Postmenopausal bleeding for undergraduate

undergraduate course lectures in Obstetrics&Gynecology prepared by Dr Manal Behery .Professor OB&Gyne .Faculty of medicine ,Zagazig University

1. POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDING
DR;MANAL BEHERY
Professor OB &GYNE
2014

2. DefDef
Postmenopausal bleeding is any Postmenopausal bleeding is any
vaginal bleeding that occurs after vaginal bleeding that occurs after
12 months of amenorrhoea in a 12 months of amenorrhoea in a
postmenopausal women .postmenopausal women .

The age of menopause is variable, The age of menopause is variable,
but for most women it is 51 yearbut for most women it is 51 year

3. Causes of postmenopausal uterine Causes of postmenopausal uterine
bleedingbleeding
Atrophic vaginitisAtrophic vaginitis
60-80%60-80%
Estrogen treatmentsEstrogen treatments
15-25%15-25%
Polyp cervical –uterine Polyp cervical –uterine
2-12%2-12%
Endometrial HyperplasiaEndometrial Hyperplasia
5-10%5-10%
Enodometrial cancerEnodometrial cancer
10%10%
No cause foundNo cause found
10%10%

4. Atrophic VaginitisAtrophic Vaginitis
It is the most common cause of It is the most common cause of
postmenopausal uterine bleedingpostmenopausal uterine bleeding
4-5 years after the menopause, 25-4-5 years after the menopause, 25-
50% of women experience 50% of women experience
symptoms due to atophic vaginitis. symptoms due to atophic vaginitis.

5. Cervical polypCervical polyp
It is the second most It is the second most
common cause of common cause of
postmenopausal postmenopausal
bleedingbleeding

6. Hormone replacement therapy(HRTHormone replacement therapy(HRT((
Any vaginal bleeding in a Any vaginal bleeding in a
menopausal woman other than the menopausal woman other than the
expected cyclical bleeding that expected cyclical bleeding that
occurs in women taking sequential occurs in women taking sequential
HRT should be managedHRT should be managed

7. Endometrial hyperplasia &Endometrial Endometrial hyperplasia &Endometrial
cancercancer
reassure women that only 10 percent of those
presenting with postmenopausal bleeding will
have endometrial cancer
90 per cent of women with endometrial
cancer will present with vaginal bleeding

8. idiopathic causeidiopathic cause
10–15 %of patients, no evident cause for the 10–15 %of patients, no evident cause for the
bleeding will be found. bleeding will be found.
It is therefore necessary to look for blood in the stool It is therefore necessary to look for blood in the stool
or urine, especially if the source of bleeding is or urine, especially if the source of bleeding is
unclear.unclear.

9. InvestigationsInvestigations
HistoryHistory
Clinical examinationClinical examination
Cervical cytology (if appropriate(Cervical cytology (if appropriate(
Ultrasound scanUltrasound scan
Saline infusion sonographySaline infusion sonography
Outpatient hysteroscopyOutpatient hysteroscopy
Endometrial biopsyEndometrial biopsy

10. HistoryHistory

11. 11--Duration and severityDuration and severity
No evidence of
association with pattern of
bleeding and malignancy
eg: one off bleed vs regular
bleeding

12. --22--Associated symptomsAssociated symptoms

13. Hormonal treatementHormonal treatement

14. Past medical and surgical historyPast medical and surgical history
•FHistory of colorectal, endometrial or other cancers
associated with hereditary non-polyposis colorectal
cancer Lynch ll syndrome

15. Clinical examinationClinical examination
•General:
•obesity?
•thyroid? pallor?
•pulse? Cachexia?

16. Abdominal and pelvic Abdominal and pelvic
examinationexamination

17. Speculum examination of the cervixSpeculum examination of the cervix

18. Bimanual examinationBimanual examination

19. Cervical smearCervical smear

20. ColposcopyColposcopy

21. Ultrasound scanUltrasound scan

22. Transvaginal ultrasound (TVUSTransvaginal ultrasound (TVUS((
•Thickened (>5mm( endometrial stripe in postmenopause ALWAYS needs
further evaluation.

23. Normal TVUS with endometrial Normal TVUS with endometrial
thickness <4mm, thickness <4mm,
with normal examination does not with normal examination does not
require further investigation require further investigation
providing bleeding has STOPPED. providing bleeding has STOPPED.

