Postmenopausal bleeding

Prepared by:

Hedi Hameed

Menopause:Is cessation of menstrual cycle for 12 consecutive

months.

Normal age for menopause(49_55)

Mean age 51.

Postmenopausal bleeding:Is unscheduled vaginal bleeding that occurs after 12

months of amenorrhea in a woman of postmenopausal age.

Causes

1. Vaginal atrophy (60_80%)

2. Hormone replacement therapy(15_25%)

3. Endometrial hyperplasia (5_10%)

4. Endometrial carcinoma 10%

5. Endometrial or cervical polyp.(2_12%).

Vaginal atrophy

Is thinning, drying and inflammation of the vaginal walls because of

having less estrogen

Clinical features:

In addition to postmenopausal bleeding: Vaginal dryness , burning

sensation, discharge, itching with increased frequency, urgency ,

incontinence and urinary tract infections.

Treatment:

1.Vaginal moisturizers

2. Estrogene either in form of creams, ring or tablet.

2.Hormone replacement therapy

A. .Estrogen- cyclical progsetrone :

Estrogene will be given everyday.

Progestrone will be given for the last (12_14) days .

Bleeding is considered normal if bleeding starts after the nineth

day of progesterone use or soon after the progestogen phase.

B. Combined estrogen-progestrone therapy:

Breakthrough bleeding is common in the first 3-6 months ,

Evaluation of the endometrium is recommended during the first

year, if bleeding is heavy, prolonged or if any bleeding occurs

after one year of use.

Endometrial hyperplasia

Is an abnormal proliferation of the endometrium (glands).

It accounts for 5_10 % of PMB.

It occurs due to excessive estrogen stimulation.

More than 4mm is significant.

classification:

1. Hyperplasia without atypia.

2. Hyperplasia with atypia

(premalignant)

TREATMENT

_ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA:

medroxyprogestrone acetate

Continous: 10mg daily for 3_6 months

cyclical:10 mg for 12 days each month

Repeat biopsy in (3_6) months.

Endometrial hyperplasia with atypia:

Hysterectomy with or without bilateral salpingo-

oopherectomy.

Endometrial carcinoma

2nd most common gynecological cancer.

Is mainly adenocarcinoma arising from the lining of the

uterus and is an estrogen-dependent tumor.

Accounts for 10% of postmenopausal bleeding.

90% of patients with endometrial cancer will present with bleeding.

Has 4 stages:

I. Confined to uterine body

II. Involves cervix

III. Outside uterus but inside the pelvis

IV. Extended to blader or rectum.

.Risk factors :

1. Early menarche

2. Late menopause

3. Nulliparity

4. Chronic anovulation(P.C.O.S)

5. Obesity (conversion of steroids to oestrone in their peripheral fat)

6. Diabetes mellitus

7. Unoppsed estrogen therapy

8. Tamoxifen therapy (ESTROGENIC ACTIVITY ON ENDOMETRIUM)

9. Personal or family history of:

endometrial, ovarian, breast or colon cancer.

Treatment

1. Stage 1 and 2 :

total abdominal hysterectomy + bilateral

salpingoopherectomy.

2. Stage 3 and 4 :

If resectable surgery followed by chemotherapy or

radiotherapy

If its not resectable neoadjuvant radiotherapy followed by

surgery.

3. High dose of progestin if unfit for surgery.(paliative)

Management

I. History

II. Examination

III.investigations

History:1. Details of the bleeding(onset, duration, amount, color,

presence of clot,whether it was related to trauma or not).

2. Associated symptoms such as pain, fever or changes in bladder or bowel function might suggest an infective process such as pyometra or the bleeding may be arising from the bowel or bladder .

3. exclude risk factors of endometrial carcinoma.

Examination1. General examination: general condition, obesity.

exclude signs of malignancy ( weight loss, pale

2. Abdominal examination: for any palpable mass.

3. pelvic examination:

inspection of the vulva and vagina, particularly looking for atrophy( The vaginal skin looks thin, red and inflamed with areas of pinpoint bleeding).

A speculum examination (cervical polyp and cancer)

A bimanual examination to evaluate uterine size, mobility

and the adnexae.

4. Per rectal examination: to exclude colorectal problems.

Investigations

1. Complete blood count

2. Coagulation studies

3. LFT, RFT

4. CHEST XRAY .

specific investigations:

I. Ultrasound (T.A.U , T.V.U)

II. CA125

III. Pippelle smear

IV. Dilitation and curetage with biopsy

V. Hysterescopy with endometrial biopsy

References

• https://fafpf.files.wordpress.com/2012/11/platon-pmb-capsule-comment-final.pdf

• http://onlinelibrary.wiley.com/doi/10.1002/tre.84/pdf