Slide 1

Report
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
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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
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PMB <50 years1% risk
PMB >80years 25% risk
Obesity 18% risk
Diabetics 21% risk
Obesity and diabetic 29% risk
Ultrasound scan
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Transvaginal if possible
Endometrial thickness <4mm or <5mm
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 <5mm
Endometrial
thickness >5mm
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
• 5mm 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
www.corkwomensclinic.ie

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