Post Menopausal Bleeding

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Post Menopausal Bleeding
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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.

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• Main aim in primary care is to identify cause and
  exclude cancer
• Start with detailed hx
• - identify risk factors
• - drug hx HRT, tamoxifen, anticoagulants.

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• Examination- abdominal for masses.
• PV- bimanual palpation to assess size, bulkiness
  uterus
• Speculum- to identify source- cervical malignancy
  or polyps, vaginal wall.

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• 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.

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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

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• Endogenous oestrogen excess
• obesity
• early menarche lt12, late menopause gt50
• 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

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• 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 lt4mm chance of cancer is 0.8. SIGN
  guidelines recommend a thickness of lt3mm can be
  used to exclude, locally guidelines are 4mm.

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• 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.

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• 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.

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• Endometrial cancer treatment
• Stage 1 TAH BSO
• Stage 2 lymph node dissection, adjuvant chemo,
  radio.

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Summary

• All women should be referred URGENTLY as
  endometrial cancer is present in approx 10
  cases.
• Normal TVUSS with endometrial thickness lt4mm,
  with normal examination does not require further
  Ix providing bleeding has STOPPED.