A 61-year-old woman who went through the menopause some years ago reports light vaginal spotting together with discomfort and bleeding after intercourse. On examination the cervix looks healthy and the vaginal walls appear pale, thinned and glistening. A transvaginal scan reports a normal-sized uterus and an endometrium measured at 2.5 mm. Which treatment is most appropriate for her symptoms?

Answer: B. Topical (vaginal) oestrogen for atrophy

PMB due to atrophy

This woman has the classic picture of genital atrophy: thin, shiny vaginal epithelium, dyspareunia, post-coital spotting, a small uterus and a thin endometrium (ET 3 mm, i.e. <=4 mm).

Why topical oestrogen

• By the diagnostic algorithm, an ET <=4 mm with no focal lesion is low risk, so no further endometrial sampling is needed and the underlying cause is treated.
• Atrophic vaginitis/endometrial atrophy is the commonest cause of PMB, and is treated with topical (vaginal) oestrogen, which restores the epithelium and relieves symptoms.

Why not the others

Hysterectomy/BSO and chemotherapy are gross over-treatment for benign atrophy; with a thin endometrium an endometrial biopsy is not mandated (the algorithm allows treating the cause); the COC is not appropriate management for atrophic PMB in a postmenopausal woman.

Caveat

If bleeding persists despite treatment, re-evaluate with sampling - persistent PMB always warrants endometrial assessment regardless of initial thickness.