What is postmenopausal bleeding?

Postmenopausal bleeding occurs when a woman of menopausal age has had 12 months without a period (amenorrhoea) and then has unscheduled (ie without hormonal treatment intervention) vaginal bleed.

What is the concern with postmenopausal bleeding?

For the majority, there is an innocent cause for the bleeding. However, the most common presenting symptom of an endometrial cancer is postmenopausal bleeding. Postmenopausal bleeding should always be taken seriously even if it amounts to no more than a small blood stained discharge.

Is there a need to investigate postmenopausal bleeding?

Postmenopausal vaginal bleeding must always be investigated. In the majority of cases no serious problem will be found but there are times when the bleeding is the first symptom of serious disease including cancer. Even when the bleeding is related to cancer, if it is diagnosed early there is a very good chance that the disease can be cured (Q32.2).

Ten per cent of women with ultrasound evidence of a thin endometrium, less than 5mm, will have further bleeding and ten per cent of these will have endometrial cancer ie 1 in 100 women with recurrent bleeding after a negative ultrasound.0801

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What could be the cause of vaginal bleeding after the menopause - PMB?

In 90% of cases examination and investigation will find either no obvious cause or an innocent one. The commonest innocent cause is atrophic vaginitis. Cervical and endometrial polyps (cervical polyps) are further common findings and they are usually benign. Occasionally cancer of the endometrium (uterus) or cervix may be found - about 10-25% being quoted.

Causes of postmenopausal bleeding

Polyps - endometrial or cervical 2-12%
Endometrial Hyperplasia 5-10%
Endometrial Cancer 10%
Estrogen treatments 15-25%
Atrophic vaginitis 60-80%
No cause found 10%

Occasionally, haematuria (blood in the urine) or rectal bleeding may mistakenly present as "postmenopausal bleeding".

Women frequently present to their gynaecologist with a period-like bleed when they have previously fulfilled the criteria for the menopause. Premenstrual type symptoms such as breast discomfort may have preceded the bleeding. Appropriate clinical examination and investigation is imperative. Once a pathological (disease) cause for the bleeding has been excluded, it would seem logical to conclude that the woman might have been correct in her belief that she had experienced menstruation again. Presumably this must have followed maturation of an egg which was scheduled to occur a year or more after the previous period (Q 2.3).


Related Medical Abstracts - Click on the paper title:-

How is postmenopausal bleeding investigated?

As with all clinical presentations, a thorough history, clinical examination and set of investigations are indicated. These should be conducted with urgency to exclude malignancy. Many hospitals now have a dedicated nurse led clinic to initiate assessment.

The notes should include:

  • the duration and severity of bleeding
  • initiating factors such as intercourse or trauma
  • medication, such as
    • HRT
    • topical estrogen
    • tamoxifen
  • PAP smears
  • Medical conditions
    • Diabetes
    • Obesity
  • Family history of gynaecological cancer.
  • Gynaecological history
  • Obstetric history

Clinical examination should include:

  • abdominal
  • bimanual pelvic
  • speculum examination of the vagina and cervix.

Investigations:

Before the advent of ultrasound, a D and C was always performed.

Nowadays if transvaginal ultrasound shows no obvious abnormality and it is less than 5mm thick, no further investigation is usually required although many would take an endometrial biopsy as a precaution. Endometrial biopsy has been shown to accurately identify endometrial cancer.0301,0801 Outpatient endometrial biopsy has a high overall accuracy in diagnosing endometrial cancer when an adequate specimen is obtained. A positive test result is more accurate for ruling in disease than a negative test result is for ruling it out. When abnormal uterine bleeding symptoms persist despite negative biopsy, further evaluation is indicated.0201

A thickened endometrium on ultrasound could represent an endometrial polyp, hyperplasia or endometrial cancer.

Pelvic ultrasound can also detect adnexal pathology. Ovarian and tubal malignancy can occasionally present with postmenopausal bleeding.

Saline infusion sonography involves introducing 5-10 ml of saline into the uterine cavity followed by transvaginal ultrasound. This may help distinguish endometrial polyps of submucosal fibroids.


How is postmenopausal bleeding managed?

Atrophic vaginitis is treated by topical estrogen.

Cervical polyps are avulsed in the outpateint clinic.

Non atypical endometrial hyperplasia can be treated with progestogens and the levonorgestrel IUS has been shown to be particularly effective.

Atypical endometrial hyperpasia and endometrial cancer requires hysterectomy.

If initial investigation suggests a benign condition, but bleeding recurs, formal hysteroscopy and D&C are indicated.



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