Dr. Ahmed jasim Ass.Prof.MBChB-DOG-FICMS COSULTANT OF GYN. & OBST. 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  Mean age is 51 years.

 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

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.

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. 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.

 Postmenopausal bleeding is any bleeding from the reproductive system that occurs six months or more after menstrual periods have stopped due to menopause.

 It is a common problem representing 5% of all gynaecology outpatient attendances. These are to eliminate endometrial cancer as the cause of the bleed.

 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.

 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.

are conditions typically associated with chronic elevations of endogenous estrogen levels or increased estrogen action at the level of the endometrium. These include Obesity. Obesity. history of chronic anovulation. history of chronic anovulation. diabetes mellitus. diabetes mellitus. estrogen-secreting tumors. estrogen-secreting tumors. exogenous estrogen unopposed by progesterone. exogenous estrogen unopposed by progesterone. tamoxifen use. tamoxifen use. a family history of Lynch type II syndrome (hereditary nonpolyposis colorectal, ovarian, or endometrial cancer). a family history of Lynch type II syndrome (hereditary nonpolyposis colorectal, ovarian, or endometrial cancer).

 Non-gynaecological causes including trauma or a bleeding disorder. bleeding disorderbleeding disorder  Use of hormone replacement therapy (HRT). hormone replacement therapyhormone replacement therapy  Vaginal atrophy. Vaginal atrophy Vaginal atrophy  Endometrial hyperplasia; simple, complex, and atypical. Endometrial hyperplasia Endometrial hyperplasia  Endometrial carcinoma usually presents as PMB, but 25% occur in premenopausal women. Endometrial carcinoma Endometrial carcinoma  Endometrial polyps or cervical polyps. cervical polypscervical polyps  Carcinoma of cervix; remember to check if the cervical smear is up- to-date. Carcinoma of cervix Carcinoma of cervix  Uterine sarcoma (rare). Uterine sarcoma Uterine sarcoma  Ovarian carcinoma, especially oestrogen-secreting (theca cell) ovarian tumours. Ovarian carcinoma Ovarian carcinoma  Vaginal carcinoma is very uncommon. Vaginal carcinoma Vaginal carcinoma  Carcinoma of vulva may bleed, but the lesion should be obvious. Carcinoma of vulva Carcinoma of vulva

 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.

 History and examination may possibly indicate cause, but it is generally accepted that postmenopausal bleeding should be treated as malignant, until proved otherwise.

 I.Non-invasive diagnostic procedures  transvaginal 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.

 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%.

 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 > 5mm endometrial 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,

 II.Invasive diagnostic procedures  1.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. endometrial biopsyendometrial biopsy

 2.Hysteroscopy  Hysteroscopy 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. endometrial samplingendometrial sampling

 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.

 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.

 Response to treatment for postmenopausal bleeding is highly individual and is not easy to predict. The out-come depends largely on the reason for the bleeding. Many women are successfully treated with hormones. As a last resort, hysterectomy removes the source of the problem by removing the uterus. However, this operation is not without risk and the possibility of complications. The prognosis for women who have various kinds of reproductive cancer varies with the type of cancer and the stage at which the cancer is diagnosed.

 Postmenopausal bleeding is not a preventable disorder. However, maintaining a healthy weight will decrease the chances of it occurring.

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