Post Menopausal Bleeding

[HollyBerri]

Hi. I haven’t had a period for about 18 months. I am on Evoril patches (75) & Utrogestan 100. All good . I have had some very light spotting recently, been to the GP and have been referred to the hospital under a cancer pathway.
I am trying not to worry too much as i have no other issues and have have googled there can be several reasons. I am waiting for a call this week for an appointment.
Has anyone been through this and tell me how it turned out- positive or not just so I know what to expect?
i am trying not to fear the worse. My last all clear smear was 3 years ago. The bleeding is very recent and very light- not even enough to need a a pad.
i have been told to keep on the HRT for now as stopping suddenly can also potentially cause problems.

@JinglingSpringbells
You are wrong on this one and it is NHS guidance to stop HRT for 6 weeks after PMB.
This is from just one of the many NHS trust protocols online:
"Postmenopausal Bleeding (PMB) is defined as an episode of bleeding in a woman at least 12 months after her last period

• If patient not on Hormone Replacement Therapy (HRT) refer to 2ww Gynaecology
• If patient on HRT:
• Stop HRT for 6 weeks and review patient
• If bleeding stopped after 6 weeks review HRT prescription
• If bleeding not stopped after 6 weeks refer to 2ww Gynaecology

NOTE - PMB would also include any breakthrough bleeding in a woman on continuous HRT after first 6 months, or after full amenorrhea has been established"

@JinglingSpringbells - if you Google it you can see it easily. I also double checked it with a friend who’s a GP.

@QueenOfHiraeth - yes exactly that. I suspect the protocol may have changed very recently as my GP had to check the guidelines before ringing me back.

@QueenOfHiraeth @Notellinganyone I have just looked at the updated NICE guidance on bleeding and it's not there.

It does seem rather odd to stop HRT as one of the most common things to happen once estrogen is stopped like this is for a bleed to happen anyway.

So what is the logic behind stopping for 6 weeks?

Don't tell anyone but I had to Google it too...
I think the theory is that most sinister causes will keep bleeding but HRT induced problems would, hopefully, stop in that time

The link is from a Devon NHS site and perhaps that doesn't necessarily apply nationwide. It does also say 'consider' rather than it being mandatory.
It's definitely not on the NICE guidance of Sept 2022.
Anyway, it's all getting away from the OP and I hope she's okay and all will be fine.

@JinglingSpringbells I think sinister causes will keep bleeding but HRT related will usually settle within 6 weeks.

This guidance looks to have been around for a while but I must confess I had never seen it either and will be updating a few colleagues next week (again!)🙄
I swear I do more CPD on MN than via clinical sites

I'm on evorel and have a mirena coil so unsure if post menopausal or not but hadn't bled for a year or 2 until recently. I went to GP, had a referral for bloods and an internal scan which was all fine. No more action.

@JinglingSpringbells There are lots of other online too for other trusts so it is fairly widespread and will, therefore have evidence behind it. It does also seem in line with some of the Advice & Guidance I have seen from gynae recently.

Guidance is always just guidance though whatever its source, it's rarely mandatory and often overridden by clinical judgement

@HollyBerri try not to worry too much - is the bleeding the only symptom? So you have any other risk factors or symptoms at all apart from bleeding?
I currently have grade 1 endo cancer - have been bleeding exceptionally heavily and continuously for several years. Also have the other existing risks of being obese, having existing Polycystic Ovary Syndrome, mother with history of breast cancer and previous hormonal contraception treatment. The only reason they never put me on the cancer pathway and made a standard referral was that I was only 36 at the time. I'm now 40.
@GreenDressy if anything was sinister, that 6 weeks isn't likely to be crucial - the majority of endo cancer is slow growing. Mine is still early stage despite being missed for 4 years.

