Postmenopausal bleeding

Question 1

Differentials for postmenopausal bleeding

(>12 months since LMP)

Answer 1

*ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE*

• Malignancy
  
  • Endometrial carcinoma
    
    • Oestrogen exposure
      
      • Menarche
      • Menopause
      • HRT (oestrogen only)
      • Tamoxifen
  • Cervical carcinoma
    
    • Smear?
• Atrophic vaginitis
• Polyps.
• Trauma.
• Hormone replacement therapy
• Bleeding disorder.

Also ask about :

• Local symptoms of oestrogen deficiency:
  
  • Vaginal dryness, soreness, superficial dyspareunia
• Itchiness (atrophy)
• Lumps or swellings at the vulva

Question 2

Causes of postmenopausal bleeding

Answer 2

• 90% benign/innocent
  
  • Atrophic vaginitis
  • Cervical/endometrial polyp
  • Trauma
• 10% endometrial/cervical cancer

Question 3

Postmenopausal bleeding history

Answer 3

• Gynae Hx
  
  • Pain
  • Discharge
• Age
• LMP
• Oestrogen exposure
  
  • Age of menarche
  • LMP
  • Tamoxifen
  • HRT
• Cervical smear Hx
• When? How much?
• Drug Hx
• Family Hx
  
  • HNPCC

Question 4

Risk factors for endometrial cancer

Answer 4

• Prolonged exposure to unopposed oestrogen
  
  • Early menarche
  • Late menopause
  • Nulliparity
  • Tamoxifen (anti-oestrogenic for breast, pro-oestrogenic for endometrium)
  • Tibolone (HRT)
  • Obesity (increased oestrogen)
  • HNPCC