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Bleeding After Menopause...

Bleeding After Menopause

Postmenopausal Bleeding

A woman is considered menopausal when a year has past since her last period. Any bleeding after the menopause is regarded as abnormal. This is referred to as postmenopausal bleed (PMB). Although in the majority of times there is no underlying pathology PMB may be associated with cancer. The prevalence of endometrial cancer in women with PMB is 3-10%, so referral for investigation is considered mandatory. Unlike other malignancies affecting women, endometrial cancer often presents at an early stage and to increase survival, accurate and timely diagnosis is paramount.

Investigation of PMB using traditional inpatient dilatation of the cervix and curettage of the endometrial has been replaced by outpatient evaluation using endometrial biopsy (EB), ultrasonography (USS) and outpatient hysteroscopy (OPH). There is now compelling evidence that women presenting for the first time with PMB should undergo initial evaluation with an USS or EB. The choice between initial testing with ultrasound or EB will depend upon patient age, disease prevalence and the availability of high quality ultrasound which may use a threshold of 5 mm endometrial thickness to define abnormal results.

USS is considered to be the instrument of choice as it is less invasive, better tolerated and preferred by women when compared with EB and OPH. It is also the only modality that has the advantage of allowing assessment of other pelvic organs in particular, opportunistic ovarian screening.

It is therefore important to receive a rapid one-stop assessment of this problem using USS and endometrial pipelle (only if indicated) to ensure correct management and avoidance of over-investigation.

Ultrasound may also be useful in the investigation of the following conditions:

  • Abnormal bleeding both in pre - and postmenopausal women
  • Ovarian cancer screening in those women with risk factors
  • Abnormal bleeding in women receiving HRT
  • Assessment of pelvic mass
  • Assessment of fibroids and determining those women who are suitable for hysteroscopic surgery