Any bleeding after the menopause is known as Post-Menopausal Bleeding (PMB) and should be taken seriously. Urgent medical advice should be sought, initially with the GP, so that appropriate tests can be carried out to reassure the woman that there is no underlying serious cause such as endometrial (womb) cancer. Women are often referred to the hospital as a two week referral (Target) so that they can be seen quickly and reassured.
Causes of PMB: The vast majority of women bleed from a lack of the hormone, estrogen which can cause thinning of the vagina and lining of the womb (atrophic vaginitis or endometritis), other women may have polyps (benign growths) in the lining of the womb (endometrium) or on the cervix (neck of the womb) that may cause them to bleed.
Other causes could be medications that women are on such as hormone replacement therapy or blood thinning agents.
However, 1 out 10 women with PMB may have an underlying gynaecological cancer, which is why it is so important to seek medical advice soon.
Women who have bleeding anytime after one year after their last period, especially after the age of 53 are at increased risk of being diagnosed with a cancer (womb, ovary, cervical, fallopian tube with endometrial (womb) cancer being the commonest in the western World).
Early endometrial cancer is usually treated very successfully by an operation, hence the importance of women being advised to seek help early once they have any abnormal bleeding.
An ultrasound of the pelvis will be recommended and this is usually a “trans-vaginal scan’ (TVS).This is when the sonographer places a probe into the vagina. This often gives clearer images of the pelvic organs. It is not painful, and women are always asked for their consent for this procedure. A friend or relative may be with the woman or a chaperone from the department can be requested, if the woman feels more comfortable.
An ultrasound will help to give further information to help reach a diagnosis, for example a thickened lining may be noted or polyps or ovarian cysts.
A small sample may be taken in the clinic (pipelle) to sample the lining of the womb. In most cases, this is a straightforward outpatient procedure with minimal discomfort. Any tissue obtained is sent for analysis.
Some women may need to have a hysteroscopy, especially if the scan has suggested a thickened lining (more than 4-5mm). A hysteroscopy involves using a camera with a small telescope to look inside the womb. If possible, the endometrial lining may be sampled for analysis or small polyps may be removed. This is generally a safe and simple procedure and can be done as an outpatient procedure, taking about 20 minutes.
However, some women may not be suitable for outpatient hysteroscopy for a number of reasons, and they may need to have the procedure performed under a light general anaesthetic. These women will normally be able to return home, accompanied by a responsible adult, the same day.
Depending upon the results of the ultrasound scan or hysteroscopy, most women will be reassured and discharged with advice.
However, some women may be asked to come for an MRI or CT of the pelvis. The images will aid in diagnosis and planning treatment.
At any stage during the investigations, it is likely some blood tests will be requested to help with planning management.
Once all the investigations have been completed, results will be reviewed and if there is a diagnosis of a gynaecological cancer, this will be discussed and best management planned at a meeting attended by gynaecologists, specialist nurses, a histo-pathologist and a radiologist.
A follow-up appointment will be made for the woman after this MDT meeting, where she will be informed of, and included in, any decisions regarding possible treatments.
This will depend upon the underlying condition. The treatment for early endometrial cancer is usually a hysterectomy. This involves removal of the womb, fallopian tubes and ovaries. It can be done by keyhole surgery (laparoscopic hysterectomy). It has been shown that women who have keyhole surgery generally do better than those who undergo the traditional method via a large cut in the abdomen.
Nitu Bajekal Nov 2013