Referral outcomes for women with bleeding on HRT to Postmenopausal bleeding Clinic.

Objectives: 

1) To review the appropriateness of referrals of women with unscheduled bleeding on HRT.

2) To evaluate whether these referrals are vetted appropriately to Postmenopausal bleeding clinics and have been seen within the 2 weeks window.

3) To assess the clinical outcomes of these referrals.

Design: Retrospective data analysis was undertaken from the electronic patient record through access to Trakcare and Clinical Portal.

Method:  A search was done of patients attending Postmenopausal bleeding Clinics led by Gynaecology consultants spanning across the three NHS Lanarkshire clinical sites between February 2022 and April 2022. 101 patients with unscheduled bleeding on HRT were randomly selected out of 528 referrals vetted to Postmenopausal bleeding clinic. Data was populated using Microsoft Excel and analyzed thereafter.

Results:  The most common age group referred were between 50-60 years old (78%). None of the patients were seen within 2 weeks of GP referral.The average time for the patient to be seen in Postmenopausal bleeding clinic was 8 weeks. Of these women, 90 patients had been on HRT for greater than 6 months (89.1%), whilst only 11 were seen in clinic before 6 months of HRT use (10.9%). 65 women had a normal transvaginal ultrasound scan (TVUSS) scan findings therefore did not require further investigation. 45 patients (45%) proceeded to outpatient hysteroscopy; 29 had a normal endometrium with no evidence of polyps or submucous fibroids (64.4%) and 16 women required Myosure polypectomy (35.5%).  All women who had an endometrial biopsy had a normal endometrial pathology with no evidence of endometrial hyperplasia or cancer (100%).

Conclusion: All patients were not seen within the recommended 2 weeks window which is out of line with best practice guidance. Improvement is needed to reduce our clinic waiting times. The majority of referrals of women with unscheduled bleeding on HRT to Postmenopausal bleeding clinics are clinically appropriate given 89.1% of these were on HRT for 6 months or greater. Despite current guidance recommending referral to Postmenopausal bleeding clinics, the risk of endometrial pathology with HRT is very low. We propose that new recommendations might be needed to adjust the progesterone dosage in HRT or counseling the patients with troublesome bleeding on stopping HRT and if persistent bleeding >6 weeks then referral should be made to Postmenopausal bleeding clinic. A different pathway for referral of unscheduled bleeding on HRT rather than suspicious of cancer pathway.