Postmenopausal bleeding

Disease class: Metrorrhagia 

Postmenopausal bleeding is defined as vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected. It can, however, occur in younger women who have experienced premature ovarian failure or premature menopause. Postmenopausal bleeding is usually benign, however, endometrial malignancy should be ruled out with urgency.

Causes

• The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
• HRT (hormone replacement therapy) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
• Endometrial hyperplasia, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
• Endometrial cancer: Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
• Cervical cancer: It is important to obtain a full record of prior cervical screening programme attendance
• Ovarian cancer: Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
• Vaginal cancer: Uncommon but can present with postmenopausal bleeding
• Other uncommon causes include trauma, vulval cancer and bleeding disorders

Investigations

• NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer¹
• A thorough history is necessary: Enquire about timing, consistency and quantity of the bleeding, as well as a full gynaecological and obstetric history. It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause. A full drug history including HRT use should be sought. Red flag symptoms for gynaecological cancer should be enquired about¹
• A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen
• Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels
• For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required
• A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
• Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen
• Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Management

• Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
• Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
• If a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
• In the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue