When to investigate

1. POST MENOPAUSAL BLEEDING (PMB)

• Endometrial cancer most commonly presents with PMB. It is therefore recommended that women presenting with PMB are referred using a suspected cancer pathway referral.
• For individuals with PMB on HRT, indications for further investigations include bleeding that has not settled after using continuous combined HRT for 6 months or bleeding after a spell of amenorrhoea.
• For further information on recognition of gynaecological cancers, see NICE CKS summaries.

2. HEAVY MENSTRUAL BLEEDING (HMB)

• The risk of endometrial cancer in premenopausal women presenting with HMB is low. However, structural lesions such as fibroids, polyps, uterine cavity abnormality, histological abnormality or adenomyosis can present with HMB. Where the history or examination suggests a high risk for this, further tests should be considered.
• NICE says to offer outpatient hysteroscopy to women with HMB if they have risk factors for endometrial pathology.
• For further information on heavy menstrual bleeding, see NICE CKS summaries.

3. INTERMENSTRUAL BLEEDING (IMB) OR POST-COITAL BLEEDING (PCB)

• The risk of endometrial cancer in premenopausal women presenting with IMB is low, although higher than that for HMB. NICE says offer outpatient hysteroscopy to women if they have symptoms of persistent IMB.
• Persistent IMB is defined as occurring for more than 3 consecutive months.
• NICE says suspect a diagnosis of cervical cancer if a woman has persistent IMB or PCB that is not due to infection or another cause.
• Women should be reassured that cervical cancer is extremely unlikely if they have an in date normal cervical smear.
• For further information on post-coital bleeding, see NICE CKS summaries.

4. DYSMENORRHOEA

• The risk of endometrial cancer in premenopausal women experiencing dysmenorrhoea is low. However, dysmenorrhoea can be caused by pelvic pathology including endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, ovarian cancer or cervical cancer. Where the history or examination suggests a high risk for this, further investigations should be considered.
• For further information on dysmenorrhoea see NICE CKS summaries.

OTHER IMPORTANT CONSIDERATIONS:

• Where there are risk factors for endometrial hyperplasia or carcinoma there should be a low threshold for investigations.
• Pregnancy should always be considered in premenopausal women.