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GPs Rebecca and Sarah discuss the risk factors for post-menopausal uterine cancer, symptoms like new onset discharge and visible haematuria, and why you should examine patients before referring them on the cancer pathway. Our GP hosts also cover taking a full patient history, hormone drug compliance and why safety netting is so important for patients who are bleeding on HRT. Plus, being aware of the increase in incidence of endometrial cancer in women in their 40s.
If you loved this episode and would like to hear more like this, please leave a review, a rating and share the episode.
GPs Talk Cancer is the podcast series from GatewayC. GatewayC is the free early cancer diagnosis resource funded by the NHS and is part of The Christie NHS Foundation Trust.
Produced by Louise Harbord from GatewayC, and Jo Newsholme from Rethink Audio.
DISCLAIMER: We know this podcast might be of interest to anybody, however it is aimed at primary care health professionals. All patient cases are based on real stories from our clinical practice as GPs. They are fully anonymised with no identifiable patient data. All featured statistics are accurate at the time of recording. All views expressed by guest speakers are their own.
Sarah: The three things you should look out for would be a postmenopausal bleed, new onset vaginal discharge or visible haematuria.
Rebecca: Hello and welcome back to season two of GPs Talk Cancer. I’m Dr. Rebecca Leon and joining me again through this podcast is Dr. Sarah Taylor. We are both practicing GPs and GP leads for Gateway C. We’re both passionate about diagnosing cancer early and in this podcast, we want to share our clinical experiences with you so you can make better, faster, and more confident cancer diagnosis in primary care. 
So, there’s some official stuff to make you aware of. We know this podcast might be of interest to anybody, but it’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymised with no identifiable patient data. 
Gateway C is the free early cancer diagnosis resource funded by the NHS and is based at the Christie NHS Foundation Trust. GatewayC is a national programme across the whole of England, Scotland, and Wales. Register online to gain access to free interactive courses, documentary-style videos, referral maps and more. 
So today we’re gonna sit down for a coffee and talk about endometrial cancers and bleeding on HRT. Sarah, how are you today?
Sarah: I’m good, thanks. How about you?
Rebecca: Yeah, fine. Thank you. Good. Nice week off?
Sarah: Very nice. Thank you. And you’ve got kids on holiday this week?
Rebecca: I do, I do. They’re all good. So today, as you say, it’s an exciting topic and I think it’s something that we see a lot of in primary care.
Sarah: It’s certainly something that’s causing a lot of anxiety and I think has become much more of a problem over the last few years because of the increased number of women on HRT. There’s stuff in the planning guidance for this year about places having pathways to make sure women are properly managed.
Rebecca: So we’re gonna be covering all of that later on.
Sarah: We are.
Rebecca: So just to start off with some statistics. So from CRUK, they actually cover uterine cancers and actually 96% of those are endometrial cancers. In females, uterine cancer is the fourth most common cancer. It accounts for 5% of all new cancer cases in females in the UK, and 3% of all new cancer cases in females and males combined. Sarah…
Sarah: Yeah. And we, we just need to remember, don’t we, that whilst we’re talking mostly through the module about females, we need to, there will be some transgender patients who were born with a uterus and they will also be at risk of endometrial cancer, so we need to think about it in them.
Rebecca: 7.4% are diagnosed via emergency presentation with the majority diagnosed via suspected cancer referral. That’s over 60%.
Sarah: Which I suppose because really we’re talking bout a red flag of postmenopausal bleeding. It is a fairly clear symptom, isn’t it?
Rebecca: So we actually think the 7.4% is still quite high.
Sarah: Yeah.
Rebecca: Okay. today we’re going to be discussing patients as we normally do. But as Sarah said earlier, this is a fairly common scenario in general practice. So we’re gonna be talking generally, and the two cases we’ll be covering, two almost cohorts of patients.
Sarah: Yeah, absolutely.
Rebecca: Okay. So are you happy to discuss…
Sarah: To start on patient one?
Rebecca: Yeah, case one.
Sarah: Yeah, so I think, I think the first thing we want to talk about is postmenopausal bleeding, which I think most primary care professionals now see as a red flag symptom and would make a suspected cancer referral. And just to be clear, we’re talking about women who haven’t, have been amenorrhoeic for a year, not on any form of hormonal contraception and then have a bleed. So if you’ve got somebody who’s not on HRT, not got a Mirena in, not got an implant, has had no period for three or four years, or even just a year, and they start bleeding, they need to be referred because this is, it’s a postmenopausal bleed and it’s a red flag symptom.
Rebecca: And just also be aware that we’re suspecting possible endometrial cancer, but it can also be cervical, vaginal or vulval. So it’s really important that these patients are examined prior to the suspected cancer referral.
