A6. Postmenopausal bleeding

Definition and causes

Postmenopausal vaginal bleeding is a red flag for malignancy. In case of vaginal bleeding more than 1 year after the last menstruation, histological examination (biopsy) by curettage or hysteroscopy should always be performed to exclude malignancy. The only exception is if they’re taking postmenopausal hormone therapy, as bleeding is expected in these cases.

The most common causes of postmenopausal bleeding are:

  • Atrophy of the vaginal mucosa or endometrium (most common cause)
  • Endometrial hyperplasia
  • Endometrial polyps
  • Submucosal fibroids
  • Endometrial cancer
  • Cervical cancer

Approximately 5 – 10% of postmenopausal women experience vaginal bleeding. The risk that the bleeding is caused by cancer increases with postmenopausal age.

Diagnosis and evaluation

As already stated, histological examination is obligatory, but evaluation begins with history and physical examination as always.

Important questions to ask include how long the bleeding as occurred, whether there are other symptoms, which medications are taken, family history of cancer, risk factors for endometrial cancer (obesity, diabetes).

Physical examination should be performed to exclude whether the bleeding is coming from someplace else, like the vagina, vulva, exocervix, anus, etc.

Transvaginal ultrasound can be used to exclude polyps or fibroids. If the endometrium is very thin (< 5 mm), endometrial cancer is unlikely. Pap smear should also be performed to exclude cervical cancer.

If other investigations can’t exclude cancer, biopsy and histological examination by dilation & curettage or hysteroscopy is necessary.

If all investigations are negative but the bleeding is still persistent, cancer is still likely and so further investigations must be performed.


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A5. Adnexal inflammatory diseases; diagnosis, differential diagnosis, and therapy

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A7. Premalignant disease and carcinoma in situ of the uterine cervix; diagnosis and therapy

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