Post-Menopausal Bleeding

Question 1

Significance of PMB

Answer 1

• Usually defined as >12 months after the last period
• 10% risk of endometrial malignancy

Question 2

Causes of PMB

Answer 2

• Commonly
  
  • Atrophic vaginitis (most common)
  • Transient ovulation
• Sometimes
  
  • Endometrial cancer
  • Polyps
  • Hyperplasias
  • Pessary-related
• Rarely
  
  • Cervical cancer
  • Ovarian cancer
  • Non-gynaecological

Question 3

Investigation of PMB

Answer 3

• Always
  
  • Hx (demography, when menopause occurred, smear Hx, volume and frequency of bleeding, HRT use (CS or CC) and risk factors (previous PMB, obesity, polycstic ovaries, Br or Ov Ca, tamoifen use))
  • Speculum examination
  • Transvaginal ultrasonography
• If required
  
  • Cervical smear
  • Endometrial biopsy
  • Diagnostic hysteroscopy

Question 4

Transvaginal ultrasonography

Answer 4

• Assess endometrial thickness
• If ET <3mm unlikely to require further investigation unless recurrent bleeding
• Biopssy using pipelle if ≥3mm (sometimes not possible or no tissue obtained)

Question 5

Hysteroscopy

Answer 5

• Required if:
  
  • Pipelle impossible
  • No tisue obtained
  • Tamoxifen use
  • Recurrent bleeding
  • Clinical suspicion is high

Question 6

PMB in HRT users

Answer 6

• Refer for cyclical if any unscheduled bleeding
• Refer for combined continuous if any bleeding

Question 7

Tamoxifen

Answer 7

• Associated with higher risk of endometrial cancer but no need to investigate unless PMB
• Hysteroscopy and curettage are gold standard

Question 8

Management of PMB

Answer 8

• Endometrial cancer (see cancer notes)
• Atrophic vaginitis - topical oestrogen cream/pessaries
• Transient ovarian activity - should settle, reassure
• Polyps - remove (hysteroscopy, in clinic)
• Hyperplasias - progestogens
• Ring/prolapse problems - oestrogens, consider prolapse surgery