Post Menopausal Bleeding (No HRT)

Who to refer:

Patients with Post-Menopausal Vaginal Bleeding and:

• Clinical examination suggests vulval/vaginal/cervical malignancy
• Currently using Tamoxifen or have used it in the past
• Lynch or Cowden Syndrome
• BRCA1 or BRCA2 carriers without bilateral salpingo-oophrectomy
• Pelvic USS with endometrial thickness (≥5.0mm): we now ask all clinicians to send an onward referral to Gynaecology (RIE>Gynaecology>PMB abnormal scan result)
• Pelvic USS where a copper IUCD present or Progesterone IUCD present for >5 years
• Pelvic USS with ovarian pathology (see ovarian cyst and ovarian cancer pathway)
• Second or subsequent episode(s) of PMB, more than 6 months since reassuring prior assessment (even if endometrium <5.0mm on prior Pelvic USS)B.

For patients on HRT, please see Unscheduled Bleeding on HRT.

There are 2 situations, as below, where patients who are, or have recently been, on HRT should be referred for a PMB USS (not an Unscheduled Bleeding on HRT USS):

• Ongoing unscheduled bleeding after a total of 12 months of HRT despite troubleshooting actions (Unscheduled Bleeding on HRT)
• Ongoing bleeding at 6 weeks since stopping HRT (Unscheduled Bleeding on HRT)

Who not to refer:

• Women with PMB, normal clinical examination and endometrial thickness less than 5.0mm, in the absence of focal pathology e.g. polyp.

How to refer:

1. For patients with PMB

Refer to Radiology for PMB USS Sci-Gateway > ELCH/LB/RIE/SJH > Clinical Radiology > LI PMB (No HRT)

If the USS report is reported as abnormal (ET ≥5mm) Primary Care Clinician to refer patient to Gynaecology

Sci-Gateway > RIE > Gynaecology > LI PMB Abnormal Ultrasound

Where the USS is reported as abnormal (ET ≥5mm) the report will be emailed by radiology to the Clinical Inbox of the referring GP practice and will require the Primary Care Clinician to inform the patient and to send a USOC SCI Gateway referral. It will also be emailed to the Gynaecology cancer clinic. 

2. For patients with PMB on tamoxifen

USOC Referral Gynaecology Sci-gateway > RIE > Gynaecology > LI Basic sign referral (select priority USOC) and simultaneous referral to Radiology for PMB USS Sci-Gateway > ELCH/LB/RIE/SJH > Clinical Radiology > LI PMB (No HRT)

3.For suspected vulval, vaginal, cervical malignancy:

USOC Referral Gynaecology Sci-Gateway > RIE> Gynaecology> LI Basic sign referral (select priority USOC)

4.For recurrent/persistent PMB:

USOC Referral Gynaecology Sci-gateway > RIE > Gynaecology > LI Basic sign referral (select priority USOC) and simultaneous referral to Radiology for PMB USS Sci-Gateway > ELCH/LB/RIE/SJH > Clinical Radiology > LI PMB (No HRT)

5.For patients with ongoing unscheduled bleeding after a total of 12 months of HRT despite troubleshooting actions Unscheduled Bleeding on HRT:

USOC Referral Gynaecology Sci-gateway > RIE > Gynaecology > LI Basic sign referral (select priority USOC) and simultaneous referral to Radiology for PMB USS Sci-Gateway > ELCH/LB/RIE/SJH > Clinical Radiology > LI PMB (No HRT)

6.For patients with ongoing bleeding at 6 weeks since stopping HRT Unscheduled Bleeding on HRT link:

USOC Referral Gynaecology Sci-gateway > RIE > Gynaecology > LI Basic sign referral (select priority USOC) and simultaneous referral to Radiology for PMB USS Sci-Gateway > ELCH/LB/RIE/SJH > Clinical Radiology > LI PMB (No HRT)