Vaginal Bleeding Algorithm

Safety

Red Flags — Exclude emergencies & urgent pathology first

Done

Before categorising, screen for haemodynamic compromise, pregnancy complications, and malignancy indicators.

First assessment: 1) Is the patient unstable? 2) Could this be pregnancy-related? 3) Is the source definitely vaginal rather than urinary or rectal? 4) Is there pain, fever, discharge, a pelvic mass or a suspicious cervix/vulva? 5) Is the patient premenopausal, perimenopausal, postmenopausal or using HRT/hormonal contraception? Then follow the separate pathway: early-pregnancy bleeding, HMB, IMB/PCB, PMB, or unscheduled bleeding on hormonal contraception/HRT.

Haemodynamic instability Assess clinically: pulse and BP, postural symptoms, mental state, capillary refill/perfusion, estimated bleeding, anticoagulant use, anaemia symptoms → 999 for shock, ongoing major haemorrhage, collapse, altered consciousness, severe symptoms or deterioration (a heart rate of 100 alone does not define shock)

Suspected ectopic pregnancy Positive pregnancy test with pain, abdominal/pelvic or cervical motion tenderness, shoulder-tip pain, syncope, peritonism or significant bleeding → direct to A&E if unstable or significant concern about pain/bleeding; stable → urgent EPAU / out-of-hours gynaecology (local pathway). Consider even without risk factors; a negative urine test does not absolutely exclude a very early or ectopic pregnancy if suspicion is high (NICE NG126)

Pregnancy loss with retained products Heavy bleeding + clots + history of recent pregnancy → Same-day / 999 if haemodynamically unstable

Postmenopausal bleeding Unexplained bleeding >12 months after LMP (even a single episode), not an expected withdrawal bleed on sequential HRT → gynaecology suspected cancer pathway referral at 55 and over; consider referral under 55 — do not assume risk is negligible (usually benign, but endometrial cancer must be excluded)

Suspicious cervix or vulval lesion Cervix that looks or feels abnormal (mass, ulceration, suspicious friable lesion), or unexplained vulval lump, ulceration or bleeding → consider a suspected cancer pathway referral (NICE NG12; do not wait for a smear). IMB/PCB with offensive discharge, pain or fever → same-day STI/PID assessment

Severe coagulopathy features Bleeding from multiple sites, purpura, recent anticoagulation overdose → 999 (DIC, haematological emergency)

Molar pregnancy signs Hyperemesis, uterus large for dates, no fetal heart → Same-day gynae (gestational trophoblastic disease)

Sepsis features Fever >38°C, rigors, tachycardia + PV bleeding → 999 (septic miscarriage, endometritis; NICE NG253)

Postmenopausal bleeding is usually benign, but endometrial carcinoma must be excluded — NICE NG12 (updated April 2026) requires a suspected cancer pathway referral for unexplained postmenopausal bleeding at 55 or over and advises considering one under 55. Ruptured ectopic pregnancy remains a cause of maternal death in the UK; the classic triad of amenorrhoea, pain, and PV bleeding must never be dismissed. Haemodynamic compromise from menorrhagia or miscarriage can be life-threatening within minutes. Gestational trophoblastic disease (GTD) is rare but highly curable if detected early — missing it is catastrophic.

Diagnose

Confirm pregnancy status & cycle pattern first

Done

Determine pregnancy status where pregnancy is possible, menopausal status, and characterise the bleeding pattern before all else.

Pregnancy test

Urine βhCG — offer to anyone in whom pregnancy is biologically possible and the result would alter management, particularly with amenorrhoea, IMB, pelvic pain, contraception failure or bleeding of uncertain origin (CoSRH: test sexually active women with problematic bleeding on hormonal contraception). Not routinely needed with confirmed menopause or where pregnancy is not biologically possible. Positive → changes entire pathway.

LMP & cycle

Date of LMP, cycle length, duration of bleeding, any missed periods. HMB is defined functionally — bleeding that affects physical, social, emotional or material quality of life (NICE NG88); patient perception and impact drive assessment, not rigid cut-offs.

Bleeding pattern

Menorrhagia (heavy regular), IMB (intermenstrual), PCB (postcoital), PMB (postmenopausal), irregular — each drives different differentials

Menopause status

PMB = bleeding more than 12 months after the LMP, unless on sequential HRT with an expected withdrawal bleed. Age 45+ with typical symptoms: diagnose menopause clinically without FSH (NICE NG23). Perimenopausal = irregular cycles >40 years. Ask about HRT use.

