Postmenopausal Bleeding

Postmenopausal bleeding is defined as any bleeding from the genital tract occurring in the postmenopausal period, arising after 12 months of amenorrhea in women of menopausal age. Vaginal bleeding is noted in about 10% of women of postmenopausal age. Postmenopausal bleeding is a common reason for early referral to gynecological services for further evaluation. Menopause accounts for 5% of office gynecology presentations. Postmenopausal bleeding has several benign and malignant etiologies. Endometrial atrophy, endometrial hyperplasia, endometrial polyps, endometrial carcinoma are common causes of PMB (postmenopausal bleeding). The commonest cause of PMB is atrophy of endometrium or vaginal mucosa but the most concerning cause is endometrial cancer. Although endometrial cancer accounts for only 10% cases of PMB, 90% of postmenopausal women with endometrial cancer present with vaginal bleeding. American College of Obstetricians and Gynecologists (ACOG) recommends TVS (transvaginal sonography) as first-line investigation for PMB. In postmenopausal female thickness of endometrium correlates with the risk for endometrial cancer. The risk of endometrial cancer increases with the increase in endometrial thickness. Endometrial biopsy should be the first-line investigation for women with high-risk factors for endometrial cancer as it is a major cause of morbidity and mortality. Type 2 endometrial cancer can present with Endometrial thickness (ET) less than 3 mm, hence persistent or recurrent uterine bleeding should be evaluated by histology. Hysteroscopy guided biopsy is considered the most reliable method for diagnosing endometrial polyps having a sensitivity of 100% and specificity of 97%. Women who are diagnosed with cervical or endometrial malignancy must be promptly referred to a gynecological oncology service for further management, as the situation demands urgency. Management of atrophy typically involves the use of vaginal moisturizers, lubricants, and topical vaginal estrogens. Presence of endometrial fluid in the absence of thickened endometrium does not require further investigation. Options for managing postmenopausal bleeding in women receiving HRT (hormone replacement therapy) include stopping HRT, switching to non-oral HRT, considering Mirena, or surgical interventions like endometrial ablation, endometrial resection, or hysterectomy in refractory cases. Staging laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, pelvic and para-aortic lymphadenectomy is indicated in cases of endometrial adenocarcinoma. It is important to identify the underlying cause of postmenopausal bleeding before deciding on a management strategy for each individual woman. Proper management of postmenopausal bleeding is essential to ensure that women receive timely and appropriate treatment if necessary.