Assessment and Management of Postmenopausal Bleeding (PDF)

QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding This Quick Summary Document (QSD) is a resource for all cl...

QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding This Quick Summary Document (QSD) is a resource for all clinicians working in healthcare in Ireland who are involved in the care of women with postmenopausal bleeding (PMB). Following a comprehensive literature review a number of evidence-based recommendations for management of postmenopausal bleeding were agreed upon. Key Recommendations 1. We recommend that menopause should be defined as the final menstrual period followed by 12 months of amenorrhoea. 2. We recommend that postmenopausal bleeding in women not taking hormone replacement therapy is defined as an episode of vaginal bleeding occurring 12 months or more after the final menstrual period. 3. We suggest that assessments should aim to identify and monitor the multiple identifiable risk factors associated with endometrial cancer. 4. We recommend that vaginal, vulval and cervical cancers are also considered in the differential diagnosis for women presenting with postmenopausal bleeding. 5. We recommend that urological and gastrointestinal cancers are also considered in the differential diagnosis for women presenting with bleeding that is thought to be coming from the genital tract. 6. We recommend that all women presenting with postmenopausal bleeding in the general practice setting should undergo a focused history and examination, including a vaginal and speculum examination, prior to referral to gynaecological services. 7. We recommend that all women with postmenopausal bleeding who are not on HRT require referral for investigation. 8. We recommend that all women with abnormal bleeding on HRT require referral for investigation. 9. We recommend that all women with abnormal bleeding on Tamoxifen require referral for investigation. 10. We recommend that women referred for investigations of postmenopausal bleeding should be seen within gynaecology units within 28 days. 11. We suggest that where possible, women referred for investigation of postmenopausal bleeding or abnormal uterine bleeding on HRT should be seen in an Ambulatory Gynaecology clinic. 12. We recommend that all gynaecology services should be able to assess and investigate women with postmenopausal bleeding. Where comprehensive ambulatory services are not yet available, in the interim, there should be a managed fast-track pathway for women with postmenopausal bleeding. 13. We recommend that all women referred for investigation of postmenopausal bleeding or abnormal uterine bleeding on HRT should undergo a transvaginal pelvic ultrasound to assess the thickness and features of the endometrium. 14. We recommend that women with postmenopausal bleeding with an endometrial thickness of ≥4mm should undergo endometrial sampling. 15. We recommend that a diagnostic hysteroscopy should be carried out where transvaginal ultrasound has detected focal endometrial pathology, or the endometrial thickness is greater than 4mm. 1  QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding 16. We recommend that women on Tamoxifen with abnormal uterine bleeding are offered diagnostic hysteroscopy with endometrial sampling as transvaginal ultrasonography for assessment of the endometrium in these women is a not a useful tool for triage. 17. We suggest that transabdominal ultrasound should be used to compliment transvaginal ultrasound where there is an enlarged uterus or pelvic mass. 18. We recommend that isolated dilation and curettage should not be used as the first line method for obtaining endometrial samples in the investigation of postmenopausal bleeding. 19. We recommend that endometrial sampling in the form of office-based biopsy is used in conjunction with transvaginal ultrasound with or without hysteroscopy for the investigation of women with postmenopausal bleeding. Blind endometrial sampling in isolation is not sufficient for investigation. 20. We recommend that the vaginoscopic approach should be the standard technique in outpatient hysteroscopy as it is better tolerated by the woman when compared to conventional hysteroscopy techniques. 21. We suggest that women with no contraindications can be advised to consider taking a non-steroidal anti- inflammatory drug (NSAID) 1-2 hours prior to their hysteroscopy to reduce post-procedure pain. This should be communicated to them in their appointment letter. 22. We recommend that hysteroscopy and repeat endometrial biopsy should be considered in women who experience unexplained, persistent, or recurrent postmenopausal bleeding in the setting of prior reassuring investigations. A low threshold for reinvestigation of these women should be maintained. Care of this patient group should be guided by a consultant Gynaecologist. 23. We suggest that in postmenopausal women without bleeding, transvaginal ultrasound findings of increased endometrial thickness ≥ 11mm requires further investigation. 24. We recommend that women taking HRT should be referred for investigation if their bleeding is persistent. 