Authors: William Wilson / Editor: Frances Balmer / Codes: ObC13, SLO1, SLO2, SLO3Published: 12/09/2023

 

Context

As an emergency physician, Post-Menopausal Bleeding (PMB) may not be a mainstream presentation however in the UK, PMB is a common presentation to primary care physicians1,2 and is the most common reason for referral to gynaecological rapid access clinics3.

Data from across the world shows that PMB accounts for approximately 5% of outpatient gynaecology visits4 and an estimated 4-11 % of postmenopausal women suffer from PMB5,6,7. It has been found that the incidence of PMB decreases with age with the likelihood of bleeding reducing with age7.

The primary care consultation rates according to age were as follows1

Age group Consultation rates
50-59

8.3/1000 women

60-69

4.7/1000 women

>70

2.2/1000 women

One of the main reasons PMB needs to be managed with swiftly and efficiently is that PMB can be an early symptom of cancer, particularly gynaecological but even haematological cancers. According to the Cancer Research UK data, in women, uterine cancer is the fourth most common cancer with close to 9700 new diagnoses and 2400 deaths every year8. Clarke et al in their systematic review and meta-analysis including 129 studies reported that the risk of endometrial cancer among women with PMB was 9%9.

A concerning fact found from primary care data analysis was that only 40% of patients presenting to primary care with PMB were referred for specialist care and the proportion of women referred decreased in women over 75, although the risk of cancer was higher in this age group2.

Learning Bite

PMB although not uncommon needs adequate attention to rule out sinister pathologies.

 

Definition

Any bleeding that occurs over one year after the last menstrual period is defined as PMB.

Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. In Western countries, it occurs at a median age of 51.4 years10.

The transition between menopause and reproductive years, commonly known as perimenopause, usually starts approximately four years ago and is often marked by irregular periods, hormone imbalances, and clinical symptoms such as insomnia, vaginal dryness, and hot flushes11,12. Apart from physiological menopause, the other types include:

  • Drug-induced menopause – or medical menopause is due to medications that suppress ovarian function such as
  • Surgical menopause – removal of ovaries in a patient who has not reached natural menopause.

Learning Bite

NICE guidelines advise that women with PMB should be urgently referred for a specialist opinion to exclude malignancy13.

Physiology of Menopause

Menopause is characterized by a marked reduction of the production of estrogens and progesterone and to some extent androgens (testosterone, dehydroepiandrosterone sulfate, and androstenedione)14.

The reproductive organs undergo progressive atrophy due to reduced estrogen and progesterone levels. The endometrium also undergoes atrophy due to the absence of cyclical hormonal stimulation15. Off late due to the use of exogenous hormonal therapy, modification of endometrium occurs, and further proliferation may occur resulting in PMB16.

Risk factors for Menopause related diseases include17:

  • Early menopause.
  • Surgical menopause or radiation.
  • Chemotherapy especially alkalytic agents.
  • Smoking, caffeine, alcohol.
  • Family history of menopausal diseases (genetic).
  • Drugs related such as GnRH, heparin, corticosteroids, and clomiphene (antioestrogen) when given over a prolonged period (over 6 months) can lead to oestrogen deficiency.
  • Diabetes.

Aetiology

The various etiologies based on their anatomic locations include17:

  Location Cause
1 Vulva trauma, vulvitis, benign and malignant lesions.
2 Vagina foreign body such as ring pessary for pro­lapse, senile vaginitis, vaginal tumour (benign as well as malignant) and post-radiation vaginitis.
3 Cervix cervical erosion, cervicitis, polyp, decubitus ulcer in prolapse, and cervical malignancy.
4 Uterus senile endometritis, tubercular endometritis, endometrial hyperplasia (10%), polyp, endometrial car­cinoma and sarcoma, and mixed mesodermal tumour.
5 Fallopian tube

Fallopian tube malignancy

6 Ovary benign ovarian tumour such as Brenner tumour, granulosa and theca cell tumour and malig­nant ovarian tumour.
7 Urinary tract urethral caruncle, papilloma, and car­cinoma of the bladder may be mistaken for genital tract bleeding.
8 Bowel bleeding from haemorrhoids, anal fissures and rectal cancer may be misleading.

Other causes include:

Drugs – exogenous estrogen, tamoxifen, anticoagulants, and non-prescription medications such as herbals/phytoestrogens.

Learning Bite

  • PMB can have a wide range of structural and non-structural causes.
  • A structured approach is required to make a good clinical assessment.

History

History of vaginal bleeding Duration and frequency Volume- number of pads changed, presence of clots. Precipitating factors – intercourse, trauma, also consider intimate partner violence
Associated symptoms Symptoms of bowel bladder function Symptoms of infection e.g. fever, dysuria, malodorous/ abnormal discharge, abdomen / pelvic pain Symptoms of anaemia e.g. dyspnoea, fatigue
Gynaecological History Age of menarche Date of last menstrual period History of gynaecological procedures, surgeries Smear test and results
Other Does the patient take any medications (e.g., hormone replacement therapy, anticoagulants), or herbal or dietary supplements? History of diabetes mellitus, obesity, hypertension Is there a family history of breast, colon, and endometrial cancer

Examination

Unstable Patient

PMB rarely presents as catastrophic hemorrhage19, however, if it does follow the ABCDE approach.

