Post Menopausal Bleeding

PMB flowchart — NHS Lothian flowchart copyright NHS Lothian

R.C & M.M 11-05-23

Who to refer:

Patients with Post-Menopausal Vaginal Bleeding in whom:

Clinical examination suggests vulval/vaginal/cervical malignancy
Women currently using Tamoxifen
Pelvic USS with endometrial thickness (≥5.0mm) : we now ask all GPs to send an onward referral to Gynaecology (RIE>Gynaecology>PMB abnormal scan result)
Pelvic USS with ovarian pathology (see ovarian cyst and ovarian cancer pathway)
Subsequent episode(s) of PMB, despite reassuring prior assessments between 6 months and 12 months ago (even if endometrium <5.0mm on recent Pelvic USS) +/- PMB despite treating vaginal atrophy with local estrogen.
Women established on continuous combined HRT for over 6 months, with endometrial thickness ≥5.0mm.

Women who are prescribed standard doses of HRT have a lower baseline risk of endometrial malignancy, especially in women who have not experienced abnormal bleeding before taking HRT and who are taking a progestogen (including progesterone intrauterine device). In most of these cases, particularly with a normal pelvic examination, PMB is likely to be the unscheduled bleeding related to HRT, and allowing time (usually 6 months) for this to settle before arranging ultrasound, or referral is reasonable.

Bleeding more than 12 months since the previous episode, should be treated as a new episode of PMB.

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.
Women with PMB who are currently taking HRT with endometrial thickness less than 5.0mm.
Do not request Pelvic Ultrasound in women with PMB who are taking combined HRT, if the following apply:
- HRT started, or preparation changed, in the 6 months prior to bleed.
- Continuous Combined HRT started within 6 months prior to bleed.
- HRT stopped within 6 weeks prior to bleed.

How to refer:

For patients with PMB

Refer to Radiology for Ultrasound

Sci-Gateway > ELCH/LB/TIE/SJH > Radiology > LI Post-Menopausal Bleeding

If the USS report is reported as abnormal (ET ≥5mm) GP 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 GP to inform the patient and to send a USOC SCI Gateway referral. It will also be emailed to the Gynaecology cancer clinic.

For patients with PMB on tamoxifen

Sci-gateway > Gynaecology > USOC and simultaneous referral for USOC USS via clinical radiology

For the following;