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Post-menopausal bleeding - not on HRT (DRAFT)

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Definition

Post-menopausal bleeding (PMB) is defined as bleeding >12months after menstruation has stopped due to the menopause, in women who are not taking HRT.

For women using systemic HRT and having unscheduled bleeding, please review the Unscheduled Bleeding advice

Causes of PMB

Endometrial cancer	10%
Endometrial or cervical polyp	2-12%
Endometrial hyperplasia	5-10%
Atrophic endometritis and vaginitis	60-80%
Exogenous oestrogens	15-25%
Cervical cancer	1-2%
Vulval cancer	<1%

Risk Factors for Endometrial Cancer

Obesity

Unopposed oestrogens

Nulliparity

Anovulatory cycles e.g. PCOS

Genetic Predisposition e.g. Lynch syndrome, 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 on the Urgent Suspected Cancer (USC) pathway via ERS.

Referral

Women should be referred on the Urgent Suspected Cancer (USC) pathway via ERS

UHBW refer on USC pathway + request an USC pelvic ultrasound

NBT – refer on USC pathway only

Gynaecology - USC (2WW)

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. In the report, 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 USC pathways.

Resources

Postmenopausal bleeding - NHS (www.nhs.uk)

PI Post-Menopausal Bleeding PMB poster (womens-health-concern.org)

Hysteroscopy - NHS (www.nhs.uk)

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.

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