Approach to post menopausal bleeding

Post menopausal bleeding

1. Approach To Post Menopausal Bleeding By Dr. Niranjan Chavan

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital Joint Treasurer, FOGSI (2021-2024) Vice President, MOGS (2021-2022) Member Oncology Committee, SAFOG (2020-2022) (2021-2023) Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses Editor-in-Chief, FEMAS & JGOG Journal 54 publications in International and National Journals with 58 citations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2021) Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16) Member, Oncology Committee AOFOG (2013-2015) Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Managing Committee IAGE (2013-17), (2018-20) Editorial Board, European Journal of Gynaec. Oncology (Italy) Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19) DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA)

3. Definition Bleeding from the genital tract after menopause ( 1 year after cessation of menses). Investigations are started in case there is bleeding after 6 months of amenorrhea in women of menopausal age group.

4. Causes of Post Menopausal Bleeding Local causes Uterus Cervix Vagina Vulva Others Systemic causes Bleeding disorders Hormone disorders Estrogen producing tumors

5. Endometrial atrophy Estrogen replacement therapy Endometrial polyps Endometrial hyperplasia Endometrial cancer 60-80 % 15-25 % 2-12 % 5-10 % 10 % Uterine causes

6. Cervix Cervical carcinoma, Cervicitis, Cervical polyp, Cervical trauma. Vagina Vaginal carcinoma, Senile atrophic vaginitis, Vaginal trauma, Foreign bodies especially pessaries, Vaginal inflammation, Vaginal polyps.

7. Vulva Vulval carcinoma, Vulvar dystrophies, Vulval trauma Others Fallopian tube carcinoma, Secondary tumors (ovarian, breast, colorectal carcinomas)

8. Risk factors Nulliparity Late menopause (>52yrs) Obesity Diabetes Mellitus Unopposed estrogen therapy Tamoxifen Atypical Endometrial Hyperplasia

9. History When was your last period ? When did the bleeding start ? Were there any precipitating factors such as trauma? What is the nature of bleeding? History of risk factors ? Any associated symptoms ?

10. Is there any personal or family history of a bleeding disorder? What is the patient’s medical history and is she taking Hormonal Replacement therapy? Past obstetrics history? Past surgical history? When was the last PAP smear done? Was it normal?

11. Examination General Examination Obesity, thyroid (hypo-hyper), Pallor Weight loss, Cachexia, fever Abdominal examination to look for any mass.

12. Per speculum examination for atrophic vaginitis, tumors of cervix, vagina, vulva or cervical polyps and Pap Smear.

13. Bimanual examination should be performed to assess uterine size, mobility and position before performing endometrial biopsy. Rectovaginal examination to look for nodularity of Cul de sac.

14. Investigations General Investigations: Complete blood count Coagulation studies Liver and Kidney function test Chest XRAY Transvaginal sonography

15. Transvaginal Sonography It is done to assess Endometrial thickness Ovarian pathology Other endometrial pathologies like Polyp, endometrial collection, cervical extension. Cut off for ET Postmenopausal: >4mm

16. The interpretation of characteristic findings on TVS: A. Cystic endometrial changes: s/o Polyps B. Homogenous thickened endometrium: s/o Hyperplasia C. Heterogenous thickened endometrium: s/o Malignancy

17. The Obstetrician & Gynecologist, Volume: 14, Issue: 4, Pages: 243-249, First published: 17 October 2012

18. Endometrial Sampling A. Out patient ( Office ) Endometrial Sampling: Office endometrial biopsy is an effective diagnostic technique that is simple to perform, does not require anesthesia , and is generally well tolerated by the patient. There are now many devices for performing endometrial biopsies in the outpatient setting.

19. Pipelle’s biopsy Advantages: Inexpensive, OPD procedure, no need of dilatation or anesthesia. Can be used without tenaculum. Causes less uterine scraping. Increased patient acceptance. Successful in obtaining adequate tissue sample in >95% cases.

20. Pipelle’s biopsy

21. Explora The disposable Explora Model by Cooper Surgicals incorporates a long nylon curette with Randall-type cutting edge, stylet and Vacu-Lok syringe that adjusts suction from approximately 15- to 20-inch Hg negative pressure (6 cc to 12 cc).

22. Tao brush It is a small flexible brush used for endometrial biopsy. Tissue upto 1.5-2 mm depth can be obtained. It gently brushes the entire endometrium so as to gather complete sampling. It is less painful and covers wider surface area.

23. Vabra Aspirator Disposable set for endometrial biopsy VABRA® is a suction curette for endometrial biopsy. Set includes flexible straight catheter, with blunt point and side-ports to allow suction and collection of the endometrial tissue, test-tube with cap and spoon, universal pipe-fitting for aspirators .