Sarah: Yeah, so I think those patients are, I mean there are some risk factors, aren’t there, that would make you more concerned about people. But actually it’s a fairly clear guideline – 12 months of amenorrhoeic, new bleed, examine the patient and refer.
Rebecca: And what are those risk factors, Sarah?
Sarah: Well, there’s a big link to obesity. There is also a link to familial cancers with Lynch syndrome, so I think that, you know, Lynch, so any family history of uterine cancers, bowel cancer, any other Lynch associated cancers, again, is a risk factor. So it’s like we, well, I think we’re a bit of a stuck record on this now, aren’t we? But actually, if you don’t ask about family history, it’s not something people will necessarily tell you and so I think it’s just another thing to ask, isn’t it?
Rebecca: Absolutely. So if we add in the complication, Sarah, of… we’ve got a lady who’s post-menopausal, as in, she’s not had a period for 12 months. She presents with a bleed, but she’s on HRT.
Sarah: Well! This has become, it is become quite a big issue, I think because there are so, I said a few minutes ago, so many more women on HRT. So a bit like when women start on the pill, it’s quite common for them to have some abnormal bleeding at the start. So bleeding in the first three months is incredibly common. It’s absolutely nothing to worry about, and we should probably just reassure people that it is likely to settle and that, you know, that we don’t need to do anything. If it goes on for longer than three months, I think the guidelines that we’ve got locally are that between three and six months, we still shouldn’t be concerned about it, but people do sometimes become irritated by it, you know, which I would absolutely understand, and then might want some treatment which might involve a change in HRT. One of the other things to, if you go beyond six months of abnormal bleeding on HRT, which, which we sort of reckon should be called unscheduled bleeding on HRT rather than a post-menopausal bleed. If you go beyond six months, that is becoming abnormal and we should think about either a suspected cancer referral or an urgent ultrasound just depending on what your local pathway is. So it’s, it’s, you know, up to six months is acceptable. Beyond six months, we should be looking into it. Obviously if there’s another risk factor, so if somebody is significantly overweight or has a high… family history, then we should think about, maybe think about referring a little bit earlier. So that’s roughly where it’s at, but I think it is quite a, it’s, it’s just caused quite a lot of problems recently, really.
Rebecca: And I think that’s really helpful that and safety netting is so important in this scenario because they come and see you, first three months almost ‘don’t worry about it’. But you almost have to also say to the patient, please do come back to us if the bleeding continues, because they may hear ‘don’t worry about it’ and they continue bleeding, bleeding, bleeding. You talked about compliance…?
Sarah: Yeah. So, so I think that, so I think that there are two things to think about when you’re talking to… three things when you’re talking about reasons for bleeding. One is compliance. So if somebody’s not taking their medication regularly and they’re missing days or they’re missing, or they’ve had a been on holiday and forgotten it, then that is a reason for bleeding and we need to reset the clock from that time. If they have a change in formulation of HRT, you would again expect that they might have some bleeding. So three months of bleeding on one type of HRT and then four or five months on another type again, isn’t of concern, as long as there are no other risk factors. And there are some medications, I can’t remember what they are to be perfectly honest, that can also interact with HRT and make you more likely to bleed. So there are a whole load of things that you just need to think about. And I think compliance is one thing that I, I do it all the time with younger women on the pill, and just say, you know, have we missed any, have you forgotten any, have you taken any late? I just don’t do it with women on HRT, do you?
Rebecca: No, I don’t. And I think the holiday thing is the big thing. You know, they go away, they forget the patch, but I think the compliance with HRT is probably less because so many women swear by it. And actually the idea of missing HRT, when we have our annual reviews and there’s some suggestion that we, that we think about coming, taking them off it, it’s almost like, please, no. So compliance is probably less of a problem, but we need to ask. But this resetting the clock, I think is so important, Sarah, and you’ve taught me this when we were discussing off-air. So I, I think just… And this is just me wanting to re-explain, to make it clear for me, a person presents with some bleeding, you change the mode of HRT, you go from a patch to a gel, for example. The clock starts again at zero when you start the gel.
Sarah: Mm. Yeah. We should probably also, when we’re talking about women, you know, postmenopausal women at risk of endometrial cancer. Just talk about those with new onset discharge because that’s something that when I’ve spoken to the gynaecologists on the course, they were saying it’s something that sometimes gets missed, that women in their fifties and sixties often don’t have new onset discharge. They much less frequently have thrush. And actually NICE guidance are that any woman who has an unexplained symptoms of vaginal discharge, who’s, where it’s a new symptom, they’ve also got thrombocytosis or haematuria should actually have an ultrasound to exclude endometrial cancer and also those with visible haematuria. And I’m reading this from the guidelines now, but I think it’s really important ’cause there are, it’s some of these funny mixes of symptoms that you need to pick up. So if you’ve got visible haematuria with anaemia, or thrombocytosis or high blood glucose, you also need an ultrasound for suspected endometrial cancer. So that’s quite a list of symptoms that we just need to, so it’s, you know, it, it, it’s looking at the blood tests, which we were going to have a bit of a chat about anyway, but just being aware that people with haematuria or with new discharge, and that’s, I suppose that’s the take home, isn’t it? You’ve got new onset discharge, or you’ve got visible haematuria, you need to think about endometrial cancer, as well as other symptoms, other causes.
