Postmenopausal_Bleeding_Flashcards

Question 1

What is postmenopausal bleeding?

Answer 1

Postmenopausal bleeding is defined as vaginal bleeding occurring after 12 months of amenorrhoea.

Question 2

Why is it important to investigate postmenopausal bleeding?

Answer 2

It is important to investigate postmenopausal bleeding to exclude malignancy.

Question 3

What is the most common cause of postmenopausal bleeding?

Answer 3

The most common cause of postmenopausal bleeding is vaginal atrophy.

Question 4

How does vaginal atrophy lead to postmenopausal bleeding?

Answer 4

Vaginal atrophy leads to postmenopausal bleeding through the thinning, drying, and inflammation of the vaginal walls due to reduced oestrogen.

Question 5

How can HRT lead to postmenopausal bleeding?

Answer 5

HRT can lead to postmenopausal bleeding through continued periods or spotting, or endometrial hyperplasia due to long-term oestrogen therapy.

Question 6

What is endometrial hyperplasia and why is it significant?

Answer 6

Endometrial hyperplasia is an abnormal thickening of the endometrium and a precursor for endometrial carcinoma.

Question 7

What are the risk factors for endometrial hyperplasia?

Answer 7

Risk factors for endometrial hyperplasia include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome, and diabetes.

Question 8

What is the significance of endometrial cancer in postmenopausal bleeding?

Answer 8

Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding.

Question 9

How is cervical cancer related to postmenopausal bleeding?

Answer 9

Cervical cancer must be considered in postmenopausal bleeding, and a full record of prior cervical screening should be obtained.

Question 10

How can ovarian cancer present with postmenopausal bleeding?

Answer 10

Ovarian cancer, especially oestrogen-secreting (theca cell) tumours, can present with postmenopausal bleeding.

Question 11

What are some uncommon causes of postmenopausal bleeding?

Answer 11

Uncommon causes of postmenopausal bleeding include trauma, vulval cancer, and bleeding disorders.

Question 12

What does NICE recommend for investigating postmenopausal bleeding in women over 55?

Answer 12

NICE recommends that women over 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer.

Question 13

What is the investigation of choice for women referred on a cancer pathway for postmenopausal bleeding?

Answer 13

The investigation of choice for women referred on a cancer pathway is a transvaginal ultrasound.

Question 14

What is the acceptable endometrial lining thickness in postmenopausal women with bleeding?

Answer 14

An acceptable endometrial lining thickness in postmenopausal women with bleeding is <5mm.

Question 15

Why might further testing be required even if the endometrial lining thickness is acceptable?

Answer 15

Further testing may be required if clinical suspicion is high, even if the endometrial lining thickness is acceptable.

Question 16

Do women on HRT with postmenopausal bleeding need investigation?

Answer 16

Yes, women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer.

Question 17

What treatments are available for vaginal atrophy causing postmenopausal bleeding?

Answer 17

Treatments for vaginal atrophy include topical oestrogens, lifestyle changes such as lubrication, and HRT.

Question 18

What can be done if postmenopausal bleeding is due to HRT?

Answer 18

Different HRT preparations can be used if bleeding is due to the type of HRT the patient is on.

Question 19

How is endometrial hyperplasia treated?

Answer 19

Endometrial hyperplasia is usually treated with dilatation and curettage to remove excess endometrial tissue.

Question 20

summarise post menopausal bleeding

Answer 20

Postmenopausal bleeding

Postmenopausal bleeding is defined as vaginal bleeding occurring after 12 months of amenorrhoea. Whilst the majority of women do not have an underlying malignancy it is important to exclude this in all women.

