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Post Menopausal Bleeding

 

This guideline is currently under review

 

This guideline applies to adults aged 18 years and over.



Introduction

  • Postmenopausal bleeding (PMB) is defined as unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause.
     
  • 1 in 10 women (not using HRT) experience PMB in the first year after the menopause. 
     
  • Up to 80% of women will experience unscheduled bleeding or spotting in the first 6 months of combined HRT treatment.
     
  • BMI over 40 and age over 65yo are significant risk factors for PMB.

 


Red flags 

  • Bleeding persisting more than 6 months after starting continuous combined HRT (CCT) or bleeding that persists more than 2 cycles after starting sequential HRT(SCT) or heavy prolonged bleeding. 
     
  • Examination findings suggestive of gynaecological cancer.

 


Assessment

  • Nature of bleeding – pink, brown, fresh
     
  • Amount (spotting, same as a normal period, more than a normal period)
     
  • Duration (single episode, recurrent)
     
  • Parity
     
  • Age of menopause
     
  • Known endometrial hyperplasia
     
  • Strong family history of breast, bowel or colon cancer
     
  • If using HRT-type of HRT, any changes in HRT preparation
     
  • Risk factors for endometrial cancer (e.g. age, obesity, breast cancer, diabetes mellitus, PCOS. Family history of endometrial cancer and Lynch syndrome)
     
  • Abdominal, VE and bimanual examinations – to look for cervical, vulval or vaginal pathology and identify/assess pelvic masses

 

 

Investigations

  • No ultrasound pelvis required prior to referral. 

 


Management

  • Check if the patient meets the Fast Track criteria, if so refer
  • For HRT users, if BMI less than 40 and/or age less than 65 years:

If bleeding occurs or persists more than 6 months after starting continuous combined HRT (CCT) or bleeding that lasts more than 2 cycles after starting sequential HRT(SCT) or heavy prolonged bleeding: 

  • Discuss stopping HRT for 6 weeks
    • If bleeding settles, endometrial cancer is very unlikely.  Restart HRT or consider changing HRT regimen without the need for further investigation. 
    • If bleeding continues or recurs after 6 weeks of stopping HRT, make fast track referral under PMB pathway.  
  • Unscheduled bleeding on SCT that settles before 6 weeks of stopping HRT or does not meet the Fast Track criteria or criteria above
    • Consider poor compliance, drug interactions and malabsorption problems.
    • If the withdrawal bleeding is heavy or prolonged, increasing the dose or changing the type of progestogen or reducing the dose of oestrogen may help.
    • If bleeding occurs early in the progestogen phase, increase the dose or change the type of progestogen.
    • If spotting occurs before the withdrawal bleed, a higher oestrogen dose could be tried.
    • If there is irregular bleeding, change the regime or increase the progestogen dose.
    • In the case of painful bleeding, change the type of progestogen.
  • Unscheduled bleeding on CCT that settles before 6 weeks of stopping HRT or does not meet the Fast Track criteria or criteria above
    • Bleeding patterns are better with lower oestrogen dose and as women get older.
    • Increase the dose or changing the type of progestogen
    • Consider an intrauterine system (e.g., Mirena).
    • If bleeding continues, consider changing to sequential HRT.
  • If the patient experiences persistent PMB within 6 months of previous investigation for PMB, and has undergone hysteroscopy and biopsy, consider other causes:
    • HRT problems – a small amount of bleeding after inserting vaginal oestrogen HRT is normal.
    • Vulvovaginal or endometrial atrophy (vaginal estrogen HRT can take up to 6 months to be effective).
    • Submucous fibroids.

 

Referral

Use Suspected Cancer Gynaecology Referral Form

Non-HRT users:

  • PMB (unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause).
  • Re-referral within 6 months of previous investigations for PMB ie “Persistent PMB”.
  • Asymptomatic endometrial thickening (> 10 mm) or suspicious endometrium on ultrasound scan.

 

HRT Users:

  • Unscheduled bleeding on HRT and > 65 years
  • Unscheduled bleeding on HRT and BMI > 40
  • Bleeding that continues for > 6 weeks after stopping HRT

 

Unscheduled bleeding is defined as :

  • Bleeding >6 months after starting continuous combined HRT
  • Heavy, frequent, a change in pattern at the end of the progestogen phase or
  • Breakthrough bleeding over 2 consecutive cycles of sequential HRT

 

If outside of the above criteria:

  • If the patient has persistent PMB (amount similar to a normal period) and a previous ultrasound showing endometrial thickness less than 4 mm, and no hysteroscopy or biopsy, make an urgent gynaecology referral. 
  • If still bleeding after 6 months, reinvestigate using clinical judgement of risk, e.g. raised BMI, smoker, age
  • Consider using Advice and Guidance if needed

 


Advice and Guidance


Consider using the menopause advice and guidance service kernowhealthcic.menopauseadviceandguidance@nhs.net


Do not request HRT advice from RCHT as they do not provide this.

 


Supporting Information

 

For professionals: Post Menopausal Bleeding Service Clinical Guideline

                                Uterine cancer statistics | Cancer Research UK

 

For patients: Postmenopausal bleeding - NHS (www.nhs.uk)

 

 

 

Page Review Information

Review date

Partial update 17/6/25

Next review date

04.01.2026

Clinical editor

Dr Melanie Schick, GP

Contributors

Miss Sophia Julian, Consultant Gynae Oncology Consultant RCHT