Rebecca: Gosh!
Sarah: There’s a lot to think about, isn’t there?
Rebecca: I think what’s difficult with visible haematuria, you’d send them down the two week urology, they come back with a normal cystoscopy and then you say, thank you very much. So it’s again, keep looking, keep thinking.
Sarah: Absolutely. And it’s also work for, you know, those of us who are working on this, some of the pathways in secondary care to say to urology, if you haven’t got a cause from this, think about a cause from something else. So I think the take home from that would be, the three things you should look out for would be a postmenopausal bleed, new onset vaginal discharge or visible haematuria, and then with risk factors of family history, high BMI, and then looking at blood tests.
Rebecca: So just talking about blood tests, you mentioned about platelets, you mentioned about glucose. Is it part of LEGO-C?
Sarah: It is, isn’t it?! Yeah, it is.
Rebecca: So the acronym is…
Sarah: It’s…
Sarah/ Rebecca: Lung…
Sarah/ Rebecca: Endometrial…
Sarah: Gastro-Oesophageal, and Colorectal.
Rebecca: LEGO-C. So high platelets could be one of those five cancers.
Sarah: Yeah, and I think it’s, so it’s, again, it’s if you’ve got somebody who’s got, and, and actually one of the other things in here is a low haemoglobins. If you’ve got somebody who’s got, you do some blood tests and they’ve got new onset high platelets in a woman, you probably need to, as part of your screening as to why they might have this, is to ask, is to make sure you particularly ask about a postmenopausal bleed.
Rebecca: So you were looking at the guidelines earlier and we should be sending for a suspected cancer referral. The other is a, an ultrasound. Are you just able just to talk about some of the parameters? ‘Cause we often get a report and our ultrasound reports I know in my area are often very detailed and they also will suggest onward referrals if they see something. But what… are there any parameters that we should maybe act on?
Sarah: Yeah, I mean, I think that really we should be trying to work to make sure that the reports are very clear for primary care professionals, because actually that’s the reason for asking the investigation. But I think so, but just as a general sort of guideline. The guidelines are that if somebody who’s on continuous HRT, you would be looking at referring if the endometrial thickness was greater than or equal to five millimetres. If they’re on sequential HRT, you’d be looking at referring if the endometrial thickness was greater than or equal to eight millimetres. I would hope that that was put into reports ‘cause I think it is quite a lot to expect our colleagues to remember. But this is all based on the British Gynaecological Cancer Society guidelines. I don’t think it’s in NICE at the moment, but hopefully if it’s updated, it’ll be in there for the NICE suspected cancer referral guidance.
Rebecca: That’s really interesting. Okay. Can we move on to the next case? As I say, this is not a, a specific patient, but it’s patients that we see, and this is, another female patient. Very young.
Sarah: Yeah.
Rebecca: Age 43. Only ’cause that’s how old I am! So, and this is somebody who is perimenopausal who is describing intermenstrual bleeding, so a different bleeding pattern, and also a change in discharge. So what will your concerns be here, Sarah?
Sarah: Well, when I spoke to, when we did the module, I spoke to Eric Watson, who was actually in my year at medical school, as obviously was your husband Matt. So the, you know, the three of us… I was talking to Eric about this and he was saying that one of the things that he thinks is going to change for some of the newly appointed gynaecology consultants is the number of younger women with endometrial cancer. Because the guidance, as I think you said earlier, is for women over the age of 50 or 55, but he was saying that they’re seeing increased numbers of women in their forties and perimenopausal women who have endometrial cancer thought to be due to increased rates of obesity and unopposed, increased oestrogen levels from the obesity. So it’s, basically it’s much more difficult, isn’t it, because you’re not gonna get a postmenopausal bleed in a woman who’s still bleeding. Women in their forties often get very…
Rebecca: Like a, just a change, isn’t it?
