Post-menopausal Bleeding
Definition
Vaginal bleeding occurring at least 12 months after the last menstrual period
All women should undergo a bimanual and speculum examination and a cervical smear taken if one has not been taken according to the national screening programme. Transvaginal sonography (TVS) has become a routine procedure for initial assessment. It measures endometrial thickness and also gives information on other pelvic pathology, such as fibroids and ovarian cysts.
TVS is less invasive than endometrial biopsy or hysteroscopy but does not give a histological diagnosis.
A thickened endometrium or a cavity filled with fluid indicates an increased risk of malignancy or other pathology (hyperplasia or polyps).
If the endometrial thickness is 4 mm or less on TVS and there was only a single episode of PMB then endometrial biopsy ± hysteroscopy is not required.
If the endometrium is thicker or there have been multiple bleeds an endometrial biopsy ± hysteroscopy should be performed.
If undertaken as an outpatient procedure, endometrium can be obtained using a Pipelle suction device. Outpatient hysteroscopy, under paracervical local anaesthetic block, can also be performed. If an endometrial polyp is found on scan, if the woman is anxious about having a procedure under local, or if vaginal access is expected to be difficult (for instance due to an atrophic vagina) then hysteroscopy and endometrial biopsy is performed under general anaesthetic as a day case procedure.
Once malignancy is excluded, atrophic vaginitis can be treated with topical oestrogen.