SGD 12 – Post-Menopausal Bleeding

Menopause
Cessation of menstrual cycle for at least 1 year

Effects of Menopause by Time of Onset

Immediate (0 – 5 years) Intermediate (3 – 10 years) Long Term (>10 years)
 Vasomotor symptoms (e.g., hot flushes, night sweats)  Vaginal dryness, soreness  Osteoporosis
 Psychological symptoms (e.g., labile mood, anxiety, (↓ Estrogen levels)  Cardiovascular disease
tearfulness)  Dyspareunia - IHD & Stroke
 Loss of concentration, Poor memory  Urgency of urine  Dementia
 Joint aches & pains  Recurrent UTI
 Dry & itchy skin  Urogenital prolapse
 Hair changes
 Decreased sexual desire
***Initial irregular or scanty vaginal bleeding is due to ↓ in estrogenic endometrial stimulation with failing ovarian function
***↓ Estrogen  ↓ cellular turnover & glandular activity  ↓ elastic & easily traumatized  Dyspareunia
***Triggers of hot flushes – Alcohol, Caffeine, Smoking
***Vasomotor symptoms worse in women with high BMI

Risk of Osteoporosis (Skeletal disorder characterized by compromised bone strength predisposing to an ↑ risk of fracture)
 Family history of Osteoporosis or hip fracture
 Smoking
 Alcoholism
 Long-term steroid use (Reduces body’s ability to absorb & Increase bone metabolism)
 Primary Ovarian Insufficiency (Premature Ovarian Failure) & Hypogonadism
 Medical treatment of gynecological conditions with induced menopause
 Disorders of thyroid and parathyroid metabolism
 Immobility
 Disorders of gut absorption, malnutrition, liver disease

Investigations
 Serum FSH
- > 30IU/l (Highly suspicious of menopause)
 History taking
- Oligomenorrhea/Amenorrhea
- Vasomotor symptoms
- Joint aches
- Minor Cognitive Changes

Management
 Diet & lifestyle
 Prevention of lung cancer
Stopping
 Reduction of CVD
smoking
 Beneficial effects on bone loss
 Reduction of calorie intake
 Fewer, less severe vasomotor symptoms
Reducing
 Beneficial effects on bone loss
alcohol
 Prevention of alcohol-related liver damage
consumption
 Reduction in incidence of breast cancer
 Reduction of CVD
 Reduction of calorie intake
 Fewer, less severe vasomotor symptoms
 Beneficial effects on bone loss
Normal BMI
 Reduction in incidence of breast cancer
 Reduction in incidence of endometrial cancer
 Reduction of CVD
 SGD 12 – Post-Menopausal Bleeding
 Non-Hormonal Approaches
Alternative and complementary treatments Non-hormonal treatments for
vasomotor symptoms
Complementar  Acupuncture Alpha-adrenergic
Clonidine
y Drug-free  Reflexology agonists
therapies  Magnetism Beta-blockers Propanolol
 Reiki Venlafaxine
 Hypnotism Modulators of Fluoxetine
Herbal/Natural  Black cohosh (Actaea racemosa) central Paroxetine
preparation  Dong quai (Angelica sinensis) neurotransmission Citalopram
 Evening primrose oil (Oenothera biennis) Gabapentin
 Gingko (Gingko biloba)
 Ginseng (Panax ginseng)
 Kava kava (Piper methysticum)
 St John’s wort (Hypericum perforatum)
‘Natural’  Phytoestrogens such as isoflavones and red clover
hormones  Natural progesterone gel
 Dehydroepiandrosterone (DHEA)

