Postmenopausal bleeding for undergraduate

POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDING

DR;MANAL BEHERYProfessor OB &GYNE

2014

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

Causes of postmenopausal uterine Causes of postmenopausal uterine bleedingbleeding

Atrophic vaginitisAtrophic vaginitis60-80%60-80%Estrogen treatmentsEstrogen treatments15-25%15-25%Polyp cervical –uterine Polyp cervical –uterine 2-12%2-12%Endometrial HyperplasiaEndometrial Hyperplasia5-10%5-10%Enodometrial cancerEnodometrial cancer10%10%No cause foundNo cause found10%10%

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.

Cervical polypCervical polyp

It is the second most It is the second most common cause of common cause of postmenopausal postmenopausal bleedingbleeding

Hormone replacement therapy(HRT)Hormone 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

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

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.

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

HistoryHistory

11--Duration and severityDuration and severity

No evidence of association with pattern of bleeding and malignancy eg: one off bleed vs regular bleeding

--22--Associated symptomsAssociated symptoms

Hormonal treatementHormonal treatement

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

Clinical examinationClinical examination

•General:

•obesity?

•thyroid? pallor?

•pulse? Cachexia?

Abdominal and pelvic Abdominal and pelvic examinationexamination

Speculum examination of the cervixSpeculum examination of the cervix

Bimanual examinationBimanual examination

Cervical smearCervical smear

ColposcopyColposcopy

Ultrasound scanUltrasound scan

Transvaginal ultrasound (TVUS)Transvaginal ultrasound (TVUS)

•Thickened (>5mm) endometrial stripe in postmenopause ALWAYS needs further evaluation.

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.

Saline infusion sonographySaline infusion sonography

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

normal cavitynormal cavity

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.

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

Endometrial Suction CuretteEndometrial Suction Curette

Pippelle : most commonly used, least discomfort

Karman Cannula

Endometrial BrushSuperior in Post-MenopausalSame as Pipelle in Pre-Menop.

)A (Pipelle endometrial suction curette. (B) Vabra aspirator.

Tao Endometrial Brush

Sampling HowSampling How??

Endometrial aspiration Endometrial aspiration

Conventional D&C Conventional D&C

Hysteroscopy & directed biopsyHysteroscopy & directed biopsy

hysteroscopyhysteroscopy

The Gold Standard- The Gold Standard- Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,

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.

Endometrial hyperplasis&endometrial polypEndometrial hyperplasis&endometrial polyp

Endometrial polyp

Management of Management of postmenopausal postmenopausal

bleedingbleeding

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

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

It is according to the It is according to the causecause: :

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, ,

Endometrial PolypsEndometrial Polyps

Removed by hysteroscopyRemoved by hysteroscopy

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

MRI early stage cancerMRI early stage cancer

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

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 OPEndometrial hyperplasia- treated with IUS or Endometrial hyperplasia- treated with IUS or

progestprogestEndometrial hyperplasia with atypia- should Endometrial hyperplasia with atypia- should

be treated as cancer. be treated as cancer.

How to approach a case of How to approach a case of abnormal Vaginal bleedingabnormal Vaginal bleeding

DR;MANAL BEHERYProfessor, Zagazig University

2014

DefinitionDefinition

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

Characteristics of Normal MenstruationCharacteristics of Normal Menstruation

Regulation of Normal Regulation of Normal MenstruationMenstruation

How do hormones workHow do hormones work??

Why EP withdrawal bleeding is self limited?

Why EP withdrawal bleeding is self limited?