Contraception use

IUD/IUS can cause irregular bleeding. Progesterone-only pill causes BTB. Combined pill — breakthrough suggests missed pills or drug interaction. Assess adherence, interactions, pregnancy and STI risk and time since starting/changing method (CoSRH).

Cervical smear

Check date of last smear and result. Cervical screening is for asymptomatic people and is not a diagnostic test for symptomatic bleeding. Do not delay referral for a suspicious cervix while awaiting cytology or HPV results; take a screening sample only if due or overdue and this does not delay assessment.

Sexual history

New partner, STI symptoms, contact bleeding → test for chlamydia and gonorrhoea according to sexual risk and local prevalence (BV is not a routine cause of contact bleeding without clinical vaginitis)

Bleeding diary

Ask patient to complete PBAC score or Menorrhagia Calendar for 1–3 cycles if non-urgent

A positive pregnancy test fundamentally redefines the differential — all non-pregnancy causes become secondary. Offer a pregnancy test whenever pregnancy is biologically possible and the result would alter management. Bleeding diaries such as the PBAC allow monitoring (HMB itself is defined by impact on quality of life — NICE NG88) and treatment response assessment, avoiding over-investigation of physiological variation.

Diagnose

Classify the presentation — Pregnancy vs Non-pregnancy cause

Done

Separate into distinct pathways — early-pregnancy bleeding, HMB, IMB, PCB, PMB, and unscheduled bleeding on hormonal contraception/HRT — because investigation thresholds, referral routes and treatment differ.

Early pregnancy bleed

βhCG positive + bleeding ≤12 weeks. Differentials: threatened/inevitable/complete/incomplete/missed miscarriage, ectopic, GTD. → A&E if unstable or significant pain/bleeding; EPAU/gynaecology if stable but ≥6 weeks, gestation uncertain or pain present; hCG and USS interpreted by the early pregnancy service; written safety-netting.

Heavy menstrual bleeding (HMB)

Regular heavy periods. PALM-COEIN classification: Polyp, Adenomyosis, Leiomyoma, Malignancy — Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified

Intermenstrual bleeding (IMB)

Bleeding between periods. Causes: cervical ectropion, polyp, endometritis, contraception-related, cervical/endometrial malignancy. Consider pregnancy; speculum if persistent, recurrent, with PCB, pain, dyspareunia, discharge, abnormal screening history or change in pattern.

Postcoital bleeding (PCB)

Bleeding after intercourse. History and speculum examination; pregnancy assessment where relevant; STI testing according to risk; assess for ectropion, polyp, trauma, atrophy and infection. Do not label every PCB as suspected cancer, nor reassure solely because the screen is normal; a cervical screening test is not a diagnostic test for symptoms — take one only if due (NHS Cervical Screening Programme).

Postmenopausal bleeding (PMB)

Bleeding >12 months after LMP, unless expected withdrawal bleeding on sequential HRT. Usually benign (atrophy, polyp) but endometrial cancer must be excluded. → suspected cancer pathway referral at 55 and over if unexplained and not attributable to HRT; consider referral under 55 (do not assume risk negligible). At any age: pelvic or abdominal mass not obviously fibroids, or ascites → suspected cancer pathway referral; cervix consistent with cancer or unexplained vulval lump, ulceration or bleeding → consider a suspected cancer pathway referral (NICE NG12); systemic concern → urgent referral. Do not rely on a normal smear or empirical vaginal oestrogen to exclude pathology.

Perimenopausal bleeding

Age >40, irregular/changing cycle. Can be physiological; assess a significant change in bleeding in women over 40 (CoSRH). Consider endometrial pathology with persistent IMB, treatment failure or endometrial risk factors (e.g. obesity, PCOS, tamoxifen) — hysteroscopy with sampling per NICE NG88/local pathway; age alone is not an NG88 criterion

Unscheduled bleeding on HRT / contraception

HRT: assess regimen, adherence, oestrogen dose, progestogen dose and duration, and whether bleeding is expected withdrawal bleeding. Unscheduled bleeding in the first 6 months after starting HRT or within 3 months of a change may be managed per the local HRT bleeding pathway (BMS) if no major risk factors and not heavy or persistent; heavy, prolonged, recurrent or late-onset bleeding → urgent investigation. Contraception: assess adherence, interactions, pregnancy and STI risk, timing since initiation/change and expected bleeding pattern; assess significant change in bleeding in women over 40 (CoSRH). These are CoSRH/BMS/local pathway recommendations, not NICE criteria.