Sarah: Yeah, lots of women get perimenopausal change in their periods anyway, don’t they? So it’s a really difficult one to work out exactly when you should be concerned. But there is an increased incidence in this age group that we need to start to be aware of, and there’s no clear guidelines on it. What he was saying really is that if you’ve got somebody who has abnormal bleeding pattern for them that persists and doesn’t respond to fairly standard treatments, maybe giving some hormonal treatment or tranexamic acid, mefenamic acid, putting a Mirena in, then you should think about investigating them. First thing would be probably, well obviously after you’ve done an examination just to check the bleeding’s not coming from the cervix or anywhere else in the gynaecological tract, would be to do an ultrasound. The ultrasound is not to look at endometrial thickness ‘cause endometrial thickness will be changing ‘cause of still having periods, but just to check for other causes such as fibroids. But after that, if you’ve got persistent abnormal bleeding, the best thing to do is to send a referral. I don’t think it necessarily needs to be a suspected cancer referral, but it will need to be relatively urgent, and I know that’s a difficult balance at the moment.
Rebecca: It’s really difficult ’cause you are almost thinking if somebody has got some pathology, would you feel comfortable starting them on a trial of HRT if they’re perimenopausal? Would you feel comfortable putting in a Mirena? So because there’s no guidance, it’s almost, we’re, we are suggesting what we may do in this scenario. And it’s just always checking in on, checking in with the patient and if there are any other kind of symptoms like post-coital bleeding, intermenstrual bleeding, which we’ve discussed. But again, intermenstrual bleeding could be perimenopausal bleeding.
Sarah: There’s no guidance, is there, for perimenopausal women for endometrial cancer. That’s part of our problem, and it’s, it, it’s a real issue.
Rebecca: And I just wanted to mention, and again, I have, there’s no science behind this. We are seeing younger women presenting with different types of cancers. And we mention it whether, that we’re seeing more endometrial cancers in younger women because of an increase in BMI. I’m just wondering if that’s something across the board with other cancers as well. Because when I’ve asked cancer specialists, why are we seeing younger people with cancers, it’s almost like, well, is it because we’re diagnosing them early? There’s, there’s a lot, we are not sure is the answer. So it’s just something to think about. Is there a link? And we did a, a really good podcast a few weeks ago, and the specialist Liz, that we were talking to, Liz O’Riordan, actually said, diet and exercise is the best thing that we can suggest and offer a patient. So again, that will also help with increasing weight.
Sarah: Yeah, and I think, I think the key with the younger women is, is to have that index of suspicion in the patient who has a risk factor, either a family history or is, or, or high BMI, who has abnormal bleeding that is persisting. Um, and I think at the end of the day you could, you can send an advice and guidance, can’t you? You can ask somebody what they, what, what they think. But the two women that I interviewed for the module, both had quite delayed diagnoses ’cause everybody thought they were perimenopausal and just kept… but also had fairly significant risk factors.
Rebecca: Okay. So I just want to give an interesting fact. We’re not doing fun facts anymore, but we’re doing an interesting fact, ’cause they’re not very fun. But endometrial cancer risk is higher in women with no children and the risk decreases with the greater number of full term pregnancies. However, risk is higher in people who’ve had their first child at 25 years or younger, compared with women who are having children later, 40 plus.
Sarah: Yeah. It’s like, it’s just sort of, one of, I was just listening to one of the podcasts that we’d done a few weeks ago when we were talking about caffeine and you know, it seems to be the same thing, doesn’t it? That some things, your risk is increased with caffeine, something, it’s decreased with caffeine. So we just sort of…
Rebecca: I know. Diet and exercise!
Sarah: Yeah. Diet and exercise don’t seem, you know, don’t seem…
Rebecca: I don’t think there’s any negatives to that!
Sarah: No!
Rebecca: So, what I’ve learned from this is about safety netting the, the patient as well, because I think the three month rule, which is what you’ve really talked about very eloquently, Sarah.
Sarah: Thank you!
Rebecca: But I think. by actually, giving the patient some onus of their own health and saying, three months please do come back to us and we can talk about changing your form of HRT… Six months, we will really consider referring you. So I think it’s really important that we do safety net the patient. Are we happy to go onto key points?
Sarah: Absolutely.
Rebecca:: Do you want to kick off?
Sarah: Yeah, because this is a really, really nice, easy one. Postmenopausal bleeding, i.e. bleeding after 12 months of a amenorrhoeic on, on women who are not on HRT is a red flag symptom.
Rebecca: It’s really important to take a clear history from the patient, ask about compliance, particularly when they’re presenting with bleeding on HRT, and check that they’re taking the medication properly and whether it needs changing.
Sarah: Risk factors for endometrial cancer are obesity, family history, and treatments like Tamoxifen, which we did touch on briefly a couple of weeks ago.
Rebecca: And if women are sent under the suspected cancer referral, hysteroscopy is the gold standard to diagnose endometrial cancer. So that’s it for today, Sarah. Thank you very much as ever. As I say, elegant and eloquent.
Sarah: Wow. Who’d have thought?!
Rebecca: Who would’ve thought! So… it’s your week off!
