Synopsis
Treat postmenopausal bleeding as a cancer signal, use ultrasound and tissue sampling without false reassurance, and connect histology, molecular testing and stage to treatment.
- Postmenopausal bleeding means vaginal bleeding more than 12 months after menstruation stopped because of menopause; identify whether the blood is vaginal, urinary or rectal.
- Under NICE NG12 updated April 2026, refer age 55 or over on the suspected-cancer pathway for unexplained postmenopausal bleeding not attributable to HRT; consider that pathway under 55.
- Bleeding is common during the first 6 months after starting systemic HRT or within 3 months of changing dose or preparation, but heavy, prolonged or later bleeding still needs assessment using current BMS-linked guidance.
- Perform consented vulval, speculum and pelvic assessment according to presentation because atrophy, cervical disease, trauma and visible lesions may be the source.
- Transvaginal ultrasound measures endometrial thickness and identifies focal or adnexal pathology. In an initial episode, a fully visualised uniform endometrium of 4 mm or less is reassuring without systemic HRT or with continuous-combined HRT; current BMS guidance uses 7 mm or less for sequential HRT.
- Endometrium above the applicable threshold, focal abnormality, poor visualisation or persistent or recurrent bleeding leads to urgent endometrial assessment by biopsy and often hysteroscopy-directed sampling.
- Definitive endometrial cancer diagnosis is histological. Standard surgical staging commonly uses total hysterectomy and bilateral salpingo-oophorectomy with nodal assessment selected by risk and specialist protocol.
- Offer Lynch syndrome testing to every person diagnosed with endometrial cancer using mismatch-repair immunohistochemistry, followed by MLH1 methylation or germline testing according to the loss pattern.
Key red flags
Unexplained bleeding more than 12 months after natural menopause in someone aged 55 or over requires a suspected-cancer pathway referral when it cannot be attributed to HRT.
Postmenopausal bleeding under age 55 still warrants consideration of the suspected-cancer pathway and should not be dismissed because age lowers absolute risk.
Persistent or recurrent bleeding needs further assessment even after a thin endometrium, benign blind biopsy or initially reassuring examination.
A visible cervical, vaginal or vulval lesion, pelvic mass, ascites or enlarged nodes redirects urgent assessment toward the anatomical abnormality as well as the endometrium.
Tachycardia, hypotension, syncope, rapidly falling haemoglobin or ongoing profuse loss requires same-day emergency management.
Investigation priorities
Measure and characterise the endometrium and assess the uterus and adnexa after postmenopausal bleeding.
Management branches
Bleeding occurs more than twelve months after menstruation stopped because of menopause.
- Assess amount, recurrence, pain, haemodynamic symptoms and whether blood is vaginal, urinary or rectal, then document HRT type and the timing of any start or change.
- Use the suspected-cancer pathway for unexplained postmenopausal bleeding at 55 or over and consider it under 55, while applying acute care to major blood loss.
- Inspect the vulva, vagina and cervix with consent and arrange rapid uterine assessment unless another source has been confidently established and managed.