Post-menopausal bleeding | Right Decisions

Background

There has been a significant increase in referrals for post-menopausal bleeding (PMB) in recent years, this is due to the increased use of Hormone Replacement Therapy (HRT).

PMB is referred through the urgent suspicion of cancer pathway as there is a 10% risk of endometrial cancer associated with true PMB.

Use of HRT can cause unscheduled bleeding. The risk of cancer in people with HRT-associated PMB is significantly lower, as evidenced in literature and shown by audit data from various NHS Health Boards.

Unscheduled bleeding in patients using HRT is no longer listed as a reason for urgent suspicion of cancer referral in the Scottish Referral Guidelines for Suspected Cancer, except where the patient has risk factors for endometrial cancer.

We propose two distinct pathways:

Patients with PMB not associated with HRT (with intact uterus) should receive a USC ultrasound.
Patients with PMB who are on HRT, should be managed according to Red, Amber, Green risk stratifications as laid out in pathway below.

Pathway recommendations

Post-menopausal bleeding - Urgent suspected cancer (USC) pathway (For patients not on hormone replacement therapy (HRT), with intact uterus)

Click the image to open the pathway

Management of unscheduled bleeding on HRT in women with intact uterus (includes peri- and post-menopausal women)

Click the image to open the pathway

Adjusting HRT to reduce unscheduled bleeding episodes

Check the patient understands how to, and is using, their prescribed HRT properly, including dose and duration of progestogen. Consider whether a combined patch or pill would reduce administration errors when compared to a separate estrogen and progestogen component.
Offer all women a 52mg Levonorgestrel Intrauterine Device (LNG-IUD), which has been shown to reduce unscheduled bleeding more effectively than other treatments.
Oral preparations provide higher rates of amenorrhoea (abnormal absence of periods) than transdermal (through the skin) preparations. If there are no risk factors for thrombosis, these may be offered:

1. as a first-line therapy, or
2. to women who experience recurrent unscheduled bleeding while using transdermal preparations

Offer vaginal estrogens if atrophic findings are identified during examination.

Prescribed estrogen dose for ultra-low, low, standard, moderate and high dose regimens*

	Ultra-low dose	Low dose	Standard dose	Moderate dose	High dose
Osetrogel	1/2 pump	1 pump	2 pumps	3 pumps	4 pumps
Sandrena	0.25mg	0.5mg	1mg	1.5-2mg	3mg^†
Lenzetto spray	1 spray	2 sprays	3 sprays	4-5 sprays^†	6 sprays^†
Patch	12.5µg	25µg	50µg	75µg	100µg
Oral estradiol	0.5mg	1mg	2mg	3mg^∧	4mg^∧

* Management of unscheduled bleeding on hormone replacement therapy - British Menopause Society

^† Off-license use,

^∧ Off-license use - rarely required to achieve symptom control,

mg = milligrams,

µg = micrograms

Progestogen dose per licensed estrogen dose in the baseline population*

Estrogen dose	Micronised progesterone		Medroxy progesterone		Norethisterone		LNG-IUD
	continuous	sequential	continuous	sequential	continuous	sequential
Ultra-low	100mg	200mg	2.5mg	10mg	5mg^†	5mg^†	One - for up to 5 years of use
Standard	100mg	200mg	2.5-5mg	10mg	5mg^†	5mg^†
Moderate	100mg	200mg	5mg	10mg	5mg	5mg
High	200mg	300mg	10mg^∧	20mg^∧	5mg	5mg

* Management of unscheduled bleeding on hormone replacement therapy - British Menopause Society

^† 1mg provides endometrial protection for ultra-low to standard dose estrogen but the lowest stand-alone dose currently available in the UK is 5mg (off-license use of three noriday POP i.e. 1.05mg, could be considered if 5mg is not tolerated).

^∧ There is limited evidence in relation to optimal MPA dose with high dose estrogen; the advised dose is based on studies reporting 10mg providing protection with up to moderate dose estrogen.