PMB
C 40 y premature ovarian failure
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40 454 premature menopause
menopause
4sy
menopause agerange
average age
255,5
45
ofmenopause 514
Post-menopausal Bleeding
Vaginal Bleeding after established menopause (12 consecutive months of amenorrhoea).
Causes
Local :
1. Atrophic vaginitis (commonest cause) - due to lack of oestrogen, vagina loses
elasticity, vaginal epi becomes thin, ph becomes alkaline and secretions dry out,
causing inflammation and bleeding.
2. Endometrial causes - Endometrial hyperplasia
- Endometrial CA
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- Endometrial polyps
- Endometritis
- Foreign body in the uterus (IUD)
3. Cervical causes - Cervical polyps
- Cervical CA
- Cervicitis
Systemic :
1. Hypothyroidism
2. Liver disease
3. Other bleeding disorders
4. Anticoagulant, anti PLT use
Consider Endometrial CA in every patient with post-menopausal bleeding, even
though it has low incidence.
History format
1. Age CRF for endometrial IAI
2. Parity nulliparity RF for endometrial IA
3. Post-menopausal bleeding :
- Age at menopause latemenopause
- Whether she’s using HRT (may have irregular bleeding)
- Duration of bleeding. If episodic, number of episodes & interval b/w episodes
- Colour (altered / fresh)
- Amount (using pads, clots, flooding)
4. Other associated symptoms :
- Vaginal discharge (Endometritis, endometrial CA & cervical CA)
- Dyspareunia & post coital bleeding (cervical / vaginal pathology)
- Abdominal / pelvic pain
- Abdominal distention / lump
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- Bleeding from other sites
- Use of drugs (anti PLT, anticoagulants)
5. Complications:
- Anaemia symptoms
- Local spread of malignancy - Haematuria, tenesmus, PR bleeding
- Back pain
- Distant metastasis - Lung (SOB, haemoptysis, cough)
- Liver (jaundice, back pain)
- Bones (back pain)
- Brain (early morning headache, vomiting, fits)
- General LOW, LOA, malaise
6. Past menstrual Hx & gynaecological Hx to find out RF :
- early menarche, late menopause
- Hx of subfertility, PCOS, HRT, Tumors of the ovaries (unopposed oestrogen)
- Contraceptive use
- has she done a pap smear in the past in the well women clinic
7. Family Hx of ovarian, breast, endometrial, colonic CA
Lynch Xh
Examination
1. Genenral - BMI, signs of PCOS
- Pallor, LN
- Other bleeding manifestations
- Ankle oedema, varicosity
2. Abdominal Ex - Lumps, liver, free fluid
3. Vaginal Ex :
- Bimanual Ex - enlarged uterus, adenexal masses, deposits in POD
- Speculum Ex - look at the cervix & vagina
Investigations
1. PAP smear to exclude cervical CA
2. TVS for endometrial thickness : If < 4mm - unlikely to be CA. Reassure.
If > 4mm needs endometrial sampling
3. FBC to detect the degree of anaemia
4. Any other Ix to exclude systemic causes
Endometrial sampling methods :
1. Pipelle endometrial sampling
Outpatient procedure. No need of anaesthesia
80% sensitive.
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2. Dilatation & curettage - the traditional method of sampling. Need admission to
hospital. Costly, but representation of the endometrium is better.
3. Hysteroscopy directed biopsy - direct visualization of the endometrium. Samples
can be taken exactly from the diseased endometrium.
Flexible - outpatient
Rigid - need admission
4. Vabra - an electronic suction device. Outpatient procedure.
PMBC
Bleeding
exitude ddX
CA RF
associated Complications In'D
other Symp anemia pessary
abd pain lumps malignancy
genital trac
frama
I vaginal discharge
general
antilogular
dysparemia local invasion
postcoital bleeding distant mets
alanthosis nigricans
mass obstruition
