Postmenopausal Bleeding

Postmenopausal bleeding is any vaginal bleeding occurring 12 months or more after the last menstrual period in a woman not on hormone therapy, or unscheduled bleeding persisting beyond 6 months of starting hormone therapy. It always requires investigation to exclude endometrial cancer.

• Frequency: about 5 to 10 percent of postmenopausal women. Endometrial cancer is found in about 5 to 10 percent of women with the symptom.
• Causes:
  • Endometrial or vaginal atrophy (about 60 to 80 percent).
  • Hormone replacement therapy (cyclical regimens give expected bleeding, but continuous combined therapy bleeding after 6 months is abnormal).
  • Endometrial polyps (about 10 percent), endometrial hyperplasia (about 5 to 10 percent), endometrial cancer (about 5 to 10 percent).
  • Cervical polyps, cervical cancer, vaginal or vulval cancer, urethral caruncle, cervicitis.
  • Tamoxifen (endometrial polyps, hyperplasia and cancer), anticoagulants, ovarian tumours producing oestrogen (granulosa cell tumours), trauma, foreign body (pessary), bleeding from urinary or bowel sources mistaken for vaginal bleeding.
• Risk factors for endometrial cancer: obesity, diabetes, hypertension, nulliparity, PCOS, unopposed oestrogen, tamoxifen, Lynch syndrome, late menopause, early menarche.

• Spotting to heavy bleeding, with or without pain, discharge or dyspareunia.
• Ask about duration, amount, relation to intercourse, hormone therapy and regimen, tamoxifen, anticoagulants, weight loss, pelvic pain, change in bowel or bladder habit, cervical screening history, family history of endometrial, colon or ovarian cancer.
• Examination: BMI, abdomen and pelvic mass, vulva, speculum (atrophy, cervical lesion, polyp, source of bleeding), bimanual (uterine size, adnexal mass), rectal examination if indicated.
• Red flags: any bleeding in a woman not on hormone therapy; recurrent bleeding; tamoxifen use; thickened endometrium; obesity or diabetes; pelvic mass; weight loss; abnormal cervix; anaemia.

• Refer urgently, to be seen within 2 weeks, for assessment of possible endometrial cancer.
• Transvaginal ultrasound: endometrial thickness of 4 mm or less (about 1 percent or less chance of cancer) allows conservative management if bleeding does not recur; above 4 mm (some clinicians use above 3 mm) needs endometrial sampling.
• Endometrial sampling: outpatient pipelle biopsy (sensitivity about 90 percent for cancer), hysteroscopy with directed biopsy or dilatation and curettage for focal lesions (polyps), non-diagnostic samples, persistent bleeding, or thickened endometrium.
• Speculum and cervical assessment, with cervical screening and colposcopy for suspicious cervical lesions.
• Bloods: full blood count, ferritin, CA-125 if an adnexal mass, glucose; pelvic MRI or CT if cancer is confirmed.
• Women on tamoxifen: endometrial assessment for any bleeding; routine ultrasound surveillance is not useful.

• Atrophy (after cancer excluded): vaginal oestrogen (estradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly; or estriol 0.1 percent cream 0.5 g nightly for 2 weeks, then twice weekly); moisturisers and lubricants; review at 12 weeks.
• Hormone therapy bleeding: reassess the regimen; for continuous combined therapy bleeding beyond 6 months needs transvaginal ultrasound and endometrial sampling; switch route or dose of progestogen if the endometrium is benign.
• Polyps: hysteroscopic polypectomy with histology.
• Endometrial hyperplasia:
  • Without atypia: levonorgestrel 52 mg intrauterine system (first line, 6 to 12 months or longer) or oral medroxyprogesterone acetate 10 to 20 mg daily or norethisterone 10 to 15 mg daily for 6 months; repeat biopsy at 6 months until two consecutive negative samples, then annual surveillance when risk persists; weight loss.
  • With atypia: total hysterectomy with bilateral salpingo oophorectomy (cancer coexists in up to 40 percent); if surgery is not suitable, levonorgestrel intrauterine system with oral progestogen and close follow up.
• Endometrial cancer: surgical staging with hysterectomy and bilateral salpingo oophorectomy; adjuvant therapy by oncology.
• Cervical, vaginal or vulval cancer: oncological referral.
• Unexplained bleeding with normal investigations: observe, and re-investigate if recurrence.
• Stop drugs contributing to bleeding where possible (review anticoagulant dose with the prescriber).
• Follow up at 6 to 12 weeks after investigation; counsel to report any further bleeding immediately.