If you bleed after the menopause it is referred to as PMB or (Post Menopausal Bleeding).
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What is PMB?
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Post-Menopausal Bleeding PMB is vaginal bleeding that starts at least 12 months after your last period
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Why does it need investigation?
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Post-menopausal vaginal bleeding must always be investigated. In most 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.
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What causes PMB?
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In 90% of cases the examination won’t reveal any cause, or the condition causing the bleeding will not be serious.
The two most common caused are:
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- Atrophic vaginitis - which is when the lining of the vagina is inflamed due to the lower levels of the circulating hormone oestrogen
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- Cervical and endometrial polyps
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In around 10% of cases, PMB will be associated with endometrial (uterine) or cervical cancer. Which are very serious conditions.
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How is PMB investigated?
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There are a range of different techniques that health care professionals might use to investigate PMB.
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Transvaginal ultrasonography (TVUS)
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This test uses ultrasound to look closely at organs in the pelvis.
Ultrasound examinations use high frequency sound waves to look inside the body. The sound waves are so high the human ear cannot hear them. The sound waves are directed at the internal body part from a small, vibrating crystal in a hand-held scanner (called a tranducer). The scanner reflects the sound or 'echoes' to create an image. An ultrasound scan doesn't produce high quality images, but it is non-invasive and doesn't involve radiation. It is commonly used to study the abdominal organs, pelvic organs and breast tissue
Depending on the view of your pelvic organs, the ultrasonographer may position the transducer on the skin of the abdomen to look through your abdominal wall (transabdominal ultrasound) or through your vagina (transvaginal ultrasound). With the transvaginal technique, the transducer is inserted directly into the vagina. It is therefore closer to pelvic structures and provides a better image quality. Ultrasound of the pelvic organs is useful for finding cysts on your ovaries, examining the lining of your uterus, and looking for cancers or benign tumours in the pelvic region.
In the investigation of PMB the ultrasound measures the thickness of the lining of the womb. This can show whether there is a likelihood of underlying cancer.
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A Pipelle test
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A Pipelle test samples the cells that line the uterus (womb) and can usually be done during the routine gynaecology examination. When this is possible a diagnosis will be made in about three quarters of all cases. Combined with a TVUS, a diagnosis will be made about 90 percent of the time.
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Out-patient hysteroscopy
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In 10% of cases the combination of a Pipelle test together with a TVUS will not provide an answer. In these cases a hysteroscopy can be done as an outpatient appointment. Hysteroscopy uses a thin telescope that is inserted through the cervix into the uterus. Modern hysteroscopes are so thin that they can fit through the cervix with minimal discomfort so there is no need for anaesthetic. They are fitted with small video cameras to allow the operator to visualise the inside of the uterus.
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Biopsy
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Involves removing a small sample of the womb lining for pathological analysis.
This is relatively painless and can usually be carried out at the same time as hysteroscopy.
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Dilation and Curette (D&C)
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Sometimes a diagnosis cannot be made after these investigations and a hysteroscopy, dilatation and curettage (D&C) of the uterus under general anaesthesia will be recommended.
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How to prepare for the test?
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No preparation is necessary in most cases. If you are having a transvaginal ultrasound, you will need to remove a tampon if you have one in place. If you are to have a transabdominal scan you will be asked to fill your bladder by drinking a few glasses of water before the test. You may continue taking all of your medications as prescribed by your health care provider. The test can be done even if there is some vaginal bleeding. If you are using a sequential HRT regimen, you may be asked to attend during the first half of your menstrual cycle.
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How is the test performed?
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You will lie on your back on a couch for the test. For transvaginal ultrasound, the probe used for internal scans is small and shaped to fit easily and painlessly into your vagina. The probe will be covered with a condom and some lubricating jelly. When the sensor is in place, a picture will appear on a TV screen, and the ultrasonographer will move the sensor in your vagina to see the uterus and ovaries from many different views. The test takes around 15 minutes to perform and will feel similar to an internal examination.
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What are the risks involved with the test?
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Studies have shown ultrasound is not hazardous and there are no harmful side effects. In addition, ultrasound does not use ionising radiation, as X-ray tests do.
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How long is it before the result of the test is known?
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Your doctor will try to schedule your ultrasound the same day as your review consultation so that the result of the ultrasound and the Pipelle test will be known. A plan for any further management will be discussed with you at this time.
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What next?
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In most cases, there may be no further visits or management. A vaginal cream containing estrogen may be recommended if the diagnosis is PMB due to thinning of the genital tissues. As mentioned above, hysteroscopy in the outpatients, or dilatation and curettage under general anaesthesia at a later time may be recommended.
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Further information
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OBGYN.net For Women
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Web: http://www.obgyn.net/women/women.asp
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Women’s Health Concern (WHC)
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Web: http://www.womens-health-concern.org/
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See related fact sheets:
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Disclaimer
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The Royal Women’s Hospital does not accept any liability to any person for the information or advice (or use of such information or advice) which is provided in this fact sheet or incorporated into it by reference.
We provide this information on the understanding that all persons accessing it take responsibility for assessing its relevance and accuracy.
Women are encouraged to discuss their health needs with a health practitioner. If you have concerns about your health, you should seek advice from your health care provider or if you require urgent care you should go to the nearest Emergency Dept.
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Published Dec 2007
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