The PALM-COEIN classification (FIGO 2011) provides a structured framework for HMB that guides targeted investigation. For PMB, endometrial carcinoma must be excluded — atrophic vaginitis (the most common cause) is a diagnosis of exclusion, not assumption. Correct categorisation prevents both under-investigation (missed cancer) and over-investigation (unnecessary procedures for normal perimenopausal changes).

Diagnose

Targeted Examination

Done

Perform targeted examination with chaperone documented. Examination is selective: HMB without other symptoms may be treated without examination in some cases; examine before LNG-IUS fitting and before relevant investigations, and with IMB, PCB, pelvic pain, pressure symptoms, suspected mass, anaemia out of proportion or possible pregnancy (NICE NG88).

Vital signs

HR, BP, O₂ sats. Assess haemodynamic status clinically (pulse, BP, postural symptoms, mental state, perfusion) — 999 for shock or ongoing major haemorrhage. Fever → sepsis screen

Pallor / anaemia

Conjunctival pallor, nail beds, capillary refill. Pallor + HMB → FBC urgent. Haemodynamic instability → 999

Abdominal exam

Palpate for uterine enlargement (fibroids, pregnancy), adnexal tenderness (ectopic, PID), peritonism → surgical emergency

Speculum examination

Visualise cervix: cervical os (open = miscarriage), cervical ectropion, polyps, contact bleeding, suspicious lesions → biopsy/urgent referral. Quantify bleeding.

Bimanual examination

Uterine size/tenderness, adnexal masses, cervical excitation (PID). Enlarged uterus + HMB → fibroids/adenomyosis

BMI

Obesity (BMI >30) is independent risk factor for endometrial cancer and anovulatory cycles. Document and address.

Thyroid

Thyroid enlargement or features of hypo/hyperthyroidism — both cause menstrual disturbance

Speculum examination is indicated for persistent or recurrent IMB, PCB, and any suspicious bleeding — it can identify cervical carcinoma, polyps, or infection visible only on direct visualisation. Cervical excitation on bimanual examination supports PID. Documenting chaperone is both medico-legal best practice and GMC requirement. Always offer chaperone before intimate examination.

Diagnose

Investigations — Targeted by presentation

Done

FBC

All patients with HMB — offer in parallel with treatment. Anaemia severity, symptoms, rate of blood loss and comorbidity determine urgency (no single Hb threshold). Thrombocytopenia → haematology

Ferritin

Consider ferritin: NICE NG88 (updated July 2026) no longer advises against testing, because iron deficiency is common in HMB. Particularly useful where iron deficiency is suspected despite a normal Hb, anaemia is present, symptoms are disproportionate, or the result will influence iron replacement or further investigation.

Coagulation / vWD screen

Consider investigation for an inherited bleeding disorder when HMB has been present since menarche and there is a personal or family history suggesting a bleeding disorder. Discuss the testing pathway with haematology — vWF results are affected by stress, pregnancy, inflammation, oestrogen and blood group. Not routine for all HMB.

TFTs

Do not routinely test thyroid function in HMB unless there are symptoms or signs of thyroid disease (NICE NG88).

Pelvic USS / hysteroscopy

Select by history and examination (NICE NG88) — not automatically required for uncomplicated HMB. Hysteroscopy: persistent IMB, suspected polyp/submucosal fibroid or endometrial risk factors. Pelvic ultrasound: palpable uterus, pelvic mass, suspected adenomyosis (TVUS preferred), significant dysmenorrhoea or suspected larger fibroids. MRI not first-line — when ultrasound is inadequate or for treatment planning. PMB: endometrial thickness thresholds depend on HRT use, regimen, scan timing and local protocol, and a thin endometrium does not end the pathway if bleeding persists or recurs — refer via the local suspected cancer/urgent gynaecology pathway and state who reviews the result.

βhCG (serum)

Pregnancy of unknown location: two serum hCG measurements as near as possible to 48 hours apart (not earlier), interpreted within the early pregnancy service (NICE NG126). Rise >63%: likely developing intrauterine pregnancy, but ectopic not excluded. Fall >50%: likely failing pregnancy, follow-up still required. Fall <50% or rise <63%: early pregnancy service review within 24 hours. hCG alone does not determine location; symptoms take priority over hCG results; do not use serum progesterone to diagnose ectopic pregnancy or viability.