24. Saline infusion sonographySaline infusion sonography

25. SonohysterographySonohysterography
TVS may miss small polyps TVS may miss small polyps
Difficult to distinguish from thickened Difficult to distinguish from thickened
endometriumendometrium
SHG helps in SHG helps in
accurate diagnosisaccurate diagnosis

26. normal cavitynormal cavity

28. EndometrialEndometrial biopsy biopsy
a tissue sample is taken from the lining of the uterus a tissue sample is taken from the lining of the uterus
(endometrium(, (endometrium(,
and is checked under a microscope for any abnormal and is checked under a microscope for any abnormal
cells or signs of cancer.cells or signs of cancer.

29. Endometrial samplingEndometrial sampling
All women with persistent menorrhogia All women with persistent menorrhogia
To diagnose or excludeTo diagnose or exclude
endometrial carcinoma or endometrial carcinoma or
HyperplasiaHyperplasia

30. Endometrial Suction CuretteEndometrial Suction Curette
Pippelle : most commonly used, least
discomfort

Karman Cannula
Endometrial Brush
Superior in Post-Menopausal
Same as Pipelle in Pre-Menop.
(A( Pipelle endometrial suction curette. (B( Vabra aspirator.
Tao Endometrial Brush

31. Sampling HowSampling How??
Endometrial aspiration Endometrial aspiration
Conventional D&C Conventional D&C
Hysteroscopy & directed biopsyHysteroscopy & directed biopsy

32. hysteroscopyhysteroscopy
The Gold Standard- The Gold Standard-
Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,

33. Indication of hystroscopyIndication of hystroscopy
When sampling cannot be performed When sampling cannot be performed
due to cervical stenos is due to cervical stenos is
Or when bleeding persists after negative Or when bleeding persists after negative
biopsy.biopsy.

34. Endometrial hyperplasis&endometrial polypEndometrial hyperplasis&endometrial polyp

35. Endometrial polyp

36. Management of postmenopausal Management of postmenopausal
bleedingbleeding

37. General treatmentGeneral treatment::
In some cases the blood loss may be In some cases the blood loss may be
excessive, rapid and possibly life threateningexcessive, rapid and possibly life threatening
Correct Correct general conditiongeneral condition(Anti-shock (Anti-shock
measure(measure(
-Hospitalization-Hospitalization

38. Rapid restoration of blood Rapid restoration of blood
volume,vital parametersvolume,vital parameters
followed by local examination to find out followed by local examination to find out
the site and source of bleedingthe site and source of bleeding

39. It is according to the It is according to the causecause : :

40. Atrophic vaginitisAtrophic vaginitis
treated by administration of topical oestrogentreated by administration of topical oestrogen
--VagifemVagifem an oestrogen within a small pessary an oestrogen within a small pessary
inserted into vaginainserted into vagina , ,

41. Endometrial PolypsEndometrial Polyps
Removed by hysteroscopyRemoved by hysteroscopy

42. When patient presents with recurrent When patient presents with recurrent
attack of bleedingattack of bleeding
Do Do pelvic MRI pelvic MRI to exclude early stage E to exclude early stage E
cancercancer
Do Do cytoscopycytoscopy to exclude bladder tumorsto exclude bladder tumors
-DO -DO sigmoidscopysigmoidscopy to exclude large bowel to exclude large bowel
tumors if the site of bleeding is uncleartumors if the site of bleeding is unclear

43. MRI early stage cancerMRI early stage cancer

44. Endometrial hyperplasia and Endometrial hyperplasia and
carcinomacarcinoma
In postmenopausal women it should be surgical and include In postmenopausal women it should be surgical and include
Total hystrectomy and bliateral salpingo-oophorectomyTotal hystrectomy and bliateral salpingo-oophorectomy
--To avoid unnecessary risk form treatment with progesteron To avoid unnecessary risk form treatment with progesteron
therapytherapy

45. SummarySummary
Vaginal atrophy: oestrogen daily for 2 weeks, Vaginal atrophy: oestrogen daily for 2 weeks,
then once- twice weekly for maintenance.then once- twice weekly for maintenance.
Polyps- removed as OPPolyps- removed as OP
Endometrial hyperplasia- treated with IUS or Endometrial hyperplasia- treated with IUS or
progestprogest
Endometrial hyperplasia with atypia- should Endometrial hyperplasia with atypia- should
be treated as cancer. be treated as cancer.

