FCO- 111 Bleeding on HRT – how do we balance missing endometrial pathology and potential harm due to over-intervention?

NICE guidelines on management of menopause in 2015 and 2019 suggested that for healthy symptomatic women, benefits of HRT outweigh the risks. HRT remains the most effective treatment for menopausal symptoms.   After years of reticence, the demand for HRT is exponential. Consequently, bleeding on HRT is increasingly reported. We suspect that it burdens the gynaecological cancer pathway. We audited the referrals for “Bleeding on HRT “and the impact on gynaecology outpatient services.

Methods

We compared referrals to target gynaecology clinics over April and October in 2019, 2021 and 2023. The clinic lists were obtained from our electronic record system (EPIC). The referrals for ‘Bleeding on HRT’ were analysed specifically looking at ultrasound scan findings, and further investigation/histology results.

Results

A total of 779 referrals were reviewed. The number of referrals for ‘Bleeding on HRT’ increased from 12.6% in 2019-2021 to 20.7% in 2023. This was statistically significant (z=2.92. p=0.003). The endometrial thickness (ET) measured on transvaginal ultrasound was less than 4.5mm in 75% of women. A total of 29 patients underwent an endometrial biopsy. Histology results were benign in 93% of cases. No case of malignancy was found.

Conclusion

We demonstrate a significant increase in referrals for bleeding on HRT. In most women the endometrium was thin and no further investigation were indicated. However, the 2ww consultations capacity was impacted. We believe patients could be managed in primary care with a risk-factor based approach, change of the progestogenic part of HRT and if persistent symptoms a community ultrasound.