A6. Postmenopausal bleeding
Postmenopausal (vaginal) bleeding (PMB) is a red flag for malignancy and a common cause of gynaecological visits. In case of vaginal bleeding beginning more than 1 year after the last menstruation, thorough evaluation should always be performed to exclude malignancy. The only exception is if they’re taking postmenopausal hormone therapy, as bleeding is expected in these cases.
Approximately 5 – 10% of postmenopausal women experience vaginal bleeding. The risk that the bleeding is caused by cancer increases with postmenopausal age.
Etiology
The most common causes of postmenopausal bleeding are:
- Atrophy of the vaginal mucosa or endometrium (most common cause)
- Endometrial hyperplasia
- Endometrial polyps
- Submucosal fibroids
- Endometrial cancer
- Cervical cancer
Endometrial cancer accounts for approx 7% of cases.
Diagnosis and evaluation
As already stated, histological examination is obligatory, but evaluation begins with history and physical examination as always.
Important questions to ask include how long the bleeding as occurred, whether there are other symptoms, which medications are taken, family history of cancer, risk factors for endometrial cancer (obesity, diabetes).
Physical examination should be performed to exclude whether the bleeding is coming from someplace else, like the vagina, vulva, exocervix, anus, etc.
Obligatory investigations include:
- Transvaginal ultrasound
- Pap smear
- Endometrial biopsy (blind)
Transvaginal ultrasound can be used to exclude polyps or fibroids, and to evaluate the thickness of the endometrium. If the endometrium is very thin (≤4 mm), endometrial cancer is highly unlikely (important value). Pap smear should be performed to exclude cervical cancer.
If these investigations can’t exclude cancer, biopsy and histological examination by dilation & curettage or hysteroscopy is necessary.
If all investigations are negative but the bleeding is still persistent, cancer is still likely and so further investigations must be performed.