Postmenopausal Bleeding
Definition
Any uterine bleeding that occurs 12 months after last menstruation
Epidemiology
Aetiology
Risk Factors (endometrial Ca)
Pathogenesis
Atrophy: hypoestrogenism --> dry uterus --> friction --> chronic inflammation --> spotting
Endometrial ca: refer to risk factors
Endometrial hyperplasia: Endo (ovarian. adrenal tumours)/ Exo (HRT) --> thickened lining --> bleed
Polyps: Growth stimulated by HRT/ tamoxifen
Clinical Features
It is endometrial cancer until proven otherwise
Symptoms
Signs
Investigations
1. Trans-vaginal ultrasound. Do a biopsy if:
2. Endometrial biopsy
Management
Source
UpToDate 2013
Any uterine bleeding that occurs 12 months after last menstruation
Epidemiology
- 5% outpatient visits
- 4-11% of postmenopausal women
Aetiology
- Atrophy (59%)
- Polyps (12%)
- Endometrial cancer (10%) --> most common adenocarcinoma
- Endometrial hyperplasia (9.8%) --> >5mm thick
- Hormonal effect (7%)
- Cervical cancer (<1%)
- Other (eg, hydrometra, pyometra, hematometra: 2%)
Risk Factors (endometrial Ca)
- Obese (adipose tissue produce oestrogen)
- Hypertensive
- DM
- Nulliparity (more menstrual cycles)
- Age
- Unopposed oestrogen therapy
- Early menarche/ late menopause
Pathogenesis
Atrophy: hypoestrogenism --> dry uterus --> friction --> chronic inflammation --> spotting
Endometrial ca: refer to risk factors
Endometrial hyperplasia: Endo (ovarian. adrenal tumours)/ Exo (HRT) --> thickened lining --> bleed
Polyps: Growth stimulated by HRT/ tamoxifen
Clinical Features
It is endometrial cancer until proven otherwise
Symptoms
- Atrophy: Vaginal dryness, dyspareunia, post-coital bleeding
- Endo ca: Obesity, HTN, DM, tamoxifen use
- Foreign body: pessary use
Signs
- BMI
- Uterus tenderness/ contour/ size
- ? local lesion/ lacerations/ foreign body
Investigations
1. Trans-vaginal ultrasound. Do a biopsy if:
- Thickness >4mm
- Endometrium with increased echogenicity
- Endometrium not visualised
- Persistent bleeding
2. Endometrial biopsy
- Pipelle 99.6% sens 98-100% spec (no anaesthesia/ LA, in clinic) for endo ca
- D+C
- Hysteroscopy (can see lesions)
Management
- Rule out endometrial ca
- Treat the cause
Source
UpToDate 2013