How often is PMB due to malignancy?
Q - What is the chance of a woman with a one-off episode of postmenopausal bleeding (without any other suggestive features in the history) of having endometrial cancer?
A - Numerous studies have looked at the risk of endometrial cancer in women who suffer from postmenopausal bleeding (PMB). Their risk ranged from 5 to 50 per cent.
Although the studies did not separate out women who had a single episode of PMB from those who had several episodes, most were investigated soon after their initial presentation.
One study attempted to predict low-risk women, excluding those with certain risk factors, and still found a risk of malignancy of 3 per cent. In addition a significant number of women were found to have complex endometrial hyperplasia a condition that should be regarded as pre-malignant.
The risk of malignancy in postmenopausal women who have even a single episode of PMB is therefore too high to ignore, and they should therefore be referred for further investigation.
This also applies to all women on HRT who have any abnormal bleeding. Some studies suggest that the risk of endometrial cancer may be increased in women on HRT, even with the addition of a progestin.
Further investigation will depend on an individual woman's risk of malignancy and any risks of further investigation. In particular, women should not be given unopposed topical oestrogens until a malignancy or complex hyperplasia has been excluded, even though such conditions as atrophic vaginitis are a common diagnosis.
Professor Ian Jacobs is
consultant in gynaecology,
and Mr Barnaby Rufford is
clinical research fellow,
gynaecological oncology unit,
St Bartholomew's Hospital, London