QuizMe 1

Postmenopausal bleeding (PMB)

A 63 year old female patient presented with vaginal bleeding for the last 4 months. Her last period was at the age of 53. She is not currently taking any hormonal replacement. Her medical history included diabetes type 2 and chronic hypertension for which she is on medication.Her BMI is 27. What is the diagnosis and what is the best next step in management?

  • Postmenopausal bleed 

  • History of metabolic syndrome  (RR 1.89)

  • Overweight BMI 25-30 (RR 1.32)

A physical examination is recommended within 2 weeks due to the high risk of endometrial cancer (5-10 %).

Primary evaluation

  • History& clinical examination
  • Transvaginal ultrasound with evaluation of endometrial lining thickness
  • Endometrial biopsy

 

If cancer confirmed:

    • MRI may be necessary to assess myometrial invasion 
    • High grade cancer or muscle involvement on MRI then CT chest,abdomen & pelvis  
    • No evidence for clinical usefulness of CA-125

 

Benign:

    • Local oestrogen treatment in women suffering from vaginal atrophy.
    • Adjust or discontinue HRT when bleeding is related to HRT.
    • Treatment is otherwise dependent on findings during the diagnostic evaluation. 

Hyperplasia: 

  • Without atypia: start with hormonal treatment.
  • With atypia: offer hysterectomy. 

Cancer:

    • Low grade: hysterectomy/BSO
    • High grade: hysterectomy/BSO + nodes +/- omentectomy
    • Advanced cancer: consider non surgical treatment firs
  •  

Benign:

  • Educate on recurrence: vaginal bleed/ discharge

Cancer:

  • combination of patient education (red flag symptoms)  and clinical evaluation (visual inspection of vagina to detect vault disease)
  • Frequency: depends on stratification of patients according recurrence, side effects and local factors  
  • Routine Imaging is unnecessary 

Postmenopausal bleeding is a common problem, although the focus of investigation of postmenopausal bleeding is on the endometrium, bleeding in the postmenopausal woman may arise from a number of extrauterine gynaecological and non gynaecological sites, such as the cervix, vagina, and urologic and gastrointestinal tracts. As a result, it is important to consider all these possibilities when evaluating a patient with postmenopausal bleeding or apparent unscheduled (“breakthrough”) bleeding who is receiving HRT. 

  1. Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, et al. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up. Int J Gynecol Cancer. 2016;26(1):2–30. 
  2. Sundar S, Balega J, Crosbie E, Drake A, Edmondson R, Fotopoulou C, et al. BGCS uterine cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol. 2017;213(August 2014):71–97.
  3. https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg_67_endometrial_hyperplasia.pdf
Authors

Dr Aya Al-Shati   & Dr. Zeinab Obeid

Reviewer

Mr Moiad Alazzam