24. Hysteroscopy Enables to visualize the entire endometrium and to take biopsy from the selected area and reduce the chance of missing early lesion. Reserved for situations with: cervical stenosis/patient tolerance doesn’t permit adequate evaluation by aspiration. Bleeding recurs after a negative EB. Specimen obtained is inadequate to explain AUB.

25. More accurate in identifying polyps and submucous myomas . Use of fluid distention media can disseminate cancer cells into peritoneum and increase stage of cancer. Therefore, hysteroscopy is not done if malignancy is suspected .

26. Establishing patterns on hysteroscopy in abnormal uterine bleeding (AUB), Gynecology and Minimally Invasive Therapy, Volume 6, Issue 4,2017.

27. B. Inpatient endometrial sampling: Dilatation and curettage ( D&C ): Dilatation and fractional curettage. Hysteroscopy and curettage/Hysteroscopy and directed endometrial biopsy.

28. Dilatation and curettage ( D&C ) It remains the gold standard . However, D&C requires anesthesia and is associated with a number of potential complications . D&C should still be considered when the endometrial biopsy is non diagnostic and there a high suspicion of cancer .

29. Fractional Curettage Starts with scraping of endocervical canal, dilatation of cervix followed by curettage from isthmus, body of uterus and fundus separately . Curettage of endometrial Carcinoma has following characteristics: profuse cheesy material, dark colour , failure to grate during curettage.

30. Atrophic Vaginitis It is the most common cause of PMB. It occurs 4-5 years after the menopause, Vaginal epithelium thins and breaks down in response to low estrogen levels. This is a benign condition, which is relatively easily treated with lubricants and topical estrogens

31. Estrogen Replacement Therapy HRT is used as first‐line treatment for the prevention or treatment of osteoporosis in menopausal women HRT is prescribed either as an estrogen‐only preparation in women who have undergone hysterectomy or as an estrogen–progestogen combination for women with a uterus to prevent endometrial hyperplasia and cancer.   Cyclical HRT   Continuous combined HRT • Continuous estrogen and cyclical progesterone for 12–14 days in a 28‐day cycle produces regular and acceptable bleeding after the end of the progestogen phase • Daily use of estrogen and progesterone should induce amenorrhea usually within 6 months of therapy

32. Unscheduled bleeding with hormone replacement therapy Article  in  The Obstetrician & Gynaecologist · January 2019

33. Endometrial Polyp Most risk factors for endometrial polyps involve increased levels or activity of endogenous or exogenous estrogen . A number of studies report an increased incidence of endometrial polyps in women on hormone replacement therapy (HRT) . A progestogen with high anti-estrogenic activity may have an important role in preventing the development of endometrial polyps.

34. Polyps develop in 2 to 36 percent of postmenopausal women treated with tamoxifen. Malignant transformation of an endometrial polyp appears to occur more frequently in women on tamoxifen (up to 11 percent) than in other women. Endometrial polyps appear to be associated with obesity . Those with a BMI ≥30 had a significantly higher rate of polyps than other women (52 versus 15 percent).

35. Endometrial Hyperplasia Abnormal proliferation of the endometrium (glands). It accounts for 5-10 % of PMB due to excessive estrogen stimulation . More than 4 mm in post menopausal is significant.

36. World Health Organization (WHO) Old Classification Of Endometrial Hyperplasia (1994) Type of Hyperplasia Percentage Typical Simple 1 complex 3 Atypical Simple 8 complex 29

37. World Health Organization (WHO) New Classification Of Endometrial Hyperplasia (2014) Non-atypical endometrial hyperplasia (benign hyperplasia) Atypical endometrial hyperplasia According to ACOG Committee 2018, endometrial thickness of <4mm or less on transvaginal USG has a greater than 99% negative value for endometrial cancer.

38. Cervical P olyps Endocervical polyps are more common than ectocervical polyps. They appear as red protrusions from the cervical os . They can be easily removed in the office by grasping with sponge forceps and twisting on their pedicle.

39. Case 1 A woman 59 years of age presents with complaints of spotting per vaginum . On examination a 2 cm polyp seen protruding from endocervical canal. It was removed with sponge forceps. Histopathology suggestive of benign endometrial polyp . The bleeding continuous and 3 months later she represents to her gynecologist. An endometrial biopsy shows grade 2 endometroid adenocarcinoma . Practice points: it is important to rule other serious causes of postmenopausal bleeding even if a seemingly obvious cause is noted.

40. Take Home Message The incidence of post menopausal bleeding is 10%. Patients with post menopausal bleeding have a 10-15% chance endometrial carcinoma. If bleeding present on Continuous combined regimens after first 6 months or once amenorrhea is established , consider as abnormal & investigate . ACOG cut off for endometrial thickness in PMB is 4 mm . Every woman with PMB should be assumed to have a carcinoma until full investigation has proved to the contrary.