Context

Postmenopausal bleeding (PMB) is defined as bleeding that occurs over one year after the last menstrual period. Most patients with PMB present to primary care^1,2, however, some will present directly to the Emergency Department, especially if PMB is severe. Emergency Department physicians must be able to manage these patients appropriately and arrange further care.

PMB is relatively common and an estimated 4-11% of postmenopausal women suffer from PMB^3-5. The incidence of PMB decreases with age⁵.

Table 1 Incidence of primary care consultation for PMB¹

As such, PMB is the most common reason for referral to gynaecological rapid access clinics⁶.

PMB can be an early symptom of gynaecological or haematological cancer. Uterine cancer is the fourth most common cancer in women with close to 9,700 new diagnoses and 2,400 deaths every year⁷. In 2018, a systematic review and meta-analysis of 129 studies reported that the risk of endometrial cancer among women with PMB was 9%⁸.

One analysis of primary care data found that only 40% of patients presenting to primary care with PMB were referred for specialist care, with a lower proportion of those being women over 75 who have a higher risk of an underlying malignant cause².

Learning Bite

PMB is a relatively common presentation but those cases caused by gynaecological cancer must be identified early. NICE guidelines advise that women with PMB should be urgently referred for a specialist opinion to exclude malignancy⁹.