Postmenopausal Uterine BleedingAhmed Salah40

Def

• Postmenopausal bleeding is any unscheduled vaginal bleeding that occurs after 12 months of amenorrhoea in a woman of postmenopausal age.

Causes of postmenopausal uterine bleeding• Atrophic vaginitis • 60-80%• Estrogen treatments• 15-25%• Polyps - endometrial or cervical • 2-12%• Endometrial Hyperplasia• 5-10%• Endometrial Cancer • 10%• No cause found• 10%

 

postmenopausal uterine bleeding&Endometrial cancer

It is important to reassure women that only 10 percent of those presenting with postmenopausal bleeding will have endometrial cancer

Although it is a worrying symptom, there are far more likely benign causes. On the other hand, about 90 per cent of women with endometrial cancer will present with vaginal bleeding

Postmenopausal Uterine Bleeding &Atrophic Vaginitis

• It is the most common cause of postmenopausal uterine bleeding

• It has been estimated that 4-5 years after the menopause, around 25-50% of women experience symptoms due to atophic vaginitis. However, only around 24% of these women with symptoms actually seek medical help

Postmenopausal Uterine Bleeding &HRT

• The age at which the menopause occurs is variable, but for most women it is in their early 50s

• At this time of their lives, many women may have already resorted to taking hormone replacement therapy (HRT), which may cause confusion over symptoms of vaginal bleeding

• However, any vaginal bleeding in a menopausal woman other than the expected cyclical bleeding that occurs in women taking sequential HRT should be managed similarly

Postmenopausal Uterine bleeding

• Other causes may be diagnosed by history, examination and appropriate investigations.

• However, in 10–15 percent of patients, no evident cause for the bleeding will be found. It is therefore necessary to look for blood in the stool or urine, especially if the source of bleeding is unclear.

• A full blood count should be obtained if the

bleeding is heavy and prolonged.

References

• http://www.healthline.com/galecontent/postmenopausal-bleeding#2

• http://www.2womenshealth.com/26-The-Menopause/26-17-Postmenopausal-Bleeding.htm

• http://www.ncbi.nlm.nih.gov/pubmed/13335063

•  

Investigations of postmenopausal uterine bleeding

Ahmed Shaaban Ali KhattabNo. : 36

Investigations

• History

• Clinical examination

• Cervical cytology (if appropriate)

• Ultrasound scan

• Saline infusion sonography

• Outpatient hysteroscopy

• Endometrial biopsy

History

Duration and severity

Hormone use

Tamoxifen

Associated symptoms

Obesity, Diabetes

• History of colorectal, endometrial or other cancers associated with hereditary non-polyposis colorectal cancer

Lynch ll syndrome

Past medical and surgical history

Clinical examination

Abdominal and pelvic examination

Speculum examination of the cervix

Bimanual examination

Direct inspection

Cervical smear

Colposcopy

Biopsy

Ultrasound scan

Transvaginal ultrasound (TVUS)

In a study of 1168 women with postmenopausal bleeding…… ,

• atrophic endometrium 3.9mm (±2.5mm)

• endometrial carcinoma 21.1mm (±8mm)

• With an endometrial thickness of less than 3mm , …

• sensitivity for detecting any endometrial disease is 92 per cent and the sensitivity for detecting cancer is 96 per cent

• a cut-off of 4mm is used to avoid hysteroscopy

Reference

• Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol 2004; 24: 736-41.

• Schwarzler P, Concin H, Bosch H, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol 1998; 11: 337-42.

• National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. Clinical guideline 27. London: NICE, June 2005. www.nice.org.uk

• Bernstein L, Deapen D, Cerhan JR, et al. Tamoxifen therapy for breast cancer and endometrial cancer risk. J Natl Cancer Inst 1999; 91: 1654-62.

• Parazzini F, La Vecchia C, Negri E, et al. Diabetes and endometrial cancer: an Italian case-control study. Int J Cancer 1999; 81: 539-42.

• Coleman BG, Arger PH, Grumbach K, et al. Transvaginal and transabdominal sonography: prospective comparison. Radiology 1988; 168: 639-43.

• Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding -- a Nordic multicenter study. Am J Obstet Gynecol 1995; 172: 1488-94.

 

Cont. Investigations of postmenopausal uterine bleeding

Ahmed Salah El-Esawy39

Saline infusion sonography

sonohysterogram is an ultrasound that goes one step further by using sterile water to distend the uterine cavity to obtain more accurate information about

fibroids, polyps, or the lining of the uterus.  .

procedure

normal cavity

fundal polyp

central polyp

hysteroscopyVisualization of endometrial cavity by endoscope.

Endometrial biopsy

Endometrial biopsy is a procedure in which a tissue sample is taken from the lining of the uterus (endometrium), and is checked under a microscope for any abnormal cells or signs of cancer.

Indications • Abnormal uterine bleeding.

• Postmenopausal bleeding .

• follow up to previously diagnosed endometrial Hyperplasia.

Contraindication

• Acute Pelvic inflammatory disease.

• Acute cervical infection.

• Clotting disorder .

• Cervical cancers.

COMPLICATIONS• Infection.

• excessive bleeding.

• uterine perforation .

• Bacteremia.

• Disturbance of undiagnosed pregnancy.

Management of postmenopausal bleedingAhmed Salah Mohamed

41

General treatment:

• 1- Correct general condition(Anti-shock measure):

• -Hospitalization

• -Assessment of blood loss:

• In some cases the blood volume may be excessive,rapid and possibly life threatening

• -So rapid restoration of blood volume,vital parameters is followed by local examination to find out the site and source of bleeding

• -Blood transfusion in needed

• -Intravenous lines

• -Elevate bed foot

• -Intravenous fluids

• -Tears need to be sutured

• -Bleeding from cervical malignancy can effectively stopped by tight vaginal packing

2-Specific treatment

• It is according to the cause :

• Vaginal atrophy :treated by administarion of topical oestrogen

• -Vagifem an oestrogen within a small pessary inserted into vagina ,

• Endometrial Polyps: removed at outpatient hysteroscopy but it may need general anaesthesia

• Endometrial hyperplasia and carcinoma :

• -In postmenopausal women it should be surgical and include Total hystrectomy and bliateral salpingo-oophorectomy

• -To avoid unnecessary risk form treatment through progesteron therapy

Management of recurrent postmenopausal bleeding

• When patient presents with recurrence ,formal hysteroscopy and Dilataion and curretage under general anassthetic is advisable

• -cytoscopy to exclude bladder tumors

• -sigmoidscopy to exclude large bowel tumors if the site of bleeding is unclear

Thank you