Post-menopausal bleeding (PMB) is a common presentation at the Royal Women's Hospital. Endometrial cancer is present in approximately 10% of patients referred with PMB.
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The menopause is defined by the World Health Organisation as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity.
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For the purposes of this guideline, an episode of bleeding 12 months or more after the last period is accepted as PMB.
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Women on hormone therapy (HT) can also have abnormal bleeding and need to be investigated as below.
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For the purposes of this guideline, women on sequential regimens, bleeding is abnormal if it is:
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- heavy or prolonged at the end of or after the progestogen phase; or
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- if it occurs at other times (breakthrough bleeding)
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Women on continuous combined regimens - it is abnormal if it:
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- occurs after the first six months of treatment; or
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- occurs after amenorrhoea has been established
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History
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In addition to the usual clinical history, attention should be given to the use of HT and its temporal relationship to bleeding, anticoagulant use, trauma, and a family history of non-polyposis colorectal cancer.
The estimated lifetime risk of developing endometrial cancer in women with this family history is around 42% to 60%.
Also note other risk factors: diabetes; women with hypertension; a past history of hyper-estrogenism (endogenous or exogenous). Examples of the latter include women with early menarche and late menopause.
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Examination
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In addition to the usual examination, note the presence or absence of obesity, signs of lower genital tract cancer especially cervix, and possible benign causes of bleeding such as urethral caruncle, atrophy, cervical polyps, and genital trauma.
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Investigation
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In addition to other indicated investigations, the following should be done:
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1st visit
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- pipelle endometrial aspiration
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- order vaginal ultrasound for assessment of endometrial thickness
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Review visit
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Recurrence
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Patients with recurrent PMB are at an extra risk. Accepting that all investigations have a false negative rate, women with recurrent PMB should be re-investigated as above after six months. Patients with persistent PMB should be investigated earlier.
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Patients on Tamoxifen
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These patients have a three to six fold greater incidence of endometrial cancer. Accordingly, PMB in this setting needs careful assessment. Saline instillation at vaginal ultrasound should be considered if there is an appearance of endometrial thickening.
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Information for patients
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Clearly, as usual, the patients need to make an informed decision on the risks and benefits of this protocol.
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If the patient is not satisfied with this level of reassurance, further investigation is justified. This should include an endometrial biopsy to obtain a histological assessment. Refer to: PMB: Consumer information.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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Please remember to read our disclaimer.
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Further Reading
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- Gull et al. Can ultrasound replace dilatation and curettage? A longitudinal evaluationof PMB and TV USG measurement of the endometrium as predictors of endometrial cancer. 2003 Am J Obstet Gynecol 188:2 401-408
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- Downes E The predictive value of OP hysteroscopy in a menopausal ClinicBJOG 1993 100:11 48-49
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- Management of abnormal bleeding in women receiving hormone replacement therapy C P Spencer, A J Cooper, and M I Whitehead BMJ 1997; 315: 37-42
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- Consensus conference soc. of radiologists in ultrasound, Goldstein et al. J Ultrasound Med 20:1025-1036, 2001
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- Evaluation of PMB: A consensus statement. Ultrasound Quarterly 18(1):61-69, March 2002
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- Scottish Intercollegiate Guidelines Network: Investigation of Post-Menopausal Bleeding http://www.sign.ac.uk/guidelines/fulltext/61/
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