Post-menopausal bleeding

Question 1

What is the definition of post-menstrual bleeding?

Answer 1

PMB is vaginal bleeding occurring at least 12m after last menstrual period

Question 2

What is the diagnosis of PMB until proven otherwise?

Answer 2

Endometrial carcinoma

Question 3

What are the causes of PMB?

Answer 3

Vaginitis (esp atrophic)
Foreign body e.g. pessary
Carcinoma of cervix or vulva
Endometrial or cervical polyps
Oestrogen withdrawal (e.g. HRT, ovarian tumour)
Cervicitis
Endometrial hyperplasia (pre-cancerous potential)
Infection e.g. candidiasis
Bleeding from excoriation (e.g. in lichen sclerosis)
Ectropion (rare in post-menopausal women)

Question 4

What risk factors are often found in patients with PMB?

Answer 4

Obese
Age
Nulliparous
HRT
Late menopause
PCOS
Granuloma cell tumour (secretes oestrogen)
FHx (breast, ovarian ca)
Lynch II syndrome

Question 5

What Ix would be indicated in PMB?

Answer 5

Bimanual and speculum
TVS (endometrial thickness >4cm = further Ix)
Endometrial sampling with papelle
Possible indication for hysteroscopy

Smear may be performed if <65y and no Hx of smears; but if smears up to date/normal, not necessary

Question 6

What may the patient confuse PMB with?

Answer 6

Bleeding from urethra/rectum

Question 7

If endometrial thickening is seen on TVS, what should be performed?

Answer 7

Endometrial biopsy +/- hysteroscopy