Post-menopausal bleeding PV

Dr Nasira Sabiha Dawood

Menopause • Menos month

• Pausis cessation last menstrual period

• Climacteric ladder the climb to the menopause

Menopause demographics

• Life expectancy of women has increased to 82 years

• 200 years ago only 30 % women lived through menopause and post menopause

• Post menopause is a condition of 20th and 21st centuries

• Age of menopause is constant

Phases • Reproductive regular cycle normal FSH • or raised in late phase

• Perimenopause heavy or oligomenorrhic till one year after FMP raised FSH

• POST MENOPAUSE one year after FMP till death

–vaginal bleeding –after twelve months of

amenorrhoea–woman of the age where the

menopause can be expected–younger women premature

menopause

POSTMENOPAUSAL BLEEDING PV

Epidemiology

• a common problem• 5% of all gynaecology

outpatient attendances• 30 % of postmenopausal

women

Causes - Benign

• Unopposed estrogen 30%• Atrophic vaginitis 30%• Atrophic endometritis• Endometrial polyps /cervical polyps 10%• Endometrial hyperplasia 5 %• Others 10%– Weight loss– Emotional stress– Trauma, bleeding disorders – Hormone replacement therapy (HRT)– Tamoxifen

Causes - malignant• Endometrial cancer 15%• Uterine sarcoma (rare) • Carcinoma of cervix • Ovarian carcinoma

Oestrogen-secreting (theca cell) ovarian tumours

• Vaginal carcinoma (very uncommon) • Carcinoma of vulva

may bleed, but lesion should be obvious

Management

• postmenopausal bleeding should be taken as malignant, until proved otherwise.

management• History

• General physical /systemic

• PELVIC EXAMINATION

management• Investigations– Blood complete picture– Urine RE– Blood glucose– Liver functions – Renal functions– Viral serology– X-ray chest – ECG

• Cervical smear

• USS

• Biopsy

Investigations• Transvaginal Ultrasound Scan(TVS)–first-line procedure–Women at higher risk of endometrial

cancer –endometrial thickness <5• thickness of >5 mm gives 7.3% likelihood of

endometrial cancer

Investigations• Endometrial biopsy– definitive diagnosis by histology– dilatation and curettage

• Hysteroscopy– to detect polyps and other benign lesions– as an outpatient procedure– some women will require GA– 'one stop' specialist clinics

several investigations are available to complement clinical evaluation, including ultrasound, endometrial sampling techniques and hysteroscopy

treatment• Atrophic endometrium

no treatment

• Atrophic vaginitisvaginal estrogen creams

• Uterine polypsremoved, can change to cancerous condition

• Uterine fibroidsshrink after menopause, enlarge or associated with PMB –

removed because of potential malignant change

• Endometrial hyperplasia– simple treated with medicines– atypical requires surgery

Study of PMB at FFH RWP

• ObjectiveTo determine the frequency and types of malignant

tumors of genital tract among post menopausal women complaining of vaginal bleeding

• Design• Descriptive

Materials and Methods• Patients 141• Included – Postmenopausal for 1 year

• Excluded– On hormone therapy Radiotherapy or chemotherapy– Hysterectomy– Trauma to the genital tract Women having coagulation disorder

Results• Total cases 141

• Uterine pathology 97 • Cervical pathology 27• Ovarian pathology 06• Vaginal pathology 01

Histopathology• Uterine Total 97• Proliferative endometrium 28• Secretory endometrium 13• Cystic hyperplasia 7• Disordered proliferation 3• Adenocarcinoma 13• Endometrial polyp 6

Necrosed decidua 3• Atrophic changes 24

Histopathology

• Ch non specific endometritis 2

Pyometra 4 • leiomysarcoma 1• Fibroid uterus 1

• Tuberculosis 1

• Decubitus ulcer 1

Histopathology• Cervix Total 27• chronic cervicitis 9 cervical polyp 7 Cervical ectopy 4 CIN 1 2 Ca Cervix 5• sq cell ca 4• adeno ca 1

ResultsAge distribution TOTAL 141

44-49 11 15.5 %50-59 72 101.52 %60-69 36 50.76 %70-79 20 28.2 %80 2 2.82 %

– Total cases 25/141

– Ca endometrium 13 18.3 %– Ca cervix 5 7.05%– Ca ovary 6 8.46% – Ca vagina 1 1.41%

– Overall frequency of cancer 32.25 %

Frequency of cancers

Histopathology• Ovary Total 7

• Granulosa cell tumor of ovary 3 • Mucinous cystadenocarcinoma 2• Papillary cystadenocarcinoma 2

Histopathology• Ca vagina sq cell carcinoma 1

Age distribution in cancers

• Ca endometrium 49-75 yrs• Ca cervix 59-71 yrs• Ca ovary 54-69• Ca vagina 73yrs

Time since menopause

• Ca endometrium 1-20 yrs• Ca cervix 1-11 yrs• Ca ovary 1-25 yrs• Ca vagina 22 yrs

Size of uterus•

• Ca endometrium bulky 10• atrophic 3

Conclusion • All patient presenting with post menopausal

bleeding PV how much slight or brief need to be investigated and treated

• Time since menopause is not important though more cases of atrophic vagintis and endometrium were seen in older age group

• Asymptomatic patients with bulky uterus need to be investigated on the same lines as PMB

• THANK YOU