33 reasonsreasons

1 -It is a universal endometrial event

Menstrual changes occurs simultaneously in all segments of endometriaum

33 reasonsreasons

2-the endometrium is structurly stable, Randome breakdown of tissue is avoided

33 reasonsreasons

Factors involved in stopping of mensesWaves of vacoconstriction Vacular stasis Endometrial collapse Clotting factors

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28

Hormone Level

EstradiolProgesterone

FSHLH

Menstrual Cycle Day

Ovulation

Endometrial Thickness

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28

Normal Menstrual

Cycle

Hormone Level

EstradiolProgesterone

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

MenorrhagiaMenorrhagiaProlonged (> 7 days) or excessive (> Prolonged (> 7 days) or excessive (> 80mL) uterine bleeding occurring at 80mL) uterine bleeding occurring at regular intervalsregular intervals

MetrorrhagiaMetrorrhagiaUterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals or between periodsintervals or between periods

MenometrorrhagiaMenometrorrhagiaUterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals, with heavy (> 80mL) or intervals, with heavy (> 80mL) or prolonged (> 7 days) menstrual flowprolonged (> 7 days) menstrual flow

PolymenhorrhePolymenhorrheaa

Uterine bleeding occurring at regular Uterine bleeding occurring at regular intervals of < 21 daysintervals of < 21 days

OligomenorrheaOligomenorrheaUterine bleeding occurring at intervals Uterine bleeding occurring at intervals of 35 days or longerof 35 days or longer

AmenorrheaAmenorrheaAbsence of uterine bleeding for 6 Absence of uterine bleeding for 6 months or longer in a non-menopausal months or longer in a non-menopausal womanwoman

classificationclassification

OrganicOrganic–SystemicSystemic

–Reproductive tract diseaseReproductive tract disease

–IatrogenicIatrogenic

DysfunctionalDysfunctional–OvulatoryOvulatory

–AnovulatoryAnovulatory

Systemic EtiologiesSystemic Etiologies

Coagulation defectsCoagulation defects

LeukemiaLeukemia

ITPITP

Thyroid dysfunctionThyroid dysfunction

Liver diseaseLiver disease

Reproductive Tract CausesReproductive Tract Causes

Gestational eventsGestational events

MalignanciesMalignancies

Benign Benign – Atrophy Atrophy – LeiomyomaLeiomyoma– PolypsPolyps– Cervical lesionsCervical lesions– Foreign bodyForeign body– InfectionsInfections

Most Common Causes of Most Common Causes of Reproductive Tract AUBReproductive Tract AUB

Pre-menarchalPre-menarchal–Foreign bodyForeign bodyReproductive ageReproductive age–Gestational eventGestational eventPost-menopausaPost-menopausall–AtrophyAtrophy

Iatrogenic Causes of AUBIatrogenic Causes of AUB

Intra-uterine deviceIntra-uterine device

Oral and injectable steroidsOral and injectable steroids

Psychotropic drugsPsychotropic drugs

Dysfunctional causesDysfunctional causes

DUB is the most DUB is the most

After pubertyAfter puberty

Before menopauseBefore menopause

After labor or abortionAfter labor or abortion

““Doctor, IDoctor, I’’m bleeding funnym 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 funnyfunny””??

How do you quantify her bleeding?How do you quantify her bleeding?

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

))Step2Step2 ( (Physical examinationPhysical 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

))Step 3Step 3 ( (investigationinvestigation

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

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

))Step4Step4 ( (medical tttmedical ttt

For women under 40 with no suspicion of organic For women under 40 with no suspicion of organic lesions eitherlesions either

Hormonal (for irregular bleeding as well as Hormonal (for irregular bleeding as well as menorrhagiamenorrhagia))

–combined OCcombined OC–progestogen only (21 days needed)progestogen only (21 days needed)

Non-hormonal (for menorrhagia)Non-hormonal (for menorrhagia)–NSAIDNSAID

–antifibrinolytic agentantifibrinolytic agent

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

Surgery treatment of Surgery treatment of AUBAUB

– Dilation and CurettageDilation and Curettagequickest 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

hystrectomyhystrectomy

Other modalities of treatmentOther modalities of treatment

Levonorgesterol releasing IUCD (Mirena)Levonorgesterol releasing IUCD (Mirena)

22..Endometrial ablationEndometrial ablationHysteroscopic 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

ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION

Uterine balloon therapyUterine balloon therapy Roller-ball endometriaal Roller-ball endometriaal ablation usting ablation usting resectoscoperesectoscope

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

Abnormal postmenopausal bleeding P Abnormal postmenopausal bleeding P BleedingBleeding

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