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ABNORMAL VAGINAL IN PRE- AND PERI-MENOPAUSAL WOMEN A diagnostic guide for General Practitioners and Gynaecologists This guide was developed to assist general practitioners and gynaecologists in assessing pre- and peri-menopausal women with abnormal , to maximise diagnostic accuracy for endometrial . This is a general guide to appropriate practice to be followed subject to the clinicians’ judgement in each individual case, and is based on the best available evidence and expert consensus (February 2011). National Centre for The Commonwealth does not accept any legal Gynaecological liability or responsibility for any loss or damages incurred by the reliance on, or interpretation of, information contained in this guide.

RISK FACTORS and Other Tests • A undertaken at the same time as an endometrial increases the GP History (including —any changes, irregularities), Exclude Risk factors for include: • A full blood count should be undertaken. chance of an adequate sample. physical examination (including speculum and ) • History of chronic A thyroid function test should only be Exclude cervical : pap undertaken if there are indicators for • A diagnostic hysteroscopy should be and identify risk factors • Exposure to unopposed oestrogen smear and screen for . thyroid disorder. Testing for coagulation performed if a TVUS is inconclusive or recommended • Polycystic syndrome (PCOS) associated diseases such as suggests intrauterine pathology. with chronic anovulation Full blood count and if required thyroid function test / for post coital bleeding is recommended for those with indications. • Aerosol lignocaine on the significantly • Exposure to testing of women who have heavy coagulation profile reduces pain and discomfort. • Strong family history of endometrial or colon menstrual bleeding is not recommended. cancer (Lynch syndrome) (D&C) Transvaginal Ultrasound (TVUS) • If a D&C is undertaken, a concurrent Low risk / no anaemia / first episode • Nulliparity History of chronic anovulation Increased risk e.g. anaemia / • TVUS is an initial screening tool for identifying hysteroscopy should be performed. of irregular bleeding and / or PCOS persistent erratic menstrual bleeding • Obesity (often with diabetes and high and low risk; it is not a diagnostic tool. hypertension) • TVUS should be performed by an experienced DEFINITIONS Conservative treatment of abnormal vaginal bleeding and monitoring NB ‘Natural’ examiner using high quality ultrasound Abnormal vaginal bleeding: an increase in equipment and a standardised measurement Request transvaginal ultrasound (TVUS) • There is no evidence of sufficient quality frequency, duration or volume of blood loss. technique. Bleeding stops Bleeding continues Report to include endometrial thickness around the safety and efficacy of natural or Conservative treatment: the use of hormone bio-identical hormones. However, many of • TVUS is best performed in the first half of the therapy or non-hormonal pharmacological these preparations contain oestrogen and are . therapy to reduce heavy bleeding, and control irregular bleeding. More aggressive treatment Focal lesion Endometrial thickness Endometrial thickness likely to carry the same risks as other types • When a TVUS is ordered, GPs should request of HRT. Bio-identical hormones come in the that the report includes the endometrial options include the surgical options of (unrelated to cancer) Routine GP surveillance* ≤ 12 mm for Pre >12 mm for Pre form of lozenges, troches or creams. thickness. The GP should also indicate on the or . < 5 mm for Peri† ≥ 5 mm for Peri† request form the menopausal status of the Pre-: is characterised by History patient (eg. pre, peri or post). continuation of regular menstrual cycles • A medical history of the woman should be without any changes in the symptoms of Consider referral Conservative treatment of abnormal taken including the menses history, the menstruation transition or hormonal