Rebecca: Thanks for listening to this podcast from Gateway C. We hope you’re enjoying this series. Please do support this podcast by leaving us a review or rating wherever you get your podcasts. And if you’ve got any topic suggestions for future episodes, we’d love to hear them. Please do include these in your review. If you’ve found this or other episodes interesting and helpful to your practice, please do share it with a friend or colleague. It really does help to spread the word. We’ve got a free uterine cancer course available on the GatewayC website, which covers endometrial cancer and up to date guidance on the management of unscheduled bleeding on HRT. All referenced studies and guidelines are in our show notes. Thank you again for listening and thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. See you again soon.
Sarah: The three things you should look out for would be a postmenopausal bleed, new onset vaginal discharge or visible haematuria.
Rebecca: Hello and welcome back to season two of GPs Talk Cancer. I’m Dr. Rebecca Leon and joining me again through this podcast is Dr. Sarah Taylor. We are both practicing GPs and GP leads for Gateway C. We’re both passionate about diagnosing cancer early and in this podcast, we want to share our clinical experiences with you so you can make better, faster, and more confident cancer diagnosis in primary care. 
So, there’s some official stuff to make you aware of. We know this podcast might be of interest to anybody, but it’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymised with no identifiable patient data. 
Gateway C is the free early cancer diagnosis resource funded by the NHS and is based at the Christie NHS Foundation Trust. GatewayC is a national programme across the whole of England, Scotland, and Wales. Register online to gain access to free interactive courses, documentary-style videos, referral maps and more. 
So today we’re gonna sit down for a coffee and talk about endometrial cancers and bleeding on HRT. Sarah, how are you today?
Sarah: I’m good, thanks. How about you?
Rebecca: Yeah, fine. Thank you. Good. Nice week off?
Sarah: Very nice. Thank you. And you’ve got kids on holiday this week?
Rebecca: I do, I do. They’re all good. So today, as you say, it’s an exciting topic and I think it’s something that we see a lot of in primary care.
Sarah: It’s certainly something that’s causing a lot of anxiety and I think has become much more of a problem over the last few years because of the increased number of women on HRT. There’s stuff in the planning guidance for this year about places having pathways to make sure women are properly managed.
Rebecca: So we’re gonna be covering all of that later on.
Sarah: We are.
Rebecca: So just to start off with some statistics. So from CRUK, they actually cover uterine cancers and actually 96% of those are endometrial cancers. In females, uterine cancer is the fourth most common cancer. It accounts for 5% of all new cancer cases in females in the UK, and 3% of all new cancer cases in females and males combined. Sarah…
Sarah: Yeah. And we, we just need to remember, don’t we, that whilst we’re talking mostly through the module about females, we need to, there will be some transgender patients who were born with a uterus and they will also be at risk of endometrial cancer, so we need to think about it in them.
Rebecca: 7.4% are diagnosed via emergency presentation with the majority diagnosed via suspected cancer referral. That’s over 60%.
Sarah: Which I suppose because really we’re talking bout a red flag of postmenopausal bleeding. It is a fairly clear symptom, isn’t it?
Rebecca: So we actually think the 7.4% is still quite high.
Sarah: Yeah.
Rebecca: Okay. today we’re going to be discussing patients as we normally do. But as Sarah said earlier, this is a fairly common scenario in general practice. So we’re gonna be talking generally, and the two cases we’ll be covering, two almost cohorts of patients.
Sarah: Yeah, absolutely.
Rebecca: Okay. So are you happy to discuss…
Sarah: To start on patient one?
Rebecca: Yeah, case one.
Sarah: Yeah, so I think, I think the first thing we want to talk about is postmenopausal bleeding, which I think most primary care professionals now see as a red flag symptom and would make a suspected cancer referral. And just to be clear, we’re talking about women who haven’t, have been amenorrhoeic for a year, not on any form of hormonal contraception and then have a bleed. So if you’ve got somebody who’s not on HRT, not got a Mirena in, not got an implant, has had no period for three or four years, or even just a year, and they start bleeding, they need to be referred because this is, it’s a postmenopausal bleed and it’s a red flag symptom.
Rebecca: And just also be aware that we’re suspecting possible endometrial cancer, but it can also be cervical, vaginal or vulval. So it’s really important that these patients are examined prior to the suspected cancer referral.
Sarah: Yeah, so I think those patients are, I mean there are some risk factors, aren’t there, that would make you more concerned about people. But actually it’s a fairly clear guideline – 12 months of amenorrhoeic, new bleed, examine the patient and refer.
Rebecca: And what are those risk factors, Sarah?
Sarah: Well, there’s a big link to obesity. There is also a link to familial cancers with Lynch syndrome, so I think that, you know, Lynch, so any family history of uterine cancers, bowel cancer, any other Lynch associated cancers, again, is a risk factor. So it’s like we, well, I think we’re a bit of a stuck record on this now, aren’t we? But actually, if you don’t ask about family history, it’s not something people will necessarily tell you and so I think it’s just another thing to ask, isn’t it?
