Post Menopausal bleeding

Dr Shaimaa Kadhim Post menopausal bleeding

Bleeding occurs after menopause (one or more year without cycle ) Age (50_55) with average age 51.5 years.Pmb is always abnormal &should be investigated.Menstruation after 55 years is abnormal. Introduction


causes percentage 1) exogenous estrogens 2)atrophic vaginitis & endometritis3)endometrial cancer 4)endometrial or cervical polyp5) endometrial hyperplasia6) miscellaneous (cervical cancer ,uterine sarcoma ,urethral caruncle ,trauma). 30%30%15%10%5%10%

factors

Exogenous estrogens Hystroctomized patients: estrogens onlyNon hystroctomized: oestrogen & progesterone to prevent endometrial hyperplasia.Severe continuous bleeding more than 4 months of HRT use should be investigated.


Genital tract atrophy Absence of oestrogen leads to thin ,dry epithelium with alkaline PH > 7.Postmenopausal vagina shrinks in diameter, splits &tears easily.Tr. HRT


ENDOMETRIAL CARCINOMA 90% presented with abnormal uterine bleeding.Screening only for high risk population by:1) pap smear.2) transvaginal ultrasound .

Urethral caruncle Small fleshy out growth of distal edge of urethra.

Endometrial & cervical polyp most of them are benign.Incidence of malignancy is 1%.Malignant tumours can present as polyp.


Management History 1) risk factors of endometrial cancer.2) trauma (coitus)3)family or personal history of malignancy.4) drug history


ExaminationGeneral examinationAbdominal examination Pelvic examinationSpeculum examination & pap smear.


Transvaginal ultrasoundSuspicious findings:1) end. Thickness > 4-5 mm.2) irregular endometrial outline.3) fluid in the end. Cavity.4) mass.If end. thickness <4-5 mm. only reassure the patient.


Out patient endometrial sampling1) aspiration biopsyA) Novak curetB) pipelle80-90% accurate

2) aspiration curettageEx. Vabra aspirator

Interpretation of results 1) if reviles carcinoma: definitive treatment of cancer.2) if endometrial hyperplasia: hysteroscopy & D&C.3) negative & the bleeding recurs or there is strong suspicion of malignancy :Hysteroscopy & D&C.


D&C under general anaesthesiaIndicated in:1)unsuccessful out patient sampling.2)inadequate sample for interpretation.3) high suspicion of cancer with negative out patient biopsy.


HysteroscopyDirect inspection of endometrial cavity.Detect 95% of intrauterine abnormality.Sensitive in identifying polyp or sub mucosal fibroid.Can be used as out patient procedure.

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