Professional Documents
Culture Documents
Menopause
Cessation of menstrual cycle for at least 1 year
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)
Post-Menopausal Bleeding
Bleeding more that 1 year after cessation of periods
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
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)