We hope this newsletter finds you in good health. Today, we delve into an important topic that impacts many women as they age: post-menopausal bleeding. While this symptom can often have benign causes, it is crucial to consider and rule out endometrial cancer as a potential underlying issue. In this edition, we will explore the differential diagnosis of post-menopausal bleeding and discuss the various types of endometrial cancer along with their management options.

Post-menopausal bleeding refers to vaginal bleeding that occurs after a woman has undergone menopause, which typically happens around the age of 50. Menopause is defined as a point in time 12 months after a woman’s last period. Any episode of bleeding in this phase of life should be taken seriously and evaluated promptly by a healthcare provider.

In addition to a thorough medical history and physical examination, the following tests may be used to diagnose uterine cancer:

• Pelvic examination: The doctor feels the uterus, vagina, ovaries, and rectum to check for any unusual findings.

• Endometrial biopsy: the doctor removes a small sample of tissue with a very thin tube. The tube is inserted into the vagina to reach the uterus through the cervix, and the tissue is removed with suction. 

• Transvaginal ultrasound: an ultrasound wand is inserted into the vagina and aimed at the uterus to take pictures. If the endometrium looks too thick, the doctor may decide to perform a biopsy.

• Dilation and curettage (D&C): A D&C is a procedure to remove tissue samples from the uterus. The patient is given anesthesia during the procedure to block the awareness of pain. A D&C is often done in combination with a hysteroscopy so the doctor can view the lining of the uterus during the procedure.

• Computed tomography (CT or CAT) scan: takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-dimensional image that shows any abnormalities or tumors.

• Magnetic resonance imaging (MRI): produces detailed images of the inside of the body using magnetic fields, not x-rays. MRI can be used to measure the tumor’s size. 

• Biomarker testing of the tumor: tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. This may also be called molecular testing of the tumor. Results of these tests can help determine whether surgery is performed in Penticton or you are referred to Vancouver for surgery. 

Several factors can contribute to post-menopausal bleeding, ranging from benign to potentially malignant causes. Some common differential diagnoses include:

1. Atrophic Vaginitis: Thinning of the vaginal tissues due to decreased estrogen levels, leading to vaginal bleeding.

2. Endometrial Atrophy: Thinning of the endometrial lining, often related to hormonal changes.

3. Endometrial Polyps: Non-cancerous growths in the uterus that can cause bleeding.

4. Endometrial Hyperplasia: An overgrowth of the endometrial lining, which can sometimes progress to cancer.

5. Endometrial Cancer: Malignant growth in the lining of the uterus.

6. Non-gynecologic causes such as from the bladder or rectum

Given the potential severity of some of these conditions, a thorough evaluation is essential.

Endometrial cancer is the most common gynecological cancer in Canada. An estimated 8,100 Canadian women were diagnosed in 2022. It primarily affects post-menopausal women, making it a significant concern in the context of post-menopausal bleeding. There are two primary types of endometrial cancer:

1. Type 1 (Endometrioid Endometrial Cancer): This is the most common type, typically associated with hormonal imbalances and obesity. It tends to have a favorable prognosis when diagnosed at an early stage.
2. Type 2 (Non-Endometrioid Endometrial Cancer): This includes various subtypes such as serous and clear cell carcinomas. Type 2 cancers are often more aggressive and less responsive to hormonal influences.

The management of endometrial cancer depends on several factors, including the type and stage of cancer, the patient's overall health, and their desire for fertility preservation. Treatment options may include:

• Surgery: Typically involves a hysterectomy (removal of the uterus) and sometimes removal of nearby lymph nodes. This is often curative for early-stage cancers.

• Radiation Therapy: Used in some cases to target cancer cells or reduce the risk of recurrence.

• Chemotherapy: May be recommended for advanced-stage or aggressive cancers.

• Hormone Therapy: In certain situations, hormone therapy may be employed, particularly for Type 1 cancers.