POSTMENOPAUSAL bleeding is bleeding occurring 1 year after menopause and has an incidence of 10 percent and a 10-15 percent risk of cancer, most endometrial cancers present with postmenopausal bleeding with the incidence being as high as 90 percent.

Bleeding can be due to many causes, but due to the risk of cancer should be investigated as soon as possible by a gynaecologist with an interest in Gynaecological oncology.

Causes are numerous and include: 1. The lining of the womb can be abnormally thickened, this is called endometrial hyperplasia and depending on how abnormal it is one can have an increased risk of cancer.

2. Endometrial polyps are a common cause of bleeding and can be associated with at least 40 percent of bleeding, most polyps are not cancerous, however some can be cancerous, in these instances blind biopsies might give a false reassurance, as a result it is recommended that these polyps be removed under direct vision by a procedure called hysteroscopy where a camera is placed in the womb, preferably in an outpatient setting.

3. Endometrial cancer is where the lining of the womb develops into a cancer and 90 percent of cancers present with bleeding.

4. Cervical causes include cervical cancer, cervical growths called polyps.

5. Vaginal causes commonly include a thinned vaginal tissue a condition called atrophic vaginitis where there is a lack of oestrogen and the vagina can be subject to being easily traumatised and bleed.

6. Vulval causes are rare and include vulval cancer.

On presentation a gynaecological history is taken, other factors noted like BMI are taken. The genitals are inspected, a speculum examination is done to rule out local causes like cervical lesions and thinning of the vaginal tissue.

An internal scan (Trans-vaginal ultrasound) is done to look at the uterus and ovaries, the lining of the womb should be thin, however if it is thickened equal to or over 4mm then a biopsy is to be performed.

If the lining of the womb is thickened the current gold standard is the patient to have an outpatient hysteroscopy (camera in the womb) and a directed biopsy. If a polyp is found, then it should be removed under direct vision, this is to make sure that it is completely removed, as some polyps can contain cancer.

If the endometrial lining is thin then the patient can be safely discharged, but should be informed that if the bleeding re-occurs they should be advised to come back again, on that presentation they would have a hysteroscopy and biopsy done, this is because rare forms of endometrial cancer can present with a thin endometrium.

If the biopsy is negative, then the patient is discharged, but should be given information that if it occurs then they should come back to be investigated again.

In summary post-menopausal bleeding is signifi cant as it can carry a risk of 10-15 percent risk of cancer and prompt investigation and management is needed to rule this out. Patients should be seen in speciality clinics by gynaecologists with an interest in Gynaecological Oncology to streamline care to offer patients the best management options and triaging, outpatient hysteroscopy is the gold standard for investigation of postmenopausal bleeding.

Dr John Barker Bsc MBBS MRCOG, Dip (Risk Management). Obstetrician/ Gynaecologist at Arnos Vale Medical Center, Consultant Obstetrician/ Gynaecologist UK He has completed the Advanced Training Skills Module in Gynaecological Oncology in the UK and runs gynaecological oncology clinics for diagnosis and management of suspected and confirmed female genital cancers.