Rebecca: Absolutely. So if we add in the complication, Sarah, of… we’ve got a lady who’s post-menopausal, as in, she’s not had a period for 12 months. She presents with a bleed, but she’s on HRT.
Sarah: Well! This has become, it is become quite a big issue, I think because there are so, I said a few minutes ago, so many more women on HRT. So a bit like when women start on the pill, it’s quite common for them to have some abnormal bleeding at the start. So bleeding in the first three months is incredibly common. It’s absolutely nothing to worry about, and we should probably just reassure people that it is likely to settle and that, you know, that we don’t need to do anything. If it goes on for longer than three months, I think the guidelines that we’ve got locally are that between three and six months, we still shouldn’t be concerned about it, but people do sometimes become irritated by it, you know, which I would absolutely understand, and then might want some treatment which might involve a change in HRT. One of the other things to, if you go beyond six months of abnormal bleeding on HRT, which, which we sort of reckon should be called unscheduled bleeding on HRT rather than a post-menopausal bleed. If you go beyond six months, that is becoming abnormal and we should think about either a suspected cancer referral or an urgent ultrasound just depending on what your local pathway is. So it’s, it’s, you know, up to six months is acceptable. Beyond six months, we should be looking into it. Obviously if there’s another risk factor, so if somebody is significantly overweight or has a high… family history, then we should think about, maybe think about referring a little bit earlier. So that’s roughly where it’s at, but I think it is quite a, it’s, it’s just caused quite a lot of problems recently, really.
Rebecca: And I think that’s really helpful that and safety netting is so important in this scenario because they come and see you, first three months almost ‘don’t worry about it’. But you almost have to also say to the patient, please do come back to us if the bleeding continues, because they may hear ‘don’t worry about it’ and they continue bleeding, bleeding, bleeding. You talked about compliance…?
Sarah: Yeah. So, so I think that, so I think that there are two things to think about when you’re talking to… three things when you’re talking about reasons for bleeding. One is compliance. So if somebody’s not taking their medication regularly and they’re missing days or they’re missing, or they’ve had a been on holiday and forgotten it, then that is a reason for bleeding and we need to reset the clock from that time. If they have a change in formulation of HRT, you would again expect that they might have some bleeding. So three months of bleeding on one type of HRT and then four or five months on another type again, isn’t of concern, as long as there are no other risk factors. And there are some medications, I can’t remember what they are to be perfectly honest, that can also interact with HRT and make you more likely to bleed. So there are a whole load of things that you just need to think about. And I think compliance is one thing that I, I do it all the time with younger women on the pill, and just say, you know, have we missed any, have you forgotten any, have you taken any late? I just don’t do it with women on HRT, do you?
Rebecca: No, I don’t. And I think the holiday thing is the big thing. You know, they go away, they forget the patch, but I think the compliance with HRT is probably less because so many women swear by it. And actually the idea of missing HRT, when we have our annual reviews and there’s some suggestion that we, that we think about coming, taking them off it, it’s almost like, please, no. So compliance is probably less of a problem, but we need to ask. But this resetting the clock, I think is so important, Sarah, and you’ve taught me this when we were discussing off-air. So I, I think just… And this is just me wanting to re-explain, to make it clear for me, a person presents with some bleeding, you change the mode of HRT, you go from a patch to a gel, for example. The clock starts again at zero when you start the gel.
Sarah: Mm. Yeah. We should probably also, when we’re talking about women, you know, postmenopausal women at risk of endometrial cancer. Just talk about those with new onset discharge because that’s something that when I’ve spoken to the gynaecologists on the course, they were saying it’s something that sometimes gets missed, that women in their fifties and sixties often don’t have new onset discharge. They much less frequently have thrush. And actually NICE guidance are that any woman who has an unexplained symptoms of vaginal discharge, who’s, where it’s a new symptom, they’ve also got thrombocytosis or haematuria should actually have an ultrasound to exclude endometrial cancer and also those with visible haematuria. And I’m reading this from the guidelines now, but I think it’s really important ’cause there are, it’s some of these funny mixes of symptoms that you need to pick up. So if you’ve got visible haematuria with anaemia, or thrombocytosis or high blood glucose, you also need an ultrasound for suspected endometrial cancer. So that’s quite a list of symptoms that we just need to, so it’s, you know, it, it, it’s looking at the blood tests, which we were going to have a bit of a chat about anyway, but just being aware that people with haematuria or with new discharge, and that’s, I suppose that’s the take home, isn’t it? You’ve got new onset discharge, or you’ve got visible haematuria, you need to think about endometrial cancer, as well as other symptoms, other causes.
Rebecca: Gosh!
