Post Menopausal Bleeding (PMB) For Women Not On HRT

 

This guideline applies to women not using HRT.
 

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
   
• Vulvo-vaginal atrophy is the cause in 90% cases
   
• Patients with PMB have approximately a 10–15% chance of having endometrial carcinoma. 90% of women with endometrial carcinoma present with vaginal bleeding.
   

In scope   

• PMB not on HRT

 

Not in scope    

• Vaginal bleeding on HRT please follow the USB on HRT page

Red Flag Features

• Unexplained PMB or new vaginal discharge
   
• Examination findings suggestive of gynaecological cancer
   
• BMI over 40 and/or age over 65yo are significant risk factors for PMB
   
• First degree relative with endometrial cancer or Lynch Syndrome.

 

Investigations required prior to referral

Ultrasound scan of the pelvis is not required prior to referral for PMB. 

 

Additional Information

NICE guideline NG12 (2015)

Consider a pelvic ultrasound scan to assess for endometrial cancer in women aged 55 and over with:

• unexplained symptoms of vaginal discharge who:
  • are presenting with these symptoms for the first time
    
    or
  • have thrombocytosis
    
    or
  • report haematuria
    
    or
• visible haematuria and:
  • low haemoglobin levels
    
    or
  • thrombocytosis
    
    or
  • high blood glucose levels. 

Please see Haematuria page for further information

 

Management optimisation

• Offer examination to rule out other causes of vaginal bleeding eg. Vulvovaginal atrophy or any vaginal/vulval/cervical pathology
   
• If any vaginal/vulval/cervical pathology is suspected then refer if appropriate using fast track suspected gynaecological cancer form or manage vulvo/vaginal atrophy once malignancy is excluded.

 

Referral

Suspected endometrial cancer:

Refer via the Fast track PMB suspected cancer pathway if:

• Patients with a uterus who have:
• Post-menopausal bleeding (defined as more than 12 months since LMP)
• Re-referral within 6 months of previous investigation for PMB (persistent PMB)
• Asymptomatic endometrial thickening (≥10mm) or suspicious endometrium on TV USS

Refer via the: fast track suspected gynaecological cancer form.

 

Suspected cervical or vulval cancer:

If cervical or vulval tumour is identified on examination then complete appropriate section on the fast track suspected gynaecological cancer form.

 

Advice and Guidance

For patients falling outside the remit of these guidelines can be obtained from vie eRS

Prior to all referrals, please remove vaginal pessaries (where applicable) to facilitate transvaginal ultrasound.

 

Supporting Information

For professionals

• Uterine cancer statistics | Cancer Research UK

 

For patients

• “The Post-Menopausal Bleeding Service: Information for Patients” leaflet
• Postmenopausal bleeding - NHS

References        

• The Post-Menopausal Bleeding Service Clinical Guideline
• NICE guideline NG12 (2015)

 

  

Page Review Information

Review date	27 June 2025
Next review date	27 June 2027
Clinical editor	Dr Melanie Schick
Contributors	Miss Sophia Julian, Consultant Gynaecologist, RCHT.