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POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDING
DR;MANAL BEHERYProfessor OB &GYNE
2014
DefDef
Postmenopausal bleeding is any Postmenopausal bleeding is any vaginal bleeding that occurs after vaginal bleeding that occurs after 12 months of amenorrhoea in a 12 months of amenorrhoea in a postmenopausal women .postmenopausal women .
The age of menopause is variable, The age of menopause is variable, but for most women it is 51 yearbut for most women it is 51 year
Causes of postmenopausal uterine Causes of postmenopausal uterine bleedingbleeding
Atrophic vaginitisAtrophic vaginitis60-80%60-80%Estrogen treatmentsEstrogen treatments15-25%15-25%Polyp cervical –uterine Polyp cervical –uterine 2-12%2-12%Endometrial HyperplasiaEndometrial Hyperplasia5-10%5-10%Enodometrial cancerEnodometrial cancer10%10%No cause foundNo cause found10%10%
Atrophic VaginitisAtrophic Vaginitis
It is the most common cause of It is the most common cause of postmenopausal uterine bleedingpostmenopausal uterine bleeding
4-5 years after the menopause, 25-4-5 years after the menopause, 25-50% of women experience 50% of women experience symptoms due to atophic vaginitis. symptoms due to atophic vaginitis.
Cervical polypCervical polyp
It is the second most It is the second most common cause of common cause of postmenopausal postmenopausal bleedingbleeding
Hormone replacement therapy(HRT)Hormone replacement therapy(HRT)
Any vaginal bleeding in a Any vaginal bleeding in a menopausal woman other than the menopausal woman other than the
expected cyclical bleeding that expected cyclical bleeding that occurs in women taking sequential occurs in women taking sequential
HRT should be managedHRT should be managed
Endometrial hyperplasia &Endometrial Endometrial hyperplasia &Endometrial cancercancer
reassure women that only 10 percent of those presenting with postmenopausal bleeding will have endometrial cancer
90 per cent of women with endometrial cancer will present with vaginal bleeding
idiopathic causeidiopathic cause
10–15 %of patients, no evident cause for the 10–15 %of patients, no evident cause for the bleeding will be found. bleeding will be found.
It is therefore necessary to look for blood in the stool It is therefore necessary to look for blood in the stool or urine, especially if the source of bleeding is or urine, especially if the source of bleeding is unclear.unclear.
InvestigationsInvestigations
HistoryHistory
Clinical examinationClinical examination
Cervical cytology (if appropriate)Cervical cytology (if appropriate)
Ultrasound scanUltrasound scan
Saline infusion sonographySaline infusion sonography
Outpatient hysteroscopyOutpatient hysteroscopy
Endometrial biopsyEndometrial biopsy
HistoryHistory
11--Duration and severityDuration and severity
No evidence of association with pattern of bleeding and malignancy eg: one off bleed vs regular bleeding
--22--Associated symptomsAssociated symptoms
Hormonal treatementHormonal treatement
Past medical and surgical historyPast medical and surgical history
•FHistory of colorectal, endometrial or other cancers associated with hereditary non-polyposis colorectal
cancer Lynch ll syndrome
Clinical examinationClinical examination
•General:
•obesity?
•thyroid? pallor?
•pulse? Cachexia?
Abdominal and pelvic Abdominal and pelvic examinationexamination
Speculum examination of the cervixSpeculum examination of the cervix
Bimanual examinationBimanual examination
Cervical smearCervical smear
ColposcopyColposcopy
Ultrasound scanUltrasound scan
Transvaginal ultrasound (TVUS)Transvaginal ultrasound (TVUS)
•Thickened (>5mm) endometrial stripe in postmenopause ALWAYS needs further evaluation.
Normal TVUS with endometrial Normal TVUS with endometrial thickness <4mm, thickness <4mm, with normal examination does not with normal examination does not require further investigation require further investigation providing bleeding has STOPPED. providing bleeding has STOPPED.