STI screen

Endocervical / vulvovaginal swabs — chlamydia + gonorrhoea NAAT (according to sexual risk and local prevalence — e.g. IMB, PCB, new partner, <25 years)

Endometrial biopsy

For HMB, do not offer blind endometrial biopsy in primary care. If sampling is indicated, obtain it at diagnostic hysteroscopy — consider for persistent IMB/irregular bleeding with obesity or PCOS, tamoxifen use or failed treatment (NICE NG88). PMB biopsy is a secondary-care investigation via the local suspected-cancer or urgent gynaecology pathway.

Do NOT order

CA-125 routinely for bleeding alone (low specificity). MRI not first-line (specialist-initiated). Do not routinely request FSH, LH, oestradiol or other female hormone tests for HMB. Routine TFTs, ultrasound or blind biopsy for HMB. Serum progesterone to diagnose ectopic pregnancy or viability.

NICE NG88 (Heavy Menstrual Bleeding, 2018, updated July 2026) recommends choosing hysteroscopy or pelvic ultrasound according to the history and examination; when ultrasound is used, TVUS is preferred (e.g. suspected adenomyosis). Endometrial thickness thresholds in PMB are ultrasound-service/gynaecology pathway criteria rather than a universal GP rule. Consider an inherited bleeding disorder with HMB since menarche plus a suggestive personal or family history; plan testing with haematology.

Refer

Referral Criteria — Urgency-stratified

Done

999

Shock, ongoing major haemorrhage, collapse, altered consciousness or deterioration (clinical assessment — not a single heart-rate threshold). Suspected ruptured ectopic. Septic shock.

Same-day gynae

Suspected ectopic (stable) → urgent EPAU / out-of-hours gynaecology; direct to A&E if significant pain or bleeding. Open os + active miscarriage. Molar pregnancy features. PID with systemically unwell patient.

Suspected cancer: Gynaecology

Postmenopausal bleeding at 55 and over not attributable to HRT (consider under 55). Consider for a cervix consistent with cervical cancer (no smear needed before referral — diagnosis is by biopsy in secondary care) and for an unexplained vulval lump, ulceration or bleeding (NICE NG12). Pelvic or abdominal mass not obviously fibroids, or ascites, at any age. Suspicious endometrial biopsy.

Colposcopy / urgent gynaecology

Visible cervical lesion (consider the suspected cancer pathway — NICE NG12). High-grade dyskaryosis (via the screening programme). Persistent PCB or IMB despite assessment, including over 40 with endometrial risk factors: urgent gynaecology or colposcopy referral per local pathway (not a NICE NG12 criterion). A normal smear does not exclude cervical cancer.

Routine Gynaecology

HMB with treatment failure, severe symptoms, suspected pathology, or fertility-preserving procedural treatment required. Suspected fibroids suitable for surgical/radiological treatment. Desire for fertility-preserving surgery.

Haematology

Suspected coagulopathy (vWD confirmed/suspected). Thrombocytopenia on FBC. Anticoagulation-related HMB requiring specialist optimisation.

EPAU

Early Pregnancy Assessment Unit: stable early-pregnancy bleeding if ≥6 weeks, gestation uncertain or pain present; hCG and USS interpreted by the service. Self-refer or GP direct-book where available.

Primary care manage

HMB with structural cause excluded, normal examination, patient wishes medical treatment. Perimenopausal bleeding after appropriate assessment per local pathway.

NICE NG12 (updated April 2026) requires suspected cancer pathway referral for unexplained PMB at 55 or over to achieve <62-day pathway target for gynaecological malignancy. EPAU access has transformed management of early pregnancy complications — direct GP referral reduces ED attendance and improves patient experience. Colposcopy is the definitive investigation for cervical pathology; direct referral without waiting for failed treatment is appropriate when malignancy is suspected.

Treat

Treatment Pathway — Condition-specific management

Done

Heavy Menstrual Bleeding (structural cause excluded): Offer LNG-IUS, tranexamic acid, NSAID, CHC or cyclical progestogen according to preference and contraindications (NICE NG88); verify every dose against the current SPC/local formulary.

