Postmenopausal bleeding is uterine bleeding occurring one year after menopause and has an incidence of ten per cent. Postmenopausal bleeding is abnormal and can be associated with a 10-15 per cent risk of cancer.
Bleeding can be due to many causes but should be investigated in a rapid access clinic and should be seen within two weeks.
The bleeding can be due to a number of causes this includes endometrial, cervical, vaginal, vulval, ovarian and rarely fallopian. Endometrial causes, which are the most common, include endometrial hyperplasia where the lining of the uterus is unusually thickened; this can range from simple hyperplasia to complex hyperplasia and complex hyperplasia with atypia which is associated with a high risk of endometrial cancer. In addition, endometrial cancer can cause a thickened endometrium which results in a bleed vaginally.
Endometrial polyps are a common cause of bleeding and can be associated with at least 40 per cent of bleeding. Most polyps are benign, however, some can be malignant.
Cervical causes include cervical cancer and ectropion. Vaginal causes commonly include atrophic vaginitis where the vaginal mucosa lacks oestrogen and can be subject to being easily traumatised.
Vulval causes are rare but can include malignancy.
On presentation, a thorough, gynaecological history is taken and other factors noted like BMI are taken. The vulva is inspected as well as the urethra; speculum examination is done to rule out local causes like cervical lesions and atrophic vaginitis.
A transvaginal ultrasound is done to look at the uterus and ovaries. The endometrial lining should be less than 4mm; if greater than 4mm then one will need an endometrial biopsy. The current gold standard is by outpatient hysteroscopy and a direct biopsy. If a polyp is found, then it should be removed preferably by hysteroscopic means to make sure that it is completely resected. This is because most polyps, although benign, can have a malignant component to them which could be in the stalk or the tip of the polyp, so they shouldn’t be removed blindly.
If the endometrial lining is less than 4mm, then the patient can be safely discharged but should be informed that if the bleeding persists, then they should be advised to return. On that presentation, they would have to get a hysteroscopy and biopsy. This is because rare forms of endometrial cancer can present with a thin endometrium.
If the biopsy is negative, then the patient is discharged but should be given information that if it occurs, then they should return to get investigated.
If the biopsy shows hyperplasia, if it is simple or complex, then progesterone therapy like provera or the Mirena coil are the treatments of choice with repeat hysteroscopy and biopsy done every six months until it has resolved. If it is complex with atypia, then hysterectomy is advised due to the risk of cancer.
If the biopsy is cancerous, then an MRI is done and the best management for the patient is discussed in a Multidisciplinary Meeting.
In summary, post-menopausal bleeding is significant as it can carry a risk of 10-15 per cent risk of cancer and prompt investigation and management is needed to rule this out. Patients should be seen in speciality clinics by gynaecologists with an interest in Gynaecological Oncology to streamline care to offer patients the best management options.
By Dr John Barker Bsc MBBS MRCOG, Dip (Risk Management).
Consultant Obstetrician/Gynaecologist at JRB Medical Centre, 7th Avenue Belleville.