Post-menopausal bleeding

Question 1

A 55-year-old (or 48) woman presents with post-menopausal bleeding. Discuss how you would assess and manage this patient.

2020 stem: 67 year old female with PV bleeding the past 2 days, soaking a pad every 4 hours. CST was 5 years ago (was normal). Some FHx of cardiovascular disease. Nulliparous, no other symptoms, never had COCP. Menopause was 15 years ago with no major issues and no HRT (They gave the info after I outlined my history). Hx/Ix/causes/Mx.

Answer 1

Impression
salient features: post-menopausal, significant PV bleeding. initially am concerned about endometrial cancer in this setting, however would consider a broad range of differentials including:
- gynae: atrophic vaginitis, cervical cancer, polyps, fibroids
- non-gynae: PR/haematuria bleeding masquerading as PV, trauma, coagulopathy

Question 2

Post-menopausal bleeding - Assessment

Answer 2

Assessment
Given bleeding, and of unknown quantity, would first utilise an A to E approach to ensure haemodynamic stability, and implement any stabilising/temporising measures if required.

Question 3

Post-menopausal bleeding - History

Answer 3

History

• sx: Onset, duration, course (post-coital, intermittent), pain SOCRATES,
• RISKS: unbalanced HRT, fam hx, sources of endogenous oestrogen
• REDF: fever, night sweats, weight loss
• gynae hx: CST, exams, use of HRT
• obstetric hx
• PMHx (coagulopathies), PSHx
• SNAP

Question 4

Post-menopausal bleeding - Examination

Answer 4

Examination

• general appearance + vital signs (fevers)
• abdominal examination: masses, focal tenderness
• Pelvic examination: speculum + bimanual: identify source of bleeding, vaginal abnormalities, masses, irregular/enlarged uterus
• systems review: metastasis

Question 5

Post-menopausal bleeding - Investigations

Answer 5

Investigations
- Key/diagnostic: TV U/S, hysteroscopy +/- biopsy (pipette, D&C, targeted)

• Bedside: speculum examination, CST, STI, vitals, could perform pipelle biopsy
• Bloods: FBC (anaemia), iron studies, coags
• imaging: consider staging imaging pending results of initial diagnostic investigations (CT-CAP, CXR)

Question 6

Post-menopausal bleeding - Management

Answer 6

Management
depends on the underlying cause, if endometrial cancer:

Components

• form MDT
• surgical staging (to identify depth of local invasion)
• adjuvant therapy depending on stage: radiation +/- hormonal therapy +/- surgical (hysterectomy - total, sub-total etc)

Question 7

endometrial cancer - staging

Answer 7

Staging
Uses FIGO staging system;
1A - limited to endometrium
1B - invading one half or more of myometrium
2 - invading to cervix but not beyond uterus
3A - tumour involving serosa and/or adnexa
3B - vaginal involvement or parametrical involvement