Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Major uterine bleeding or malignant obstruction
Haemodynamic bleeding, symptomatic severe anaemia, sepsis from pyometra or obstructive renal failure from advanced pelvic disease requires immediate physiological stabilisation before complete cancer staging.
Action: Use ABCDE care, obtain large-bore access, FBC, coagulation, renal profile and crossmatch, give blood products and antibiotics when indicated and involve gynaecology, interventional radiology, urology and oncology urgently for examination, tamponade, embolisation, drainage, stenting, nephrostomy, radiotherapy or surgery.
Synopsis
Investigate postmenopausal and abnormal uterine bleeding promptly, obtain representative endometrial histology, integrate anatomical and molecular risk and coordinate curative surgery, fertility-sparing care, adjuvant treatment and recurrence management.
Postmenopausal bleeding is the key early presentation. Most cases are not cancer, but every episode needs timely assessment and a cervical smear is not an endometrial test.
First-line evaluation commonly combines speculum and bimanual examination with transvaginal ultrasound; an endometrial thickness of 4 mm or less lowers risk but does not end investigation of persistent bleeding.
The diagnostic reference standard is representative endometrial histology from outpatient biopsy or hysteroscopy-directed sampling; focal lesions and repeated bleeding favour hysteroscopy.
Key red flags
Any postmenopausal bleeding requires prompt endometrial assessment even when the volume is small, anticoagulation is present or cervical screening is normal.
Pyometra or haemorrhage
Fever, uterine tenderness, purulent discharge or haemodynamic bleeding requires urgent infection and haemostasis management.
Investigation priorities
01
First-line transvaginal ultrasoundFirst stepFirst line
Measure endometrial thickness and morphology and identify focal lesions, fibroids, adnexal disease and pelvic fluid.
02
Preferred outpatient endometrial biopsyPreferred
Obtain tissue efficiently for diffuse hyperplasia and carcinoma in a patient able to tolerate office sampling.
Management branches
Postmenopausal bleedingImage and obtain representative tissue
A patient reports any vaginal bleeding after menopause.
Confirm the bleeding source with speculum and pelvic examination, assess haemodynamic state and arrange transvaginal ultrasound through the urgent pathway.
Obtain outpatient biopsy for a thickened or suspicious lining and use hysteroscopy-directed sampling for a focal lesion, insufficient biopsy or recurrent bleeding despite a thin lining.
Key medicines
Carboplatin and paclitaxelA common 21-day systemic regimen gives carboplatin AUC 5 to 6 and paclitaxel 175 mg/m² intravenously on day 1 for six cycles, adjusted to setting, renal function, marrow, neuropathy and response.
Levonorgestrel intrauterine systemInsert a 52 mg levonorgestrel-releasing intrauterine system within a specialist fertility-sparing protocol, sometimes combined with oral progestogen, and replace only according to product life and surveillance plan.
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.