Postmenopausal bleeding for undergraduate

Postmenopausal bleeding for undergraduate

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  POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDING DR;MANALBEHERY Professor OB &GYNE 2014
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  DefDef Postmenopausal bleeding isanyPostmenopausal bleeding is any vaginal bleeding that occurs aftervaginal bleeding that occurs after 12 months of amenorrhoea in a12 months of amenorrhoea in a postmenopausal women .postmenopausal women . The age of menopause is variable,The age of menopause is variable, but for most women it is 51 yearbut for most women it is 51 year
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  Causes of postmenopausaluterineCauses of postmenopausal uterine bleedingbleeding Atrophic vaginitisAtrophic vaginitis 60-80%60-80% Estrogen treatmentsEstrogen treatments 15-25%15-25% Polyp cervical –uterinePolyp cervical –uterine 2-12%2-12% Endometrial HyperplasiaEndometrial Hyperplasia 5-10%5-10% Enodometrial cancerEnodometrial cancer 10%10% No cause foundNo cause found 10%10%
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  Atrophic VaginitisAtrophic Vaginitis Itis the most common cause ofIt is the most common cause of postmenopausal uterine bleedingpostmenopausal uterine bleeding 4-5 years after the menopause, 25-4-5 years after the menopause, 25- 50% of women experience50% of women experience symptoms due to atophic vaginitis.symptoms due to atophic vaginitis.
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  Cervical polypCervical polyp Itis the second mostIt is the second most common cause ofcommon cause of postmenopausalpostmenopausal bleedingbleeding
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  Hormone replacement therapy(HRTHormonereplacement therapy(HRT(( Any vaginal bleeding in aAny vaginal bleeding in a menopausal woman other than themenopausal woman other than the expected cyclical bleeding thatexpected cyclical bleeding that occurs in women taking sequentialoccurs in women taking sequential HRT should be managedHRT should be managed
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  Endometrial hyperplasia &EndometrialEndometrialhyperplasia &Endometrial cancercancer reassure women that only 10 percent of those presenting with postmenopausal bleeding will have endometrial cancer 90 per cent of women with endometrial cancer will present with vaginal bleeding
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  idiopathic causeidiopathic cause 10–15%of patients, no evident cause for the10–15 %of patients, no evident cause for the bleeding will be found.bleeding will be found. It is therefore necessary to look for blood in the stoolIt is therefore necessary to look for blood in the stool or urine, especially if the source of bleeding isor urine, especially if the source of bleeding is unclear.unclear.
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  InvestigationsInvestigations HistoryHistory Clinical examinationClinical examination Cervicalcytology (if appropriate(Cervical cytology (if appropriate( Ultrasound scanUltrasound scan Saline infusion sonographySaline infusion sonography Outpatient hysteroscopyOutpatient hysteroscopy Endometrial biopsyEndometrial biopsy
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  HistoryHistory
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  11--Duration and severityDurationand severity No evidence of association with pattern of bleeding and malignancy eg: one off bleed vs regular bleeding
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  --22--Associated symptomsAssociated symptoms
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  Hormonal treatementHormonal treatement
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  Past medical andsurgical historyPast medical and surgical history •FHistory of colorectal, endometrial or other cancers associated with hereditary non-polyposis colorectal cancer Lynch ll syndrome
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  Clinical examinationClinical examination •General: •obesity? •thyroid?pallor? •pulse? Cachexia?
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  Abdominal and pelvicAbdominaland pelvic examinationexamination
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  Speculum examination ofthe cervixSpeculum examination of the cervix
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  Bimanual examinationBimanual examination
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  Cervical smearCervical smear
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  ColposcopyColposcopy
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  Ultrasound scanUltrasound scan
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  Transvaginal ultrasound (TVUSTransvaginalultrasound (TVUS(( •Thickened (>5mm( endometrial stripe in postmenopause ALWAYS needs further evaluation.
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  Normal TVUS withendometrialNormal TVUS with endometrial thickness <4mm,thickness <4mm, with normal examination does notwith normal examination does not require further investigationrequire further investigation providing bleeding has STOPPED.providing bleeding has STOPPED.
