Management of Post Menopausal bleeding Dr Matt Hewitt

PMB • 1 year after cessation of periods • 10 -15% chance of endometrial cancer • 90% or endometrial cancers present with PMB • Requires immediate assessment • If referred should be classified as urgent • (Persistent vaginal discharge)

Causes of PMB • • • Atrophic vaginitis Endometrial/cervical polyps Endometrial cancer Cervical cancer Vulval/Vaginal cancer Endometrial hyperplasia Vulval sin disorders Prolapse Ovarian/fallopian Ca • Anal rectal tumours • Bladder pathology

Endometrial cancer Risk factors • Obesity • Unopposed oestrogen • Polycystic ovarian disease • Nulliparity • ↑ age Prognosis • Presents early • Curative treatment likely

Endometrial cancer • • • PMB <50 years 1% risk PMB >80 years 25% risk Obesity 18% risk Diabetics 21% risk Obesity and diabetic 29% risk

Ultrasound scan • • • Transvaginal if possible Endometrial thickness <4 mm or <5 mm Irregular endometrium Fluid within cavity Inability to see endometrium

US of the endometrium

U/S and endometrial cancer • Sensitivity of 96% • Specificity 39%- 50% • Possible increase sensitivity with endometrial sampling

PMB or Persistent vaginal discharge Examination Normal Abnormal U/S scan Endometrial thickness <5 mm Endometrial thickness >5 mm Bleeding persists Refer No Yes Consider referral D and C Obese/elderly Hysteroscopy Polyp Atrophy Other Remove Consider Vagifem Rx Refer appropriately D and C Hysteroscopy If bleeding persists despite normal scan refer If bleeding persists after hospital investigation re -refer

Tamoxifen • Increased risk of endometrial cancer 3 to 6 fold • No evidence for routine screening • Therefore PMB and Tamoxifen requires referral

Thickened endometrium in asymptomatic women • No trial has yet been done • Data from UKCTOCS • 5 mm endometrial thickness sensitivity 77% specificity 85% • Indicates possibility of value of screening • Refer!

PMB and HRT requires investigation when Sequential regimens • If heavy or prolonged after end of progesterone phase • Break-through bleeding Continued combined regimes • Bleeding after first 6 months of commencement of treatment • After amenorrhoea has been established

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