46. How to approach a case of How to approach a case of
abnormal Vaginal bleedingabnormal Vaginal bleeding
DR;MANAL BEHERY
Professor, Zagazig University
2014

47. DefinitionDefinition
Any uterine bleeding that is excessive in Any uterine bleeding that is excessive in
amount ,duration or frequancyamount ,duration or frequancy

48. Characteristics of Normal MenstruationCharacteristics of Normal Menstruation

49. Regulation of Normal Regulation of Normal
MenstruationMenstruation

50. How do hormones workHow do hormones work??

52. Iys LlyL&OYENPs&s1L 1RRNOe4L
OHLHR10L1O;OYRN– Why EP withdrawal bleeding
is self limited?

53. 33 reasonsreasons
1- It is a universal endometrial event

Menstrual changes occurs simultaneously
in all segments of endometriaum

54. 33 reasonsreasons
2-the endometrium is structurly stable ,
Randome breakdown of tissue is avoided

55. 33 reasonsreasons
Factors involved in stopping of menses
Waves of vacoconstriction
Vacular stasis
Endometrial collapse
Clotting factors

56. 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Hormone
Level
Estradiol
Progesterone
FSH
LH
Menstrual Cycle Day
Ovulation
Endometrial
Thickness
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Normal
Menstrual
Cycle

57. Hormone
Level
Estradiol
Progesterone
Endometrial
Thickness
0 2 4 6 8 10 12 14 16 18
20
0 2 4 6 8 10 12 14 16 18
20
Weeks
Breakthrough
Withdrawal
Anovulatory
Bleeding in PCOS
Lower limit
of normal

58. MenorrhagiaMenorrhagia
Prolonged (> 7 days) or excessive (> 80mL) Prolonged (> 7 days) or excessive (> 80mL)
uterine bleeding occurring at regular uterine bleeding occurring at regular
intervalsintervals
MetrorrhagiaMetrorrhagia
Uterine bleeding occurring at irregular Uterine bleeding occurring at irregular
intervals or between periodsintervals or between periods
MenometrorrhagiaMenometrorrhagia
Uterine bleeding occurring at irregular Uterine bleeding occurring at irregular
intervals, with heavy (> 80mL) or prolonged intervals, with heavy (> 80mL) or prolonged
(> 7 days) menstrual flow(> 7 days) menstrual flow
PolymenhorrheaPolymenhorrhea
Uterine bleeding occurring at regular Uterine bleeding occurring at regular
intervals of < 21 daysintervals of < 21 days
OligomenorrheaOligomenorrhea
Uterine bleeding occurring at intervals of 35 Uterine bleeding occurring at intervals of 35
days or longerdays or longer
AmenorrheaAmenorrhea
Absence of uterine bleeding for 6 months or Absence of uterine bleeding for 6 months or
longer in a non-menopausal womanlonger in a non-menopausal woman

59. classificationclassification
OrganicOrganic
–SystemicSystemic
–Reproductive tract diseaseReproductive tract disease
–IatrogenicIatrogenic
DysfunctionalDysfunctional
–OvulatoryOvulatory
–AnovulatoryAnovulatory

60. Systemic EtiologiesSystemic Etiologies
Coagulation defectsCoagulation defects
LeukemiaLeukemia
ITPITP
Thyroid dysfunctionThyroid dysfunction
Liver diseaseLiver disease

61. Reproductive Tract CausesReproductive Tract Causes
Gestational eventsGestational events
MalignanciesMalignancies
Benign Benign
–Atrophy Atrophy
–LeiomyomaLeiomyoma
–PolypsPolyps
–Cervical lesionsCervical lesions
–Foreign bodyForeign body
–InfectionsInfections

62. Most Common Causes of Most Common Causes of
Reproductive Tract AUBReproductive Tract AUB
Pre-menarchalPre-menarchal
–Foreign bodyForeign body
Reproductive ageReproductive age
–Gestational eventGestational event
Post-menopausaPost-menopausall
–AtrophyAtrophy

63. Iatrogenic Causes of AUBIatrogenic Causes of AUB
Intra-uterine deviceIntra-uterine device
Oral and injectable steroidsOral and injectable steroids
Psychotropic drugsPsychotropic drugs

64. Dysfunctional causesDysfunctional causes
DUB is the most DUB is the most
After pubertyAfter puberty
Before menopauseBefore menopause
After labor or abortionAfter labor or abortion

65. ““Doctor, I’m bleeding funnyDoctor, I’m bleeding funny””
What is your first question?What is your first question?
How do you help her define How do you help her define “bleeding “bleeding
funny”?funny”?
How do you quantify her bleeding?How do you quantify her bleeding?