Sarah: There’s a lot to think about, isn’t there?
Rebecca: I think what’s difficult with visible haematuria, you’d send them down the two week urology, they come back with a normal cystoscopy and then you say, thank you very much. So it’s again, keep looking, keep thinking.
Sarah: Absolutely. And it’s also work for, you know, those of us who are working on this, some of the pathways in secondary care to say to urology, if you haven’t got a cause from this, think about a cause from something else. So I think the take home from that would be, the three things you should look out for would be a postmenopausal bleed, new onset vaginal discharge or visible haematuria, and then with risk factors of family history, high BMI, and then looking at blood tests.
Rebecca: So just talking about blood tests, you mentioned about platelets, you mentioned about glucose. Is it part of LEGO-C?
Sarah: It is, isn’t it?! Yeah, it is.
Rebecca: So the acronym is…
Sarah: It’s…
Sarah/ Rebecca: Lung…
Sarah/ Rebecca: Endometrial…
Sarah: Gastro-Oesophageal, and Colorectal.
Rebecca: LEGO-C. So high platelets could be one of those five cancers.
Sarah: Yeah, and I think it’s, so it’s, again, it’s if you’ve got somebody who’s got, and, and actually one of the other things in here is a low haemoglobins. If you’ve got somebody who’s got, you do some blood tests and they’ve got new onset high platelets in a woman, you probably need to, as part of your screening as to why they might have this, is to ask, is to make sure you particularly ask about a postmenopausal bleed.
Rebecca: So you were looking at the guidelines earlier and we should be sending for a suspected cancer referral. The other is a, an ultrasound. Are you just able just to talk about some of the parameters? ‘Cause we often get a report and our ultrasound reports I know in my area are often very detailed and they also will suggest onward referrals if they see something. But what… are there any parameters that we should maybe act on?
Sarah: Yeah, I mean, I think that really we should be trying to work to make sure that the reports are very clear for primary care professionals, because actually that’s the reason for asking the investigation. But I think so, but just as a general sort of guideline. The guidelines are that if somebody who’s on continuous HRT, you would be looking at referring if the endometrial thickness was greater than or equal to five millimetres. If they’re on sequential HRT, you’d be looking at referring if the endometrial thickness was greater than or equal to eight millimetres. I would hope that that was put into reports ‘cause I think it is quite a lot to expect our colleagues to remember. But this is all based on the British Gynaecological Cancer Society guidelines. I don’t think it’s in NICE at the moment, but hopefully if it’s updated, it’ll be in there for the NICE suspected cancer referral guidance.
Rebecca: That’s really interesting. Okay. Can we move on to the next case? As I say, this is not a, a specific patient, but it’s patients that we see, and this is, another female patient. Very young.
Sarah: Yeah.
Rebecca: Age 43. Only ’cause that’s how old I am! So, and this is somebody who is perimenopausal who is describing intermenstrual bleeding, so a different bleeding pattern, and also a change in discharge. So what will your concerns be here, Sarah?
Sarah: Well, when I spoke to, when we did the module, I spoke to Eric Watson, who was actually in my year at medical school, as obviously was your husband Matt. So the, you know, the three of us… I was talking to Eric about this and he was saying that one of the things that he thinks is going to change for some of the newly appointed gynaecology consultants is the number of younger women with endometrial cancer. Because the guidance, as I think you said earlier, is for women over the age of 50 or 55, but he was saying that they’re seeing increased numbers of women in their forties and perimenopausal women who have endometrial cancer thought to be due to increased rates of obesity and unopposed, increased oestrogen levels from the obesity. So it’s, basically it’s much more difficult, isn’t it, because you’re not gonna get a postmenopausal bleed in a woman who’s still bleeding. Women in their forties often get very…
Rebecca: Like a, just a change, isn’t it?
Sarah: Yeah, lots of women get perimenopausal change in their periods anyway, don’t they? So it’s a really difficult one to work out exactly when you should be concerned. But there is an increased incidence in this age group that we need to start to be aware of, and there’s no clear guidelines on it. What he was saying really is that if you’ve got somebody who has abnormal bleeding pattern for them that persists and doesn’t respond to fairly standard treatments, maybe giving some hormonal treatment or tranexamic acid, mefenamic acid, putting a Mirena in, then you should think about investigating them. First thing would be probably, well obviously after you’ve done an examination just to check the bleeding’s not coming from the cervix or anywhere else in the gynaecological tract, would be to do an ultrasound. The ultrasound is not to look at endometrial thickness ‘cause endometrial thickness will be changing ‘cause of still having periods, but just to check for other causes such as fibroids. But after that, if you’ve got persistent abnormal bleeding, the best thing to do is to send a referral. I don’t think it necessarily needs to be a suspected cancer referral, but it will need to be relatively urgent, and I know that’s a difficult balance at the moment.
