🩺 Post-menopausal PV Bleeding

Post-menopausal bleeding (PMB) is defined as vaginal bleeding occurring at least 12 months after the cessation of menstruation in women not on HRT, or unexpected bleeding in those on HRT. It is a high-priority clinical presentation in the UK, as it is the hallmark symptom of endometrial cancer. All women presenting with PMB should be referred via an urgent 2-week wait pathway for specialist assessment and imaging.

Clarify the nature of the bleeding (spotting vs. heavy flow) and any associated symptoms like pelvic pain or discharge. Confirm the time since the last menstrual period (menopause is defined as >12 months of amenorrhoea). Take a detailed gynaecological history, including parity, smear history, and use of Hormone Replacement Therapy (HRT) or Tamoxifen. Identify risk factors for endometrial cancer, such as Lynch syndrome, nulliparity, or polycystic ovary syndrome (PCOS). Ask about systemic symptoms like weight loss or bowel habit changes.

Perform a thorough general examination, noting BMI as obesity is a significant risk factor. A speculum examination is essential to visualise the cervix and vaginal walls to exclude local causes such as cervical polyps, cervicitis, or atrophic vaginitis (characterised by thin, pale, friable mucosa). A bimanual examination should be performed to assess uterine size, contour, and the presence of any adnexal masses. Rectal examination may be necessary if there is uncertainty about the source of bleeding.

The most common cause is atrophic vaginitis or endometrial atrophy. Other causes include endometrial polyps, cervical polyps, and endometrial hyperplasia (with or without atypia). Endometrial carcinoma is the most serious concern, found in approximately 10% of PMB cases. Rare differentials include cervical cancer, vaginal cancer, or oestrogen-secreting ovarian tumours (e.g., granulosa cell tumours). Always exclude non-gynaecological causes like haematuria or rectal bleeding.

Any post-menopausal bleeding; heavy or persistent bleeding; associated pelvic mass; unexplained weight loss; bleeding in women taking Tamoxifen.

Transvaginal ultrasound (TVUS) is the first-line investigation to measure endometrial thickness (ET); a threshold of <4mm has a high negative predictive value for cancer. If the ET is ≥4mm, or if there are clinical concerns/recurrent bleeding, an endometrial biopsy (e.g., Pipelle) is required. Hysteroscopy with directed biopsy or Dilatation and Curettage (D&C) is the gold standard for definitive diagnosis, particularly if Pipelle sampling is unsuccessful or inconclusive. Cervical smears are not a diagnostic tool for PMB but should be up to date.

In the UK, PMB is considered endometrial cancer until proven otherwise, even though atrophic vaginitis is the most common cause. Obesity is a major risk factor for endometrial cancer due to peripheral conversion of androgens to oestrogens. If a patient is on HRT, PMB still requires investigation, though it is often related to the regimen. Tamoxifen use increases the risk of endometrial hyperplasia and carcinoma; these patients require high vigilance if they present with spotting.

Aligned with the Gynaecology and Oncology sections of the MLA. Requires knowledge of the 2-week wait (2WW) criteria for suspected gynaecological cancers. Students must understand the diagnostic pathway from TVUS to hysteroscopy. Managing patient anxiety during the "cancer wait" is a core communication skill.