Not all postmenopausal bleeding requires an immediate ultrasound scan. The need for investigation depends on whether you are taking hormone replacement therapy (HRT), your individual risk factors, and the pattern of bleeding.
If You Are Not Taking HRT
Any vaginal bleeding occurring more than 12 months after your last period should be assessed promptly. In most cases, you will be referred for a transvaginal ultrasound scan to measure the thickness of the womb lining (endometrium) and possibly a biopsy. We can refer you to gynaecology promptly for this but this should also be managed quickly on the NHS as well.
If You Are Taking HRT
Bleeding can be a common side effect when starting or changing HRT. The British Menopause Society (BMS) advises that many women can be managed safely without an immediate scan if the bleeding pattern is expected and there are no significant risk factors for endometrial cancer.
When It Is Usually Safe to Wait
It is often reasonable to monitor symptoms and adjust HRT before arranging a scan if:
- Bleeding starts within the first six months of beginning HRT.
- Bleeding occurs within three months of changing the dose or type of HRT.
- The bleeding is light and not becoming heavier.
- There are no major risk factors for endometrial cancer, such as obesity, diabetes, polycystic ovary syndrome (PCOS), Lynch syndrome, or prolonged exposure to unopposed oestrogen.
In these situations, we may recommend adjusting your HRT regimen and reviewing your symptoms over the following weeks before considering further investigations.
When a Scan Should Be Arranged Sooner
A transvaginal ultrasound scan is usually recommended if:
- Bleeding first occurs more than six months after starting HRT.
- Bleeding begins more than three months after a change in HRT treatment.
- Bleeding persists despite adjustments to HRT.
- Bleeding becomes heavy, prolonged, or troublesome.
- You have significant risk factors for endometrial cancer or are significantly concerned.
- The bleeding pattern is unexpected for the type of HRT you are taking.
How can we help?
If you are concerned you are having an unexpected bleeding or change to you bleeding pattern please do book in for a women’s health consult and we can explore your symptoms in more detail and either make changes to HRT or contraception if on or arrange further investigations if needed.
Written by: Dr. Rachel Tomlinson, Women’s Health Service Lead / GP
Last reviewed: June 26