Postmenopausal Bleeding (OSCE focused)

Candidate Instructions: You are the medical student in the gynaecology outpatient clinic. A 62-year-old woman presents with vaginal bleeding. Take a focused history and explain to the examiner what further investigations and management you would consider. You do not need to perform a physical examination. You have 8 minutes.

Key OSCE Focus 🔑

• PMB is endometrial cancer until proven otherwise ⚠️.
• Systematic gynaecological history (menstrual, obstetric, sexual, HRT, smear history).
• Ask about risk factors: obesity, diabetes, tamoxifen, unopposed oestrogen.
• Screen for red flag features and other causes (atrophy, polyps, infection).

History to Cover 📝

• Bleeding history: Onset, duration, amount, relation to intercourse, clot passage.
• Menstrual history: Age at menopause, previous cycles, HRT use.
• Obstetric history: Parity, deliveries, complications.
• Gynaecological history: Smear results, past pelvic surgery.
• Medical history: Hypertension, diabetes, thyroid disease, coagulopathy.
• Drug history: HRT, tamoxifen, anticoagulants.
• Family history: Gynaecological or bowel cancers.
• Systemic review: Weight loss, pelvic pain, urinary or bowel changes.

Examiner Prompts (if asked) 👩‍⚕️

• She went through menopause at 54.
• No HRT use. No previous abnormal smears.
• One episode of light vaginal bleeding last week, painless.
• No significant PMH except hypertension.
• Mother had endometrial cancer at 70.

Investigations 🔬

• First line: Transvaginal ultrasound (TVUS) – endometrial thickness ≥ 4 mm is abnormal and needs biopsy.
• Endometrial sampling: Pipelle biopsy or hysteroscopy ± biopsy if inadequate sample.
• Cervical smear: If not up to date, though not a test for endometrial cancer.
• Bloods: FBC, coagulation profile, +/- CA-125 if ovarian pathology suspected.

Management 🚑

• Urgent referral: All women with PMB should be referred to the “2-week wait” suspected cancer pathway.
• If cancer confirmed: staged by imaging + oncology MDT; treatment is usually total hysterectomy + bilateral salpingo-oophorectomy ± adjuvant therapy.
• If benign causes (atrophy, polyp, HRT-related): reassurance or minor intervention (e.g. polypectomy, topical oestrogen).

Examiner’s Marking Guide 📋

• Introduces self, gains consent, takes structured history.
• Asks about HRT, tamoxifen, family history, red flags.
• Mentions urgent referral (2-week wait).
• Mentions TVUS + biopsy as first-line investigations.
• Considers both malignant and benign causes.

📊 Differential Diagnosis of Postmenopausal Bleeding

Common Differentials ⚖️

• Endometrial carcinoma (most important).
• Endometrial hyperplasia.
• Endometrial or cervical polyps.
• Atrophic vaginitis (most common benign cause).
• Ovarian tumours (rare).

🧑‍⚕️ Case Examples - Postmenopausal Bleeding

• Case 1 (Endometrial carcinoma): 🎗️ A 68-year-old woman presents with painless vaginal bleeding 15 years after her menopause. She is obese and has type 2 diabetes. Transvaginal ultrasound shows endometrial thickness of 10 mm, and biopsy confirms endometrial adenocarcinoma. Teaching point: Always rule out malignancy - PMB is a red flag.
• Case 2 (Endometrial hyperplasia): 🧬 A 55-year-old woman on oestrogen-only HRT reports irregular spotting. Ultrasound shows thickened endometrium, biopsy reveals hyperplasia without atypia. Teaching point: Unopposed oestrogen causes endometrial proliferation; needs progestogen or surveillance.
• Case 3 (Atrophic vaginitis): 🌸 A 70-year-old woman complains of recurrent light bleeding and vaginal dryness. Pelvic exam shows pale, atrophic vaginal mucosa that bleeds on contact. Teaching point: Atrophic changes are the commonest benign cause of PMB; topical oestrogen cream is effective.
• Case 4 (HRT-related bleeding): 💊 A 59-year-old woman on continuous combined HRT presents with irregular spotting in the first 6 months of therapy. Pelvic ultrasound is normal. Teaching point: Breakthrough bleeding is common early in HRT use; persistent or late bleeding still warrants investigation.
• Case 5 (Cervical polyp): 🧪 A 63-year-old woman presents with occasional post-coital spotting. Speculum examination reveals a small, friable cervical polyp. Histology confirms a benign lesion after removal. Teaching point: Benign cervical or vaginal lesions can cause PMB, but cancer must always be excluded first.