Investigations

The following may in indicated in the investigation of PMB, but not all these will take place in the Emergency Department:

Bloods: Take a full blood count, coagulation profile, and consider TFTs if there is evidence of thyroid disease. In unstable patients also take a VBG and G&S, U&Es and LFTs.

STI screen: If symptoms are consistent with STI or infection

Pregnancy test: It is unlikely but not unheard of for a woman to assume she has entered the menopause when she is amenorrhoeic because she is pregnant.

Transvaginal ultrasound (TVUS): TVUS is used in the initial evaluation of PMB. The endometrial lining in TVUS is identified as a uniformly sonolucent double layer. Endometrial thickness less than 4mm has a 99% negative predictive value for endometrial cancer in patients with PMB²¹. However, data exists for different endometrial thicknesses as well with 3mm and 5mm used^4,22.

Other anatomical abnormalities can also be well demonstrated using TVUS.

Hysteroscopy and biopsy: Hysteroscopy followed by biopsy is becoming the most preferred mode of investigation of PMB to rule out malignancy²³. It is considered to be superior to blind endometrial biopsy and to dilation and curettage^24,25. Diagnostic hysteroscopy with endometrial biopsy is recommended in any of the following conditions¹³:

• Persistent vaginal bleeding
• Focal or structural pathology
• Endometrium is not visualised clearly on TVUS.

Learning Bite

The majority of patients with PMB in the ED require only simple blood tests and then referral back to their GP or to an OP Gynaecology Clinic for further investigation.