Post-Menopausal Bleeding

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 bleeding.

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 tests do.

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.