RCOG World Congress 2025

MANAGEMENT OF POSTMENOPAUSAL BLEEDING IN WOMEN ON HRT IN SECONDARY CARE

Natasha D’Souza, Sofia Lekka, Suraya Miah, Lukasz Polanski, Denise Quinton, AyshiniSamarasinghe

Department of Obstetrics and Gynaecology, North West Anglia NHS Foundation Trust, United Kingdom

INTRODUCTION

HRT is currently being utilised widely for the relief of menopausal symptoms.1 The annual report of the NHS Business Services Authority (NHSBSA) highlighted that there was a 22% increase in HRT prescriptions during 2023/24 when compared to 2022/23.1 Unscheduled bleeding within the first six months of initiating HRT or, within three months of a change in dose or preparation in those already established on HRT, is common.2 It can affect up to 38% of people using sequential HRT and 41% using continuous combined HRT.2 It is a major factor leading to repeat consultations and cessation of HRT.2

NICE has laid out robust guidance for referral pathways to aid with the early detection of endometrial cancer.3 This includes invasive testing (hysteroscopy and biopsy) if unscheduled bleeding on HRT persists for more than 6 months.3,4

AIMS AND OBJECTIVES

·To identify the number of patients referred on the 2 week wait (2ww) pathway to either the Scan and Pipelle (S&P) or outpatient hysteroscopy (OPH) clinic.

·Identify the number of patients who underwent endometrial biopsies.

·Outcome of the referral- if discharged or referred to Oncology MDT.

DESIGN

Baseline data was collected retrospectively over 2 years of women with unscheduled bleeding on HRT referred on the 2ww pathway.

METHOD

The data set comprised patients referred to the Outpatient Hysteroscopy (OPH) and Scan & Pipelle clinic via the virtual 2 week wait triage pathway from January 2022 to December 2023 (24 months).

The inclusion criteria comprised women more than 45 years with perimenopausal or postmenopausal bleeding (PMB) or unscheduled bleeding. The patients were divided into 2 cohorts- symptoms with or without HRT.

Review of electronic records included clinic letters, notes and investigation results (ultrasound scan, histopathology).

RESULTS

Endometrial malignancy (including pre-cancerous endometrial hyperplasia)

·Detection rate: 4.45% (N=107).

·Mean Endometrial Thickness(ET): 11mm. Median Endometrial Thickness(ET): 10.8mm

·Concerning ultrasound characteristics: ET>4mm, heterogenous or irregular appearing endometrium, polyps, fluid in endometrial cavity, haematometra, evidence of myometrial invasion.

Deep dive into patients on HRT

·43.17% (N=1037) of the patients referred on the 2ww pathway were on HRT.

·99.13% (N=1028) of these patients were found to have a benign endometrial pathology.

·Patients on HRT diagnosed with an endometrial malignancy comprised 0.37% (N=9/2402) of the entire cohort studied and 7.76% of those diagnosed with an endometrial malignancy.

In the outpatient hysteroscopy clinic 45.1%(N=920) did not undergo endometrial biopsy and therefore did not have a hysteroscopy either.

The most common reason was the repeat scan showing an ET <4 mm thickness with no concerning features; these patients were then discharged.

Following discharge

•70 patients re-attended the clinic between 3-12 months later with persistent symptoms which were deemed benign

•2 patients were diagnosed with endometrial cancer on re-referral

CONCLUSION

The number of endometrial malignancies detected is consistent with national data. Additional findings highlight a need to revise the referral process for patients on HRT with unscheduled bleeding as <1% are finally diagnosed with an endometrial malignancy. Outpatient hysteroscopy referrals can be reduced by increasing the appointments in the S&P clinic which might be more cost-effective.

Careful consideration for revision of the current guidance for investigating patients on HRT with unscheduled bleeding is warranted as this not only causes undue psychological stress to patients but also strains the services in terms of manpower and funding.

ACKNOWLEDGEMENTS

The authors would like to thank the Obstetrics and Gynaecology Department and the multidisciplinary team in the Gynaecological Oncology Unit at Peterborough City Hospital for their support.

REFERENCES

1. NHS Business Service Authority. NHS report shows an increase in HRT item prescriptions. 2024.. https://media.nhsbsa.nhs.uk/press-releases/ea62263d-af14-4a66-908c-537718def812/nhs-report-shows-an-increase-in-hrt-item-prescriptions

2. Ettinger B, Li DK, Klein R. Unexpected vaginal bleeding and associated gynecologic care in postmenopausal women using hormone replacement therapy: Comparison of cyclic versus continuous combined schedules. Fertil Steril. 1998;69(5):865-869.

3.Scenario: Referral for suspected gynaecological cancer | Management | Gynaecological cancers - recognition and referral | CKS | NICE. 2025.

4.Management of unscheduled bleeding on hormone replacement therapy (HRT). Published online 2024.

CONTACT INFROMATION

Department of Obstetrics and Gynaecology, Peterborugh City Hospital, North West Anglia NHS Foundation Trust, Edith Cavell Campus, Bretton gate, Peterborough PE3 9GZ United Kingdom.

Email: natasha.dsouza@nhs.net

RCOG World Congress 2025

Management of Postmenopausal bleeding in women on HRT in Secondary care

Poster Presenter

Authors

Affiliations

Part of Topic