Post menopause bleed

[chocolatemonster]

Had my last period March 2019 and started bleeding yesterday. Light and not like a proper period.

I phoned the GP for an appt but they are only doing telephone triage first. The nurse called me. I explained that I am also experiencing lower back pain (last couple of months) and also pain in my left hip more recently. She thinks that's unrelated and general aches.

My smear is due so she has booked me in for that on Monday in the hope the bleeding has stopped and she said to kill 2 birds with one stone she can examine me then.

Should I be asking anything else? Everything I have read suggests it should be a 2 week referral so unsure what the nurse will be able to detect in an examination? Also the smear I assume is not sufficient on it's own to ascertain any issues? The nurse also said to cancel and rearrange appt if I am still bleeding Monday.

I am 51. Any advice greatly appreciated.

[JinglingHellsBells]

@chocolatemonster You need a 2-week urgent referral for a scan. That is the standard practice with PMB. Nothing less. A smear is irrelevant TBH and a nurse is not qualified to make the call OR examine you. She would only be able to see your cervix and the reason for an ultrasound scan is to rule out womb cancer.

I find it hard to believe a HCP doing smears doesn't know this. Pretty awful.

[chocolatemonster]

@JinglingHellsBells
Thank you for replying. That's what I thought as well so it seemed a bit strange that this action was recommended particularly as she said to cancel the appointment if I am still bleeding.

I think she is doing the smear as she knows that's due as well but I was confused about her saying she would examine me and if necessary refer me for a scan. What could she possibly see that would enable her to decide whether to refer or not?

Do you think I should push for the referral? I am sure the aches are unrelated but I would like to be sure.

[JinglingHellsBells]

Unless she has Xray eyes she can't see anything! :)

I have had PMB and even under a top meno consultant I had to have scans etc.

It's shocking she is to stupid over this.

Yes of course push for a referral.

The guidance for GPs from the RCOG is simply treat all PMB as endometrial cancer until proved otherwise. I've read the guidelines, partly for work as I'm a health writer, and also for my own information.

[chocolatemonster]

I think she may be a nurse practitioner rather than a nurse although I am not sure what the difference is

[JinglingHellsBells]

*so stupid :)

[JinglingHellsBells]

Makes no difference. The rule is the rule. You need to ask to see the GP or at least insist on another phone call and maybe educate her on the guidance- she's just ignorant.

[chocolatemonster]

@JinglingHellsBells do you think I should phone back before Monday or just wait until then and insist then I get referred?

[ThroughThickAndThin01]

I’m going through this and my GP has been outstanding. On the first day of bleeding I rang the surgery and a GP rang me back; told me to do a urine sample in the surgery that evening which I did. She explained that it would be tested for an infection and if it wasn’t one then I’d be put on the 2 week wait referral. It clearly isn’t an infection as I had a letter through with a CT scan appointment, and the next day for an appointment for a cystoscopy.

I’m nervous of something untoward being found but pleased I’m being seen so quickly tbh.

A bit like you, I had three days of bleeding which has now totally stopped, but followed by lower left back pain which I’m thinking is kidney. I have everything crossed that it’s something as simple as a kidney stone which has now passed.

[flysoginger]

A couple of years ago I went to see my gp with a post menopausal bleed. I was told it was standard to refer me under the two week referral rule. Gp also did an internal exam there and then incase it was anything obvious.

[chocolatemonster]

@ThroughThickAndThin01 glad you are being seen so quickly and really hope it turns out to be nothing.

@EleanorRising that sounds a bit vague - considering referring. How do they make that decision? Not using Vagifem.

I am hoping it's just my hormones having a last surge and it's a mini period.

[JinglingHellsBells]

@EleanorRising can you link to the Nice guidance as that's news to me :)

Last time I read the ROCG guidance for PMB it was the red flag two-week referral.

There are hundreds of women on other forums- like Menopause Matters- where GPs are referring immediately for a scan.

Yes, it's good to check for an erosion but the blood from an erosion tends to happen after impact- ie sex- and women who are post meno tend not to have erosions as they are hormonally driven.

OP it is probably just your hormones but I am not aware of the under 55 and over 55 rule and would appreciate the link.

[JinglingHellsBells]

@EleanorRising I don't think your over-55 thing is right.

