Postmenopausal bleeding: investigation pathway, endometrial-cancer risk and the RCOG GTG 67 hyperplasia interaction

A 63-year-old woman tells you she has had "a brownish smear" for two days, a year after her last period. The temptation is to reassure her that "at this age it's just atrophy". Do not. That smear carries the same endometrial-cancer risk as a heavy bleed — about 9% — and PMB is the symptom that captures roughly 90% of endometrial cancers. Your job is to run a structured one-stop workup, exclude cancer, and treat the cause. This topic is the investigation pathway.[1][4]

Overview and definition

PMB is an umbrella term for any vaginal bleeding, however small, that happens 12 months or more after the last menstrual period. The 12-month anchor matters: a woman who is still menstruating is perimenopausal, not postmenopausal, and her bleeding is worked up as reproductive-age abnormal uterine bleeding (cross-link to the AUB topic). Once she has passed 12 months of amenorrhoea, any bleeding is PMB and is cancer until proven otherwise.[1][12]

The definition deliberately casts a wide net, because the signal-to-noise trade-off favours over-investigation:[1]

• Most PMB is benign — atrophy is the commonest cause — but the minority that is cancer is early and curable if found.
• Volume does not predict malignancy. A spot, a smear, a single episode and a heavy bleed carry the same cancer risk.
• PMB is the gateway symptom. About 91% (95% CI 87-93%) of women with endometrial cancer report it.[1]