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What initial investigations should I perform for a patient presenting with abnormal uterine bleeding to rule out endometrial cancer?
Answer
Guideline-Aligned (High Confidence)
Generated by iatroX. Developer: Dr Kola Tytler MBBS CertHE MBA MRCGP (General Practitioner).
Last reviewed: 16 August 2025
Initial investigations to exclude endometrial cancer for a patient presenting with abnormal uterine bleeding depend on the patient's age and specific symptoms.
- For women aged 55 and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped), a suspected cancer pathway referral should be made for endometrial cancer 4,5.
- For women aged under 55 with post-menopausal bleeding, a suspected cancer pathway referral for endometrial cancer should be considered 4.
- For women aged 55 and over with specific symptoms such as unexplained vaginal discharge (presenting for the first time, or with thrombocytosis, or reporting haematuria), or visible haematuria with low haemoglobin levels, thrombocytosis, or high blood glucose levels, a direct access ultrasound scan should be considered to assess for endometrial cancer 4.
- For women with heavy menstrual bleeding (HMB) where endometrial pathology is suspected (e.g., persistent intermenstrual bleeding or risk factors for endometrial pathology such as obesity, polycystic ovary syndrome, or tamoxifen use), outpatient hysteroscopy should be offered 1. An endometrial biopsy should be considered at the time of hysteroscopy for these high-risk women 1. It is important that an endometrial sample is only obtained in the context of diagnostic hysteroscopy, and 'blind' endometrial biopsy should not be offered 1.
- If a woman declines outpatient hysteroscopy, hysteroscopy under general or regional anaesthesia can be offered 1. If hysteroscopy is declined, pelvic ultrasound can be considered, but its limitations for detecting uterine cavity causes of HMB should be explained 1.
- A full blood count should be carried out for all women with HMB 1. A physical examination should also be performed before any investigations 1.
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