Postmenopausal bleeding occurs in up to 10% of women over 55 years old, with the majority having a benign cause. All women experiencing postmenopausal bleeding should be urgently referred to evaluate for endometrial cancer, which is present in approximately 10% of cases. Evaluation involves transvaginal ultrasound to measure endometrial thickness, examination, and endometrial biopsy if thickness is over 4mm or examination is abnormal. Endometrial cancer risk factors include increased age, obesity, nulliparity, hormone therapy use, and family history. Treatment depends on cancer stage, ranging from surgery for stage 1 cancer to chemotherapy and radiation for stage 2 or higher.
2. PMB
• Definition:
– An episode of bleeding 12 months or more after the
LMP.
• Common problem.
- Occurs in up to 10% women over 55yrs.
- Majority (about 90%) have a benign cause.
- No evidence of association with pattern of bleeding and
malignancy eg: one off bleed vs regular bleeding.
3. • Main aim in primary care is to identify cause and
exclude cancer:
• Start with detailed hx:
- identify risk factors
- drug hx HRT, tamoxifen, anticoagulants.
4. • Examination- abdominal for masses.
• PV- bimanual palpation to assess size, bulkiness
uterus
• Speculum- to identify source- cervical malignancy
or polyps, vaginal wall.
5. Causes PMB
• Endometrial carcinoma
• Cervical carcinoma
• Vaginal atrophy: decreased oestrogen leads to
thinning of vaginal skin, thin pale vagina may bleed
on contact
• Endometrial hyperplasia +/- polyp covers a wide
range of changes in the endometrium, atypical
hyperplasia is premalignant
• Cervical polyps: common in perimenopausal women,
benign, pink protrusions from os.
• Hormone producing ovarian tumours- rare, produce
oestrogen which causes hyperplasia.
6. Risk Factors for endometrial ca:
• Age
– peak incidence 65-75 yrs
– 93% diagnosed aged 50yrs and over
• PMH
– endometrial hyperplasia or polyps
– breast or ovarian ca
– DM
7. • Endogenous oestrogen excess
– obesity
– early menarche <12, late menopause >50
– nulliparity- pregnancy reduces risk by 30% after
1st birth and 25% after each subsequent
– PCOS
• Drug hx of exogenous oestrogen excess
– Unopposed oestrogen HRT
– Tamoxifen
• FH of HNPCC- patients have an 80% lifetime
risk of developing endometrial ca
8. Making a Diagnosis:
• All women with PMB should be referred under 2ww.
• USS: TVUS is investigation of choice- can look at
endometrial thickness, structural abnormalities,
polyps, fibroids, exclude ovarian malignancy.
• Measuring endometrial thickness aims to identify
those who are more likely to have underlying cancer
<4mm chance of cancer is 0.8%. SIGN guidelines
recommend a thickness of <3mm can be used to
exclude, locally guidelines are 4mm.
9. Investigations
• endometrial biopsy- effective screening for
endometrial cancer. Blind sampling will miss
some cancers.
• Hysteroscopy is the gold standard- allows direct
visualisation of uterine cavity, assessment of
structural abmormalities, directed biopsy of
specific lesions. Indicated when sampling cannot
be performed due to cervical stenosis or when
bleeding persists after negative biopsy.
• One-stop gynae clinics.
10. Management of PMB
• Vaginal atrophy: oestrogen daily for 2 weeks,
then once- twice weekly for maintenance.
• Polyps- removed as OP
• Endometrial hyperplasia- treated with IUS or
progest
• Endometrial hyperplasia with atypia- should
be treated as cancer.
12. Summary
• All women should be referred URGENTLY as
endometrial cancer is present in approx 10%
cases.
• Normal TVUSS with endometrial thickness
<4mm, with normal examination does not
require further Ix providing bleeding has
STOPPED.
