Postmenopausal Bleeding Flashcards
What is postmenopausal bleeding?
Postmenopausal bleeding is defined as vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected.
Give differentials for postmenopausal bleeding
- Vaginal atrophy
- HRT
- Endometrial hyperplasia
- Endometrial cancer
- Cervical cancer
- Ovarian cancer
- Vaginal cancer
- Trauma
- Vulval cancer
- Bleeding disorders
What is the most common cause of postmenopausal bleeding?
The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding.
What is the most important differential to exclude in postmenopausal bleeding?
Endometrial cancer.
What are the NICE guidelines surrounding postmenopausal bleeding?
NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer.
What should be asked in the history for postmenopausal bleeding?
- Timing?
- Consistency and quantity of the bleeding
- Full gynaecological and obstetric history
- Risk factors
- Especially for endometrial cancer
- Establish a menstrual timeline from menarche to menopause
- Full drug history including HRT
What may be found on abdominal and vaginal examination in postmenopausal bleeding?
Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen.
What immediate testing can investigate postmenopausal bleeding?
Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels.
When referred via the two week wait pathway for postmenopausal bleeding, what is the investigation of choice?
A transvaginal ultrasound is the investigation of choice.
What is the acceptable endometrial lining thickness for post-menopausal women?
The transvaginal ultrasoun assesses the endometrial lining thickness. For post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required.
How is endometrial cancer diagnosed?
A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy. This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy.