Saline infusion sonographySaline infusion sonography
SonohysterographySonohysterography
TVS may miss small polyps TVS may miss small polyps
Difficult to distinguish from thickened Difficult to distinguish from thickened
endometriumendometrium
SHG helps in SHG helps in
accurate diagnosisaccurate diagnosis
normal cavitynormal cavity
EndometrialEndometrial biopsy biopsy
a tissue sample is taken from the lining of the uterus a tissue sample is taken from the lining of the uterus (endometrium), (endometrium),
and is checked under a microscope for any abnormal and is checked under a microscope for any abnormal cells or signs of cancer.cells or signs of cancer.
Endometrial samplingEndometrial sampling All women with persistent menorrhogia All women with persistent menorrhogia
To diagnose or excludeTo diagnose or exclude endometrial carcinoma or endometrial carcinoma or HyperplasiaHyperplasia
Endometrial Suction CuretteEndometrial Suction Curette
Pippelle : most commonly used, least discomfort
Karman Cannula
Endometrial BrushSuperior in Post-MenopausalSame as Pipelle in Pre-Menop.
)A (Pipelle endometrial suction curette. (B) Vabra aspirator.
Tao Endometrial Brush
Sampling HowSampling How??
Endometrial aspiration Endometrial aspiration
Conventional D&C Conventional D&C
Hysteroscopy & directed biopsyHysteroscopy & directed biopsy
hysteroscopyhysteroscopy
The Gold Standard- The Gold Standard- Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,
Indication of hystroscopyIndication of hystroscopy
When sampling cannot be performed When sampling cannot be performed due to cervical stenos is due to cervical stenos is
Or when bleeding persists after negative Or when bleeding persists after negative biopsy.biopsy.
Endometrial hyperplasis&endometrial polypEndometrial hyperplasis&endometrial polyp
Endometrial polyp
Management of Management of postmenopausal postmenopausal
bleedingbleeding
General treatmentGeneral treatment::
In some cases the blood loss may be In some cases the blood loss may be excessive, rapid and possibly life threateningexcessive, rapid and possibly life threatening
Correct Correct general conditiongeneral condition(Anti-shock (Anti-shock measure)measure)
-Hospitalization-Hospitalization
Rapid restoration of blood Rapid restoration of blood volume,vital parametersvolume,vital parameters
followed by local examination to find out followed by local examination to find out the site and source of bleedingthe site and source of bleeding
It is according to the It is according to the causecause: :
Atrophic vaginitisAtrophic vaginitis
treated by administration of topical oestrogentreated by administration of topical oestrogen
--VagifemVagifem an oestrogen within a small pessary an oestrogen within a small pessary inserted into vaginainserted into vagina, ,
Endometrial PolypsEndometrial Polyps
Removed by hysteroscopyRemoved by hysteroscopy
When patient presents with recurrent When patient presents with recurrent attack of bleedingattack of bleeding
Do Do pelvic MRI pelvic MRI to exclude early stage E to exclude early stage E cancercancer
Do Do cytoscopycytoscopy to exclude bladder tumorsto exclude bladder tumors
-DO -DO sigmoidscopysigmoidscopy to exclude large bowel to exclude large bowel tumors if the site of bleeding is uncleartumors if the site of bleeding is unclear
MRI early stage cancerMRI early stage cancer
Endometrial hyperplasia and Endometrial hyperplasia and carcinomacarcinoma
In postmenopausal women it should be surgical and include In postmenopausal women it should be surgical and include Total hystrectomy and bliateral salpingo-oophorectomyTotal hystrectomy and bliateral salpingo-oophorectomy
--To avoid unnecessary risk form treatment with progesteron To avoid unnecessary risk form treatment with progesteron therapytherapy
SummarySummary
Vaginal atrophy: oestrogen daily for 2 weeks, Vaginal atrophy: oestrogen daily for 2 weeks, then once- twice weekly for maintenance.then once- twice weekly for maintenance.
Polyps- removed as OPPolyps- removed as OPEndometrial hyperplasia- treated with IUS or Endometrial hyperplasia- treated with IUS or
progestprogestEndometrial hyperplasia with atypia- should Endometrial hyperplasia with atypia- should
be treated as cancer. be treated as cancer.
