Post Menopausal Bleeding (PMB)
NHS Tayside RefGuide
Who to refer
- Women as above not on HRT.
- Women as above on HRT after the below pathway and initial primary care investigations has been followed. Certain instances of women with PMB on HRT require direct secondary care referral – please see below pathway.
Who not to refer
- Women with PMB with previous hysterectomy for benign reasons and normal examination – treat with vaginal oestrogen for 3 months, if persistent symptoms after 3 months, refer via SCI Gateway/Gynaecology/ USC Fast Track clinic
- Women with PMB with previous hysterectomy for malignancy and suspicion of recurrence – refer SCI Gateway/Gynaecology/USC Fast Track clinic
- Women with a localised reason for PMB on examination (i.e. vulval, vaginal, cervical lesion) - refer SCI Gateway/Gynaecology/ USC Fast Track clinic
- Women with PMB on HRT – please follow the referral pathway link below and primary care investigations and refer to secondary care if indicated as per pathway below. Certain instances of women with PMB on HRT require direct secondary care referral – please see below pathway.
How to refer
SCI Gateway/Gynaecology/PMB (see exceptions above under who should be referred via SCI Gateway to general gynaecology).
Condition Description
PMB is vaginal bleeding after 1 year of amenorrhoea at the age when menopause is expected.
PMB can be an early sign for possible endometrial cancer (among many causes) – this RefGuide relates to women with PMB and an intact uterus and no obvious local reasons for bleeding (vulva, vaginal, cervical lesions). The aim of the investigations using this PMB pathway is exclusion/detection of endometrial cancer.
The background to the recent updates in the Postmenopausal Bleeding (PMB) pathway stems from a significant surge in secondary care referrals driven by a rise in Hormone Replacement Therapy (HRT) prescriptions. Historically, any postmenopausal vaginal bleeding triggered an automatic, urgent two-week-wait (2WW) cancer pathway referral. However, because unscheduled breakthrough bleeding is a highly common side effect when starting or adjusting HRT, applying the standard PMB pathway to all HRT users overwhelmed gynaecology services and caused unnecessary patient anxiety. The incidence of endometrial cancer in women not taking HRT is approximately 10%. In contrast the incidence of endometrial cancer in women on HRT is significantly lower 1-2% with continuous combined HRT and 5% in sequential HRT.
Primary Care Investigations/Management
As per NHS Tayside PMB Referral Pathways
Useful resources
Scottish Referral Guidelines for Suspected Cancer 2025 – Gynaecological cancers (p 22-25)
Management of unscheduled bleeding on hormone replacement therapy (HRT) - British Menopause Society
01-BMS-GUIDELINE-Management-of-unscheduled-bleeding-HRT-NOVEMBER2024-A.pdf