 Hormone Replacement Therapy

Hormones Estrogen Progesterone
Used  Estradiol (Main physiological estrogen)  Norethisterone
 Estrone sulphate  Levonorgestrel
 Estriol  Dydrogesterone
 Conjugated equine estrogen  Medroxyprogesterone acetate
 Drospirenone
 Micronized progesterone
Routes of  Oral (daily tablet)
Administration - Cheap
- Influence lipid metabolism & coagulation system (due to 1 st pass metabolism)
 Transdermal (Patches or Gel)
- Direct delivery of estradiol into the circulation
- Avoid adverse effects on the liver & coagulation system
- Estradiol though – Small vaginal tablets, Vaginal ring, Vaginal cream
 Intrauterine Releasing System
- Provides contraception, Control troublesome bleeding, Provide endometrial protection for up
to 5 years
Beneficial  Symptom improvement: Vasomotor symptoms, Sleep patterns
Effects  Prevention of osteoporosis: ↑ bone mineral density, ↓ incidence of fragility fractures
 Lower genital tract: Dryness, Soreness, Dyspareunia
 CVD: Preventative effect if started early in menopause

Post-Menopausal Bleeding
Bleeding more that 1 year after cessation of periods

What is important to exclude?

 Endometrial pathology
 Vaginal atrophy (↓ estrogen level  vaginal epithelium thin & breaks down)

About
 Red flag symptom for gynecological cancer (should always be taken seriously)
 Careful inspection of the external genitalia followed by speculum examination
 Benign causes of PMB  HRT & Vaginal atrophy

Causes
 Endometrial carcinoma  Cervical carcinoma
 Atrophic vaginitis (Treat with topical estrogens)  Malignant ovarian tumour (Estrogen producing
 Endometrial atrophy tumour)
 Endometrial hyperplasia
Diagnosis & Investigation
 SGD 12 – Post-Menopausal Bleeding
 TVUSS
- Direct visualization of the endometrial cavity
- Endometrium thickness:<4mm  cancer unlikely, >4mm, Irregular endometrial outline, Fluid in cavity  Biopsy
 Saline infusion sonography
 Hysteroscopy – Performed under LA (GA if cervical stenosis or poorly tolerated)  Visualized endometrium & direct biopsy
 Endometrial sampling (Gold standard = Hysteroscopy + Biopsy)
- OPD: Pipelle (plastic cannula), Vabra aspirator, Novak aspirator, Karman curette
- Hysteroscopy can detect 95% IU abnormalities (e.g. polyps, submucous fibroids)
- Complications: Uterine perforation, Infections, Excessive bleeding
 Endometrial biopsy
- Histological assessment  Type & Grade
Possible Endometrial Biopsy Findings
 Proliferative, Secretory, Benign or Atrophic endometrium
 Inactive endometrium
 Tissue insufficient for analysis
 No endometrial tissue seen
 Simple or complex (adenomatous) hyperplasia without atypia
 Cervical smear
 Cervical biopsy
 FBC
 Coagulation profile
 Pap smear
 HPV test

Management of other causes of Post-Menopausal Bleeding

Diagnosis Management
Atrophic vaginitis Topical oestrogen cream, oestrogen pessaries
Cervical polyp Remove via speculum examination using polyp forceps
Endometrial polyp Remove under direct visualization at hysteroscopy + Dilatation & Curettage
Endometrial cancer Total Abdominal Hysterectomy + Bilateral Salpingo-oophorectomy + washings +/- adjuvant therapy
Cervical cancer Surgery or radiotherapy according to staging
Simple/Complex Progesterone : oral preparation or Mirena (LNG-IUS)
Hyperplasia
Atypical Hyperplasia Total Abdominal Hysterectomy as significant risk of progression to malignancy

Endometrial Hyperplasia
1. Definition
 Increase in the glandular to stromal tissue ratio to more than 1

2. About
 Frequently asymptomatic
 PMB is associated with endometrial hyperplasia in about 15%

3. Normal Histology
 Body of uterus has 2 layers (Endometrium & Myometrium)
 Endometrium or Mucosa consisting of glands & Stroma undergoes cyclical changes (Proliferative phase & Secretory
phase) in response to estrogen & progesterone in reproductive life

4. Predisposing factors
Exogenous stimulation Endogenous stimulation
 Unopposed estrogen HRT  Obesity
 Tamoxifen therapy  Anovulation
 Ovarian Stromal Hyperplasia

5. Classification
Endometrial Hyperplasia Atypical Endometrial Hyperplasia
 Simple  Simple
 Complex (Adenomatous)  Complex (Adenomatous with atypia)