OG32.2 | Post-Menopausal Bleeding — Summary & Reflection

KEY TAKEAWAYS

Post-menopausal bleeding is any vaginal bleeding ≥12 months after the last menstrual period — it mandates urgent investigation because approximately 10% is due to endometrial carcinoma. The cardinal rule: PMB is endometrial carcinoma until proven otherwise. Causes include (in order of importance to exclude): endometrial carcinoma (~10–15%), followed by endometrial atrophy (~30–40%), endometrial polyp (~15–25%), HRT-related bleeding, cervical pathology, vaginal atrophy. Risk factors for endometrial carcinoma: obesity, nulliparity, diabetes, late menopause, PCOS, unopposed oestrogen/tamoxifen, Lynch syndrome. Investigation: speculum examination → TVS (endometrial thickness >4–5 mm in a woman not on HRT → sampling mandatory) → Pipelle biopsy (first-line) or hysteroscopy + directed biopsy (gold standard). MRI for preoperative staging once carcinoma is confirmed. FIGO staging is surgical: Stage IA (<50% myometrial invasion) to Stage IV (distant mets). Management: TAH+BSO+lymph node assessment for endometrial carcinoma; adjuvant RT±chemo for Stage IB, Grade 3, or Type II histology; hysteroscopic polypectomy for polyps; topical oestrogen for atrophy. A second episode of PMB requires re-investigation regardless of prior normal findings.

REFLECT

Think about the woman in the opening case — her GP's reassurance that it was 'just vaginal dryness' was a missed alarm symptom. What could have happened if she delayed presentation further? How would you explain to her, in plain language, why the investigation is urgent without causing unnecessary distress? Reflect on the 10% rule: if you see 10 women with PMB in a year, one will have endometrial carcinoma. How does this prior probability change your threshold for investigation compared to a symptom where malignancy occurs in 1 in 1,000 cases? What public health message would you give to postmenopausal women about recognising and reporting PMB early?