Postmenopausal bleeding

Definition

Basic Principle

• Principle: Any bleeding after menopause is considered requiring workup until cancer is excluded.
• Most common finding: The most common finding is endometrial atrophy.
• Carcinoma incidence: A carcinoma is found in approx. 10% of cases, rising with age.
• Definition: Menopause is defined as final period (after 12 months of amenorrhea).

• Postmenopausal bleeding is abnormal uterine bleeding occurring more than one year after the permanent cessation of menstruation due to loss of ovarian follicular activity.
• The menopause is diagnosed clinically after one year of amenorrhoea; bleeding after this point is considered abnormal.
• In the United States the average age at menopause is 51 years.

Occurrence & epidemiology

Epidemiology

• Postmenopausal bleeding is the reason for about two-thirds of all gynaecological office visits by postmenopausal women.
• About 10% of women with postmenopausal bleeding have an intrauterine malignancy.
• Conversely, around 90% of postmenopausal women with endometrial carcinoma had vaginal bleeding.

Aetiopathogenesis

Causes and risk factors

• The commonest cause is atrophy of the endometrium or lower genital tract; other common causes are endometrial hyperplasia and polyps.
• Risk factors for type I endometrial carcinoma are obesity, older age, early menarche, late menopause, hypertension, diabetes and Lynch syndrome.
• Type I cancers are endometrioid and account for 70–80% of endometrial carcinomas; type II cancers are non-endometrioid and less often associated with these risk factors.

Clinical features

Atrophy as a source of bleeding

• What is seen on speculum examination: pale, smooth, vulnerable mucosa.
• Typical accompanying symptoms: dryness, burning, itching, dyspareunia.
• A wet mount shows: parabasal cells, elevated pH.
• Why the atrophy develops: oestrogen deficiency: thinner epithelium, glycogen loss.
• Additional consequences: urinary tract infections and urgency.

More facts from the study questions

• Atrophy of the endometrium and vagina is the most common cause of postmenopausal bleeding.
• In recurrent postmenopausal bleeding, an invasive investigation is mandatory.
• This applies even if the endometrial thickness measured by ultrasound is unremarkable.
• Fluid in the uterine cavity can indicate cervical stenosis with an underlying carcinoma.
• This finding therefore always requires investigation postmenopausally.
• Endometrial carcinoma is found in approximately one in ten cases of postmenopausal bleeding.
• The proportion of carcinomas increases with the patient's age.
• In a patient with postmenopausal bleeding, invasive investigation is performed from an endometrial thickness of 3 to 4 mm.
• Without bleeding, the cut-off is about 5 mm.
• Oestrogen deficiency leads to thinning of the epithelium, revealing deeper cell layers (parabasal cells).

Diagnosis

Examination

• Clinical examination: The examination procedure includes inspection, speculum, palpation, vaginal ultrasound.
• Cervical work-up: Cytological and colposcopic investigation is performed if bleeding is from cervical canal or smear is abnormal.

Endometrial Thickness

• Cut-off value with bleeding: The cut-off value for postmenopausal bleeding is an endometrium of 3–4 mm.
• Fluid in the cavity: Postmenopausal fluid in the uterine cavity is a finding requiring workup (suspected carcinoma).

Typical imaging findings

• Ultrasound: The endometrial stripe is thin, smoothly bordered and homogeneous throughout; the measurement is well below 5 mm. No fluid collection, no focal mass, and the border with the myometrium is intact everywhere.

• Transvaginal ultrasound is an efficient, non-invasive method for detecting endometrial pathology.
• With a pre-test probability of 10%, an endometrium below 4 mm lowers the probability of carcinoma to about 2.4%, below 5 mm to about 5%.
• Histological confirmation is obtained by endometrial biopsy or D&C.

Keep learning in the app

Further reading (selection)

1. A Clinicopathological Evaluation of Postmenopausal Bleeding and Its Correlation with Risk Factors for Developing Endometrial Hyperplasia and Cancer: A Hospital-Based Prospective Study (J Midlife Health 2019, PubMed Central)
2. StatPearls: Postmenopausal Bleeding (NCBI Bookshelf)
3. DocCheck Flexikon, Endometriumkarzinom
4. DocCheck Flexikon, Kolpitis

Cross-references