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Postmenopausal bleeding (486)

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Post menopausal Bleeding (PMB) is defined as unscheduled bleeding after one year of amenorrhoea. Women with this symptom are at increased risk of endometrial cancer and require urgent assessment. 

Referral

Patients with PMB should be seen within 2 weeks of referral to allow compliance with the 62 day National Guideline on cancer treatment times. To facilitate this all PMB referrals should be upgraded to ‘Urgent’ when letters are vetted. Where possible, patients should be assessed at a dedicated PMB/ one-stop clinic.

History

A full medical history is required including smear history. Particular attention should also be paid to drug history including HRT use, current or past tamoxifen use and use of anticoagulants such as warfarin, heparin and clopidogrel which many women take for cardiac problems.

Examination

All women with PMB should undergo speculum and bimanual pelvic examination. This can be facilitated by use of a virgin speculum. Patients should have an EUA if, despite these measures, examination proves impossible

Investigation

The initial investigation of choice is the measurement of endometrial thickness by transvaginal ultrasound scan. Endometrial biopsy is reserved for those women whose endometrial thickness exceeds a specified cut-off as follows:

  • Group 1: Women who have never used any HRT OR have not used HRT for more than one year OR are using continuous combined HRT.

Endometrial biopsy is required if the endometrial thickness exceeds 3mm.

  • Group 2: Women who are using sequential HRT OR have done so in the past year.

Endometrial biopsy is required if the endometrial thickness exceeds 5mm.

If the histology report in either group states ‘insufficient tissue for analysis’ and the ET has been thickened then the patient should have a hysteroscopy, if this hasn’t already been done, and a repeat biopsy.

  • Group 3:  Women who are current users of tamoxifen.

Tamoxifen is associated with distortion of the endometrial architecture.

Consequently, ultrasonography is a poor means of detecting endometrial cancer in this group. All such women should undergo hysteroscopy and endometrial biopsy.

Other Issues

  • This guideline refers to women who present with PMB for the first time. Those with recurrent symptoms after 6 months should be re-investigated, and women with persistent bleeding within 6 months of initial investigation should undergo hysteroscopy and endometrial biopsy.

  • There is no published evidence regarding the assessment of PMB in women taking Selective Estrogen Receptor Modifiers (SERMs) other than tamoxifen, eg Raloxifene. It is recommended that the precautionary principle applies and these women be treated in the same way as those taking tamoxifen i.e. undergo hysteroscopy and endometrial biopsy.

  • Transabdominal ultrasound scan may be used as a complementary investigation e.g. if the uterus is particularly enlarged or a wider view of the abdomen is required. It may also be used in the assessment of the small number of women in whom transvaginal scanning is technically impossible.

  • There is no evidence to support the use of endometrial thickness measurements and the associated cut-offs in the assessment of women with peri-menopausal bleeding. These women should undergo clinical evaluation as per menstrual disorder patients.

  • If an IUS or IUCD is in situ, patients should undergo transvaginal scan and biopsy. The coil may be left in place but will compromise the validity of ET measurements (hence the need for biopsy).

  • Endometrial biopsy is also required if:
    • there is an incomplete/poor view on ultrasound i.e the endometrial stripe is not seen along its length.
    • there is fluid within the endometrial cavity.
    • there is irregularity of the endometrial echo, regardless of the ET measurement. These women should also undergo hysteroscopy.

The preceding version of this GG&C guideline referenced SIGN guideline No.61 – The Investigation of Postmenopausal Bleeding (2002). This was withdrawn in February 2015. In the absence of any current national guidance, this revised version refers to current good practice standards. 

Editorial Information

Last reviewed: 14/07/2022

Next review date: 14/07/2025

Author(s): Morton Hair.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 486