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  Saline infusion sonographySalineinfusion sonography
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  SonohysterographySonohysterography TVS may misssmall polypsTVS may miss small polyps Difficult to distinguish from thickenedDifficult to distinguish from thickened endometriumendometrium SHG helps inSHG helps in accurate diagnosisaccurate diagnosis
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  normal cavitynormal cavity
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  EndometrialEndometrial biopsybiopsy  atissue sample is taken from the lining of the uterusa tissue sample is taken from the lining of the uterus (endometrium(,(endometrium(,  and is checked under a microscope for any abnormaland is checked under a microscope for any abnormal cells or signs of cancer.cells or signs of cancer.
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  Endometrial samplingEndometrial sampling Allwomen with persistent menorrhogiaAll women with persistent menorrhogia To diagnose or excludeTo diagnose or exclude endometrial carcinoma orendometrial carcinoma or HyperplasiaHyperplasia
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  Endometrial Suction CuretteEndometrialSuction Curette Pippelle : most commonly used, least discomfort Karman Cannula Endometrial Brush Superior in Post-Menopausal Same as Pipelle in Pre-Menop. A( Pipelle endometrial suction curette. (B( Vabra aspirat. Tao Endometrial Brush
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  Sampling HowSampling How?? Endometrial aspirationEndometrial aspiration  Conventional D&CConventional D&C  Hysteroscopy & directed biopsyHysteroscopy & directed biopsy
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  hysteroscopyhysteroscopy The Gold Standard-TheGold Standard- Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,
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  Indication of hystroscopyIndicationof hystroscopy When sampling cannot be performedWhen sampling cannot be performed due to cervical stenos isdue to cervical stenos is Or when bleeding persists after negativeOr when bleeding persists after negative biopsy.biopsy.
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  Endometrial hyperplasis&endometrial polypEndometrialhyperplasis&endometrial polyp
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  Endometrial polyp
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  Management of postmenopausalManagementof postmenopausal bleedingbleeding
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  General treatmentGeneral treatment:: Insome cases the blood loss may beIn some cases the blood loss may be excessive, rapid and possibly life threateningexcessive, rapid and possibly life threatening CorrectCorrect general conditiongeneral condition(Anti-shock(Anti-shock measure(measure( -Hospitalization-Hospitalization
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  Rapid restoration ofbloodRapid restoration of blood volume,vital parametersvolume,vital parameters followed by local examination to find outfollowed by local examination to find out the site and source of bleedingthe site and source of bleeding
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  It is accordingto theIt is according to the causecause::
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  Atrophic vaginitisAtrophic vaginitis treatedby administration of topical oestrogentreated by administration of topical oestrogen --VagifemVagifem an oestrogen within a small pessaryan oestrogen within a small pessary inserted into vaginainserted into vagina,,
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  Endometrial PolypsEndometrial Polyps Removedby hysteroscopyRemoved by hysteroscopy
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  When patient presentswith recurrentWhen patient presents with recurrent attack of bleedingattack of bleeding  DoDo pelvic MRIpelvic MRI to exclude early stage Eto exclude early stage E cancercancer  DoDo cytoscopycytoscopy to exclude bladder tumorsto exclude bladder tumors  -DO-DO sigmoidscopysigmoidscopy to exclude large bowelto exclude large bowel tumors if the site of bleeding is uncleartumors if the site of bleeding is unclear
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  MRI early stagecancerMRI early stage cancer
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  Endometrial hyperplasia andEndometrialhyperplasia and carcinomacarcinoma In postmenopausal women it should be surgical and includeIn postmenopausal women it should be surgical and include Total hystrectomy and bliateral salpingo-oophorectomyTotal hystrectomy and bliateral salpingo-oophorectomy --To avoid unnecessary risk form treatment with progesteronTo avoid unnecessary risk form treatment with progesteron therapytherapy
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  SummarySummary Vaginal atrophy: oestrogendaily for 2 weeks,Vaginal atrophy: oestrogen daily for 2 weeks, then once- twice weekly for maintenance.then once- twice weekly for maintenance. Polyps- removed as OPPolyps- removed as OP Endometrial hyperplasia- treated with IUS orEndometrial hyperplasia- treated with IUS or progestprogest Endometrial hyperplasia with atypia- shouldEndometrial hyperplasia with atypia- should be treated as cancer.be treated as cancer.
