1. Postmenopausal bleeding
Dr. Alia Kareem

2. 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.

3. 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

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

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

6. 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 .

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

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

9. 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

10. 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

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

12. 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

13. Thin endometrium in postmenopausal bleeding by TVU

14. Hysterosonograpgy for suspected endometerial polyp on USS

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

16. Diagnostic D&C

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

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

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

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

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