A 66 year old woman had two episodes of post-coital vaginal bleeding in the last week. She has not had any withdrawal bleeds for more than 12 years. Her last cervical smear was 3 years ago which showed no abnormalities. What is the SINGLE most appropriate initial action?
A. Repeat cervical smear
B. Topical oestrogen cream
C. Thyroid function test
D. Transvaginal ultrasound
E. Abdominal CT scan
The idea here is to think of endometrial cancer. Any women who has postmenopausal bleeding should have a transvaginal ultrasound to determine the endometrial thickness. If the endometrium is thick, hysteroscopy with endometrial biopsy would be arranged.
Atrophic vaginitis could also cause postmenopausal bleeding or postcoital bleeding. But it is more important to rule out endometrial cancer because of it’s seriousness. Remember, postmenopausal bleeding is cancer until proved otherwise.
A cervical smear is offered every 5 years in the UK if in the age group of 50 to 64 years old. Thus, having a cervical smear that was normal 3 years ago is a usual phenomenon. A repeat cervical smear is not necessary.
Endometrial cancer
Endometrial cancer is classically seen in post-menopausal women. Classically, endometrial cancer presents as postmenopausal bleeding (PMB) and, although this is not the only cause, it must be excluded.
Risk factors for endometrial cancer: • Obesity • Nulliparity • early menarche • late menopause • unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously • diabetes mellitus • tamoxifen • polycystic ovarian syndrome
Features In PLAB, they will always present with postmenopausal bleeding
Investigation • first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value • hysteroscopy with endometrial biopsy gives the definitive diagnosis