It is recognized that good communication is central to the clinician-patient
relationship and to good clinical care. Patients require information about
the reasons for investigating their condition, the methods of testing, an
explanation of the procedures themselves, as well as options available for
management of established conditions.
What is Post-menopausal bleeding (PMB)?
Post-menopausal bleeding involves vaginal bleeding following a woman's last
menstrual period. For the purposes of this guideline, an episode of bleeding
12 months or more after the last period is accepted as post-menopausal
Why does post-menopausal bleeding need investigation?
Post-menopausal vaginal bleeding must always be investigated. In the
majority of cases no serious problem will be found but there are times when
the bleeding is the first symptom of serious disease including cancer. Even
when the bleeding is related to cancer, if it is diagnosed early there is a
very good chance that the disease can be cured.
What causes post-menopausal bleeding?
In 90% of cases examination and investigation will find either no obvious
cause or an innocent one. The commonest innocent cause is atrophic vaginitis
(inflammation of the lining of the vagina due to the lower levels of the
circulating hormone oestrogen at this time). Cervical and endometrial polyps
are further common findings and they are usually benign. In around 10% of
cases, PMB will be associated with endometrial (uterine) or cervical cancer.
How is post-menopausal bleeding investigated?
There are a range of different techniques which health care professionals
might use to investigate PMB. Transvaginal ultrasonography (TVUS) is
described in detail below. Hysteroscopy uses a thin telescope that is
inserted through the cervix into the uterus. Modern hysteroscopes are so
thin that they can fit through the cervix with minimal discomfort. They are
fitted with small video cameras to allow the operator to visualise the
inside of the uterus. Biopsy involves removing a small sample of the womb
lining for pathological analysis. This is painless and can usually be
carried out at the same time as hysteroscopy.
How accurate are the test results for post-menopausal bleeding?
All women have an underlying chance of developing endometrial cancer which
is dependent on their use of HRT and a range of other factors. TVUS measures
the thickness of the lining of the womb and the test results can be
interpreted to show how the underlying likelihood of cancer is either
increased or decreased in the light of the measured endometrial thickness.
The risks of cancer are given in ranges which reflect the accuracy of the
TVUS technique. Your doctor will discuss the test results with you and will
come to a decision with you as to whether any further investigation or
treatment is required.
What is ultrasound?
Ultrasound is a harmless way to show the structures inside your pelvis using
high-frequency sound waves and a type of sonar detection system to generate
a black and white picture. Depending on the view of your pelvic organs, the
radiographer may position the ultrasound machine's transducer wand to look
through your abdominal wall (transabdominal ultrasound) or to look through
your vagina (transvaginal ultrasound). With the transvaginal technique, the
ultrasound transducer (a hand-held probe) is inserted directly into the
vagina. It is therefore closer to pelvic structures than with the
conventional transabdominal technique (probe on skin of the abdomen),
providing superior image quality. Ultrasound of the pelvic organs is used to
scan for pregnancy and is also useful for finding cysts on your ovaries,
examining the lining of your uterus, looking for causes of infertility, and
looking for cancers or benign tumours in the pelvic region.
How to prepare for the test?
No preparation is necessary in most cases. If you are having a transvaginal
ultrasound, you will need to remove a tampon if you have one in place. If
you are to have a transabdominal scan you will be asked to fill your bladder
by drinking a few glasses of water before the test. You may continue taking
all of your medications as prescribed by your health care provider. The test
can be performed without concern at any stage of a woman's menstrual cycle,
however if you are using a sequential HRT regimen, you may be asked to
attend during the first half of your menstrual cycle.
How is the test performed?
You will lie on your back on a couch for the test. For transvaginal
ultrasound, the probe used for internal scans is small and shaped to fit
easily and painlessly into your vagina. The probe will be covered with a
clean condom and some lubricating jelly. When the sensor is in place, a
picture will appear on a TV screen, and the radiographer will move the
sensor in your vagina to see the uterus and ovaries from many different
views. The test takes around 15 minutes to perform and will feel similar to
an internal examination.
What are the risks involved with the test?
Studies have shown ultrasound is not hazardous and there are no harmful side
effects. In addition, ultrasound does not use ionising radiation, as X-ray
How long is it before the result of the test is known?
You might be able to get an indication of the results of your test
immediately. However, the test will be recorded on paper or film and the
recording can be formally reviewed by a radiologist, a process that might
take a day or two before your doctor has the report.