Unscheduled Bleeding on Hormone Replacement Therapy (HRT)

Unscheduled Bleeding on Hormone Replacement Therapy

We hope that this information leaflet will help you to understand your care options. We hope that you will feel comfortable to ask questions of your health professional so that you can work together to make a plan that meets your needs and priorities.

Remember you can always ask the healthcare professional to explain things differently, explain things again, or to write down information for you.

What is unscheduled bleeding on Hormone Replacement Therapy?

When patients are post-menopausal we worry if a lady has bleeding (post-menopausal bleeding). We know that around 1 in 10 women with post menopausal bleeding can have endometrial cancer (cancer of the lining of the womb). We therefore need to be sure we investigate it appropriately and in a timely manner.

For patients who are taking hormone replacement therapy (HRT) this differs slightly. Hormone replacement itself can cause bleeding to occur and we know for the majority of ladies the risk endometrial cancer is lower with HRT. Despite this a small proportion (around 1-2%) of women with unscheduled bleeding on HRT will have some endometrial changes, including endometrial cancer.

Why did my GP change my HRT prior to my referral?

As part of the national guidance, people who don’t have multiple risk factors for endometrial cancer should have an ultrasound scan done by their GP. If this is normal your GP may have altered your HRT to help prevent the bleeding for up to six months.

The progesterone component of your HRT is designed to help prevent thickening of the womb lining and reduce your chances of bleeding and endometrial changes. Changing this to another dose, route or medication can sometimes help stop bleeding on HRT. In some circumstances it is appropriate to try these prior to referral.

If you continue to have the bleeding after six months, it is heavy or you have multiple risk factors then your GP will refer you into the hospital service.

What happens next?

Your GP has referred you via the ‘unscheduled bleeding on HRT pathway’. This is a service aiming to see you and evaluate your bleeding as quickly as possible. We aim to see all patients within six weeks of referral. If you have not received an appointment within six weeks then please see your GP to chase this.

The majority of patients will require two appointments – one for an ultrasound scan that will be performed with your permission with a probe in the vagina, followed by one appointment to be seen by a gynaecologist in clinic.

What shall I expect in clinic?

You will be seen by a gynaecologist who will discuss your symptoms with you and assess your ultrasound scan result. From this they will discuss with you a plan as to how to investigate your bleeding further. Broadly this will be done in one of three ways:

1. A speculum and vaginal examination only – where symptoms are unconcerning and the scan suggests the lining of the womb is thin. This is to check for other causes of bleeding from the genital tract.
2. A speculum and a vaginal examination, followed by a biopsy of the womb lining – where symptoms are mildly concerning and/or the lining of the womb appears mildly thickened;
3. A hysteroscopy (camera test into the womb through the vagina) with a biopsy of the lining of the womb – where symptoms are concerning, the lining of the womb is thickened or there is other things seen within the womb which need further investigation.

What is an endometrial biopsy and how is it done?

An endometrial biopsy is where we take a small sample of the lining of the womb (endometrium) and send it away to be analysed under a microscope. This is the most definitive way we have of checking whether there are any problems with the lining of the womb. This is mainly to detect cancer but may also show other non-cancerous changes, which may need treatment or further follow up.

An endometrial biopsy is generally done using a small tube called a Pipelle ©. A speculum is inserted into the vagina and the device passed through the neck of the womb. This then creates a small amount of suction and is moved around to take a scraping of the lining of the womb. During the procedure you may feel some sharp cramping pains but these generally settle quite quickly. The biopsy itself takes less than a minute. You can have pain relief after the procedure if necessary.

What is a hysteroscopy?

You may be one of the women who needs to go on and have a hysteroscopy (camera inside the womb). If you are, your clinician will discuss this with you further. We will aim to do this on the same day as your clinic appointment if possible. You can access our patient information leaflet on ‘Outpatient Hysteroscopy’ using the link.

https://staging.worcsacute.mixd.co.uk/leaflets/outpatient-hysteroscopy

What will happen after the clinic appointment?

The clinician who sees you will discuss a plan with you before you leave. Feel free to ask any questions you may have.

The majority of patients will have the following outcomes:

1. Discharged back to the care of their GP;
2. Await endometrial biopsy result and if normal be discharged back to their GP;
3. Sent for further investigation or treatment.

What about my HRT?

Your clinician will discuss HRT changes with you and may be able to advise you how you could change things. You can also discuss this with your GP.

Further information can be found on the NHS website:

https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt

You can fill out the following table with your healthcare professional. This will help you to think about which option is best for you, given your individual situation. Doing nothing is also an option.

My Options include…	The Benefits Why is this option good for me?	The Risks What is not so good about this option for me?
To have treatment
To do nothing
Alternative treatment(s)

You might also want to ask…

• How quickly should I expect to see an improvement?
• Who should I contact if I have questions after I leave today?
• Do I need to come back to the hospital again? Or to see my GP after today?
• Where can I go to get more information?
• What lifestyle changes could I make to support my recovery?

Remember you can always ask the Doctor to explain things differently, explain things again, or to write down information for you.

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:

Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:

The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day. If you are unable to understand this leaflet, please communicate with a member of staff.

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