How to approach a case of How to approach a case of abnormal Vaginal bleedingabnormal Vaginal bleeding
DR;MANAL BEHERYProfessor, Zagazig University
2014
DefinitionDefinition
Any uterine bleeding that is excessive in Any uterine bleeding that is excessive in amount ,duration or frequancyamount ,duration or frequancy
Characteristics of Normal MenstruationCharacteristics of Normal Menstruation
Regulation of Normal Regulation of Normal MenstruationMenstruation
How do hormones workHow do hormones work??
Why EP withdrawal bleeding is self limited?
Why EP withdrawal bleeding is self limited?
33 reasonsreasons
1 -It is a universal endometrial event
Menstrual changes occurs simultaneously in all segments of endometriaum
33 reasonsreasons
2-the endometrium is structurly stable, Randome breakdown of tissue is avoided
33 reasonsreasons
Factors involved in stopping of mensesWaves of vacoconstriction Vacular stasis Endometrial collapse Clotting factors
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Hormone Level
EstradiolProgesterone
FSHLH
Menstrual Cycle Day
Ovulation
Endometrial Thickness
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Normal Menstrual
Cycle
Hormone Level
EstradiolProgesterone
Endometrial Thickness
0 2 4 6 8 10 12 14 16 18 20
0 2 4 6 8 10 12 14 16 18 20 Weeks
Breakthrough
Withdrawal
Anovulatory Bleeding in PCOS
Lower limit of normal
MenorrhagiaMenorrhagiaProlonged (> 7 days) or excessive (> Prolonged (> 7 days) or excessive (> 80mL) uterine bleeding occurring at 80mL) uterine bleeding occurring at regular intervalsregular intervals
MetrorrhagiaMetrorrhagiaUterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals or between periodsintervals or between periods
MenometrorrhagiaMenometrorrhagiaUterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals, with heavy (> 80mL) or intervals, with heavy (> 80mL) or prolonged (> 7 days) menstrual flowprolonged (> 7 days) menstrual flow
PolymenhorrhePolymenhorrheaa
Uterine bleeding occurring at regular Uterine bleeding occurring at regular intervals of < 21 daysintervals of < 21 days
OligomenorrheaOligomenorrheaUterine bleeding occurring at intervals Uterine bleeding occurring at intervals of 35 days or longerof 35 days or longer
AmenorrheaAmenorrheaAbsence of uterine bleeding for 6 Absence of uterine bleeding for 6 months or longer in a non-menopausal months or longer in a non-menopausal womanwoman
classificationclassification
OrganicOrganic–SystemicSystemic
–Reproductive tract diseaseReproductive tract disease
–IatrogenicIatrogenic
DysfunctionalDysfunctional–OvulatoryOvulatory
–AnovulatoryAnovulatory
Systemic EtiologiesSystemic Etiologies
Coagulation defectsCoagulation defects
LeukemiaLeukemia
ITPITP
Thyroid dysfunctionThyroid dysfunction
Liver diseaseLiver disease
Reproductive Tract CausesReproductive Tract Causes
Gestational eventsGestational events
MalignanciesMalignancies
Benign Benign – Atrophy Atrophy – LeiomyomaLeiomyoma– PolypsPolyps– Cervical lesionsCervical lesions– Foreign bodyForeign body– InfectionsInfections
Most Common Causes of Most Common Causes of Reproductive Tract AUBReproductive Tract AUB
Pre-menarchalPre-menarchal–Foreign bodyForeign bodyReproductive ageReproductive age–Gestational eventGestational eventPost-menopausaPost-menopausall–AtrophyAtrophy
Iatrogenic Causes of AUBIatrogenic Causes of AUB
Intra-uterine deviceIntra-uterine device
Oral and injectable steroidsOral and injectable steroids
Psychotropic drugsPsychotropic drugs
Dysfunctional causesDysfunctional causes
DUB is the most DUB is the most
After pubertyAfter puberty
Before menopauseBefore menopause
After labor or abortionAfter labor or abortion
““Doctor, IDoctor, I’’m bleeding funnym bleeding funny””
What is your first question?What is your first question?
How do you help her define How do you help her define ““bleeding bleeding funnyfunny””??
How do you quantify her bleeding?How do you quantify her bleeding?