Causes
vaginal atrophy
the most common cause of postmenopausal bleeding
the thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
HRT (hormone replacement therapy)
periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
endometrial hyperplasia
an abnormal thickening of the endometrium and a precursor for endometrial carcinoma
risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
endometrial cancer
although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
cervical cancer
it is important to obtain a full record of prior cervical screening programme attendance
ovarian cancer
can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
vaginal cancer
uncommon but can present with postmenopausal bleeding
other uncommon causes include
trauma
vulval cancer
bleeding disorders

Investigations for postmenopausal bleeding
NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer
for those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice
the endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm
however, it may miss some pathology and if clinical suspicion is high, further testing is required
women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Treatment by cause of postmenopausal bleeding
once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
if a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
in the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue

Question 21

**A 57-year-old woman presents to her GP with a three-month history of intermittent vaginal bleeding, which often occurs after sexual intercourse. The blood is dark red and lacks a strong odour. She reached menopause at the age of 54 and has experienced mild hot flushes that have not required treatment. She also reports vaginal dryness. She is not on any regular medications, and her last cervical smear test was negative. Overall, she feels well.

What is the most likely cause of this woman’s postmenopausal bleeding?

Cervical cancer
Endometrial cancer
Endometrial hyperplasia
Vaginal atrophy
Vulval cancer

Answer 21

Vaginal atrophy

Vaginal atrophy is the most common cause of postmenopausal bleeding

Vaginal atrophy is indeed the correct diagnosis as it is the most frequent cause of postmenopausal bleeding. This condition arises from the thinning and drying out of vaginal tissues due to decreased levels of oestrogen associated with menopause.

Cervical cancer is an unlikely diagnosis in this case, considering the patient’s recent negative cervical smear test. This result significantly reduces the likelihood of cervical cancer. Cervical cancer more commonly presents with vaginal discharge, suprapubic pain, white/red patches on the cervix, vaginal bleeding and urinary symptoms. These symptoms are not consistent with this patient.

Endometrial cancer, while a recognised cause of postmenopausal bleeding, is not the most likely explanation in this instance. Its prevalence is less than that of vaginal atrophy. The patient’s overall state of health further suggests that endometrial cancer is an improbable diagnosis. Nonetheless, it remains an important differential to exclude promptly.

Endometrial hyperplasia is also an unlikely diagnosis for this patient. It more commonly affects individuals who are obese or have certain risk factors such as the use of tamoxifen, which do not pertain to this case.

Vulval cancer generally does not manifest with postmenopausal bleeding as a sole symptom; thus, it is not a probable cause in this context. Instead, vulval cancer presents with a lump associated with lymphadenopathy, vulval itching, pain and changes in skin colour and thickening.
**

Question 22

A 55-year-old woman attends her gynaecology appointment due to a new onset of post-coital bleeding, she is otherwise physically active with no past medical history. Her last menstrual period was 24 months ago. She has a 20-pack-year smoking history and does not drink alcohol, she is physically active and takes no medication.

What is the most common diagnosis for this presentation?

Cervical cancer
Endometrial cancer
Endometrial hyperplasia
Ovarian cancer
Vaginal atrophy

Answer 22

Vaginal atrophy

Vaginal atrophy is the most common cause of postmenopausal bleeding

Vaginal atrophy: This is the correct answer, the most common cause of post-menopausal bleeding, which arises due to the drying and thinning of the vaginal walls due to the reduction of oestrogen. This increases the risk of post-coital bleeding particularly.

Cervical cancer: This answer is incorrect as although a cause of post-coital bleeding, it is not the most common cause in this age category, its prevalence peaks in the reproductive years.

Endometrial cancer: This answer is incorrect as although post-menopausal bleeding is a key presentation of endometrial cancer it is not the most common cause. However, it is important to rule out.

Endometrial hyperplasia: This answer is incorrect, as although a cause for post-menopausal bleeding, it is not the most common cause. Additionally, no risk factors are described in the clinical note such as obesity or diabetes. Smoking is a protective factor due to its anti-oestrogenic effects.

Ovarian cancer: This answer is incorrect, as although it more often affects post-menopausal women, post-coital bleeding is not a key symptom of the condition. Although, it can occur it is a rarer cause than vaginal atrophy making it, not the most appropriate answer. Ovarian cancer often presents with non-specific symptoms, e.g., bloating, changes to bowel habits, urinary frequency, and weight loss.