POSTMENOPAUSAL BLEEDING.pdfnjueueueyueejey

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1. POSTMENOPAUSAL BLEEDING
It mean bleeding after menopause.
If the woman not using HRT, it is always abnormal.
If the woman using HRT as sequential method,
unscheduled bleeding is abnormal& should be
investigated.

2. Causes
1.Atrophic vaginitis.
2.Endometrial or cervical polyp.
3.Endometrial hyperplasia.
4.Endometrial carcinoma.
5.Cervical carcinoma.

3. The most common cause is atrophic vaginitis where
the vaginal epithelium become thin& breakdown due
to decrease oestrogen.
However,10% of women with postmenopausal
bleeding have endometrial cancer . So this must be
excluded promptly.

4. Management
History :
1.History of the last cycle(to ensure she has menopause).
2.History of postcoitalbleeding(possible cervical polyp
or cancer ).
3.History of drug intake like HRT or tamoxifen.
4.History of last Pap smear.

5. Examination:
1.Abdominal & pelvic examination for any pelvic mass.
2.Speculum examination will show vaginal atrophy ,
cervical polyp or possible cancer & Pap smear done if
not done at it’s time.

6. Investigations
Transvaginalultrasound should be done for all
patients .If it is endometrial thickness 3mm or
more(5mm or more if the patient on HRT), if there is
irregular endometrial outline or fluid within the
uterine cavity the patient need endometrial biopsy.
The majority of women have thin regular
endometrium & can be reassured as endometrial
carcinoma excludedwithout further investigation.

8. Endometrial biopsy can be taken using samplers like
Pipelleendometrial sampler as outpatient.
Hysteroscopy can be done as outpatient or under
anaesthesiato investigate postmenopausal bleeding &
it allow inspection of endometrium for any
abnormality & directed biopsy can be taken. Then,
histopathologicalexamination of biopsy done.
Dilatation & curettage is old method used for taking
endometrial biopsy.

9. Tamoxifenis drug used for breast cancer.Itprevent
progression of breast cancer & prevent the disease in
the other breast.
It is non-steroidal drug with antioestrogenicaction on
the breast but mild oestrogenceffect on the
endometrium . So prolong use may cause endometrial
hyperplasia , polyp or carcinoma but it’s benefit for the
breast greater than the risk.

10. If a woman on tamoxifendevelop post-menopausal
bleeding , endometrial sampling always done
regardless the ultrasound findings & preferably by
hysteroscopy.

11. TREATMENT
According to cause:
1.Atrophic vaginitis: local oestrogen cream or pessary.
2.Cervical polyp: It can be removed through speculum
using polyp forceps.
3.Endometrial polyp: It can be removed under direct
vision by hysteroscopy.

12. 4.Endometrial hyperplasia: Histopathologicalreport
may show simple , complex or atypical hyperplasia.
Simple & complex hyperplasia without atypiatreated
by giving progesterone as oral or levonorgestril
intrauterine system(Mirena). Atypical hyperplasia
treated by total hysterectomy because of risk of
progression into carcinoma.

13. 5.Endometrial cancer: treated by total hysterectomy
with bilateral salpingo-oophorectomywith or without
adjuvant therapy.