QuestionSBA
QuestionChoice
Sulfasalazine is unlikely to be contributing to her vaginal bleeding and should not be suddenly stopped in a patient with inflammatory arthritis.
49891
e
Stop sulfasalazine for a period of four weeks
QuestionChoice
If her bleeding appeared to be due to vulvovaginal atrophy, increasing her estradiol may be beneficial, but this is not the case here.
49888
b
Increase estradiol pessaries to one 10 microgram pessary daily for two weeks
QuestionChoice
Whilst Mirena coils are licenced for managing heavy menstrual bleeding, this does not appear to be menstrual bleeding here, so this would be inappropriate.
49890
d
Swap her copper coil for a Mirena coil
QuestionChoice
Whilst this woman no longer requires contraception and could have her copper coil removed, this would be unlikely to address the issue of her new postmenopausal bleeding, which requires investigation.
49889
c
Remove her copper coil
QuestionChoice
This woman has postmenopausal bleeding, which requires urgent referral to gynaecology for investigation of endometrial cancer.
49887
a
Urgent referral to gynaecology
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
10014
A 54-year-old woman presents to her general practitioner with intermittent vaginal bleeding. She describes bleeding almost every day, of varying severity. There is no associated pain. She had her last menstrual period at age 51 and does not complain of any menopausal symptoms. She has a copper coil in situ, which was inserted when she was 48.

She has a past medical history of type 2 diabetes and rheumatoid arthritis.

She takes the following medications:

- Metformin 1g twice daily
- Sulfazalazine 500mg four times a day
- Co-codamol 30/500mg as required
- Estradiol intravaginal pessary 10 micrograms twice weekly

What is the most appropriate management?
a