Postmenopausal bleeding is bleeding or spotting following menopause (i.e. confirmed 12 months after your last period).

• Thinning, including:
  • Vaginal atrophy (70%) → inflammation/thinning of the vaginal lining
  • Vulval atrophy
  • Endometrial atrophy → thinning of the uterine lining
• Endometriosis → womb tissue grows somewhere else
• Growth, including:
  • Cervical polyps → growths in the cervix which is not cancerous
  • Uterine polyps, endometrial polypps → growths in the uterus which is not cancerous
  • Uterine fibroid → growth in the uterus which is not cancerous
  • Endometrial hyperplasia (10%) → thickened endometrium, often because of HRT (hormone replacement therapy)
  • Cancers, including:
    • Endometrial cancer (10%)
    • Cervical cancer (<1%)
    • Uterine sarcoma
    • Vaginal cancer
    • Vulval cancer
• Exogenous estrogen (20%), e.g. HRT
• Non-gynecological, including:
  • Pelvic trauma
  • Bleeding from the urinary tract
  • Bleeding from the rectum

Source: 2099-54-postmenopausal-bleeding.html">RANZCOG

• Hx:
  • Characterization
  • Associated trauma → pelvic trauma
  • Pain
  • Weight loss → cancer
  • Use of HRT, type, duration
  • Hysterectomy
  • Drugs, including:
    • Tamoxifen → associated w/ changes to the endometrium, including polyps, hyperplasia and cancer
    • Especially those containing estrogen, including intake of soy
  • PMH of breast cancer
  • FH of cancers
  • BMI → risk factor for endometrial cancer
  • Abdominal palpation for discernable masses
• Blood test
• Speculum exam, for:
  • Inspection of the vulva and vagina → atrophy, trauma, foreign body
  • Pap test (sample of cervix) → cervical cancer
  • Bimanual, evaluating uterine size
  • Vaginal swab → infection
• Transvaginal U/S, for increased endometrial thickness (>5mm) → endometrial hyperplasia, endometrial cancer
• Biopsy of the endometrium, using either D&C or pipelle test → endometrial cancer
• Hysteroscopy, to take photos of the cervix, uterus and endometrium

• Pt's who are on HRT and have a uterus (i.e. no hysterectomy), require progesterone for endometrial protection

• In 90% of cases, a particular cause of postmenopausal bleeding will not be found

• Threatened miscarriage (<24 weeks)
• APH (>24 weeks)
• PPH (>birth)
• Vaginal bleeding (category)