Postmenopausal bleeding carries a 10% risk of endometrial carcinoma — NICE NG12 mandates 2WW referral. Ectopic pregnancy rupture causes 0.2–0.5% of maternal deaths 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 has >95% cure rate if detected early — missing it is catastrophic.

A positive pregnancy test fundamentally redefines the differential — all non-pregnancy causes become secondary. NICE HG recommends urine βhCG in all women of reproductive age with abnormal bleeding. Cycle characterisation using validated tools (PBAC ≥100 = heavy menstrual bleeding) allows objective monitoring and treatment response assessment, avoiding over-investigation of physiological variation.

The PALM-COEIN classification (FIGO 2011) provides a structured framework for HMB that guides targeted investigation. For PMB, endometrial carcinoma is present in 10% of cases — 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).

Speculum examination is mandatory for IMB, PCB, and any suspicious bleeding — it can identify cervical carcinoma, polyps, or infection visible only on direct visualisation. Cervical excitation on bimanual examination has 95% sensitivity for PID. Documenting chaperone is both medico-legal best practice and GMC requirement. Always offer chaperone before intimate examination.

NICE NG88 (Heavy Menstrual Bleeding 2018) specifies transvaginal USS as first-line structural investigation — it outperforms transabdominal USS for endometrial and submucous fibroid pathology. Endometrial thickness >4mm on TVS in PMB has 96% sensitivity for endometrial cancer but specificity of only 60%, hence biopsy is required for histological confirmation. vWD is under-diagnosed in women with HMB — the American College of Obstetricians recommends screening all adolescents with HMB since menarche.

NICE NG12 mandates 2WW referral for PMB 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.

NICE NG88 places the LNG-IUS as first-line for HMB — it outperforms all medical treatments with 90% blood loss reduction. Tranexamic acid has NNT of 3 for clinically meaningful reduction in HMB (Cochrane 2000). NSAIDs have additional analgesic benefit but are contraindicated in renal impairment, peptic ulcer disease, and NSAID hypersensitivity. Topical oestrogen for atrophic vaginitis delivers estradiol concentrations 1000× lower than systemic HRT — MHRA 2020 guidance confirms it is safe for long-term use including in most breast cancer survivors.

Weight loss of ≥10% body weight restores ovulatory cycles in 55–100% of obese women with anovulatory HMB (Reproductive Biology and Endocrinology, 2019). Lifestyle interventions are disease-modifying, not merely adjunctive — addressing anovulation through weight loss avoids long-term hormonal treatment and reduces endometrial cancer risk. Vaginal lubricants have equivalent efficacy to topical oestrogen for atrophic vaginitis symptoms in women unable to use hormone therapy.

The PBAC (Pictorial Blood Assessment Chart) is validated as a primary care tool — a score >100 correlates with measured blood loss >80mL/cycle (HMB definition). 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.