Approach to postmenopausal bleeding: Clinical sciences

Postmenopausal bleeding is any vaginal bleeding that occurs after menopause. Menopause is defined as an absence of menstrual bleeding for twelve months in patients 40 years and older, with an average age of 51, who don't have another reason for amenorrhea, such as a hysterectomy. Vaginal bleeding after menopause is the presenting symptom in the majority of cases of postmenopausal endometrial carcinoma, as well as in other genital tract cancers. Benign causes of postmenopausal bleeding can arise from any site along the genital tract and can come from structural problems, such as fibroids, polyps, and urogenital atrophy.

Your first step in evaluating a patient who presents with postmenopausal bleeding is to perform a CABCDE assessment to determine if they are stable or unstable. If the patient is unstable, control any life-threatening hemorrhage by using IV hormone therapy, with or without surgical intervention. Also stabilize the airway, breathing, and circulation; obtain IV access; and monitor vital signs.

Here’s a clinical pearl! It’s unusual for a patient to present with uncontrolled postmenopausal bleeding. In this situation, strongly consider underlying comorbidities like coagulopathy, anticoagulation therapy, or malignancy.

Alright, now that unstable patients are taken care of, let’s talk about stable patients. The first step is to obtain a focused history and physical examination. Always determine menopausal status by obtaining an accurate menstrual history, and if the patient’s menopausal status is uncertain, obtain an hCG test to rule out pregnancy.

Here’s a high-yield fact! Menopausal patients with significant vasomotor symptoms can be treated with systemic hormone therapy like oral or transdermal options, as long as there’s no personal history of breast cancer or undiagnosed abnormal uterine bleeding. It’s common for patients to have irregular light vaginal bleeding during the first six months of hormone replacement therapy. However, if bleeding persists, worsens, or occurs after six months, be sure to evaluate it.

Now let’s assess for genital tract bleeding by anatomic site, starting with vaginal pathology. In these patients, history usually reveals vaginal dryness or dyspareunia and possibly postcoital bleeding. On physical examination, they’ll have signs of vaginal atrophy and possibly fissures, abrasions, and mucosal bleeding. In this case, consider vaginal pathology. You can assess the vaginal discharge with saline microscopy and obtain a vaginal pH. If the microscopy demonstrates parabasal cells, few white blood cells, with a pH greater than 4.5, this supports a diagnosis of atrophic vaginitis, also known as genitourinary syndrome of menopause.

Time for a clinical pearl! If you see evidence of vaginal abrasions and mucosal bleeding, consider trauma and assess for sexual assault. Also be aware that trauma to the vaginal mucosa can occur after initiating sexual intercourse with a new partner, or can be due to a foreign object in the vagina, such as a pessary.

Next, let’s consider cervical pathology. The history may include a previously abnormal pap test, a new sexual partner, intermenstrual or postcoital bleeding, or abnormal vaginal discharge. In this case, consider cervical pathology.

Perform a pap test if indicated based on last pap timing and results, as well as a test for sexually transmitted infections or STIs with nucleic acid amplification testing, or NAAT, for gonorrhea, chlamydia, and trichomonas. If the pap test is normal and there is a soft polypoid mass at the cervical os, you have made a diagnosis of a cervical polyp.

Here’s a clinical pearl! While most cervical polyps are benign, they should still be removed by a simple in-office polypectomy to rule out more significant pathology or malignant transformation within the polyp.

However, if the pap test is normal, the STI testing is positive for gonorrhea, chlamydia, or trichomonas, and the physical exam reveals a cervix that’s either friable or has evidence of mucopurulent cervical discharge, the diagnosis is infectious cervicitis.

Finally, if the pap test is abnormal with a possible lesion or mass on the cervix, think about cervical dysplasia or cancer, and then perform a colposcopy with biopsies. If the biopsies reveal dysplastic epithelial or glandular cells without invasion, the diagnosis is cervical dysplasia. However, if the biopsies reveal cancerous epithelial or glandular cells with invasion, the diagnosis is cervical cancer.

Alright, now let’s move on to endometrial pathology. History may include the use of medications that affect the endometrial lining, such as hormone replacement therapy; aromatase inhibitors, like letrozole; or selective estrogen receptor modulators, SERMs, like tamoxifen. Additionally, it might reveal anticoagulation use or the presence of a coagulopathy, which increases the likelihood of bleeding. Also consider risk factors for endometrial hyperplasia or carcinoma, such as diabetes, obesity, or a family history of a hereditary cancer syndrome.