urgent USS to assess the endometrium at UHBW and to the gynae 2WW clinic at NBT.

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.

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

If asymptomatic incidental ovarian cysts are detected then an ORADS (ovarian-adnexal reporting and data system) ultrasound score should be given. Advice should be given as to what level of referral and further imaging is required. ORADS 4 and 5 pelvic masses always require a referral to gynaecology via 2WW 

Post Menopausal Bleeding on HRT

Unscheduled Bleeding in Patients on HRT

When assessing patients on HRT who have unscheduled bleeding please consider the following:

  • Review HRT regime and duration.
  • Check cervical smears are up to date.
  • Perform a vaginal examination to establish location of bleeding.

Assess length and heaviness of bleeding and risk factors for hyperplasia (1) and then use the following pathway to decide on next steps:

Urgent Suspected Cancer Referrals

Indications for USC(2WW) referrals (see also the Gynaecology - USC (2WW) page)

  • Persistent unscheduled bleeding on continuous or cyclical HRT >6 months since starting or >3 months since dose or preparation change
  • Unscheduled bleeding on HRT <6 months with risk factors for hyperplasia (1) or heavy bleeding.

*TVUSS requests:

  • NBT - Direct requests for TVUSS for patients on a USC(2WW) pathway is currently not available at NBT. Please refer and do not request an ultrasound - this will be arranged by secondary care.
  • UHBW - A direct access TVUSS request should be made (priority: cancer) at the same time as USC(2WW) referral. 


(1) Risk Factors for Hyperplasia - 1 or more major or 2 or more minor risk factors:

  • Major: BMI>40, Lynch syndrome, unopposed oestrogen use (off license)
  • Minor: BMI>30, diabetes, hypertension, liver disease, PCOS


Abnormal vaginal bleeding on testosterone

Please see information on Gender Identity (Remedy BNSSG ICB)


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.