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Textbook/Obstetrics and gynaecology/Postmenopausal bleeding and urgent cancer exclusion/Rapid
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Postmenopausal bleeding and urgent cancer exclusion

Essential points for quick revision.

2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Stabilise major bleeding before cancer work-up

Haemodynamic compromise, continuous heavy loss, severe anaemia, sepsis or severe pelvic pain requires immediate acute gynaecological care even though the underlying cause still needs malignancy exclusion.

Action: Use ABCDE, obtain urgent bloods and crossmatch, involve senior gynaecology and control bleeding; resume the diagnostic cancer pathway as soon as the patient is stable.

Synopsis

Treat postmenopausal bleeding as a cancer-exclusion presentation, localise genital and non-genital sources, interpret transvaginal endometrial thresholds in ordinary and HRT contexts, and escalate persistent or recurrent bleeding to histology.

  • Postmenopausal bleeding means vaginal bleeding after at least 12 months of spontaneous amenorrhoea from menopause; ask about HRT, tamoxifen, anticoagulants and whether blood may be urinary or rectal.
  • Refer unexplained PMB through the urgent suspected-cancer pathway at age 55 or older under NICE and consider the same pathway in younger patients.
  • Examine vulva, vagina and cervix with consent and a chaperone to identify atrophy, trauma, polyp or visible malignancy, but continue endometrial assessment even when atrophy seems likely.

Key red flags

Any genital bleeding more than 12 months after the final spontaneous menstrual period is abnormal and should not be dismissed as a late period.

Recurrent thin-endometrium bleeding

A second episode after an initially reassuring scan can reflect a missed focal lesion and reactivates specialist assessment.

Investigation priorities

01
Urgent referral assessmentFirst step

Apply NICE age and symptom criteria and avoid delay while routine tests are arranged.

Management branches

First episodeRefer, examine and triage the endometrium

Any unexplained genital bleeding occurs after established menopause.

  1. Apply NICE suspected-cancer referral criteria immediately, document HRT, tamoxifen, anticoagulants, risk and whether urinary or rectal bleeding is possible.
  2. Perform consented vulval, speculum and pelvic examination and arrange transvaginal ultrasound within the urgent local pathway.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom