1. Post-menopausal bleeding Definition –Any vaginal bleeding after a period of amenorrhoea of 6 months or more in the perimenopausal age group –Menstruation after age 55 years –Vaginal bleeding in the presence of raised FSH and LH values in perimenopausal age group

2. Aetiology “danger” table Carcinomas (Cx, endometrium, sarcomas) Submucous fibroids Endometrial polyps Oestrogen therapy Bleeding from bladder or rectum Trauma Atrophic endometritis

3. Aetiology “frequency” table Atrophic endometritis 40-45% Malignancies 25% –Endometrial carcinoma –Cervical carcinoma –Uterine sarcomas –Endometrial hyperplasia Polyps and fibroids 10-15% Hormone therapy 25% Other disorders 10%

4. Approach to patient with PMB History –“Full”, of bleeding, medication, trauma, climacteric complaints, medical status, operations Examination –General and systemic, abdomen –Note obesity, diabetes, anemia, hypertension –Gynaecologic: inspection, speculum, e/e smear, bimanual examination

5. Special tests Endometrial thickness measurement on ultrasound –Side-to-side 4mm or less: 97% chance for atrophy Endometrial sampling –Outpatient procedure, small vacuum pipettes D&C and hysteroscopy –If not possible to do sampling in office

6. Management Treat the cause Atrophy: topical or systemic oestrogens Polyps or fibroids: usually hysterectomy Hyperplasia: P Rx or hysterectomy Malignancies: treat as for specific type Follow-up