Emphasis on Circulation is required with Pulse and Blood pressure recordings.

Always be attentive to unexplained tachycardia, as the blood pressure may not drop initially20.

Stable patient

Complete primary survey

Abdomen examination – look for abdomen mass or tenderness or signs of peritonism20.

Pelvic examination- Let’s face it, this is not something a lot of ED physicians are comfortable with however it provides invaluable information21.

Vaginal examination will help provide clues about trauma, foreign body, mass, discharge, or cervical motion tenderness20.

Read more about vaginal specula in the ED, in the very informative blog right here21.

Learning Bite

A structured history and examination will help rule out emergent diagnoses in the ED.

General investigations

The clinical profile of the patient will help define the initial investigations in the ED.

ED investigations in Hemodynamically STABLE patients 20,22,23 ED investigations in Hemodynamically UNSTABLE patients18,20
Full blood count including smear Full blood Count
Systemic profile – Liver/Renal/Thyroid function tests Venous blood gas
Coagulation profile Coagulation profile
STI workup Blood group and save
  Renal profile

Specific gynaecology investigations

Transvaginal ultrasound (TVUS)

TVUS is used in the initial evaluation of PMB24.  Endometrial lining in TVUS is identified as a uniformly sonolucent double layer and its thickness is of great significance.

Studies have suggested that endometrial thickness less than 4mm has a 99% negative predictive value for endometrial cancer in patients with PMB24. However, data exists for different endometrial thicknesses as well with 3mm and 5mm used25,26.

Other anatomical abnormalities can also be well demonstrated using TVUS.

Hysteroscopy and biopsy

Hysteroscopy followed by biopsy is becoming the most preferred mode of investigation of PMB to rule out malignancy27.

It is considered to be superior to blind endometrial biopsy and Dilation and curettage28,29.

Diagnostic hysteroscopy with Endometrial biopsy is recommended in any of the following conditions14:

  • Persistent vaginal bleeding
  • Focal or structural pathology
  • Endometrium is not visualized clearly on TVUS.

Learning Bite

Most stable patients do not require a heavy battery of investigations in the ED. Choose your patients well.

PMB in unstable patients

The management of a patient with PMB of an unstable patient will follow the same principles of management of catastrophic hemorrhage20.

A primary survey following the ABCDE approach is required as always20.

Setting up of two large bore IV cannulas with blood investigations including FBC, group, and save and activating local Massive Transfusion Protocol.

An urgent ED gynaecology review is required20,22,23.

PMB in stable patients

In the event the patient is clinically stable and not anaemic can be treated by following local trust guidelines.

This can be a referral to outpatient gynaecology clinics or rapid-access gynaecology services30.

The gynaecology clinics usually involve setting up a TVUS and hysteroscopy and biopsy under a two-week wait pathway13.

Treatment algorithm for PMB in a stable patient14

 

Disposition

Most patients with PMB can be discharged with appropriate gynaecology referrals13. Patients with anaemia or hemodynamic instability will require admission for further treatment20.

Learning Bite

In the ED, seek advice from your seniors or gynaecology colleagues as to what the best pathway for the patient would be to reduce the chances of loss of follow-up.

  • PMB is not a classic ED-OBGYN presentation and hence our knowledge about it may be lacking. Correct this now.!
  • PMB in the community still represents a significant presenting complaint to the GPs.
  • The aetiology of PMB can be quite broad ranging from foreign bodies to polyps to malignancy and hence requires a structured history, examination, and appropriate use of investigations.
  • It is vital to assess each case of PMB systematically and thoroughly as it may represent an early presentation of underlying malignancy.
  • PMB usually does not present with catastrophic haemorrhage, however, ALWAYS primary survey for the win.
  • Urgent referrals to the gynaecology team may not be always appropriate. Refer to local guidelines in stable patients for disposition.
  1. Scottish Intercollegiate Guidelines Network. Investigation of Postmenopausal Bleeding. Guideline 61. Supplementary Material. Accessed on October 24th 2022.
  2. Parker C, Hippisley-Cox J, Coupland C, Vinogradova Y. Rectal and postmenopausal bleeding consultation and referral of patients with and without severe mental health problems. / Br J Gen Pract 2007;57:371–6.
  3. Otify M, Fuller J, Ross J, Shaikh H, Johns J. Endometrial pathology in the postmenopausal woman–an evidence based approach to management. The Obstetrician & Gynaecologist. 2015 Jan;17(1):29-38.
  4. Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol 2004; 24:736.
  5. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33.