ODOBGYNDECODED

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Postmenopausal bleeding

Bleeding in pregnancyAbdominal pain in pregnancyReduced fetal movementsHeadache + high BP in pregnancy/postpartumFever in pregnancy/postpartumDyspnoea in pregnancyVaginal discharge / cervicitisAcute pelvic pain (non-pregnant)Postmenopausal bleedingInfertility evaluation
Immediate red flags:
  • Heavy/repeated PMB
  • On tamoxifen
  • Palpable pelvic mass
  • Suspicious cervical lesion
Urgent workup:
  • TVS endometrial thickness
  • Outpatient pipelle biopsy
  • Hysteroscopy if failed/inconclusive

Structured differential — act in priority order

PriorityConditionKey featuresAction
CANNOT MISS
Endometrial carcinoma/hyperplasia
Thickened endometrium/risk profile
Oncology pathway →
CANNOT MISS
Cervical cancer
Contact bleeding/lesion
Biopsy + staging referral →
COMMON
Atrophic endometrium/vaginitis
Thin friable tissues, thin endometrium
Treat AFTER biopsy excludes malignancy
COMMON
Polyps
Focal lesion on US/saline scan
Polypectomy with histology
CONSIDER
HRT-related
Regimen timing correlation
Investigate first, then adjust regimen

First moves

  1. Every PMB investigated - never assume HRT/atrophy without sampling