Referral criteria from primary care - intermenstrual bleeding (IMB)

• Criteria for referral to secondary care are (1):
  
  very heavy bleeding with shock, or,
• 
  anaemic secondary to heavy bleeding, or,
• failure of medical treatment in women under 40 years old, or,
  
  
• irregular or heavy period in a woman of any age with a structurally abnormal uterus, or,
  
  
• if the patient has polycystic ovarian disease where anovulatory menstrual abnormalities do not respond to medical therapy
  
  
• if a woman is over 40 years old with menorrhagia of recent onset, persistent intermenstrual bleeding or increased frequency of menstrual bleeding
  • a patient over 40 years old may require referral for irregular periods because it may be difficult to distinguish between intermenstrual and menstrual loss.

Also should be referred if:

• urgent two week referral
  • there is a suspicion of underlying cancer. Suspicious findings would include, for example, a pelvic mass or abdominal mass, an abnormal cervix or cervical smear, irregular bleeding, repeated intermenstrual bleeding, or post-coital bleeding
• if menorrhagia despite 3 month's drug treatment, the heavy bleeding persists and is interfering with the quality of life. Failure is best based upon the woman's own assessment
• if menorrhagia and patient wishes to explore the possibility of surgical intervention rather than persist with drug treatment

Also see the urgent referral guidance for suspected gynaecological cancer in the linked item below.

Notes:

Also been noted that the following patients should be referred to the secondary care for further evaluation:

• women at high risk of endometrial cancer, such as those with a family history of hormone dependent cancer, those with prolonged and irregular cycles, and women on tamoxifen
  
  
• women in whom irregular bleeding might lead to discontinuation of hormonal contraception. Such women are best referred to their local family planning centre where there will be clinics for complex contraceptive problems
  
  
• all women over 45 years with intermenstrual bleeding should have a biopsy and those under 45 with persistent symptoms or risk factors for endometrial cancer should also be referred

Reference:

1. Heavy menstrual bleeding: assessment and management. NG88. NICE Guideline (March 2018 - updated May 2021)