variability. to gynaecologist vaginal bleeding and monitoring nature of the current bleeding problems, • Invasive procedures should be undertaken Peri-menopause: about or around the the patient’s quality of life with respect to (when possible) by the relevant specialist menopause. The average length of this stage is the current problem and any other related (gynaecologist, gynaecological oncologist). Bleeding stops Bleeding continues 5 years. Cyclic irregularities increase as women symptoms. • If insufficient material is obtained for enter this stage with prolonged ovulatory and • Heavy bleeding and irregular bleeding a histological diagnosis, no further anovulatory cycles. Levels of follicle stimulating Routine GP surveillance* patterns should be investigated. Over 80mls investigation is required in the absence of hormone and oestradiol oscillate frequently of blood loss is considered to be heavy ongoing bleeding unless the woman has an with decreasing luteal function. menstrual bleeding. Blood loss could be endometrial thickness over 12mm for pre- refer to gynaecologist Refer to gynaecologist for endometrial biopsy (with or without hysteroscopy). measured using a pictorial blood loss chart menopausal women and 5mm for as it is quick, easy and provides a relatively peri-menopausal women ROUTINE GP SURVEILLANCE* Appointment should ideally be within 6 weeks of referral accurate way to measure menstrual blood • Adequate samples from are Practitioners should ask their patients to come Benign loss. Whether the bleeding is clinically more likely to be obtained if performed back for a follow up appointment if they notice significant should also be explored e.g. simultaneously with a hysteroscopy. any changes or have any concerns about their Negative and Insufficient sample anaemia, days off work. menstrual/ blood loss pattern. Ongoing repeat Low risk bleeding stops Diagnostic Hysteroscopy TVUS is not recommended for women in the INVESTIGATIONS absence of ongoing symptoms. Risk factors or • Diagnostic hysteroscopy is a highly specific, Negative and accurate, safe and clinically useful tool for Observe persistent bleeding Pelvic Examination bleeding continues Suspected or detecting intrauterine abnormalities and to Confirmed • A pelvic examination should be undertaken ENDOMETRIAL THICKNESS IN confirmed direct treatment at the specific pathology while PERI-MENOPAUSAL WOMEN† Treatment of Hysteroscopy and D&C malignant when a woman presents with abnormal avoiding needless surgery. pre-malignant Interpretation of endometrial thickness in the benign condition condition vaginal bleeding. The speculum examination • A thick can obscure a complete condition peri-menopausal woman is dependent on the should include the cervix and , and view of the , so to achieve optimal time of the menstrual cycle during which the Negative inspection of the . visualisation diagnostic hysteroscopy should be ultrasound is performed. Most accurate results performed in the follicular phase of the cycle. are achieved if performed on days 4–7 of cycle, when menses have ceased. refer to gynaecologiCAL ONCOLOGIST PRE-MALIGNANT: Consult with MALIGNANT: Refer to gynaecological oncologist and refer gynaecological oncologist where appropriate for management www.canceraustralia.gov.au VAGINAL BLEEDING IN POST-MENOPAUSAL WOMEN A diagnostic guide for General Practitioners and Gynaecologists This guide was developed to assist general practitioners and gynaecologists in assessing post-menopasual women with vaginal bleeding, to maximise diagnostic accuracy for endometrial cancer. This is a general guide to appropriate practice to be followed subject to the clinicians’ judgement in each National Centre for individual case, and is based on the best available evidence and expert consensus (February 2011). The Commonwealth does not accept any legal liability Gynaecological Cancers or responsibility for any loss or damages incurred by the reliance on, or interpretation of, information contained in this guide.