Good luck ladies who are waiting. I hope all is well and you get lovely benign results

Hi. I am trying to get the timeline right as my memory is appalling. My last proper period was in summer 2021 - i can remember that as i was on holiday and it was completely unexpected and the first one i had for months. Probably a couple of light bleeds in the following 6 months then nothing until recently so over a year.
Sorry if that’s slightly different to what i originally said which was very approximate.
The GP did say that HRT can cause it but generally when you start taking it or change the dosage so it was unlikely to be that which is why she double checked about wether to stop taking it.
I have no other symptoms and feel generally well. I do feel a bit bloated at certain tones of the day but that’s normal for me.
The good news is I have an appointment next week at gynaecology, presumably for a scan so its all been really quick. I am trying not to worry.
One thing i didn’t realise is that smear tests go from 3 to 5 years when you are over 50. I originally rang up as i thought i was due one. That’s really off as clearly lots of issues so i am not sure what the logic is behind that.

This is the NICE advice, for comparison .https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/

• Unscheduled vaginal bleeding is a common adverse effect of HRT within the first 3 months of treatment.

• Monthly cyclical regimens should produce regular withdrawal bleeding towards the end of the progestogen phase.

• Continuous combined HRT commonly produces irregular breakthrough bleeding or spotting in the first 4–6 months of treatment. If bleeding persists beyond 6 months, becomes heavier, or occurs after a spell of amenorrhoea, endometrial pathology should be excluded. See the CKS topic on Gynaecological cancers - recognition and referral for more information.

• Unpredictable or unexpected bleeding may also be due to non-adherence with treatment, drug interactions, or a gastrointestinal disorder (which may affect drug absorption).

• If serious gynaecological pathology has been excluded, altering the progestogen part of the regimen may improve bleeding problems. Options include:

• Increasing the duration or dose of the progestogen, or changing the type of progestogen, for example switching to the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) combined with an oral or transdermal oestrogen preparation.

@HollyBerri Smear tests- you can always have them privately if you want to. Most private hospitals do them for around £75 (sometimes done by local GPs earning a bit more money!) or there are women's private health clinics . The main thing now it the HPV test and if that's clear, you may not need smears so often depending on your medical history and lifestyle (new sexual partners mean a potential new risk.)

@JinglingSpringbells Thank you. I am very familiar with NICE and CKS as I use them all the time

Hi . Thankyou for all the reassurance. I have had my scan and seen the consultant. Everything looks clear. She took a biopsy (i think that’s what she said anyway). So i need to wait for that result but she doesn’t think its anything to worry about.
she did say it can happen sometimes. I hope it reassures anyone else who has similar but please get to the Drs and get it checked out straight away.

That's really good news! Hope it puts your mind at rest a bit.

Thanks for this reassuring thread Holli and contributors. I’m awaiting my call to clinic for checks. The Gp nurse was very reassuring and has referred me to gynaecology within two weeks to have things checked. I’ve been reading the thread and it’s calmed me down somewhat.

This just happened to me. Been for a scan and all ok, but they told me it's likely HRT related and suggested that when I began HRT I wasn't post menopause but in perimenopause therefore HRT I'm on needs review. The bleeding and infact the way I was feeling was exactly like a period. I know one thing and that's I have no intention of stopping or pausing HRT. Best thing ever.

My last light bleed was 2021. My periods had actually stopped 17 months before, but briefly started again. I was a bit worried in 2021 but did nothing. It was just after a covid jab and I read in here that post menopause women had suddenly got a period after the jab. Basically I bottled it.

I am not on HRT. I don't have smears. I suffer from vaginismus so smears have been a no no. 4 weeks ago I had spotting in my pants before bed. The next morning I had bloated abdominal and discomfort , which I now have had for 4 weeks. Three weeks ago I conceded defeat snd went to GP. Immediately referred me as urgent cancer referral.

The NICE guidelines changed in Oct. No longer two weeks - 2-4 weeks. I am being seen this weekend.

I am bricking it. Not only a bad diagnosis but because of the vaginismus issue. It is going to be embarrassing. Would bury my head in the sand but I can't live with the discomfort. Being a woman is somewhat burdensome isn't it?

Meant to mention, I have been suffering from high amounts of work related stress. I am sure it is related. Fingers crossed I get the all clear. If I do I am never stressing again. This is a wake up call in that area.

Can anyone send me some comforting words on what to expect. I have not received the appointment letter and doubt I will get it in time. The appointment was only made yesterday. They could not email it.