Postmenopausal bleeding Dr. Alia Kareem

Postmenopausal bleeding Postmenopausal bleeding (PMB) is defined as vaginal bleeding after the menopause. Menopause is permenant cessation of menstruation that diagnose after 12 months of amenorrhea in a middle aged woman.

incidence Reported in up to 10% of post-menopausal women. Majority of PMB is result from benign cause Around 10 percent of women with PMB will be found to have endometrial cancer

Etiology according to source Uterus: Atrophic endometritis Endometrial polyp Endometrial hyperplasis Endometrial carcinoma Uterine sarcoma

Etiology according to source Cervical: Polyp cancer Vaginal: Atrophic vaginitis, local trauma from ring/shelfpessary cancer (rare).

Other causes of PMB Bleeding disorders Ovarian tumor: secreting hormone or pelvic vessel congestion extra genital bleeding may be mistaking as vaginal bleeding: GIT:cancer, diverticulitis, inflammatory bowel disease),hemorrhoids. urethral caruncle, urethral diverticula, urethral prolapse/eversion,ca,heamaturia .

Etiology according to frequency Atrophic vaginitis or endometritis 40-60% Endometrial hyperplasia 12% Endometrial cancer 10%

approach to diagnosis main aim is to excluding ca of endometerium History Examination Investigatiion

history Last peroids to confirm menopause. Any episoides of menopausal bleeding should be investigated Severity and duration of bleeding Post coital bleeding : cx polyp or ca Risk factors for ca of endometerium Hx of loss wt or appetite Drug history of anticoagulant,HRT , tamoxifene

examination General: signs of anaemia, LAP,WT Abdomen: Assess for masses. Speculum: Assess vulva, vagina(atrophy or malignancy )and cervix( polyp,malignancy) Bimanual palpation :uterin size,mobility or adenaxial masses

investigation Bloods: FBC (anaemia). Radiology: Pelvic USS ,HSG Tissue diagnosis: out patient Pipelle biopsy,D&C hysteroscopy

Pelvic USS Endometrial thickness : 4mm or more in menopausal bleedingor 5mm or more for post menopausal on RHT is indicated for endometrial biosy Myometrial masses adenaxial mass

Thin endometrium in postmenopausal bleeding by TVU

Hysterosonograpgy for suspected endometerial polyp on USS

Tissue diagnosis out patient endometerial sampling Pipelle`s biopsy(office biopsy

Diagnostic D&C

Hyseroscopy direct visulization of endometerial cavity and taking endometerial biopsy, removal of polyp

Hysteroscopy -indications Focal thickness on TVU Inadequate biopsy Persistent VB with negative biopsy

Treatment according to the cause Atrophic vaginitis or endometritis( HRT Cervical polyp :polypectomy Endometerial polyp: removal under direct visulization by hysteroscopy

Endometerial hyperplasia Without atypia: high dose oral progestogen or Mirena With atypia : TAH

Ca of endometerium(according tostaging TAH+ BSO+ staging+ adjuvant therapy