Document type
Clinical pathways
East and North Hertfordshire
Output type
Clinical Pathways
Post-Menopausal Bleeding Management

Post-Menopausal Bleeding Management

Have a high suspicion of malignancy with Post-menopausal bleeding.  Please refer to the acute trusts 2WW referral criteria and any investigations needed before referral. 

ENHT 2WW criteria

If the following red flags are present, refer urgently to specialist care on the 2WW referral pathway:

  • Suspicious looking cervix
  • Suspicious vulval lesion
  • Suspicious vaginal mass

In the following patients, refer for urgent transvaginal ultrasound (select "2ww” on ICE) and refer on 2ww pathway for hysteroscopy.  DO NOT AWAIT RESULTS OF TVUS BEFORE SENDING 2WW REFERRAL

  • Tamoxifen use (current or within last year)
  • Bleeding is prolonged, heavy or progressive

For all other patients, refer for urgent transvaginal ultrasound (select "2ww” on ICE). Await results of TVUS before referring on 2ww pathway to hysteroscopy (TVUS will be performed and report available within 2 weeks). Refer on 2ww for hysteroscopy if:

  • Endometrial thickness ≥5mm (or <5mm but high suspicion)
  • USS measurement of ETT unsatisfactory, unable to assess or ill-defined
  • Other suspicious findings resulting in recommendation from sonographer for 2ww referral

If ultrasound is negative, the most likely diagnosis is vaginal atrophy.  Consider trial of vaginal oestrogen.  If bleeding persists six weeks despite treatment for atrophy, or becomes heavier, refer under 2ww for hysteroscopy.

For subsequent presentations of PMB following normal investigation:

  • If it is >6 months since prior investigation, treat as a new presentation as above
  • If it is <6 months since prior investigation:
    • If negative ultrasound, refer under 2ww for hysteroscopy (if bleeding has become heavier, or despite 6 weeks of treatment for vaginal atrophy)
    • If patient has had hysteroscopy and TVUS, refer to gynae under 2ww.  Address referral to consultant who performed original hysteroscopy

Include in referral:

  • TVUS report if available
  • Last menstrual period
  • Bleeding history including post-menopausal bleed, history of menarche, previous episodes
  • History of any medication and hormonal treatments
  • Red flag symptoms e.g. weight loss
  • Any previous investigations
  • Medical (especially hormonal treatment) and surgical history including gynaecological / obstetric history, smear history and parity
  • Findings on pelvic examination/ speculum