Postmenopausal bleeding

Gynaecology

Clinic, referred promptly

The first question

Is this endometrial cancer, until proven otherwise?

01
Confirm
Bleeding a year or more after the last period, or unscheduled bleeding on hormone therapy; separate from urinary or rectal bleeding.
02
Examine
Vulva, vagina, cervix on speculum; screening if due; bimanual.
03
Transvaginal ultrasound
Endometrial thickness: 4 mm or less makes cancer unlikely; more, or persistent bleeding, means sampling.
04
Sample
Office endometrial biopsy; hysteroscopy with biopsy if inadequate, if a polyp is seen, or if bleeding persists.

Where it is

Each opens the structure on the 3D pelvis.

Diagnosis	Favours	Against	Urgency
Endometrial cancer or hyperplasia	Thickened endometrium, risk factors, persistent bleeding	Thin endometrium and a single episode	urgent
Atrophic endometrium or vaginitis	Thin endometrium, atrophic vagina, light spotting	Thickened endometrium	routine
Endometrial or cervical polyp	Polyp on scan or speculum	None seen	routine
Hormone therapy bleeding	Expected withdrawal on a cyclical regimen; early months of a continuous one	Bleeding after the first 6 months of continuous therapy, or heavy	routine
Cervical cancer	Visible lesion, postcoital bleeding, no screening history	Normal cervix and screening	urgent
Vulvar or vaginal lesion	Visible lesion	Normal examination	urgent

Pitfalls this pathway refuses