Post-Menopausal Bleeding
Dr. Ahmed jasimAss.Prof.
MBChB-DOG-FICMS
COSULTANT OF GYN. & OBST.
is the permanent cessation of menstruation resulting from loss of ovarian follicular activity.
It can only be determined after 12 months' spontaneous amenorrhoea.
Mean age is 51 years.
Menopause
is the period of time in which the ovaries are beginning to fail, where endocrine, biological, and clinical changes are seen. It ends with the final menstrual period.
Length of the transition is approximately 4 years
Menopause transition
is the time period over which the ovaries are failing (when symptoms begin) up until the cessation of menstruation, and ends 12 months after the final menstrual period.
Perimenopause
is the time after the menopause, that is, after the permanent cessation of menstruation. It can only be determined after 12 months of spontaneous amenorrhoea.
In practice this definition is difficult to apply, especially in women who have started hormone replacement therapy (HRT) in the perimenopause. It has been estimated that by the age of 54 years, 80% of women are postmenopausal .
Postmenopause
Definition
Postmenopausal bleeding is any bleeding from the reproductive system that occurs six months or more after menstrual periods have stopped due to menopause.Epidemiology
It is a common problem representing 5% of all gynaecology outpatient attendances. These are to eliminate endometrial cancer as the cause of the bleed.Description
Menopause, the end of ovulation and menstrual periods, naturally occurs for most women at age 40–55 years. The process of ending ovulation and menstruation is gradual, spanning one to two years.Postmenopausal bleeding is different from infrequent, irregular periods (oligomenorrhea) that occur around the time of menopause.
Description
Many women experience some postmenopausal bleeding. However, postmenopausal bleeding is not normal. Because it can be a symptom of a serious medical condition, any episodes of postmenopausal bleeding should be brought to the attention of a doctor.Women taking hormone replacement therapy ) HRT) are more likely to experience postmenopausal bleeding. So are obese women, because fat cells transform male hormones (androgens) secreted by the adrenal gland into estrogen.
Risk factors for endometrial cancer
are conditions typically associated with chronic elevations of endogenous estrogen levels or increased estrogen action at the level of the endometrium. These includeObesity.
history of chronic anovulation.
diabetes mellitus.
estrogen-secreting tumors.
exogenous estrogen unopposed by progesterone .
tamoxifen use.
a family history of Lynch type II syndrome (hereditary nonpolyposis colorectal, ovarian, or endometrial cancer).
Aetiology
Non-gynaecological causes including trauma or a bleeding disorder.
Use of hormone replacement therapy (HRT).
Vaginal atrophy.
Endometrial hyperplasia; simple, complex, and atypical.
Endometrial carcinoma usually presents as PMB, but 25% occur in premenopausal women.
Endometrial polyps or cervical polyps.
Carcinoma of cervix; remember to check if the cervical smear is up-to-date.
Uterine sarcoma (rare).
Ovarian carcinoma, especially oestrogen-secreting (theca cell) ovarian tumours.
Vaginal carcinoma is very uncommon.
Carcinoma of vulva may bleed, but the lesion should be obvious.
Once menopause occurs, estrogen and progesterone are no longer produced by the ovaries; nor are they produced in any appreciable amounts by the liver and fat. The endometrium regresses to some degree, and no further bleeding should occur. When bleeding does resume, therefore, endometrium must be evaluated.
Pathophysiology
ManagementHistory and examination may possibly indicate cause, but it is generally accepted that postmenopausal bleeding should be treated as malignant, until proved otherwise.
Investigations
I.Non-invasive diagnostic procedurestransvaginal ultrasound scan (TVUS) is an appropriate first-line procedure to identify which women with PMB are at higher risk of endometrial cancer.
As TVUS is a non invasive test with 91 % sensitivity and 96 % specificity . it should be done for all women with postmenopausal bleeding.
if the endometrial thickness is >5mm. and if the patient pre test probability is low ,office endometrial biopsy and SIS should be done to determine whether the endometrium is symmetrically thickened.
BUT if the patient pre test probability is high , a fractional curettage biopsy or a hysteroscopic guided biopsy is recommended.
Investigations
The mean endometrial thickness in postmenopausal women is much thinner than in premenopausal women. Thickening of the endometrium may indicate the presence of pathology. In general, the thicker the endometrium, the higher the likelihood of important pathology, i.e. endometrial cancer being present. The threshold in the UK is 5 mm; a thickness of >5 mm gives 7.3% likelihood of endometrial cancer. A thickness of <5 mm has a negative predictive value of 98%.Investigations
A refinement of vaginal probe ultrasound is saline infusion sonography (SIS). A salt water (saline) solution is injected into the uterus with a small tube (catheter) before the vaginal probe is inserted. The presence of liquid in the uterus helps make any structural abnormalities more distinct. These two non-invasive procedures cause less discomfort than endometrial biopsies and D & Cs, but D & C still remains the definitive test for diagnosing uterine cancer.
TVUS
endometrial thickness is > 5mmendometrial thickness is < 5mm
If low risk
If high risk
D/C biopsy OR
hysteroscopy
office endometrial
biopsy and SIS
But symptoms
persist
follow
In women with continued bleeding after a negative initial evaluation, further testing
with hysteroscopically directed biopsy is essential,
Investigations
II.Invasive diagnostic procedures1.Endometrial biopsy
A definitive diagnosis in postmenopausal bleeding is made by histology. previously endometrial samples have been obtained by dilatation and curettage. Nowadays it is more usual to obtain a sample by endometrial biopsy, which can be undertaken using samplers. Endometrial biopsy can be performed as either an outpatient procedure, or under general anaesthetic (GA). All methods of sampling the endometrium will miss some cancers.
Investigations
2.HysteroscopyHysteroscopy and biopsy (curettage) is the preferred diagnostic technique to detect polyps and other benign lesions. Hysteroscopy may be performed as an outpatient procedure, although some women will require GA.A significant development has been direct referral to 'one stop' specialist clinics. At such clinics several investigations are available to complement clinical evaluation, including ultrasound, endometrial sampling techniques and hysteroscopy. Following such assessment, reassurance can be given or further investigations or treatment can be discussed and arranged.
Treatment
It is common for women just beginning HRT to experience some bleeding. Most women who are on HRT also take progesterone with the estrogen and may have monthly withdrawal bleeding. Again, this is a normal side effect that usually does not require treatment.Treatment
Postmenopausal bleeding due to bleeding of the vagina or vulva can be treated with local application of estrogen or HRT.When diagnosis indicates cancer, some form of surgery is required. The uterus, cervix, ovaries, and fallopian tubes may all be removed depending on the type and location of the cancer. If the problem is estrogen- or androgen-producing tumors elsewhere in the body, these must also be surgically removed. Postmenopausal bleeding that is not due to cancer and cannot be controlled by any other treatment usually requires a hysterectomy.
