Model essay. Postmenopausal bleeding.

A woman if referred by her General Practitioner with post-menopausal bleeding. Critically evaluate the management.

Answer.

About 10% of women with post-menopausal bleeding (PMB) have genital tract cancer, usually endometrial, though all gynaecological cancers can present in this way.

Department of Health guidelines stipulate that urgent referral (being seen within 2 weeks) applies to women over the age of 55, not on HRT , who have had repeated episodes of bleeding or a single heavy bleed.

Other cases must be seen “early”, i.e. within 4 – 6 weeks, although in practice all women with PMB tend to be seen urgently.

Ideally these women should be seen in a dedicated PMB clinic with suitably trained staff and facilities for transvaginal scanning (TVS) and outpatient hysteroscopy and endometrial sampling.

PMB generates much anxiety and staff should be trained to provide support and counselling.

Early appointments and appropriate information leaflets, e.g. relating to what will be done when attending the clinic and why, will help to alleviate anxiety.

Reassurance about the good outcomes of treatment of most gynaecological cancers diagnosed early is also helpful.

A history should be taken.

It should ensure that the bleeding is vaginal and not rectal or urethral.

It should look for factors that point to the presence of malignancy.

E.g. the duration of the bleeding and repeated or prolonged episodes of bleeding (though the SIGN document on PMB says that the pattern of bleeding does not correlate well with the risk of malignancy), associated symptoms: foul-smelling discharge, post-coital bleeding and the interval from the menopause, the longer the interval, the greater the risk, etc.

Pelvic pain can be due to secondary spread.

A history of treated genital tract malignancy or pre-malignancy is a risk factor, as is belonging to a Lynch type II (HNPCC) family, which gives about a 60% risk of endometrial cancer and for which there is yet no screening programme.

BRCA1 & 2 increase the risk of ovarian cancer, which can present with PMB.

Unopposed oestrogen in HRT or PCOS increases the risk as does tamoxifen.

It is important to check the cervical smear history.

Other risk factors like hypertension, obesity and diabetes are often quoted, but they are relatively weak.

The history should look for benign explanations: warfarin use, HRT and bleeding that is related to coitus in a patient with vaginal soreness and dryness, who may simply have atrophic vaginitis.

The history should look for factors that might complicate investigation or treatment, particularly if general anaesthesia is needed, e.g. heart failure, severe COAD or drug therapy like warfarin, digoxin or steroids.

General examination may raise suspicion of 1^ry or 2^ry disease: abdominal mass, ascites, cachexia, lymphadenopathy.

It might detect disease that could complicate investigation or treatment: thyrotoxicosis, heart failure etc.

It might identify other possible causes of the bleeding: e.g. generalised bruising due to a coagulation defect or leukaemia in conjunction with splenomegaly and lymphadenopathy.

Gynaecological examination should look for evidence of malignancy: ulceration, masses etc. and for possible benign causes: polyps, atrophic vaginitis and so on.

A smear should be taken if not done recently.

TVS is a huge advance in managing PMB. It looks for masses like ovarian tumours and possible benign causes like sub-mucous fibroids.

Crucially, it measures endometrial thickness (ET). If this is < 4 mm., there is little or no risk of endometrial malignancy.

Hospitals will use 4 or 5 mm. as a cut-off level. If the ET is less and no other problem has been identified, the woman is reassured that there is minimal risk of pathology and discharged, although advised that recurrence of the PMB could happen and should be reported promptly to her GP.

ET > 4 of 5 mm. is investigated with hysteroscopy and endometrial biopsy, using the Pipelle.

D&C without hysteroscopy is no longer an acceptable method of investigation.

Subsequent investigation and treatment will depend on whether or not pathology is identified.

At one extreme the patient may be discharged, as above.

At the other she might need major treatment such as Wertheim’s hysterectomy, radiotherapy and chemotherapy.

PMB is a suitable subject for audit and patient satisfaction surveys.

Words: 644.

If you can think of any improvements to this essay, please let me know.

I wrote the following from scratch in 20 minutes.

I took a minute or two to re-read it and add a couple of bits.

This means that I would have saved about 4 minutes in the exam for a more difficult essay.

You will be able to do the same if you prepare a model essay and transfer its plan to a card.

If you have rehearsed the card often enough and the essay comes up in the exam, you will have a big smile on your face.

In the exam you will be given a template.

This tells you what will get marks.

There will be three or four sections.

So you are unlikely to asked to write everything that is here.

Each section will have a number of marks allocated.

This tells you how many points you need to make.