Approach To A Patient With Post Menopausal Bleeding

MCPS Family Medicine ( Sample Questions)

A 55 year old diabetic lady presents with post menopausal bleeding for 1 month. She had menopause at the age of 50 years. She has 2 children. On examination she is a healthy looking obese lady. Her abdominal and pelvic examination are normal.

1. What further in history needs to be elaborated?
2. What are the most likely differentials?
3. Outline the relevant investigations and management plan?

Question Solved:



1. What further in history needs to be elaborated?

Answer: The patient should be asked about:

• The duration of bleeding
• The amount and flow of bleeding
• Any associated pain
• Any previous episodes of bleeding since her menopause.
• Is she sexually active / recent changes in sexual practices 
• Use of any hormonal medications.
• When was the last pap smear done and what was the result.
• Any history of recent trauma to the pelvic region. 
• Any abnormal urinary symptoms like burning or pain in the flanks ( blood may be urinary in origin confused for vaginal bleeding)
• Any history of blood in stools ( rule out rectal bleeding) 
• Family history of uterine, cervical or ovarian cancer

2. What are the most likely differentials?

Answer: Differential Diagnosis for Post Menopausal Bleeding;

• Atrophic vaginitis  ( most common cause) 
• Endometrial hyperplasia ( Obesity may be the cause of this problem)
• Endometrial carcinoma
• Uterine fibroids / polyps
• Infection of the uterine lining (endometritis)
• Cancer of the cervix or vagina
• Medications such as hormone therapy or tamoxifen 
• Pelvic trauma
• Bleeding from the urinary tract or rectum mistaken for vaginal bleeding

3. Outline the relevant investigations and management plan?

Answer:

Investigations: needed in this patient include:

• Complete blood count ( decreased Hb indicates anemia and excess blood loss, Increased WBC count indicates infection)
• Transvaginal ultrasound  ( rule out any pathology in the pelvic organs including fibroids or polyps)
• Pap smear to screen for cervical cancer
• Endometrial biopsy to rule out endometrial cancer. 
• Urine D/R and stool D/R to rule out urinary or gastrointestinal causes of bleeeding.

Management plan: depends upon the result of the investigations :

1. Give iron supplements to correct anemia if present.

2. Estrogen creams can help if the cause of bleeding is only atrophic vaginitis.

3. If a local pathology is found like a polyp or fibroid surgical removal may be needed.
4. Endometrila hyperplasia may be treated with progesterone supplements or surgery to remove the thickened areas of endometrium.

5. In case of endometrial carcinoma a total hysterectomy along with removal of ovaries and fallopian tubes may be needed as well as followup for any metastasis is required.