Rebecca: It’s really difficult ’cause you are almost thinking if somebody has got some pathology, would you feel comfortable starting them on a trial of HRT if they’re perimenopausal? Would you feel comfortable putting in a Mirena? So because there’s no guidance, it’s almost, we’re, we are suggesting what we may do in this scenario. And it’s just always checking in on, checking in with the patient and if there are any other kind of symptoms like post-coital bleeding, intermenstrual bleeding, which we’ve discussed. But again, intermenstrual bleeding could be perimenopausal bleeding.
Sarah: There’s no guidance, is there, for perimenopausal women for endometrial cancer. That’s part of our problem, and it’s, it, it’s a real issue.
Rebecca: And I just wanted to mention, and again, I have, there’s no science behind this. We are seeing younger women presenting with different types of cancers. And we mention it whether, that we’re seeing more endometrial cancers in younger women because of an increase in BMI. I’m just wondering if that’s something across the board with other cancers as well. Because when I’ve asked cancer specialists, why are we seeing younger people with cancers, it’s almost like, well, is it because we’re diagnosing them early? There’s, there’s a lot, we are not sure is the answer. So it’s just something to think about. Is there a link? And we did a, a really good podcast a few weeks ago, and the specialist Liz, that we were talking to, Liz O’Riordan, actually said, diet and exercise is the best thing that we can suggest and offer a patient. So again, that will also help with increasing weight.
Sarah: Yeah, and I think, I think the key with the younger women is, is to have that index of suspicion in the patient who has a risk factor, either a family history or is, or, or high BMI, who has abnormal bleeding that is persisting. Um, and I think at the end of the day you could, you can send an advice and guidance, can’t you? You can ask somebody what they, what, what they think. But the two women that I interviewed for the module, both had quite delayed diagnoses ’cause everybody thought they were perimenopausal and just kept… but also had fairly significant risk factors.
Rebecca: Okay. So I just want to give an interesting fact. We’re not doing fun facts anymore, but we’re doing an interesting fact, ’cause they’re not very fun. But endometrial cancer risk is higher in women with no children and the risk decreases with the greater number of full term pregnancies. However, risk is higher in people who’ve had their first child at 25 years or younger, compared with women who are having children later, 40 plus.
Sarah: Yeah. It’s like, it’s just sort of, one of, I was just listening to one of the podcasts that we’d done a few weeks ago when we were talking about caffeine and you know, it seems to be the same thing, doesn’t it? That some things, your risk is increased with caffeine, something, it’s decreased with caffeine. So we just sort of…
Rebecca: I know. Diet and exercise!
Sarah: Yeah. Diet and exercise don’t seem, you know, don’t seem…
Rebecca: I don’t think there’s any negatives to that!
Sarah: No!
Rebecca: So, what I’ve learned from this is about safety netting the, the patient as well, because I think the three month rule, which is what you’ve really talked about very eloquently, Sarah.
Sarah: Thank you!
Rebecca: But I think. by actually, giving the patient some onus of their own health and saying, three months please do come back to us and we can talk about changing your form of HRT… Six months, we will really consider referring you. So I think it’s really important that we do safety net the patient. Are we happy to go onto key points?
Sarah: Absolutely.
Rebecca:: Do you want to kick off?
Sarah: Yeah, because this is a really, really nice, easy one. Postmenopausal bleeding, i.e. bleeding after 12 months of a amenorrhoeic on, on women who are not on HRT is a red flag symptom.
Rebecca: It’s really important to take a clear history from the patient, ask about compliance, particularly when they’re presenting with bleeding on HRT, and check that they’re taking the medication properly and whether it needs changing.
Sarah: Risk factors for endometrial cancer are obesity, family history, and treatments like Tamoxifen, which we did touch on briefly a couple of weeks ago.
Rebecca: And if women are sent under the suspected cancer referral, hysteroscopy is the gold standard to diagnose endometrial cancer. So that’s it for today, Sarah. Thank you very much as ever. As I say, elegant and eloquent.
Sarah: Wow. Who’d have thought?!
Rebecca: Who would’ve thought! So… it’s your week off!
Rebecca: Thanks for listening to this podcast from Gateway C. We hope you’re enjoying this series. Please do support this podcast by leaving us a review or rating wherever you get your podcasts. And if you’ve got any topic suggestions for future episodes, we’d love to hear them. Please do include these in your review. If you’ve found this or other episodes interesting and helpful to your practice, please do share it with a friend or colleague. It really does help to spread the word. We’ve got a free uterine cancer course available on the GatewayC website, which covers endometrial cancer and up to date guidance on the management of unscheduled bleeding on HRT. All referenced studies and guidelines are in our show notes. Thank you again for listening and thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. See you again soon.