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?
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 %).
- 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
- 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.
- Without atypia: start with hormonal treatment.
- With atypia: offer hysterectomy.
- Low grade: hysterectomy/BSO
- High grade: hysterectomy/BSO + nodes +/- omentectomy
- Advanced cancer: consider non surgical treatment firs
- Educate on recurrence: vaginal bleed/ discharge
- 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.
- 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.
- 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.