Post-menopausal Bleeding

A symptom, not a diagnosis — cancer must be excluded. Refers to any bleeding (including light spotting) 12 months or more after the final menstrual period. Can be a marker for cervical, endometrial or myometrial cancer in around 10% of cases — most commonly it’s related to polyps and atrophic vaginitis as well as hormone therapy and endometrial hyperplasia.

History and examination

Ask about the bleeding (amount, duration), associated symptoms (e.g. pain), medication changes/adherence, gynaecological history including any cancers, and HRT use/duration (could this be breakthrough bleeding?). Examine with speculum (vagina and cervix), co-test (HPV and microscopy), bimanual, and abdominal exam.

Investigations

Transvaginal ultrasound — an endometrial echo ≤5mm has a 99% negative predictive value for cancer. Refer to gynaecology if endometrial thickness is over 4mm or bleeding is persistent; if under 4mm with no suspicious features, conservative management is reasonable. Hysteroscopy and endometrial biopsy if referred.

Referral algorithm: history (years since menopause, tamoxifen use), examination and risk-factor assessment, plus FBC where indicated. Women on tamoxifen: exclude cervical pathology (cervical screening test ± chlamydia test) first. All other women: request TVUS. Endometrial thickness ≤4mm with no risk factors → GP surveillance, reassess with endometrial biopsy if bleeding persists. Endometrial thickness >4mm, focal lesions, persistent bleeding, or risk factors present → refer to gynaecology for endometrial biopsy ± hysteroscopy, ideally within 6 weeks.

Management of benign causes

• Urogenital atrophy (vaginal/cervical/endometrial epithelial shrinkage) — vaginal oestrogen is the treatment of choice.
• Endometrial polyps or submucosal fibroids — diagnosed on ultrasound, treated with polypectomy/resection.
• Endometrial hyperplasia — high-dose progesterone or hysterectomy.

Rarer causes presenting as postmenopausal bleeding: uterine sarcoma, ovarian granulosa cell tumour, vaginal or vulval cancer.