Postmenopausal bleeding — urgent assessment

PLAB 2 & PRES 3 · obs-gyn · medium · 8 minutes

Candidate brief

You are a doctor in a GP practice. Mrs Linda Evans, 61, has attended after noticing vaginal bleeding twice during the past week. Her last menstrual period was 8 years ago. Assess her symptoms, explain your concerns and agree on an appropriate management plan. No physical examination is required, but verbalise any examination or investigations you would offer.

What examiners look for

Postmenopausal bleeding is any vaginal bleeding occurring more than 12 months after the final natural menstrual period. Every episode requires assessment, even if it occurs only once or consists of a small amount of spotting, pink discharge or brown discharge. Common causes include vaginal or endometrial atrophy and benign polyps, but endometrial, cervical and other gynaecological cancers must be excluded. Ask whether the bleeding could be urinary or rectal and check for postcoital bleeding, abnormal discharge, pelvic pain, weight loss and systemic symptoms. Review HRT, tamoxifen, anticoagulants, cervical screening history and endometrial-cancer risk factors. Offer an appropriate pelvic examination with informed consent, privacy and a chaperone. Do not use cervical screening as a substitute for investigating symptoms. A normal previous screening result does not exclude cervical or endometrial cancer. UK mode: unexplained postmenopausal bleeding in someone aged 55 or over requires referral through the suspected endometrial-cancer pathway. Ireland mode: arrange prompt referral through the local postmenopausal-bleeding or ambulatory gynaecology service. Explain the reason for referral honestly without telling the patient that she definitely has cancer.

Guideline references

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