RISK FACTORS HISTORY Endometrial Biopsy GP History (including years since menopause and tamoxifen use), Risk factors for endometrial cancer include: • All vaginal bleeding should be investigated. • Invasive procedures should be undertaken physical examination (including speculum and pelvic examination) Exclude cervical pathology: • History of chronic anovulation • Dark, blood stained or ‘unusual for the (when possible) by the relevant specialist pap smear +/- chlamydia test (gynaecologist, gynaecological oncologist). and identification of risk factors • Exposure to unopposed oestrogen woman’ discharge is a possible symptom of endometrial cancer. However, clear or • If a patient has post-menopausal bleeding • Polycystic ovary syndrome (PCOS) yellow is usually not and an endometrial thickness of greater associated with chronic anovulation indicative of a malignant aetiology. than 4mm, an endometrial biopsy should Full blood count (where indicated) • Exposure to tamoxifen • Review the patient’s history, especially with be undertaken with an endometrial • Strong family history of endometrial or regard to risk factors, pattern of bleeding, sampling device. colon cancer (Lynch syndrome) the relationship between bleeding and the • Adequate samples from biopsies are • Nulliparity use of HRT. more likely to be obtained if performed All other women with Women on Tamoxifen • Obesity (often with diabetes and simultaneously with a hysteroscopy. post-menopausal bleeding hypertension) INVESTIGATIONS • Endometrial thickness > 8mm Diagnostic Hysteroscopy Pelvic Exam • Diagnostic hysteroscopy is a highly Request transvaginal ultrasound (TVUS) NB ‘Natural’ hormones • All women presenting with post- specific, accurate, safe and clinically useful Refer to gynaecologist tool for detecting intrauterine abnormalities Report to include endometrial thickness • There is no evidence of sufficient quality menopausal bleeding should have a pelvic (consider transvaginal ultrasound (TVUS) and to direct treatment at the specific around the safety and efficacy of natural or examination. The speculum examination prior to referral to assess for pathology while avoiding bio-identical hormones. However, many of should include the cervix and vagina, and unnecessary surgery. presence of polyps) these preparations contain oestrogen and inspection of the vulva. Endometrial thickness Endometrial thickness are likely to carry the same risks as other • Undertaking a hysteroscopy at the same ≤ 4 mm > 4 mm or focal lesions types of HRT. Bio-identical hormones come Ultrasounds time as a biopsy increases the chance of an adequate sample. in the form of lozenges, troches or creams. • Ultrasonography of endometrial thickness No Persistent bleeding alone, using best quality studies cannot • Hysteroscopy with biopsy is preferable risk factors and/or risk factors be used to accurately rule out endometrial as the first line of investigation in women Practice Points hyperplasia or carcinoma. taking tamoxifen. • Patients recover significantly faster from GP surveillance* and Tamoxifen Transvaginal Ultrasound (TVUS) outpatient hysteroscopy than from day reassessment with endometrial • Endometrial biopsy should be used case hysteroscopy, though this may not • TVUS is an initial screening tool for biopsy if persistent bleeding to assess women on tamoxifen always be available as a diagnostic tool in identifying high and low risk; experiencing vaginal bleeding, as all areas. it is not a diagnostic tool. TVUS has been shown to be neither • Aerosol lignocaine on the cervix significantly sensitive nor specific for neoplasia • TVUS should be performed by an experienced reduces pain and discomfort. refer to gynaecologist Refer to gynaecologist for endometrial biopsy (with or without hysteroscopy). in these women. examiner using high quality ultrasound Appointment should ideally be within 6 weeks of referral equipment and a standardised measurement HRT technique. Dilation and Curettage (D&C) Benign • Vaginal bleeding or spotting may be • When a TVUS is ordered, GPs should request • If a D&C is undertaken, a concurrent an expected side effect of HRT, thus that the report includes the endometrial hysteroscopy should be performed. Negative and Insufficient sample Low risk routine evaluations of the endometrium thickness. The GP should also indicate on the bleeding stops are not essential in the first 6 months. request form the menopausal status of the GP SURVEILLANCE* Risk factors or However, if bleeding persists after the patient (eg. pre, peri or post). Negative and Practitioners should ask their patients to Observe persistent bleeding initial 6 months, evaluation should be • For patients on sequential HRT, TVUS bleeding continues Suspected or come back for a follow up appointment if Confirmed undertaken. Bleeding outside the time of measurements should take place during confirmed they notice any changes, have any concerns malignant progestin withdrawal is deemed atypical the first half of the cycle. Hysteroscopy and D&C pre-malignant for women using cyclic progestins, and or experience further bleeding. condition Treatment of condition requires investigation. Ongoing repeat TVUS is not recommended for women in the absence of ongoing benign condition Negative DEFINITIONS Post-menopausal bleeding: spontaneous symptoms. vaginal bleeding that occurs more than one year after the last episode of bleeding. refer to gynaecologiCAL ONCOLOGIST PRE-MALIGNANT: Consult with MALIGNANT: Refer to gynaecological oncologist and refer gynaecological oncologist where appropriate for management www.canceraustralia.gov.au