No pathology / fibroids <3 cm without cavity distortion / adenomyosis

Levonorgestrel IUS First-line

First-line for HMB with no identified pathology, fibroids under 3 cm without cavity distortion, or suspected/diagnosed adenomyosis. Consider suitability, uterine anatomy, infection risk, pregnancy exclusion and patient preference. Irregular bleeding may continue for more than 6 months — wait at least 6 cycles to assess benefit. Licence duration differs by product and indication (contraception, HMB, endometrial protection) — check the current SPC and local formulary.

Non-hormonal option

Tranexamic acid

Commonly 1g TDS during menstruation — dose and maximum daily dose per current SPC/local formulary. Adjust or avoid in significant renal impairment; consider contraindications and thrombotic history. Review if bleeding is persistent, atypical or not responding. Not a substitute for investigating IMB or PMB. Can combine with NSAIDs.

Dysmenorrhoea + HMB

NSAID (mefenamic acid)

NSAIDs generally reduce menstrual blood loss and dysmenorrhoea (NICE NG88). Mefenamic acid 500mg TDS during period if suitable — check contraindications and current SPC (caution: peptic ulcer disease, significant renal impairment, NSAID hypersensitivity, certain cardiovascular conditions, pregnancy). Use with PPI if GI risk.

Step 2Combined hormonal contraception — only after full UKMEC assessment: age, smoking, BMI, migraine (particularly with aura), hypertension, VTE history or thrombophilia, cardiovascular disease, interacting medicines, postpartum status, liver disease and other UKMEC conditions. 3 cycles minimum trial.

Step 3Cyclical oral progestogen — may be considered; specify the regimen from the current local formulary/prescribing reference and product SPC (check contraindications including current or previous thromboembolic disease, liver disease and hormone-sensitive disease). Depot medroxyprogesterone acetate is not a simple HMB step — it needs individual assessment (bleeding pattern, bone health, age).

Step 4Refer gynaecology if treatment fails, symptoms are severe or pathology is suspected — for endometrial ablation, fibroid embolisation, myomectomy, or hysterectomy depending on patient preference and pathology.

Concurrent iron deficiency anaemia:

Iron deficiency anaemia (stable)

Oral iron per local formulary (e.g. ferrous sulfate 200mg once daily or alternate days — BSG 2021; choice, formulation and tolerability per formulary). Check Hb response (around 4 weeks is reasonable) and continue after correction per the iron-deficiency pathway.

Severe or symptomatic anaemia

Severe or symptomatic anaemia, ongoing heavy bleeding, syncope, chest pain, dyspnoea, tachycardia or inability to manage orally requires same-day clinical assessment. Blood transfusion and IV iron are hospital decisions based on the clinical picture and local protocols (no universal Hb threshold).

IMB / PCB

Assess before treating: consider pregnancy; speculum if persistent, recurrent, with PCB, pain, dyspareunia, discharge, abnormal screening history or change in pattern; chlamydia/gonorrhoea testing by sexual risk. Then treat cause (STI → antibiotics with partner notification, ectropion → reassure/refer, polyp → refer). Visible cervical or vulval lesion → urgent specialist assessment. Do not prescribe empirical hormones to suppress unexplained IMB. A normal smear does not exclude cervical cancer.

PMB — atrophic vaginitis

Topical oestrogen — do not attribute PMB to atrophy without appropriate assessment. Once serious pathology has been excluded and atrophy is clinically evident, low-dose vaginal oestrogen may be offered (e.g. Vagifem 10mcg vaginal tablet daily for 2 weeks, then twice weekly — check current SPC for dose, contraindications and warnings; or Ovestin cream). Persistent or recurrent bleeding requires reassessment. History of breast cancer: discuss with the oncology/menopause specialist.

Next steps: see Heavy menstrual bleeding · Iron deficiency anaemia · Pelvic inflammatory disease · Menopause and HRT

NICE NG88 places the LNG-IUS as first-line for HMB with no identified pathology, fibroids <3 cm without cavity distortion, or adenomyosis — benefit may take at least 6 cycles. NSAIDs have additional analgesic benefit but are contraindicated in renal impairment, peptic ulcer disease, and NSAID hypersensitivity. Topical oestrogen for atrophic vaginitis has low systemic absorption — NICE NG23 advises it can be continued for as long as needed; in women with a history of breast cancer, discuss with their oncology team first.

Lifestyle

Non-Pharmacological Interventions

Done

Weight management Obesity is associated with anovulatory bleeding and increased risk of endometrial hyperplasia/cancer. Offer weight-management support where appropriate as part of general health and endometrial-risk reduction; do not present it as a primary treatment for acute HMB.

