Postmenopausal Bleeding: GYN for the PCP

Postmenopausal Bleeding

Postmenopausal bleeding (PMB) should always be investigated!

What defines PMB?

Menopause is defined as 12 months of no period or bleeding. PMB is any bleeding, spotting, or tiny amount of pink or brown discharge that occurs after this 12-month period of time. It doesn't matter whether it lasts for a week, a day, or even minutes—any and all PMB needs further investigation.

Why is PMB so concerning?

Although most patients with PMB experience bleeding secondary to atrophic changes (thinning out) of the vagina, vulva, or the lining of the uterus, the differential diagnosis includes (but is not limited to) uterine, cervical, rectal, or urinary pathologies; skin abrasions; infections; and vulvar dystrophies. Depending on age and risk factors, 1%-14% of women with PMB will have endometrial (uterine) cancer.

There are two types of uterine cancer that differ in histology, treatment and prognosis: type I (most common) and type II (less common, but usually high-grade with a poorer prognosis).

What are the chances this patient might have uterine cancer?

Multiple risk factors have proven to be associated with endometrial cancer, including:

Age (mean age at diagnosis in the United States is 63 years);
White race (usually for type I cancer; African American women tend to have the more aggressive type II cancer);
Prolonged exposure to unopposed estrogen: Endogenous (obesity, chronic anovulation/polycystic ovarian syndrome [PCOS], estrogen-producing tumors) or exogenous (hormone replacement therapy, tamoxifen) sources are usually linked to type I uterine cancer;
Early menarche, late menopause, nulliparity; and
Smoking (linked to type II cancer).

Obesity, especially if associated with hypertension and diabetes mellitus; nulliparity; PCOS; irregular menstrual cycles; and genetic predispositions (Lynch and Cowden syndromes) are also risk factors for developing uterine cancer at an earlier age.Protective factors for endometrial cancer include previous use of combined oral contraceptive pills, depot shots, and the levonorgestrel intrauterine device.

What is the workup for PMB, and what can primary care providers do to initiate the process?

There is currently no available routine laboratory test or imaging to screen for endometrial cancer.

In addition to the history and physical/pelvic exam (if conducted), the PCP reviews the patient's risk factors, family history, and constitutional symptoms; obtains lab tests (Pap smear, complete blood cell count if symptomatic anemia is suspected, and vaginal cultures to rule out infections); and reviews the patient's medication list (anticoagulants, exogenous hormones). If the PCP elects not to do a pelvic exam, the patient should be referred as soon as possible to a clinician who can conduct this exam.

What are we looking for on the pelvic exam?

The pelvic exam can be very informative. The vulva and vagina may show thinning of the skin, indicating atrophy or presence of lichen sclerosis, for example. Look for abrasions or trauma, cervical polyps, or abnormal vaginal or cervical growth. Check for presence of a foul-smelling discharge indicating possible infection, and examine for urethral and rectal pathologies. A bimanual exam might reveal an enlarged uterus, a large ovarian cyst, or a pelvic mass.

What's the next step?

The most useful diagnostic tools in evaluating PMB are pelvic ultrasound and endometrial biopsy. Women with PMB can be assessed initially with either an endometrial biopsy or transvaginal ultrasound; the initial evaluation does not require both tests.

The PCP can help the gynecologist expedite the process of evaluation of PMB by ordering transvaginal ultrasound. This is of great value for the gynecologist before seeing the patient because it helps channel the next steps in the evaluation of PMB. It also reduces patient anxiety while waiting to see the gynecologist and cuts down on the number of visits, because it will provide the gynecologist with information to discuss with the patient at the first visit.

What can be learned from the transvaginal ultrasound?

We are looking at the endometrial thickness. An endometrial thickness > 4 mm can be caused by benign intrauterine pathologies (polyps, fibroids), or it can suggest malignancy. Endometrial assessment will help differentiate those two categories when the lining is > 4 mm (Figure 1) and is required. Further evaluations includes in-office endometrial biopsy or hysteroscopy, sonohysterography, or D&C (dilation and curettage).

Figure 1. Ultrasound image showing uterine contour (yellow line) and thickened endometrium ( > 4 mm).

An endometrial thickness < 4 mm usually indicates a thin atrophic endometrium, and biopsy is not required (Figure 2).

Figure 2. Ultrasound image showing thin endometrium ( < 4 mm) (arrow).

However, some type II endometrial cancers may present with PMB and endometrial thickness < 4 mm; therefore recurrent or persistent PMB and the presence of risk factors would require endometrial histologic assessment as well in those cases.

Transvaginal ultrasound also looks at the ovaries, to identify suspicious cysts or the presence of pelvic masses or ascites, which typically indicates advanced cancer.

The patient in this case was appropriately referred to a gynecologist; her ultrasound showed endometrial thickening of 14 mm. She underwent hysteroscopy with D&C, which revealed multiple uterine polyps that were removed. Pathology of the polyps showed that they were benign. She had no recurrent bleeding.

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