Post Menopausal Bleeding
🌸 Postmenopausal Bleeding (PMB) = any vaginal bleeding occurring >12 months after the last menstrual period.
⚠️ Always considered cancer until proven otherwise and warrants urgent investigation.
Most causes are benign, but ~10% are due to endometrial cancer.
📖 About
- Any vaginal bleeding >6–12 months after menopause
- May present as pink spotting, brown discharge, or frank bleeding
- Affects ~20% of postmenopausal women
⚠️ Causes of PMB
- 🧬 Endometrial cancer – present in ~10% of cases, bleeding is usually the first sign
- 🎗️ Cervical cancer – rare but important to exclude
- 🌸 Endometrial atrophy – thinning of the lining due to low oestrogen
- 🌿 Atrophic vaginitis – inflammation and fragility of vaginal mucosa
- 🟣 Endometrial hyperplasia – excess oestrogen stimulation, may progress to carcinoma
- 🔴 Cervical / endometrial polyps – usually benign but may cause spotting
- 💊 Hormone replacement therapy (HRT) – may cause irregular light bleeding
🩺 History to Ask
- 💊 HRT use (type, duration)
- 🩹 Associated symptoms – cramps, pelvic or back pain
- ❤️ Dyspareunia (pain with intercourse)
- ⚖️ Weight loss/gain, fatigue, night sweats
- 🚻 Changes in bowel/bladder habits
- 🌡️ Fever, chills → possible infection
🔬 Investigations
- 🧪 Bloods: FBC, U&E, CRP, TFTs, coagulation screen
- 🧫 Cervical smear (if due)
- 🖥️ Transvaginal ultrasound (TVUS): Endometrial thickness >4 mm is concerning
- 🔎 Endometrial biopsy (outpatient Pipelle or hysteroscopy-guided)
- 📹 Hysteroscopy ± dilation & curettage for persistent bleeding or inconclusive biopsy
💊 Management
- 📌 Urgent 2-week referral to a dedicated PMB clinic (rule out malignancy)
- 🔹 Treat underlying cause (atrophy, polyps, hyperplasia, infection, malignancy)
- 🔪 Dilation & Curettage (D&C): Used diagnostically/therapeutically in selected cases
- 🩸 Tranexamic acid for heavy bleeding if no contraindications
- 🚫 Avoid tampons (use pads) → reduce trauma/infection risk
- ⚠️ Avoid unnecessary anticoagulant/aspirin use if possible
📚 Teaching Pearls
- 🚨 Postmenopausal bleeding is cancer until proven otherwise
- 🖥️ TVUS endometrial thickness cutoff: 4 mm
- 🌸 Atrophy is the most common benign cause
- 🧬 Endometrial hyperplasia is a precursor to carcinoma