Iron-rich diet Red meat, dark leafy greens, fortified cereals. Vitamin C with meals may help non-haem iron absorption. Dietary advice does not replace iron treatment where iron deficiency is present.

Review aspirin use Aspirin may increase menstrual bleeding. NSAIDs generally reduce menstrual blood loss and dysmenorrhoea and are a NICE treatment option for HMB (check contraindications).

Period tracking app Recommend Clue, Flo, or menstrual diary. Provides objective PBAC data for GP consultations and allows identification of abnormal patterns.

Stress and cycle regulation Stress may affect cycle regularity, but persistent or new abnormal bleeding still requires appropriate assessment. Signpost to CBT, mindfulness apps, or stress management services.

Menopause/urogenital symptoms — pelvic floor exercises Separate from bleeding management. For associated dyspareunia / urinary symptoms with atrophic vaginitis. Kegel exercises 3× daily. Refer to pelvic health physiotherapist if not improving in 3 months.

Menopause/urogenital symptoms — lubricants Separate from bleeding management. Non-hormonal: Replens (3× weekly), Sylk (daily). Use alongside topical oestrogen or as alternative if oestrogen declined.

Alcohol reduction Alcohol metabolised to oestrone in the liver — heavy use worsens oestrogen-driven HMB and endometrial thickening. Advise ≤14 units/week with alcohol-free days.

Obesity is associated with anovulatory bleeding and endometrial hyperplasia/cancer risk; weight-management support is part of general health and endometrial-risk reduction, not a primary treatment for acute HMB. Lubricants can help vaginal dryness in genitourinary syndrome of menopause, including when hormones are declined.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Early / around 4 weeks

Review sooner if symptoms are severe, anaemia is significant or treatment is poorly tolerated. Check FBC after starting iron per the local anaemia pathway (around 4 weeks is reasonable, not mandatory). Assess menstrual diary / PBAC score. Confirm referral receipt if made.

3 months

Assess treatment response after about 3 months, or once enough time has passed for the chosen treatment (LNG-IUS: at least 6 cycles). Review menopausal treatment 3 months after starting or changing, then at least annually (NICE QS143). Adjust or escalate if the response is inadequate. Check iron stores if anaemia.

6 months

Full reassessment if HMB not controlled. Confirm gynaecology referral outcome. LNG-IUS: irregular bleeding may continue for more than 6 months — wait at least 6 cycles to assess benefit.

Annual

Cervical screening per the national programme (not part of the annual review). BMI and weight. Review all medications for menstrual impact. Reassess menopausal status in perimenopausal women.

999 safety-net

Very heavy bleeding that is not settling, or bleeding with dizziness, fainting, breathlessness or a racing heart (patient advice — does not replace clinical assessment). Pregnant or could be pregnant with severe or one-sided abdominal pain, shoulder-tip pain, fainting or heavy bleeding. Fever with shivering, feeling very unwell or a racing heart.

Same-day safety-net

Same-day assessment for heavy bleeding with dizziness or fainting, symptoms of severe anaemia, possible pregnancy, severe pain, or rapidly worsening bleeding. A pragmatic trigger such as soaking a pad every hour may be used as safety-netting; it is not a NICE threshold. New fever + bleeding (endometritis/PID). Any bleeding or pain in early pregnancy without the 999 features (EPAU / out-of-hours gynaecology). Bleeding heavier than usual or not settling. Failure of medical treatment with symptomatic anaemia. New contact bleeding after treatment started.

Results & referral responsibility

Document who reviews each result (pregnancy test, hCG, FBC, ultrasound, histology) and who confirms referral receipt and completion. Give written safety-netting for early-pregnancy bleeding.

Re-refer if

PMB recurs after a normal initial assessment — re-refer or reassess even if the previous ultrasound was reassuring. HMB recurs after ablation. New suspicious symptoms (weight loss, pelvic mass, lymphadenopathy).

The PBAC (Pictorial Blood Assessment Chart) can support monitoring, but NICE NG88 defines HMB by its impact on quality of life rather than measured blood loss. Medical treatment of HMB should produce measurable improvement within 3 months — failure to respond is an indication for gynaecological review to exclude structural or endometrial pathology that may have been missed. Recurrent PMB requires re-referral even if previous investigations were normal, as endometrial cancer risk persists with each new episode.