66. A practical approach (step1) HISTORYA practical approach (step1) HISTORY
•11--AgeAge(before puberty, reproductive age ,PM(before puberty, reproductive age ,PM((
•22--Pattern of bleedingPattern of bleeding: cyclic or a cyclic: cyclic or a cyclic
•3Marital state3Marital state: complication of pregnancy: complication of pregnancy
•44 Drug intake Drug intake ,hormonal ttt, HRT,hormonal ttt, HRT
•::55 previousprevious treatmenttreatment

67. ))Step2) Physical examinationStep2) Physical examination
•AbdomenAbdomen: palpable mass? : palpable mass?
•PelvisPelvis: cervical or vaginal lesion?: cervical or vaginal lesion?
• Bimanual exaBimanual exam:uterine size m:uterine size
•Speculum Speculum :cervical lesion:cervical lesion
•PRPR: rectum or parametrium: rectum or parametrium

68. ))Step 3) investigationStep 3) investigation
TVS TVS to assess endometrial thicknessto assess endometrial thickness
Sonohystrography Sonohystrography
endometrial aspirateendometrial aspirate
HysteroscopyHysteroscopy
CT ,MRI for endometrial invasion CT ,MRI for endometrial invasion

69. Consider those investigations ONLY IFConsider those investigations ONLY IF
–cervical smear cervical smear if sexually active and last if sexually active and last
smear more than 1 year agosmear more than 1 year ago
–CBC CBC if menorrhagiaif menorrhagia
–Thyroid function, coagulation profile only Thyroid function, coagulation profile only
when history suggestivewhen history suggestive

70. ))Step4) medical tttStep4) medical ttt
For women under 40 with no suspicion of For women under 40 with no suspicion of
organic lesions eitherorganic lesions either
Hormonal (for irregular bleeding as well as Hormonal (for irregular bleeding as well as
menorrhagiamenorrhagia((
–combined OCcombined OC
–progestogen only (21 days neededprogestogen only (21 days needed((
Non-hormonal (for menorrhagiaNon-hormonal (for menorrhagia((
–NSAIDNSAID
–antifibrinolytic agentantifibrinolytic agent

71. Step 5 When to referStep 5 When to refer??
No response to medical treatmentNo response to medical treatment
Over the age of 40Over the age of 40
Uterus > 10 week size or irregularUterus > 10 week size or irregular
High risk of endometrial Cancer (obesity, DM, High risk of endometrial Cancer (obesity, DM,
PCOD)PCOD)
Cervical pathology suspectedCervical pathology suspected

72. Surgery treatment of Surgery treatment of AUBAUB
– Dilation and CurettageDilation and Curettage
quickest way to stop bleeding in patients quickest way to stop bleeding in patients
who are hypovolemicwho are hypovolemic
appropriate in older women (>35)to exclude appropriate in older women (>35)to exclude
malignancy but is inferior to hysteroscopymalignancy but is inferior to hysteroscopy
follow with medroxyprogesterone acetate, follow with medroxyprogesterone acetate,
OCP’s, or NSAID’s to prevent recurrenceOCP’s, or NSAID’s to prevent recurrence

73. hystrectomyhystrectomy

74. Other modalities of treatmentOther modalities of treatment
Levonorgesterol releasing IUCD (MirenaLevonorgesterol releasing IUCD (Mirena((

75. 22..Endometrial ablationEndometrial ablation
Hysteroscopic methodsHysteroscopic methods
–Endometrial laser ablationEndometrial laser ablation
–Electrosurgical endometrial ablationElectrosurgical endometrial ablation
–Loop endometrial ablationLoop endometrial ablation
–Roller-ball endometriaal ablation usting resectoscopeRoller-ball endometriaal ablation usting resectoscope
Nonhysteroscopic methodsNonhysteroscopic methods
–Radio-frequency-induced thermal endometrial ablationRadio-frequency-induced thermal endometrial ablation
–Microwave Microwave endometrial ablationendometrial ablation
–Uterine balloon therapyUterine balloon therapy
–3.Hysterectomy3.Hysterectomy

76. ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION
Uterine balloon therapyUterine balloon therapy Roller-ball endometriaal Roller-ball endometriaal
ablation usting ablation usting
resectoscoperesectoscope

77. Abnormal Uterine Bleeding in Abnormal Uterine Bleeding in
Women of Childbearing AgeWomen of Childbearing Age

78. Abnormal postmenopausal bleeding P Abnormal postmenopausal bleeding P
BleedingBleeding

79. THANK YOU