Post-menopausal bleeding PV Dr Nasira Sabiha Dawood

Menopause Menos month Pausis cessation last menstrual period Climacteric ladder the climb to the menopause

Menopause demographics Life expectancy of women has increased to 82 years 200 years ago only 30 % women lived through menopause and post menopause Post menopause is a condition of 20 th and 21 st centuries Age of menopause is constant

Phases Reproductive regular cycle normal FSH or raised in late phase Perimenopause heavy or oligomenorrhic till one year after FMP raised FSH POST MENOPAUSE one year after FMP till death

– vaginal bleeding – after twelve months of amenorrhoea – woman of the age where the menopause can be expected – younger women premature menopause POSTMENOPAUSAL BLEEDING PV

Epidemiology a common problem 5% of all gynaecology outpatient attendances 30 % of postmenopausal women

Causes - Benign Unopposed estrogen 30% Atrophic vaginitis 30% Atrophic endometritis Endometrial polyps /cervical polyps 10% Endometrial hyperplasia 5 % Others 10% – Weight loss – Emotional stress – Trauma, bleeding disorders – Hormone replacement therapy (HRT) – Tamoxifen

Causes - malignant Endometrial cancer 15% Uterine sarcoma (rare) Carcinoma of cervix Ovarian carcinoma Oestrogen-secreting (theca cell) ovarian tumours Vaginal carcinoma (very uncommon) Carcinoma of vulva may bleed, but lesion should be obvious

Management postmenopausal bleeding should be taken as malignant, until proved otherwise.

management History General physical /systemic PELVIC EXAMINATION

management Investigations – Blood complete picture – Urine RE – Blood glucose – Liver functions – Renal functions – Viral serology – X-ray chest – ECG

Cervical smear USS Biopsy

Investigations Transvaginal Ultrasound Scan(TVS) – first-line procedure – Women at higher risk of endometrial cancer – endometrial thickness <5 thickness of >5 mm gives 7.3% likelihood of endometrial cancer

Investigations Endometrial biopsy – definitive diagnosis by histology – dilatation and curettage Hysteroscopy – to detect polyps and other benign lesions – as an outpatient procedure – some women will require GA – 'one stop' specialist clinics several investigations are available to complement clinical evaluation, including ultrasound, endometrial sampling techniques and hysteroscopy

treatment Atrophic endometrium no treatment Atrophic vaginitis vaginal estrogen creams Uterine polyps removed, can change to cancerous condition Uterine fibroids shrink after menopause, enlarge or associated with PMB – removed because of potential malignant change Endometrial hyperplasia – simple treated with medicines – atypical requires surgery

Study of PMB at FFH RWP Objective To determine the frequency and types of malignant tumors of genital tract among post menopausal women complaining of vaginal bleeding Design Descriptive

Materials and Methods Patients 141 Included – Postmenopausal for 1 year Excluded – On hormone therapy Radiotherapy or chemotherapy – Hysterectomy – Trauma to the genital tract Women having coagulation disorder

Results Total cases 141 Uterine pathology 97 Cervical pathology 27 Ovarian pathology 06 Vaginal pathology 01

Histopathology Uterine Total 97 Proliferative endometrium 28 Secretory endometrium 13 Cystic hyperplasia 7 Disordered proliferation 3 Adenocarcinoma 13 Endometrial polyp 6 Necrosed decidua 3 Atrophic changes 24

Histopathology Ch non specific endometritis 2 Pyometra 4 leiomysarcoma 1 Fibroid uterus 1 Tuberculosis 1 Decubitus ulcer 1

Histopathology Cervix Total 27 chronic cervicitis 9 cervical polyp 7 Cervical ectopy 4 CIN 1 2 Ca Cervix 5 sq cell ca 4 adeno ca 1

Results Age distribution TOTAL % % % % %

– Total cases 25/141 – Ca endometrium % – Ca cervix % – Ca ovary % – Ca vagina % – Overall frequency of cancer % Frequency of cancers

Histopathology Ovary Total 7 Granulosa cell tumor of ovary 3 Mucinous cystadenocarcinoma 2 Papillary cystadenocarcinoma 2

Histopathology Ca vagina sq cell carcinoma 1

Age distribution in cancers Ca endometrium yrs Ca cervix yrs Ca ovary Ca vagina 73yrs

Time since menopause Ca endometrium 1-20 yrs Ca cervix 1-11 yrs Ca ovary 1-25 yrs Ca vagina 22 yrs

Size of uterus Ca endometrium bulky 10 atrophic 3

Conclusion All patient presenting with post menopausal bleeding PV how much slight or brief need to be investigated and treated Time since menopause is not important though more cases of atrophic vagintis and endometrium were seen in older age group Asymptomatic patients with bulky uterus need to be investigated on the same lines as PMB

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