Dr Chris Barclay welcomes the new SIGN guidance on the management of women with bleeding after the menopause
SIGN has recently issued guidelines, based on current best practice, for clinicians in both primary and secondary care on the management of women with post-menopausal bleeding (PMB).
The guideline, Investigation of post-menopausal bleeding, defines PMB as an episode of vaginal bleeding occurring 12 months or more after the last period.
The incidence of endometrial cancer is low before the age of 50 years but rises rapidly thereafter, peaking in the 60-69 year age group. PMB, on the other hand, is much more common in the early postmenopausal years. The consequence is that the chance of PMB signifying endometrial cancer is much higher in older women.
In women aged 50-59 years, 14.3 in 1000 will experience PMB each year; and yet the incidence of endometrial cancer is just 6.36 in 100 000.
Tamoxifen increases the risk of developing endometrial cancer, which is also more common in women with a family history of hereditary non-polyposis colorectal cancer.
Previously, all women with PMB were referred to a gynaecologist and offered uterine curettage (D&C). This is no longer the case as it is now clear that D&C is a very insensitive test. Most evidence at present favours the use of transvaginal ultrasonography as the initial investigation.
The principal investigation in primary care is pelvic examination. In secondary care several options may be available. These include transvaginal ultrasonography (to measure the thickness and define the character of the endometrium), endometrial biopsy, curettage and hysteroscopy. Some units have set up one-stop PMB clinics where all these are available. SIGN gives guidance to gynaecologists on the place of each of these investigations.
I found the guideline most useful because it offers solid advice for a number of common clinical situations:
- True PMB: The risk of endometrial cancer rises with age, so all older women should be referred.
- Abnormal premenopausal bleeding: This is only rarely a sign of endometrial cancer except in women with hereditary non-polyposis colorectal cancer.
- Abnormal perimenopausal bleeding: This is a common situation at a time when endometrial cancer is uncommon - manage as with true PMB but refer if it is persistent or accompanied by worrying features.
- Abnormal bleeding in sequential HRT users: Consider referral if bleeding is heavy or prolonged at the end or after the progestogen phase or if there is breakthrough bleeding.
- Abnormal bleeding in continuous combined HRT users: This is not uncommon in the first few months of therapy - refer if it occurs after 6 months of use or 6 months of established amenorrhoea.
- Recurrent PMB: For women who experience further episodes of PMB, consider reinvestigating if more than 6 months have elapsed since the last investigation.
- Tamoxifen and endometrial cancer: Screening asymptomatic women has not been shown to be beneficial, but refer all patients with PMB.
PMB is common, but endometrial cancer is the cause in only around 10% of cases. GPs should balance the risks of disease in each woman. Not all cases need immediate referral but PMB in older women, those on tamoxifen, with sinister signs or if the patient wishes it, should be referred.
The advice provided by this SIGN guideline is both useful and pragmatic.
Scottish Intercollegiate Guidelines Network. SIGN 61: Investigation of post-menopausal bleeding. A national clinical guideline. Edinburgh: SIGN, October 2002. The guideline can be downloaded from the SIGN website: www.sign.ac.uk