Standard operating procedure

Abnormal Bleeding & Red Flag Referral SOP

How [Organisation Name] recognises emergency and suspected cancer red flags, manages unscheduled bleeding on hormone replacement therapy (HRT) by risk stratification under the 2024 joint national guideline, sends patients to 999 or same-day care when needed, and tracks every referral to a recorded outcome

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment, systems and information required
  • 6. Red flag screening at every contact
  • 7. Emergency red flags
  • 8. Suspected cancer and other urgent red flags
  • 9. Unscheduled bleeding on HRT
  • 10. Postmenopausal bleeding not on HRT and bleeding on vaginal oestrogen alone
  • 11. Making, tracking and closing referrals
  • 12. Safety netting and patient information
  • 13. Records
  • 14. Training and competence
  • 15. Monitoring and audit
  • 16. Related documents
  • 17. Review and version control
  • 18. Appendix A - Referral and Failsafe Log
  • 19. Disclaimer

CQC fundamental standard

Regulation 9 (Person-centred care)
This document is written to evidence that standard. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Legislation & standards it maps to

  • National Institute for Health and Care Excellence (NICE) guideline NG23, Menopause: identification and management (as last updated, including the April 2026 amendments on unscheduled bleeding on HRT).
  • NICE guideline NG12, Suspected cancer: recognition and referral (as last updated, including the April 2026 amendments on ovarian cancer and endometrial cancer).
  • NICE guideline NG128, Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.
  • British Menopause Society, Royal College of Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, College of Sexual and Reproductive Healthcare (formerly the Faculty of Sexual and Reproductive Healthcare), Royal College of General Practitioners and Getting It Right First Time: Management of unscheduled bleeding on hormone replacement therapy (HRT), joint guideline (2024), and the Getting It Right First Time summary guide (June 2024).
  • British Menopause Society consensus statements and Tools for Clinicians.
  • General Medical Council (GMC), Good practice in proposing, prescribing, providing and managing medicines and devices, including the sections on remote prescribing and on medicines requiring additional safeguards.
  • GMC, Remote consultations guidance and decision flowchart.
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 9 (Person-centred care), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 20 (Duty of candour).
  • Mental Capacity Act 2005 and Equality Act 2010.
  • UK General Data Protection Regulation, Data Protection Act 2018 and the Records Management Code of Practice (2023).
  • Care Quality Commission (CQC) assessment framework: the five key questions (safe, effective, caring, responsive and well-led) and the quality statements of the single assessment framework, and the sector-specific framework for primary care and community services when it replaces them.

Who it applies to

All prescribing clinicians (whether registered with the General Medical Council, the Nursing and Midwifery Council or the General Pharmaceutical Council), the [Clinical Lead], the Registered Manager, and administrative and patient-support staff who take calls, messages or bookings, including self-employed and locum staff, for consultations delivered in person or remotely

