Should a gynaecologist examine me for postmenopausal bleeding before ultrasound?

[Alicay]

Had 3 days of PMB/cramps & wasnt able to see GP on Monday so saw a private gynae today (Wed). He said he wasn't concerned and booked me in for an ultrasound in 2 weeks. He didn't physically examine me at all and I'm really concerned that he didn't - surely he should be checking the pelvis for lumps and bumps/doing an internal? I actually offered and he said no! I've had a polyp before which was seen on physical exam. Can't decide whether this guy is not doing what he should be so to try again with the GP. PMB is a red flag symptom for cancer....

Post menopausal bleeding. Defined as bleeding after a year with no periods. Hope you get sorted. At your age if you still have a regularish cycle it will be defined as dysfunctional uterine bleeding. Both need looking into.

I’d want to do a visual examination of the cervix, take swabs and refer for scan.

I wouldn’t be able to do a smear unless it was actually due or overdue, as the lab would reject it. It’s a screening tool, not a diagnostic tool.

(Not a GP, just an ANP).

I didn't see the GP at all. I phoned the GP and asked to be referred on the 2 week pathway which they did. I had a scan and then afterwards a physical exam then an MRI I had a large cyst which was removed 18 months later -yes,I waited that long,it was awful!

Have filled out a form with GP practice - asking for advice and will go with what they say. Really persuaded now I should have had an exam.

Having been down a similar path, I adopt a belt and breeches approach, so definitely chase up for an examination. I had postmenopausal bleeding, an exam and then an ‘abnormal’ transvaginal/trans abdominal scan which put me on the two week suspected cancer pathway. Polyp removed and biopsy was clear, ovarian cysts coming and going but simple and a medium sized fibroid.
My GP was supposed to request a CA125 blood test before the biopsy (said on the notes) but it wasn’t done, however I have the NHS app and went into the surgery and made sure they did it. Things do get overlooked, so it’s good to advocate for yourself like you are.

The internal ultrasound is the key investigation- to see if the lining of the uterus is abnormally thickened

I hope @Alicay you won't mind jumping on here, as I am currently being investigated for exactly the same thing at the moment.

May I ask the experts on here what are the usual, non-scary, reasons for PMB?

But you still need to visualise the cervix to exclude pathology there.

So yes she needs examining!

Endometrial cancer is not the only cause of post menopausal bleeding. A scan will exclude that but won't exclude a cervical cause.

@Alicay Did the consultant ask about your smear tests- when the last one was done, etc? They won't have access to your NHS medical records if you saw them privately. I agree with other posters that, although a scan is required, you should also have been asked about smear tests and if you would consent to an examination to see if you had anything like a cervical polyp or some other (likely) benign condition.

We don't know how long it is since your last period, your age, if you're on HRT or not. The consultant could have made a decision based on all of those, In women under 50 a period can appear some time later (and be normal) but nevertheless a quick look should have been part of the consultation.

Sorry but the gynaecologist also does do a regular exam in addition to the transvaginal ultrasound. Personally, I think a gynaecologist is better trained and has more experience in spotting abnormalities, including cancer, than a GP because that’s their speciality. No offence to GPs on here, I think a GP has the toughest job in medicine.

It is the same imho with all specialties ie dermatology. For example, I had to argue with a GP to refer me for a skin lesion they grudgingly referred me saying it’s definitely not skin cancer….but it was absolutely skin cancer. The GP was wrong that time.

But not necessarily by the GP. The GP did the right thing by referring to gynaecology. Anything they suspected or not would still need to be examined by a gynaecologist. There is no point subjecting women to extra vaginal exams.
The fact it’s only 2 weeks until OP sees a consultant gynaecologist is a good thing.

My GP didn’t examine me, I was just referred for a scan.

I agree.

But surely there is some protocol here that GPs adhere to before arranging scans?

Is it not reasonable to ask them to check for cervical issues like a polyp or an ectropion before referring for a scan?

Not in place of a scan but as a routine exam?

OP hasn't said if her GP asked if she was up to date with smears etc.
If she'd had one recently, that was less of an issue and probably not necessitating an exam.

No. I have always been sent straight for scan.

@LoremIpsumCici I think all the suggestions are getting confused about what happened.
The OP went to see a gynaecologist and wasn't examined hence why I was saying someone needed to look. If you just get referred for a scan you don't usually get examined in that appointment as it's done by a sonographer...I certainly didn't get examined when I had both my episodes of PMB but my GP did look. The PMB referral pathway does not send you to a gynaecologist in many areas,(certainly doesn't where I work and only a scan so the GP does need to take that on)
I agree GPs have less experience of looking at the cervix but I think probably a higher rate of referral if we think something looks not quite right as we don't see enough cervixes to know what a normal variation it.

Yes.

I would expect an appt with a private gynaecologist to cover all bases especially if she was paying £300 ish for the appt.

OP hasn't said if she was asked about smear tests and if they'd been done recently. That could rule out anything serious (though not 100%) but the dr ought to have looked for polyps or an ectropion. Even if they were found, the scan was still necessary to check everything else.

But it depends.

There are so many variables here.
Is this PMB linked to HRT?
How long has it been going on?
Is a smear overdue?
When does the bleeding occur- (ie after sex?) when a cervical issue is more liekly.

It's not black and white.

I had near constant bleeding about a decade ago and had a transvaginal scan which found a uterine polyp.

I had it removed and the consultant said I also had what they used to call cervical erosion and so he treated that at the same time.

So presumably they spot problems with the cervix when they remove the polpys anyway so the chances of it being missed are slim to non-existent.

I guess the issue is if they find nothing on the TVS but then they'd carry on looking for the cause, wouldn't they?