1. Postmenopausal
Uterine Bleeding
Ahmed Salah
40

2. Def
• Postmenopausal bleeding is any
unscheduled vaginal bleeding that
occurs after 12 months of
amenorrhoea in a woman of
postmenopausal age.

3. Causes of postmenopausal uterine
bleeding
•
Atrophic vaginitis
•
60-80%
•
Estrogen treatments
•
15-25%
•
Polyps - endometrial or cervical
•
2-12%
•
Endometrial Hyperplasia
•
5-10%
•
Endometrial Cancer
•
10%
•
No cause found
•
10%

4. postmenopausal uterine bleeding
&Endometrial cancer
It is important to reassure women that only 10
percent of those presenting with
postmenopausal bleeding will have endometrial
cancer
Although it is a worrying symptom, there
are far more likely benign causes. On the
other hand, about 90 per cent of women
with endometrial cancer will present with
vaginal bleeding

5. Postmenopausal Uterine Bleeding &
Atrophic Vaginitis
•
It is the most common cause of postmenopausal
uterine bleeding
•
It has been estimated that 4-5 years after the
menopause, around 25-50% of women
experience symptoms due to atophic vaginitis.
However, only around 24% of these women with
symptoms actually seek medical help

6. Postmenopausal Uterine Bleeding
&HRT
•
The age at which the menopause occurs is
variable, but for most women it is in their early
50s
•
At this time of their lives, many women may
have already resorted to taking hormone
replacement therapy (HRT), which may cause
confusion over symptoms of vaginal bleeding
•
However, any vaginal bleeding in a
menopausal woman other than the expected
cyclical bleeding that occurs in women taking
sequential HRT should be managed similarly

7. Postmenopausal Uterine bleeding
•
Other causes may be diagnosed by history,
examination and appropriate investigations.
•
However, in 10–15 percent of patients, no evident
cause for the bleeding will be found. It is therefore
necessary to look for blood in the stool or urine,
especially if the source of bleeding is unclear.
•
A full blood count should be obtained if the bleeding
is heavy and prolonged.

8. References
• http://www.healthline.com/galecontent/postmenopa
usal-bleeding#2
• http://www.2womenshealth.com/26-TheMenopause/26-17-Postmenopausal-Bleeding.htm
• http://www.ncbi.nlm.nih.gov/pubmed/13335063
•

9. Investigations of
postmenopausal
uterine bleeding
Ahmed Shaaban Ali Khattab
No. : 36

10. Investigations
• History
• Clinical examination
• Cervical cytology (if appropriate)
• Ultrasound scan
• Saline infusion sonography
• Outpatient hysteroscopy
• Endometrial biopsy

11. History

12. Duration and severity

13. Hormone use

14. Tamoxifen

15. Associated symptoms

16. Obesity, Diabetes

17. • History of colorectal, endometrial or other cancers
associated with hereditary non-polyposis colorectal
cancer
Lynch ll
syndrome

18. Past medical and surgical history

19. Clinical examination

20. Abdominal and pelvic examination

21. Speculum examination of the cervix

22. Bimanual examination

23. Direct inspection

24. Cervical smear

25. Colposcopy

26. Biopsy

27. Ultrasound scan

28. Transvaginal ultrasound (TVUS)

29. In a study of 1168 women with
postmenopausal bleeding , ……
• atrophic endometrium  3.9mm (±2.5mm)
• endometrial carcinoma 21.1mm (±8mm)
• With an endometrial thickness of less than 3mm ,
…
• sensitivity for detecting any endometrial disease is
92 per cent and the sensitivity for detecting cancer
is 96 per cent
• a cut-off of 4mm is used to avoid hysteroscopy

33. Reference
•
Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an
emphasis on endometrial cancer detection. J Obstet Gynaecol 2004; 24: 736-41.
•
Schwarzler P, Concin H, Bosch H, et al. An evaluation of sonohysterography and diagnostic
hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol 1998; 11: 33742.
•
National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. Clinical
guideline 27. London: NICE, June 2005. www.nice.org.uk
•
Bernstein L, Deapen D, Cerhan JR, et al. Tamoxifen therapy for breast cancer and endometrial cancer
risk. J Natl Cancer Inst 1999; 91: 1654-62.
•
Parazzini F, La Vecchia C, Negri E, et al. Diabetes and endometrial cancer: an Italian case-control study.
Int J Cancer 1999; 81: 539-42.
•
Coleman BG, Arger PH, Grumbach K, et al. Transvaginal and transabdominal sonography: prospective
comparison. Radiology 1988; 168: 639-43.
•
Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women
with postmenopausal bleeding -- a Nordic multicenter study. Am J Obstet Gynecol 1995; 172: 1488-94.

34. Cont. Investigations of postmenopausal uterine
bleeding
Ahmed Salah El-Esawy
39

35. Saline infusion sonography
sonohysterogram is an ultrasound that goes one step further by
using sterile water to distend the uterine cavity to obtain more
accurate information about fibroids, polyps, or the lining of the
uterus.

36. procedure

37. normal cavity

38. fundal polyp

39. central polyp

44. hysteroscopy
Visualization of endometrial cavity by endoscope.

45. Endometrial biopsy
Endometrial biopsy is a procedure in which a tissue
sample is taken from the lining of the uterus
(endometrium), and is checked under a microscope
for any abnormal cells or signs of cancer.

46. Indications
• Abnormal uterine bleeding.
• Postmenopausal bleeding .
• follow up to previously diagnosed endometrial
Hyperplasia.

47. Contraindication
• Acute Pelvic inflammatory disease.
• Acute cervical infection.
• Clotting disorder .
• Cervical cancers.

48. COMPLICATIONS
•
Infection.
•
excessive bleeding.
•
uterine perforation .
•
Bacteremia.
•
Disturbance of undiagnosed pregnancy.

49. Management of
postmenopausal bleeding
Ahmed Salah Mohamed
41

50. General treatment:
• 1- Correct general condition(Anti-shock measure):
• -Hospitalization
• -Assessment of blood loss:
• In some cases the blood volume may be
excessive,rapid and possibly life threatening

51. • -So rapid restoration of blood volume,vital
parameters is followed by local examination to find
out the site and source of bleeding

52. • -Blood transfusion in needed
• -Intravenous lines
• -Elevate bed foot
• -Intravenous fluids
• -Tears need to be sutured
• -Bleeding from cervical malignancy can effectively
stopped by tight vaginal packing

53. 2-Specific treatment
• It is according to the cause :

54. • Vaginal atrophy :treated by
administarion of topical oestrogen
• -Vagifem an oestrogen within a small pessary
inserted into vagina ,

55. • Endometrial Polyps: removed at
outpatient hysteroscopy but it may need general
anaesthesia

56. • Endometrial hyperplasia and carcinoma :
• -In postmenopausal women it should be surgical
and include Total hystrectomy and bliateral
salpingo-oophorectomy
• -To avoid unnecessary risk form treatment through
progesteron therapy

57. Management of recurrent
postmenopausal bleeding
• When patient presents with recurrence ,formal
hysteroscopy and Dilataion and curretage under
general anassthetic is advisable
• -cytoscopy to exclude bladder tumors
• -sigmoidscopy to exclude large bowel tumors if the
site of bleeding is unclear

58. Thank you