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Amenorrhoea
An absence of periods or bleeding.
Ascites
A build-up of fluid in the abdomen, which can be a sign of ovarian or other cancer.
Body mass index (BMI)
A measure of weight relative to height, used here because a higher BMI increases the risk of endometrial cancer.
British Gynaecological Cancer Society (BGCS)
The professional society for specialists in cancers of the female reproductive organs.
British Menopause Society (BMS)
The UK specialist society for health professionals working in menopause care, which publishes guidance and Tools for Clinicians.
British Society for Gynaecological Endoscopy (BSGE)
The professional society for gynaecologists who use keyhole and hysteroscopic techniques.
Cancer antigen 125 (CA125)
A blood test that can be raised in ovarian cancer and some non-cancerous conditions; NICE sets age-specific thresholds for acting on it.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
College of Sexual and Reproductive Healthcare (CoSRH)
The professional body for sexual and reproductive healthcare, formerly the Faculty of Sexual and Reproductive Healthcare.
Continuous combined HRT
HRT taken as oestrogen and progestogen every day, intended to be bleed-free once settled.
Cowden syndrome
An inherited condition that increases the risk of several cancers, including endometrial cancer.
Data Protection Act 2018
The UK law, alongside the UK GDPR, governing how personal information is handled.
Duty of candour
The legal duty (Regulation 20) to be open and honest with a patient when something goes wrong that causes, or could cause, significant harm.
Endometrium
The lining of the womb, which can thicken and become abnormal.
Endometrial biopsy
Taking a small sample of the womb lining to examine under a microscope.
Equality Act 2010
The law protecting people from discrimination, including on the grounds of sex and gender reassignment.
Face, Arm, Speech, Time (FAST) test
A quick check for stroke: face drooping, arm weakness, speech problems, time to call 999.
Failsafe
A tracking system that ensures every referral or test reaches a recorded outcome.
Faster Diagnosis Standard
The national standard that people referred with suspected cancer are diagnosed or have cancer ruled out within 28 days.
General Medical Council (GMC)
The regulator of doctors in the UK.
General Pharmaceutical Council (GPhC)
The regulator of pharmacists and pharmacy technicians in Great Britain.
General practitioner (GP)
The patient's family doctor.
Getting It Right First Time (GIRFT)
A national programme to improve care by reducing unwarranted variation; it co-authored the 2024 bleeding guideline and its summary guide.
Haematuria
Blood in the urine; visible haematuria can be seen by eye.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that registered providers must meet, enforced by the CQC.
Hormone replacement therapy (HRT)
Medicines that replace oestrogen, usually with a progestogen if the patient has a womb, to relieve menopause symptoms.
Hysteroscopy
A procedure using a thin camera passed through the cervix to look inside the womb, often with a biopsy.
International units per millilitre (IU/mL)
The unit in which CA125 blood test results are reported.
Levonorgestrel intrauterine system (LNG-IUS)
A hormone-releasing device placed in the womb; the 52 mg type can provide the progestogen part of HRT.
Lynch syndrome
An inherited condition that increases the risk of bowel, endometrial and some other cancers.
Medicines and Healthcare products Regulatory Agency (MHRA)
The UK regulator of medicines and medical devices, which runs the Yellow Card scheme for reporting side effects.
Mental Capacity Act 2005
The law on how to decide whether a person can make a particular decision, and how to act if they cannot.
National Institute for Health and Care Excellence (NICE)
The body that publishes national clinical guidelines in England.
NICE NG12
NICE guideline Suspected cancer: recognition and referral.
NICE NG23
NICE guideline Menopause: identification and management.
NICE NG128
NICE guideline Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.
Nursing and Midwifery Council (NMC)
The regulator of nurses and midwives in the UK, and nursing associates in England.
Polycystic ovary syndrome (PCOS)
A hormonal condition that can cause irregular or absent ovulation, which increases endometrial cancer risk.
Postmenopausal bleeding
Vaginal bleeding more than 12 months after periods have stopped.
Records Management Code of Practice (2023)
National guidance on how long health and care records are kept and how they are managed.
Royal College of General Practitioners (RCGP)
The professional body for general practitioners.
Royal College of Obstetricians and Gynaecologists (RCOG)
The professional body for specialists in obstetrics and gynaecology.
Sequential HRT
HRT in which a progestogen is taken for part of each month, producing a monthly bleed.
Standard Operating Procedure (SOP)
A written step-by-step instruction for carrying out a task consistently and safely.
Summary of Product Characteristics (SmPC)
The regulator-approved document describing how a medicine is used, including when it must be stopped.
Suspected cancer pathway referral
An urgent referral, as defined by NICE, to a service that can quickly confirm or rule out cancer.
Transient ischaemic attack (TIA)
A 'mini-stroke': stroke symptoms that resolve, which is a medical emergency because a full stroke may follow.
Transvaginal ultrasound (TVUS)
An internal ultrasound scan used to measure the thickness of the womb lining.
Tricycling HRT
A regimen in which the progestogen is taken only every third month.
UK General Data Protection Regulation (UK GDPR)
The UK's main law on collecting and using personal information.
Unscheduled bleeding
Bleeding on HRT outside the pattern expected for that type of HRT.
Venous thromboembolism (VTE)
A blood clot in a vein, such as a deep vein thrombosis in the leg or a pulmonary embolism in the lung.
Yellow Card scheme
The MHRA system for reporting suspected side effects of medicines.

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