This is a recent guidance from the RCOG and it says very clearly that women with PMB must be seen within 2 weeks for a scan. it's dated May 2020 and is a document produced for care during the pandemic.

www.rcog.org.uk/globalassets/documents/guidelines/2020-05-21-joint-rcog-bsge-bgcs-guidance-for-management-of-abnormal-uterine-bleeding-aub-in-the-evolving-coronavirus-covid-19-pandemic-updated-final-180520.pdf


Postmenopausal bleeding
• PMB is a red flag symptom because 5 - 10% of women will have endometrial cancer6. Clinical management of PMB should be focused on identifying cancer.

• Women with PMB should initially be managed by remote communication to:
o Confirm the symptom.
o Determine if they have any symptoms of COVID-19.
o Be informed that a 2 week wait referral to secondary care will be made.
o Women who have suspected or confirmed COVID-19 should be advised to self-isolate and informed that they will not be seen in secondary care until they are no longer likely to be
infectious (e.g. 14 days from the onset of symptoms) and arrangements should be made for retesting (viral clearance) in line with local policies. Women with suspected COVID-19 should be
advised to self-isolate and arrange a SARS-COV-2 viral testing via NHS 111 or online via
www.gov.uk/apply-coronavirus-test
o This risk of horizontal viral transmission from hospital assessment for COVID-19 vulnerable /
shielding patients’ needs to be balanced against the risk of delay in diagnosis of a gynaecological
cancer on a case by case basis. SARS-COV-2 viral testing of asymptomatic vulnerable patients to
mitigate risk should be considered in accordance with local protocols and national guidance2.
• In secondary care:
o A speculum examination should be performed because a normal cervix on speculum
examination in women who have a negative cervical smear excludes cervical cancer.
o Measurement of the endometrial thickness (ET) by transvaginal ultrasound scan (TVS) should be
the first line test in accordance with local protocols and national guidance7.
o Women can be discharged with an endometrial thickness (ET) of < 4mm on TVS because the risk
of endometrial cancer is very low7.
o Further endometrial evaluation is indicated if the ET is > 4 mm7 in accordance with local
protocols and national guidance. If local practice is to undertake a hysteroscopy but access to

[Crocky]

I rang my gp a couple of months ago and booked a routine appointment. After it was booked the receptionist asked if she could record why it was booked. I told her post menopausal bleeding. Two minutes after putting the phone down I got a call back saying i needed a same day appointment. Was sent to hospital for blood tests the next morning to check for cancer markers and an urgent ref to gynaecologist. My appointment was within two weeks and I had a scan and consultant appointment on the same day. Luckily all is well and the bleeding remains unexplained.
This is what should be happening to you. Please call back.

[Uptide]

I'm also going through this at the moment. I saw my GP at the beginning of October and eventually got my scan yesterday. I had a scan and a biopsy and now have 2-3 weeks until the results.

I would definitely push to be referred for a scan if I were you. Good luck.

[chocolatemonster]

I still don't understand the consider part as it just appears to be based on age. What would make them not consider referral if under 55 or does it mean still refer but not necessarily within 2 weeks?

[JinglingHellsBells]

@EleanorRising A screen shot of something doesn't rally work- can you not link to the actual web page? It's not actually possible to see the whole page you'd posted.

And in any case they 2 columns appear to say the same thing!

I am sure that the link I left from the RCOG guidance is far more up to date and reliable (it's May 2020) than something in NICE. It's completely unequivocal- refer to secondary pathway within 2 weeks.

[JinglingHellsBells]

@EleanorRising The only difference is the word 'consider'. Sometimes they defer a scan if a woman is using HRT as it can cause some odd bleeds in the first few months etc etc. and wait and see how it goes.

Most drs will send a woman for a scan.

[Crocky]

I gave my experience but not my age. I’m 49. No hrt.

[AnyFucker]

What would make them not consider referral if under 55 or does it mean still refer but not necessarily within 2 weeks?

I have been through this process. One incidence of PMB. I had telephone triage with the gp, who after taking my history, consulted with a colleague as to whether my referral should be under the 2WW pathway or "just" classed as urgent. This decision, she told me, was based on the fact I was 54 and 11 months old.

Within 2 weeks I had bloods, an internal scan, a hysteroscopy and endometrial biopsy. I didn't have a smear as I am not due until next year.