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Case History

image A 54-year-old patient complains of post-menopausal bleeding (PMB) for a 'few months'. She is not on hormone replacement therapy (HRT) and her last menstrual period was over one year ago. Relevant features in her medical history are obesity and type 2 diabetes.

How do you clinically assess this patient?

Which is the most cost-effective triage for the evaluation of PMB?

Which endometrial thickness cut-off points are of significance in PMB?

When do you sample the endometrium in PMB?

How do you manage an initial negative investigation and persisting PMB?


image Post-menopausal bleeding (PMB) can be defined as (a) bleeding from the genital tract following at least six months of continuous amenorrhoea in menopausal women not on HRT or (b) breakthrough vaginal bleeding in post-menopausal women receiving HRT.

How do you clinically assess this patient?

The principal aim of investigation in PMB is to identify or exclude endometrial or cervical pathology, most notably endometrial cancer. The reported incidence of endometrial cancer in patients with PMB ranges from 9% to 12%. The probability of cancer as the underlying cause of PMB is age-dependent and increases from 9% for patients in their 50s to 60% for those in their 80s.1 Although endometrial cancer and other cancers are significant conditions to exclude in PMB, the most common causes for PMB are nonmalignant and include atrophic changes and HRT problems (Table 14.1).

Table 14.1Causes of post-menopausal bleeding

If a woman presents with PMB it is important to take a history to establish (a) if there are any risk factors associated with endometrial cancer (e.g. obesity, diabetes) and (b) if the reason for the bleeding in a woman taking HRT might be caused by poor compliance, poor gastrointestinal absorption (e.g. gastroenteritis) or drug interactions. An abdom inal and pelvic examination is mandatory in all women complaining of PMB, as vulvar or vaginal lesions, signs of trauma, and cervical polyps or other cervical abnormalities have to be excluded. This examination also gives the opportunity to take a routine cervical smear if this is appropriate.2

Which is the most cost-effective triage for the evaluation of PMB?

Transvaginal ultrasound scanning (TVS) has become the gold standard for the initial non-invasive assessment of PMB (Figure 14.1). It measures endometrial thickness and will also give information on other pelvic pathology such as fibroids and ovarian cysts. TVS-initiated triage has substantial cost savings versus biopsy-based algorithms in evaluating typical populations of post-menopausal women with abnormal vaginal bleeding.3

Figure 14.1

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