QuestionSBA
QuestionChoice
This might be useful later down the line as a staging scan for malignancy
32004
b
Computed tomography (CT) scan of the pelvis
QuestionChoice
CA-125 is commonly elevated in cases of ovarian cancer and is a useful screening test for ovarian malignancy. This woman is not presenting with symptoms of ovarian cancer (e.g. abdominal fullness, urinary frequency/urgency and changes in bowel habit) therefore this would not be an appropriate first-line test
32007
e
CA-125
QuestionChoice
This is a screening test for cervical cancer, and would not be first-line in a postmenopausal patient with red flag features for malignancy. However it would be useful to note in the history if the patient's smear tests are up to date and if she has had any treatment to the cervix
32005
c
Cervical smear testing
QuestionChoice
This is a diagnostic investigation for cervical cancer, which is typically found in younger females with a high-risk sexual history. Colposcopy would be indicated if a cervical abnormality was seen, or if infection with human papilloma virus (HPV) was found on a routine cervical smear
32006
d
Colposcopy
QuestionChoice
Postmenopausal bleeding raises a high suspicion for endometrial cancer. An urgent transvaginal ultrasound is the most useful first-line test to determine endometrial thickness and assess for any uterine abnormality (e.g. fibroids). The ultrasound result would determine the need for further investigation such as endometrial biopsy, blood tests, hysteroscopy or further pelvic imaging
32003
a
Transvaginal ultrasound
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
6401
Postmenopausal bleeding necessitates urgent investigation, with transvaginal ultrasound being the first-line test to assess for endometrial abnormalities.
A 65 year old woman comes into A&E with a 2 week history of bloody spotting on her underwear. She is surprised to find this as she went through menopause 15 years ago. She has been married to her husband of 25 years and has no children. Past medical history includes type 2 diabetes and obesity.

What is the next best investigation?
a