QuestionSBA
QuestionChoice
The patient is experiencing recurrent vaginal bleeding after many years of attaining menopause, which can be a sign of endometrial cancer. **NICE guidelines recommend a 2 week wait suspected cancer pathway referral for women aged 55 years and over with postmenopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause).**
62348
a
Urgent two-week wait cancer referral
QuestionChoice
This patient's cervical smear was already performed three years ago and was unremarkable, which makes the possibility of cervical cancer less likely. Therefore, repeating the cervical smear would not be an appropriate next step in management.
62349
b
Repeat cervical smear
QuestionChoice
Although HRT helps with her postmenopausal symptoms (such as hot flushes, vaginal dryness, reduced sex drive, etc.,) which she might be currently experiencing, there isn't any evidence stating that it increases the chance of endometrial cancer, or otherwise causes post-menopausal bleeding. Hence, it is not the appropriate choice.
62350
c
Stop HRT
QuestionChoice
The patient is experiencing bleeding after intercourse, which is not a typical symptom of menopause and can be a sign of a more serious underlying condition such as endometrial cancer. Delaying the referral and treatment for six months would not be appropriate and could potentially allow the condition to progress.
62352
e
Reassure and review after six months
QuestionChoice
Tranexamic acid is a medication that is used to treat heavy menstrual bleeding (menorrhagia). However, in this case, the patient is experiencing bleeding after intercourse, which is not a typical symptom of menorrhagia. Additionally, the patient is postmenopausal and has not had a period in nine years. Therefore, prescribing tranexamic acid would not be an appropriate next step in management.
62351
d
Prescribe tranexamic acid
QuestionComment
Do you still refer if the woman is under 55?
26663
User
subscriber
Ketone Dorsal
Concept
Chapter
# Summary
  
 
Postmenopausal bleeding is an important symptom that requires thorough investigation due to the potential for serious underlying pathology, such as endometrial cancer. The primary investigations include referral to gynaecology, transvaginal ultrasound, and biopsy of the endometrium. Management strategies will be determined based on the underlying cause of the bleeding. 
  
 
# Definition
  
Postmenopausal bleeding is any vaginal bleeding that occurs after a patient has not experienced periods for 12 months or more, and who are not receiving hormone therapy. If a woman is receiving hormone replacement therapy (HRT), bleeding is considered postmenopausal if it occurs more than 6 months after menstruation has stopped.
  
 
# Aetiology
  
The most common causes of postmenopausal bleeding include:

* Endometrial atrophy
* Vaginal atrophy
* Endometrial polyps
* Uterine fibroids
* Endometrial cancer. 

Other less common causes include cervical cancer, ovarian tumours and certain medications, such as hormone replacement therapy (HRT) and anticoagulants.
  
 
# Signs and symptoms
  
 
Further symptoms to postmenopausal bleeding will depend on the underlying cause, but may include pelvic pain, weight loss, and systemic symptoms of malignancy.
  
 
# Differential Diagnosis
  
 
  - **Endometrial cancer:** Often the only symptom is postmenopausal bleeding.
  - **Vaginal atrophy:** Can also cause pruritus, dyspareunia, and vaginal discharge.
  - **Cyclical combined HRT:** Causes regular vaginal bleeding. With continuous HRT, it is common to experience breakthrough bleeding in the first 6 months.
  - **Bleeding disorders:** May be suggested if there is frequent bleeding elsewhere (e.g. recurrent epistaxis) or a family history of a bleeding disorder.
  
 
# Investigations
  
All cases of postmenopausal bleeding should be referral to gynaecology under the 2-week wait pathway. 

The gynaecologist will likely consider the following investigations: 

**Bedside:**

- Bimanual and speculum examination

**No blood tests** are required for diagnosis in the first instance, though if underlying bleeding/clotting disorders are suspected a clotting screen would be indicated. 

**Imaging:**

  - Transvaginal ultrasound to look for abnormal thickening of the endometrium
  - CT CAP: performed following diagnosis of endometrial cancer, for FIGO staging 

**Special tests:**

  - Biopsy of the endometrium, obtained via hysteroscopy or pipelle

**2 Week Wait Criteria**

- All cases of postmenopausal bleeding in women aged 55 or older should be referred to gynaecology under a 2-week wait. 

- In women aged under 55, a 2-week wait referral should also be considered.

- For those not referred in the immediate instance who have a TV USS performed, refer under 2-week wait if endometrial thickness is >4mm, or if otherwise high clinical suspicion of endometrial cancer remains. 

 
# Management
  
 
The management of postmenopausal bleeding is guided by the underlying cause. This may include hormonal therapy for conditions such as endometrial atrophy, surgical interventions for polyps or cancers, or supportive care for symptoms related to vaginal atrophy. In all cases, ongoing monitoring is essential to ensure that treatment is effective and to detect any changes in the patient's condition.


# NICE Guidelines

[Click here for NICE guidelines on Gynaecological Cancers](https://cks.nice.org.uk/topics/gynaecological-cancers-recognition-referral/)

# References

[Patient Info: Postmenopausal bleeding](https://patient.info/doctor/postmenopausal-bleeding)
2613
3457
Postmenopausal bleeding
Topic
26
Gynaecology
12531
A 58-year-old woman presents to the GP complaining of bleeding after having intercourse for the past year. She has had ten episodes of mild vaginal bleeding in the past six months. She had regular periods until nine years ago and has not had bleeding in the last six years. She is currently on hormone replacement therapy (HRT). Otherwise, her past medical history is insignificant. Her cervical smear was unremarkable three years ago. A speculum examination shows a normal cervix and vagina.

What is the most appropriate next step in management?
a