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What is Post Menopausal Bleeding [PMB]?

Postmenopausal bleeding is defined as vaginal bleeding occurring over 12 months after periods have stopped in a woman of the age where the menopause can be expected. Hence it does not apply to a young woman who has had amenorrhoea from anorexia nervosa or a pregnancy followed by lactation. It can apply to younger women following premature ovarian failure or premature menopause.

It is common and represents 5% of all gynaecology OPD attendances.

Risk factors:

It is likely to occur if exogenous oestrogens are taken. Polycystic ovary disease increases risk. Use of combined oral contraceptives decreases risk.

Causes:

• Non-gynaecological causes including trauma or a bleeding disorder

• Use of hormone replacement therapy

• Vaginal atrophy

• Endometrial hyperplasia - simple, complex, and atypical

• Endometrial carcinoma usually presents as PMB but 25% occur in premenopausal women

• Endometrial polyps or cervical polyps

• Cancer of cervix (is cervical smear up to date?)

• Ovarian cancer, especially oestrogen-secreting (theca cell) ovarian tumours

• Vaginal cancer is very uncommon. Cancer of vulva may bleed but the lesion should be obvious

Management:

History and examination may possibly indicate cause but the dictum is that postmenopausal bleeding should be treated as malignant [cancer] until proved otherwise. This requires urgent evaluation by a qualified gynaecologist.

Investigation:

• A transvaginal scan is used to measure endometrial thickness and 4mm is used as the cut-off point.

• Hysteroscopy may be performed as this gives a view of the inside of the uterus

• D&C is performed along with the hysteroscopy or a hysteroscopic guided biopsy is taken

A paper from San Francisco looked at postmenopausal women, with and without PMB but not taking HRT. They found that in a postmenopausal woman with vaginal bleeding, the risk of cancer is approximately 7.3% if her endometrium is  5 mm thick or more and less than 0.07% if it is less than 5 mm. In a postmenopausal women without vaginal bleeding, the risk of cancer is approximately 6.7% if the endometrium is over 10mm thick and 0.002% if the endometrium is less than 10 mm. They estimated that around 5% of women with endometrial cancer do not have PMB. If the endometrium is over 11mm thick the risk of cancer rises from 4.1% at age 50 to 9.3% at age 79

The accuracy of assessing endometrial thickness in women with diabetes and obesity has been questioned.

Outcome:

• Where pathology is found it needs to be treated and prognosis will depend upon the condition and, if malignant, the stage.

• After an initial hysteroscopy and biopsy have excluded uterine pathology there is no need to repeat the procedure unless there are very strong grounds for suspecting an occult cancer. If transvaginal ultrasound measured endometrial thickness of less than 5 mm it provides additional reassurance that there is no sinister underlying pathology.

• Most women who have negative investigations will have no further problems and failure to make a diagnosis is not uncommon.

Important points to keep in mind:

• Most women with PMB will not have significant pathology but the dictum remains that postmenopausal bleeding is cancer until proved otherwise.

• PMB in women on HRT still needs investigation.

• An obvious lesion like atrophic vaginitis does not exclude another lesion.

• Many women are unable to distinguish between vaginal and urinary bleeding and some are unable to distinguish rectal bleeding. This may need investigating.