25. We recommend that women taking sequential HRT should be referred for investigation if they experience irregular bleeding despite adjustment, more than 3 months of commencing treatment, or if their bleeding increases in heaviness or duration. 26. We recommend that women taking continuous combined HRT should be referred for investigation if they experience bleeding beyond six months of commencing therapy, or if bleeding occurs after a significant spell of amenorrhoea. Where additional risk factors exist clinical discretion may warrant earlier referral. 2  QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding Algorithm Presenting Complaint Patient attends GP with suspected vaginal bleeding GP Diagnosis Bleeding Not Vaginal in After a thorough history Origin Recurrent PMB and examination including GP management or onward gynaecological examination referral where deemed the GP diagnoses PMB appropriate GP Referral Vaginal bleeding on Same day referral by GP to hospital via electronic patient sequential HRT – increase referral system requesting Fast Track PMB heaviness or duration of bleeding, or bleeding irregular Vaginal bleeding on Triage System continuous combined Weekly or twice weekly review of referrals. Patients who meet HRT – bleeding beyond PMB criteria are fast tracked into appointment system and six months of therapy, or given appointment to be seen within 28 days. bleeding after amenorrhoea Ambulatory Gynaecology Clinic One-stop clinic where patients can undergo transvaginal ultrasound, outpatient endometrial sampling and hysteroscopy. Patients can be seen and treated in one session. Theatre Patients who are unable to complete their investigations in ambulatory gynaecology clinics will have these done in the operating theatre. End of Diagnostic Pathway Endometrial cancer ruled out with normal endometrium on hysteroscopy or negative endometrial biopsy. Patients diagnosed with endometrial cancer are referred into gynaecology oncology services. 3  QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding Auditable standards Audit using the key recommendations as indicators should be undertaken to identify where improvements are required and to enable changes as necessary, and to provide evidence of quality improvement initiatives. Auditable standards for this Guideline include: 1. Time from first GP/community practitioner presentation to referral being made by GP/community practitioner to gynaecology services 2. Time from referral being made by GP/community practitioner to appointment date being given hospital services 3. Number of cases completed in one Ambulatory Gynaecology clinic visit 4. Number of cases that could not be completed in Ambulatory Gynaecology and subsequently required inpatient investigations and management. 5. The time from incomplete outpatient investigations to complete inpatient investigations and management 6. Number of women who took pre-procedure analgesia and their reported pain scores during and after hysteroscopy 7. Percentage of adequate endometrial samples 8. False negative investigation outcome 9. Timeline from referral to cancer diagnosis and to cancer treatment 10. Unscheduled hospital admissions following Ambulatory Gynaecology appointment for a related clinical event 11. Patient experience 12. The number of women who withdraw from the diagnostic track Recommended reading: 1. HSE Nomenclature for Clinical Audit – https://www.hse.ie/eng/about/who/nqpsd/ncca/nomenclature-a- glossary-of-terms-for-clinical-audit.pdf 2. HSE National Framework for developing Policies, Procedures, Protocols and Guidelines at https://www.hse. ie/eng/about/who/qid/nationalframeworkdevelopingpolicies/ 3. Clarke MA, Long BJ, Del Mar Morillo A, Arbyn M, Bakkum-Gamez JN, Wentzensen N. Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta- analysis. JAMA Intern Med. 2018 Sep 1;178(9):1210-22. https://pubmed.ncbi.nlm.nih.gov/30083701/ 4. Munro MG, Southern California Permanente Medical Group’s Abnormal Uterine Bleeding Working Group. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. Perm J. 2014;18(1):55-70. https://pubmed.ncbi.nlm.nih.gov/24377427/ 5. Bachmann LM, ter Riet G, Clark TJ, Gupta JK, Khan KS. Probability analysis for diagnosis of endometrial hyperplasia and cancer in postmenopausal bleeding: an approach for a rational diagnostic workup. Acta Obstet Gynecol Scand. 2003 Jun;82(6):564-9. https://pubmed.ncbi.nlm.nih.gov/12780428/ 6. Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA. 2002 Oct 2;288(13):1610-21. https://pubmed.ncbi.nlm.nih.gov/12350192/ 7. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2004 Oct;24(5):558-65. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.1704 Authors Duffy A, Ní Bhuinneain M, Burke N, Murphy C. National Clinical Practice Guideline: Assessment and Management of Postmenopausal Bleeding. National Women and Infants Health Programme and The Institute of Obstetricians and Gynaecologists. December 2022 https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/ https://www.rcpi.ie/faculties/obstetricians-and-gynaecologists/national-clinical-guidelines-in-obstetrics- and-gynaecology/ 4  QUICK SUMMARY DOCUMENT Assessment and Management of Postmenopausal Bleeding 5