Speakers - 2026

Title: Unscheduled Bleeding on HRT: Are GP Referrals Aligned with 2024 BMS Guidelines?

Abstract

Background:
Unscheduled bleeding (USB) is a common side effect of hormone replacement therapy (HRT), affecting up to 40% of users. Recent increases in HRT prescribing have been accompanied by a rise in urgent gynaecology referrals via the two-week wait (2WW) pathway, despite minimal increases in cancer diagnoses. Updated 2024 guidance from the British Menopause Society aims to improve risk stratification and reduce unnecessary referrals.

Aim:
To assess whether general practice referrals to the gynaecology 2WW pathway for USB on HRT align with updated BMS guidelines, and to evaluate pre-referral management.

Methods:
A retrospective audit was conducted in a primary care setting from July 2024. Twenty-five patients referred via the 2WW pathway for USB on HRT were identified from a cohort of 681 patients receiving HRT. Data collected included patient demographics, HRT regimen, timing of bleeding, risk factors, investigations, referral pathway, and outcomes. Referrals were assessed against BMS standards for appropriate investigation and escalation.

Results:
Only 7/25 referrals (28%) were consistent with BMS guidance. The majority (16/25, 64%) were inappropriate, most commonly due to referral to 2WW where urgent transvaginal ultrasound (TVUS) within 6 weeks was indicated. Common issues included referral within 6 months of initiating HRT or within 3 months of regimen change, and inadequate documentation of risk factors and HRT compliance. Two cases (8%) were not applicable due to alternative gynaecological pathology.

Conclusion:
There is a significant discrepancy between current practice and BMS guidance in the management of USB on HRT, with overuse of the 2WW pathway. Improved education, documentation, and adherence to guideline-based investigation pathways may reduce unnecessary referrals, optimise resource use, and improve patient experience.

How the audience can use this

Attendees will be able to:

• Apply a clear decision-making pathway for USB (urgent TVUS vs 2WW referral)
• Improve risk stratification using recognised major and minor risk factors
• Identify when reassurance and conservative management are appropriate
• Recognise common pitfalls leading to over-referral

How this helps in clinical practice

This work directly supports clinicians by:

• Reducing unnecessary 2WW referrals, easing pressure on secondary care services
• Minimising patient anxiety associated with urgent cancer pathways
• Improving documentation quality (BMI, risk factors, HRT compliance)
• Supporting safer, more consistent evidence-based decision-making

 Practical solutions provided

• Highlights a clear gap between guidelines and real-world practice
• Demonstrates that many cases can be safely managed with timely TVUS rather than urgent referral
• Provides a basis for:
  • Quick-reference tools
  • EMIS templates / checklists
  • Teaching sessions for primary care clinicians