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Unexplained postmenopausal bleeding — MSRA MCQ

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Moderateall topics relevant for this examUnexplained postmenopausal bleedingMSRA

A 55-year-old woman consults after noticing a small amount of bright-red vaginal spotting when wiping this morning. Her last menstrual period was 13 months ago. She has no pelvic pain, vaginal discharge, urinary symptoms, rectal bleeding or unintentional weight loss. She is not using HRT or tamoxifen. Speculum examination is unremarkable, and her cervical screening test was high-risk HPV negative 10 months ago. What is the most appropriate next step?

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Correct answer: A — Arrange a suspected cancer pathway referral for endometrial cancer

This is postmenopausal bleeding: vaginal bleeding occurring more than 12 months after menstruation has stopped. She is aged 55 years and the bleeding is unexplained because it cannot be attributed to HRT or an identified benign cause. NICE recommends a suspected cancer pathway referral for endometrial cancer in this situation. A single, scant episode does not reduce the required referral urgency. A routine gynaecology referral is insufficient because NICE specifies the suspected cancer pathway at age 55 years or over. Urgent direct-access ultrasound is recommended by NICE for a different presentation: unexplained vaginal discharge or visible haematuria in older people with specified additional features; it does not replace the pathway referral for unexplained postmenopausal bleeding. Repeat cervical screening is inappropriate: a recent negative HPV result and a normal cervix do not evaluate the endometrium. Vaginal atrophy is a possible benign cause, but in this case there are no examination findings establishing it, so empirical topical oestrogen must not delay assessment for endometrial cancer.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer, Endometrial cancer (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG12: Suspected cancer: recognition and referral — Recommended actions organised by symptom and findings of primary care investigations (Updated 15 April 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations