Unexpected or unscheduled vaginal bleeding on HRT

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Devon Menopause Service 

The Devon Menopause A&G Service (Pilot) provides a specialist advice and guidance support relating to the management of menopause symptoms to Primary Care Clinicians across Devon. This service will be provided by Sexual and Reproductive Health Consultants and British Menopause Society trained GPs.

The response time back to General Practice will be within two weeks.

Its scope:

• Patients whose symptoms are not controlled after two HRT preparations tried for a minimum of 3 months per preparation
• Patients with complex histories where safe prescription of HRT is unclear
• Patients under the age of 40 with confirmed diagnosis of premature ovarian insufficiency (iatrogenic or spontaneous) where management advice is required
• Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 4mm on continuous combined HRT who have failed to respond to primary care management
• Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 7mm on sequential HRT who have failed to respond to primary care management
• Patients with persistent unscheduled bleeding less than six months after starting HRT or less than three months after changing HRT preparation in patients without risk factors for endometrial cancer (see unscheduled bleeding pathway)

Please see the ‘Red Flags’ section to ascertain if urgent suspicion of cancer referral is required.

You can access or refer using this service via their website

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Unscheduled Bleeding on HRT Ultrasound Pathway

The Unscheduled Bleeding on HRT pathway is a new ultrasound referral service for women with a uterus who are experiencing new or changed vaginal bleeding whilst using either sequential or continuous HRT. After a gynae examination, please refer for an urgent Trans-vaginal ultrasound scan via this pathway (USS normally within 6 weeks) if there is :

Unscheduled bleeding on HRT and

Any one of:	Any two of:
First bleed more than 6 months after starting HRT Bleeding continuing more than 3 months after adjustments of HRT in absence of other risk factors On HRT and bleeding is prolonged or heavy	BMI 30-39 Diabetes PCOS (or anovulatory cycles) Unopposed oestrogen 3-6 months Inadequate progestogen* 6-12 months Expired LNG-IUD

If the endometrium on USS is found to be >4mm in post-menopausal women or >7mm in perimenopausal women, then a referral to the Urgent Suspected Cancer pathway will be made by secondary care.

If the endometrium is normal after the USS, the care will be passed back to the refer. Please then adjust HRT or if needed refer to the Devon Menopause Advice and Guidance Service as above.

Please use the Urgent Suspected Cancer pathway for women Not on HRT with post-menopausal bleeding  or with unscheduled bleeding on HRT and:

any of:	three or more of:
BMI 40 or more Unopposed oestrogen > 6m sHRT > 5y Inadequate progestogen* >12m Familial risk (Lynch, Cowden)	BMI 30-39 Diabetes PCOS (or anovulatory cycles) Unopposed oestrogen 3-6m Inadequate progestogen* 6-12m Expired LNG-IUD

Please see below links for Unscheduled bleeding on HRT referral form, flow chart and clinical reference guides:

*PLEASE DO NOT USE ICE TO REFER BUT USE THE LINKS ABOVE*

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