A practical approach (step1) HISTORYA practical approach (step1) HISTORY
•11--AgeAge(before puberty, reproductive age ,PM)(before puberty, reproductive age ,PM)
•22--Pattern of bleedingPattern of bleeding: cyclic or a cyclic: cyclic or a cyclic
•3Marital state3Marital state: complication of pregnancy: complication of pregnancy
•44 Drug intake Drug intake ,hormonal ttt, HRT,hormonal ttt, HRT
•::55 previousprevious treatmenttreatment
))Step2Step2 ( (Physical examinationPhysical examination
• AbdomenAbdomen: palpable mass? : palpable mass?
• PelvisPelvis: cervical or vaginal lesion?: cervical or vaginal lesion?
• Bimanual exaBimanual exam:uterine size m:uterine size
• Speculum Speculum :cervical lesion:cervical lesion• PRPR: rectum or parametrium: rectum or parametrium
))Step 3Step 3 ( (investigationinvestigation
TVS TVS to assess endometrial thicknessto assess endometrial thickness
Sonohystrography Sonohystrography
endometrial aspirateendometrial aspirate HysteroscopyHysteroscopy CT ,MRI for endometrial invasion CT ,MRI for endometrial invasion
Consider those investigations ONLY IFConsider those investigations ONLY IF
–cervical smear cervical smear if sexually active and last if sexually active and last smear more than 1 year agosmear more than 1 year ago
–CBC CBC if menorrhagiaif menorrhagia
–Thyroid function, coagulation profile only Thyroid function, coagulation profile only when history suggestivewhen history suggestive
))Step4Step4 ( (medical tttmedical ttt
For women under 40 with no suspicion of organic For women under 40 with no suspicion of organic lesions eitherlesions either
Hormonal (for irregular bleeding as well as Hormonal (for irregular bleeding as well as menorrhagiamenorrhagia))
–combined OCcombined OC–progestogen only (21 days needed)progestogen only (21 days needed)
Non-hormonal (for menorrhagia)Non-hormonal (for menorrhagia)–NSAIDNSAID
–antifibrinolytic agentantifibrinolytic agent
Step 5 When to referStep 5 When to refer??
No response to medical treatmentNo response to medical treatment Over the age of 40Over the age of 40 Uterus > 10 week size or irregularUterus > 10 week size or irregular
High risk of endometrial Cancer (obesity, DM, High risk of endometrial Cancer (obesity, DM, PCOD)PCOD)
Cervical pathology suspectedCervical pathology suspected
Surgery treatment of Surgery treatment of AUBAUB
– Dilation and CurettageDilation and Curettagequickest way to stop bleeding in patients quickest way to stop bleeding in patients who are hypovolemicwho are hypovolemic
appropriate in older women (>35)to exclude appropriate in older women (>35)to exclude malignancy but is inferior to hysteroscopymalignancy but is inferior to hysteroscopy
follow with medroxyprogesterone acetate, follow with medroxyprogesterone acetate, OCP’s, or NSAID’s to prevent recurrenceOCP’s, or NSAID’s to prevent recurrence
hystrectomyhystrectomy
Other modalities of treatmentOther modalities of treatment
Levonorgesterol releasing IUCD (Mirena)Levonorgesterol releasing IUCD (Mirena)
22..Endometrial ablationEndometrial ablationHysteroscopic methodsHysteroscopic methods
– Endometrial laser ablationEndometrial laser ablation– Electrosurgical endometrial ablationElectrosurgical endometrial ablation– Loop endometrial ablationLoop endometrial ablation– Roller-ball endometriaal ablation usting resectoscopeRoller-ball endometriaal ablation usting resectoscope
Nonhysteroscopic methodsNonhysteroscopic methods– Radio-frequency-induced thermal endometrial ablationRadio-frequency-induced thermal endometrial ablation– Microwave Microwave endometrial ablationendometrial ablation– Uterine balloon therapyUterine balloon therapy
– 3.Hysterectomy3.Hysterectomy
ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION
Uterine balloon therapyUterine balloon therapy Roller-ball endometriaal Roller-ball endometriaal ablation usting ablation usting resectoscoperesectoscope
Abnormal Uterine Bleeding in Abnormal Uterine Bleeding in Women of Childbearing AgeWomen of Childbearing Age
Abnormal postmenopausal bleeding P Abnormal postmenopausal bleeding P BleedingBleeding
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