Abnormal Uterine Bleeding Referral Information

Menorrhagia

Women with regular heavy menstrual bleeding should initially be managed by remote communication. They should be reassured that the complaint is common and that the risk of malignancy is very low.

History should describe the severity of the symptoms, the possibility of anaemia and the likely cause.

If there are no significant symptoms of anaemia, medication should be prescribed with due consideration of relevant contraindications (NICE guidelines)

Women should be referred to secondary care for further management if:

• Bleeding is torrential and / or prolonged.
• Bleeding is ongoing and unmanageable despite recommended oral treatments
• Significant anaemia is suspected.

Women being referred to secondary care should have the following examination and investigations included with the referral:

• A pelvic examination
• A full blood count to diagnose anaemia.
• If locally available, a pelvic ultrasound / other recent imaging reports

Consider the following interim therapies for women being referred to secondary care:

• oral or intravenous iron infusion according to the severity of the anaemia and associated symptoms.
• Tranexamic acid and a course of high dose oral progestogens to rapidly supress acute bleeding.
• NICE recommended medical treatments that have not been used including the levonorgesterol- releasing intrauterine system.
• Gonadotrophin releasing hormone (GnRH) analogues for refractory bleeding despite use of recommended NICE medical treatments and / or in the presence of significant uterine fibroids. This is a high-tech prescription so would need to be organised in conjunction with hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established or delivery via the nasal route. Addback hormone replacement therapy (HRT) should be considered, once bleeding is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.

Intermenstrual Bleeding

Women with IMB should initially be managed by remote communication. Women should be reassured that IMB is common and symptoms often spontaneously resolve and that underlying cancer is rare.

A relevant clinical history should describe the severity of the symptoms and enquire about the likely cause:

• Cervical smear history
• Use of hormonal preparations
• Pregnancy should be excluded
• Likelihood of STI

Where the likelihood of sexually transmitted infection or genital tract cancer is considered negligible, then management options to discuss include:

• Reassurance.
• Observation with phone follow up to see if the IMB subsides.
• Change in hormonal contraceptives in current users.
• Trial of hormonal contraceptives in non-users.

Women should be asked to come for a pelvic examination, preferably in primary care, if:

• There is a risk of sexually transmitted infection (take genital tract swabs).
• Cervical cancer is suspected because of associated post-coital bleeding and / or offensive vaginal discharge.

Women should be referred to secondary care for further investigation of IMB if:

• Cervical cancer is suspected on pelvic examination.
• Endometrial cancer is suspected because of persistent IMB (i.e. occurring for at least 3 consecutive months) in women over 40 years who are not using hormonal contraceptives.

Post-Menopausal Bleeding

Referrals for PMB will be triaged urgently and an individualised plan of action made taking into account additional risk factors for malignancy, and whether hospital attendance should be deferred for COVID vulnerable individuals eg., those cocooning, or currently in self-isolation.

Women presenting with postmenopausal bleeding will firstly have a pelvic ultrasound to determine endometrial thickness. The scan report is reviewed by a consultant and a decision is then made regarding the need for hysteroscopy / tissue sampling. It would be helpful to include information such as smear history, HRT use, pelvic examination findings and BMI. If for any reason you feel the patient would not be suitable for a transvaginal scan or outpatient hysteroscopy please let us know.

Post Coital Bleeding

Women with PCB should initially be managed by remote communication. If they have an in-date negative cervical screening test, a cervical cancer is extremely unlikely and patients should be reassured.

Women with PCB who do not have an in-date negative cervical screening test need to be seen for a speculum examination and for a smear to be taken.

If they have any risk factors for a sexually transmitted disease, they should have genital tract swabs taken or referred to a Sexual Health Clinic for further investigation and management.