PMB (Post Menopause Bleeding)

The PMB clinic is situated within the Jigsaw building on the Bournemouth Hospital site and Harbourside Gynaecology Unit at Poole Hospital. Patients are referred by their GP or via the unscheduled bleeding on HRT pathway. A walk-in service is not offered.

Women experiencing bleeding after the menopause will be referred to an urgent PMB clinic. Bleeding can be caused by many reasons, but in very few cases it may prove to be cancer; this is why it is important for an urgent referral.

During the appointment, the patient will be seen by a doctor and will have a transvaginal ultrasound scan. This is where the ultrasound transducer goes into the vagina. The transvaginal ultrasound scan will measure the thickness of the lining of the womb and assess for ovarian cysts. If the lining of the womb is thickened patients will be offered a hysteroscopy within the same appointment.

A hysteroscopy is a thin camera that is inserted into your womb via your cervix and can see the lining of your womb using sterile water to distend it. This is usually well tolerated but for women who find it painful they can have this at a later date under general anaesthetic. The hysteroscopy will be able to see if the lining is suspicious for cancer. It will also be able to diagnose polyps (a non-cancerous growth of the womb). In some clinics they may offer to remove this at the same time. They may take a biopsy of the womb lining to be certain that there is no evidence of cancer. This may take a few weeks to come back, and you often get the result by letter.

Sometimes it is difficult to perform the hysteroscopy in an outpatient setting and the doctor might ask the patient to come back and have the procedure under general anaesthetic. It is recommended that simple painkillers are taken prior to the appointment.

If the womb lining is thin a doctor will offer to conduct a speculum examination to look for other causes of bleeding.

If an ultrasound scan is not available at the time of the appointment the doctor will book an appointment for the patient with the Ultrasound scan department requesting a scan. The doctor will then check the results of that scan and inform the patient if they need to come back for a hysteroscopy in a different appointment.

Unscheduled bleeding on HRT

Unscheduled bleeding on Hormone Replacement Therapy (HRT) is a common problem. If this occurs within the first 6 months of starting HRT or within 3 months of changing dose or regime you can be reassured that this is normal. If bleeding occurs after this time, it is recommended that a transvaginal ultrasound is conducted to rule out the risk of endometrial (lining of the womb) cancer.

Because the risk of endometrial cancer in women with bleeding on HRT is very low (1 in 100 women), a separate pathway has been designed that can be arranged via your GP. If the lining of the womb is thickened or an ovarian cyst is identified, you will be referred to a gynaecology cancer diagnostic clinic. This will be offered in the two weeks following your ultrasound.

Women who have a thin womb lining unscheduled bleeding on HRT should see their GP to check for other causes of bleeding such as atrophic vaginitis (dryness of the vagina secondary to menopausal changes), infections (e.g. thrush or sexually transmitted diseases) and cervical polyps.

For most women who have bleeding on HRT it is often to do with the balance between hormones of oestrogen (the hormone that helps improve the menopausal symptoms) and progesterone (the hormone that helps protects the womb from cancer). Women who are experiencing bleeding on HRT often require an increase or change to the progesterone component of their HRT. If women can manage their symptoms with lower doses of oestrogen this can also help reduce their risk of bleeding. Your GP will be able to help you with this.

It is important that medications are not forgotten or missed as this can also trigger bleeding. If the bleeding persists after the adjustment of HRT we would recommend seeing your GP who may still consider a referral to the cancer diagnostic team even if your womb lining on ultrasound is normal.