Approach to postmenopausal bleeding: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:50

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.

Unstable patient0:50–1:35

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.

Stable patient1:35–2:28

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.

Vaginal pathology2:28–3:42

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.

Cervical pathology3:42–5:35

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.

Endometrial pathology5:35–10:08

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.
Here’s a high-yield fact! Two hereditary cancer syndromes associated with endometrial carcinoma are Lynch syndrome, which is linked to ovarian and colon cancer, and Cowden syndrome, which is associated with breast and colon cancer.Since you’re considering endometrial pathology, obtain a pelvic ultrasound to assess the endometrial lining.
If the endometrial lining is 4 millimeters or less, the diagnosis is an atrophic endometrium.Here’s another high-yield fact!
An endometrial lining of 4 millimeters or less has a high negative predictive value for endometrial cancer. If a patient has a single episode of bleeding and the endometrial lining is less than or equal to 4 millimeters, no further evaluation is needed.
However, if a patient returns with another episode of bleeding, repeat evaluation, and endometrial sampling as needed. Okay, back to the patient.
If the endometrial lining is greater than 4 millimeters, evaluate it further to rule out malignant endometrial pathology.
You could perform a blind endometrial biopsy, which means inserting a pipelle into the uterus and collecting a sample of the endometrium.
However, it’s usually better to evaluate the endometrium for discrete lesions to biopsy. This can be done either with a sonohysterogram, which involves injecting a small amount of saline into the endometrial cavity during transvaginal ultrasonography; or by hysteroscopy, which is a direct visualization of the uterine cavity using a hysteroscope.
The decision to perform one or the other is determined by factors like the availability of resources, the patient’s medical comorbidities, and cancer risks.
If the sonohysterogram reveals an intracavitary filling defect or the hysteroscopy reveals an endometrial or intracavitary mass, the diagnosis is an endometrial polyp or submucosal leiomyoma.
You should then perform a biopsy to confirm the diagnosis. A blind biopsy following sonohysterography may not adequately sample the mass, so hysteroscopy with directed biopsy will be needed.
In the end, the biopsy may reveal a benign polyp or leiomyoma, or it may reveal a malignant lesion such as a carcinoma or a leiomyosarcoma.Okay, let’s go back to the sonohysterogram and hysteroscopy.
If the sonohysterogram does not reveal a filling defect, or the hysteroscopy does not reveal a mass, perform an endometrial biopsy, either by using a blind technique or under direct visualization using hysteroscopy.
If the endometrial biopsy shows regular spacing of the endometrial glands within the stroma, the diagnosis is benign endometrium.
On the other hand, if the biopsy demonstrates crowding of the endometrial glands within the stroma and possibly nuclear atypia, you can diagnose endometrial hyperplasia.
Here’s a high-yield fact! Atypical endometrial hyperplasia is also called endometrial intraepithelial neoplasia or EIN, and is considered a premalignant condition or a precursor to endometrial carcinoma.Finally, if the biopsy is positive for crowded endometrial glands within little intervening stroma; but with nuclear atypia; and significant glandular irregularity, that’s endometrial carcinoma.Next, we have myometrial pathology.

Myometrial pathology10:08–10:43

The history may reveal the sequelae of uterine enlargement, such as pelvic pressure, urinary frequency, or constipation; while the physical examination may show an enlarged uterus with an irregular contour.
In this case, consider myometrial pathology and obtain a pelvic ultrasound. If the pelvic ultrasound reveals a myometrial mass, it’s typically a benign uterine leiomyoma, or less frequently, the highly aggressive leiomyosarcoma.

Adnexal pathology10:43–11:50

You should also consider adnexal pathology. Be sure to ask questions about risk factors for ovarian or fallopian tube cancers, such as a family history of hereditary cancer syndromes.
The patient may report pelvic or abdominal pain, bloating, or a thin vaginal discharge. Possible physical exam findings include an adnexal mass, bleeding from the cervical os, and a watery, blood-tinged vaginal discharge.In these cases, consider adnexal pathology and obtain a pelvic ultrasound.
If the ultrasound reveals a complex adnexal mass and possibly free fluid in the pelvis, the diagnosis may be fallopian tube or ovarian cancer.
Any complex adnexal mass in a postmenopausal patient is a significant finding, so promptly obtain serum tumor markers and refer for gynecologic surgical evaluation, as surgery is necessary to diagnose and manage fallopian tube or ovarian cancer.

Alternative diagnosis11:50–12:07

Finally, after assessing for common genital tract causes of postmenopausal bleeding, consider and assess for alternative diagnoses, such as hemorrhoids, colorectal cancer, bladder cancer, or urethral disease.
Alright, as a quick recap… Postmenopausal bleeding is any bleeding that occurs after menopause. Common causes include atrophic vaginitis, cervical polyps, cervicitis, cervical dysplasia, and cervical cancer.

Review12:07–12:51

Endometrial causes include atrophic endometrium; benign or malignant endometrial polyps or submucosal leiomyomas; as well as a benign endometrium, endometrial hyperplasia, or endometrial carcinoma.
Finally, consider other gynecologic sources such as uterine leiomyomas, fallopian tube or ovarian cancer, and consider non-gynecologic sources as