L3
Post-menopausal Bleeding
D. Marwa
Is defined as vaginal bleeding after menopause .in women not taking HRT, any bleeding is
abnormal. In women on combined cyclical HRT, bleeding in progesterone free period is
normal. Unscheduled bleeding refers to bleeding at other times and this is abnormal and
should be investigated.
Causes of PMB
1. atrophic vaginitis
The majority of cases due to low dose of estrogen.
2. Endometrial ca
About 10% of cases of PMB
3. Endometrial hyperplasia
4. Endometrial polyp
5. Cervical malignancy
Management
Full history
examination
investigation
cervical smear
trans vaginal u/s
endometrial thickness <4 mm less likely to be malignant
Endometrial thickness >4 mm need further evaluation .
endometrial sampling
Endometrial biopsy either by diagnostic D&C or diagnostic hystroscope.
Treatment
Depend on the cause if atrophic vaginitis local or systemic hormonal therapy.
Hormonal replacement therapy
The theory surrounding the window of opportunity suggest that HRT is most beneficial in
first 10 years after natural menopause. however ,many women continue to experience
marked vasomotor symptoms.
Indication for varies types of +HRT
1- estrogen only for women without uterus
2- sequential HRT for premature ovarian failure LMP <12 months
3- continous combined HRT for >12 months on sequential HRT
1year post LMP IF >50 years old
2 years post LMP if <50 years old
4- estrogen +mirena IUS for women preferring IUS to systemic progesterone
Women required HRT+contraception
Women with preexisting IUS required HRT
BENEFITS OF HRT
1. treatment of vasomotor symptoms
2. treatment of urinary symptom
3. prevent and treat osteoporosis
4. decrease risk of ca colon
CONTRINDICATIONS TO HRT
1. pregnancy
2. suspicion of breast cancer
3. suspicion of endometrial cancer
4. acute active liver ds
5. uncontrolled HTN
6. confirmed VTE
7. migraine
Complication of HRT
1. increase risk of ca breast
2. increase risk of ca endometrial
3. increase risk of thromboembolic phenomena
4. increase risk of IHD
Mubark A. Wilkins