Background
"The occurrence of vaginal bleeding following a woman's last menstrual cycle"
The average age of menopause is 51
10% of Post Menopausal Bleeds are caused by Endometrial Cancer
From the HSE/RCPI Guideline on The Investigation of Post Menopausal Bleeding:
- an episode of bleeding ≥12 months after the last period is accepted as postmenopausal
- For women on tibolone or continuous combined HRT 6 months is accepted as post menopausal
- *The HSE guideline focuses on the detection of endometrial cancer (the most serious potential underlying cause of PMB). It must be remembered, however, that PMB may also be the presenting symptom of cervical or vulval cancer
Causes/Cancer Risk factors
Causes of PMB
- Atrophic vaginitis (Menopause-related thinning of the lining of the vagina):
- Usually presents with spotting
- Polyps (from the lining of the uterus or cervix)
- Use of HRT
- Endometrial hyperplasia (10% will be cancer)
- Endometrial Cancer (presents as PMB or a change in Menstrual Bleeding)
- Cervical Cancer (presents as Intermenstrual Bleeding or Post Coital Bleeding)
- Vulval cancer
Risks for Endometrial Cancer
- Older HRT regimens that utilise unopposed oestrogen
- Obese with Diabetes
- Hypertension
- On Tamoxifen
- Hx hyper-oestrogenism (early menarche / late menopause)
- Hereditary non-polyposis colorectal cancer (HNPCC) is one of the commonest inherited cancer syndromes (Lynch Syndrome)
Initial approach
- FBC, Clotting
- TFTs if otherwise symptomatic
- Abdominal exam as a basic level
Management
- If clinically well, discharge with an internal letter for the Rapid Access Post Menopausal Bleeding Clinic in 2-3 weeks (and a letter for the GP)
- ALL (even recurrences) need to be referred to the Rapid Access Post Menopausal Bleeding Clinic
- If anaemic or otherwise clinically unwell, admit under O&G (no further imaging should be required which delays admission but if something is easily arranged which will improve the patient journey/patient safety then it should be arranged)