Makindo Medical Notes

🌸 Postmenopausal Bleeding (PMB) = any vaginal bleeding occurring >12 months after the last menstrual period. ⚠️ Always considered cancer until proven otherwise and warrants urgent investigation. Most causes are benign, but ~10% are due to endometrial cancer.

📖 About

• Any vaginal bleeding >6–12 months after menopause
• May present as pink spotting, brown discharge, or frank bleeding
• Affects ~20% of postmenopausal women

⚠️ Causes of PMB

• 🧬 Endometrial cancer – present in ~10% of cases, bleeding is usually the first sign
• 🎗️ Cervical cancer – rare but important to exclude
• 🌸 Endometrial atrophy – thinning of the lining due to low oestrogen
• 🌿 Atrophic vaginitis – inflammation and fragility of vaginal mucosa
• 🟣 Endometrial hyperplasia – excess oestrogen stimulation, may progress to carcinoma
• 🔴 Cervical / endometrial polyps – usually benign but may cause spotting
• 💊 Hormone replacement therapy (HRT) – may cause irregular light bleeding

🩺 History to Ask

• 💊 HRT use (type, duration)
• 🩹 Associated symptoms – cramps, pelvic or back pain
• ❤️ Dyspareunia (pain with intercourse)
• ⚖️ Weight loss/gain, fatigue, night sweats
• 🚻 Changes in bowel/bladder habits
• 🌡️ Fever, chills → possible infection

🔬 Investigations

• 🧪 Bloods: FBC, U&E, CRP, TFTs, coagulation screen
• 🧫 Cervical smear (if due)
• 🖥️ Transvaginal ultrasound (TVUS): Endometrial thickness >4 mm is concerning
• 🔎 Endometrial biopsy (outpatient Pipelle or hysteroscopy-guided)
• 📹 Hysteroscopy ± dilation & curettage for persistent bleeding or inconclusive biopsy

💊 Management

• 📌 Urgent 2-week referral to a dedicated PMB clinic (rule out malignancy)
• 🔹 Treat underlying cause (atrophy, polyps, hyperplasia, infection, malignancy)
• 🔪 Dilation & Curettage (D&C): Used diagnostically/therapeutically in selected cases
• 🩸 Tranexamic acid for heavy bleeding if no contraindications
• 🚫 Avoid tampons (use pads) → reduce trauma/infection risk
• ⚠️ Avoid unnecessary anticoagulant/aspirin use if possible

📚 Teaching Pearls

• 🚨 Postmenopausal bleeding is cancer until proven otherwise
• 🖥️ TVUS endometrial thickness cutoff: 4 mm
• 🌸 Atrophy is the most common benign cause
• 🧬 Endometrial hyperplasia is a precursor to carcinoma