Postmenopausal bleeding — structured SAQ (15 marks)

(a) Definition and cancer risk (3 marks)

• Definition (1 mark): postmenopausal bleeding is any vaginal bleeding occurring 12 months or more after the last menstrual period.^[1]
• Cancer risk (1 mark): the pooled endometrial-cancer risk is about 9% (95% CI 8-11%).^[1]
• Source (1 mark): the Clarke 2018 systematic review and meta-analysis (JAMA Internal Medicine; 129 studies, 40,790 women), and about 91% of endometrial cancers present with PMB.^[1]

(b) Source-by-source assessment (3 marks)

• History (1 mark): confirm genuine menopause, elicit volume, duration, tamoxifen and risk factors, and screen for urinary and rectal sources.^[1]
• Examination (1 mark): abdominal palpation, speculum to visualise the cervix and vagina, vulval inspection, and bimanual for an adnexal mass.
• Rationale (1 mark): endometrial cancer accounts for only about 10% of PMB — a cervical, vulval, vaginal, ovarian or non-gynaecological source must be excluded before attributing the bleed to the endometrium.

(c) Ultrasound interpretation and sampling (4 marks)

• Threshold (1 mark): a double-layer thickness of 6 mm exceeds the 4 mm low-risk cut-off; sampling is indicated (Karlsson: at 4 mm or less the residual risk is about 5.5% and no cancer was thinner than 5 mm).^[2]
• Focal lesion logic (1 mark): a focal lesion makes a blind Pipelle inadequate — the correct escalation is saline contrast sonohysterography or hysteroscopy with a directed biopsy.
• Evidence (2 marks): against hysteroscopy as the reference standard, blind sampling sensitivity is about 90% for cancer and 82% for atypical hyperplasia but only 39% for any endometrial disease including polyps (van Hanegem 2016) — a blind biopsy can miss a focal cancer.^[3]

(d) Atypical hyperplasia management (3 marks)

• Definitive management (2 marks): under RCOG Green-top 67, atypical hyperplasia / EIN is a premalignant lesion; for a woman not seeking fertility the definitive management is hysterectomy, with fertility-sparing high-dose progestin under a gynae-oncology MDT only if fertility is desired.^[4]
• Justification (1 mark): the risk of concurrent endometrial carcinoma is high — about 43% at hysterectomy in the Trimble 2006 GOG series — so observation or incomplete sampling is unsafe.^[4]

(e) Tamoxifen caveat (2 marks)

• Mechanism (1 mark): tamoxifen is a partial endometrial oestrogen agonist that raises endometrial-cancer risk (NSABP B-14 relative risk about 7.5) and causes polyps and subendometrial cysts.^[5]
• Interpretation (1 mark): subendometrial cysts can artefactually inflate the measured thickness, so the 6 mm result must be interpreted with caution — but the bleed itself still drives investigation; bleeding on tamoxifen is PMB.^[5]