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  How to approacha case ofHow to approach a case of abnormal Vaginal bleedingabnormal Vaginal bleeding DR;MANAL BEHERY Professor, Zagazig University 2014
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  DefinitionDefinition Any uterine bleedingthat is excessive inAny uterine bleeding that is excessive in amount ,duration or frequancyamount ,duration or frequancy
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  Characteristics of NormalMenstruationCharacteristics of Normal Menstruation
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  Regulation of NormalRegulationof Normal MenstruationMenstruation
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  How do hormonesworkHow do hormones work??
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  Why EP withdrawalbleeding is self limited? Why EP withdrawal bleeding is self limited?
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  33reasonsreasons 1-It is auniversal endometrial event Menstrual changes occurs simultaneously in all segments of endometriaum
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  33reasonsreasons 2-the endometrium isstructurly stable, Randome breakdown of tissue is avoided
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  33reasonsreasons Factors involved instopping of menses Waves of vacoconstriction Vacular stasis Endometrial collapse Clotting factors
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  0246810121416182022242628 Hormone Level Estradiol Progesterone FSH LH Menstrual Cycle Day Ovulation Endometrial Thickness 0246810121416182022242628 Normal Menstrual Cycle
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  Hormone Level Estradiol Progesterone Endometrial Thickness 024681012141618 20 024681012141618 20Weeks Breakthrough Withdrawal Anovulatory Bleeding in PCOS Lowerlimit of normal
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  MenorrhagiaMenorrhagia Prolonged (>7 days) or excessive (> 80mL)Prolonged (> 7 days) or excessive (> 80mL) uterine bleeding occurring at regularuterine bleeding occurring at regular intervalsintervals MetrorrhagiaMetrorrhagia Uterine bleeding occurring at irregularUterine bleeding occurring at irregular intervals or between periodsintervals or between periods MenometrorrhagiaMenometrorrhagia Uterine bleeding occurring at irregularUterine bleeding occurring at irregular intervals, with heavy (> 80mL) or prolongedintervals, with heavy (> 80mL) or prolonged (> 7 days) menstrual flow(> 7 days) menstrual flow PolymenhorrheaPolymenhorrhea Uterine bleeding occurring at regularUterine bleeding occurring at regular intervals of < 21 daysintervals of < 21 days OligomenorrheaOligomenorrhea Uterine bleeding occurring at intervals of 35Uterine bleeding occurring at intervals of 35 days or longerdays or longer AmenorrheaAmenorrhea Absence of uterine bleeding for 6 months orAbsence of uterine bleeding for 6 months or longer in a non-menopausal womanlonger in a non-menopausal woman
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  classificationclassification OrganicOrganic –SystemicSystemic –Reproductive tract diseaseReproductivetract disease –IatrogenicIatrogenic DysfunctionalDysfunctional –OvulatoryOvulatory –AnovulatoryAnovulatory
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  Systemic EtiologiesSystemic Etiologies CoagulationdefectsCoagulation defects LeukemiaLeukemia ITPITP Thyroid dysfunctionThyroid dysfunction Liver diseaseLiver disease
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  Reproductive Tract CausesReproductiveTract Causes Gestational eventsGestational events MalignanciesMalignancies BenignBenign – AtrophyAtrophy – LeiomyomaLeiomyoma – PolypsPolyps – Cervical lesionsCervical lesions – Foreign bodyForeign body – InfectionsInfections
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  Most Common CausesofMost Common Causes of Reproductive Tract AUBReproductive Tract AUB Pre-menarchalPre-menarchal –Foreign bodyForeign body Reproductive ageReproductive age –Gestational eventGestational event Post-menopausaPost-menopausall –AtrophyAtrophy
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  Iatrogenic Causes ofAUBIatrogenic Causes of AUB Intra-uterine deviceIntra-uterine device Oral and injectable steroidsOral and injectable steroids Psychotropic drugsPsychotropic drugs
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  Dysfunctional causesDysfunctional causes DUBis the mostDUB is the most After pubertyAfter puberty Before menopauseBefore menopause After labor or abortionAfter labor or abortion
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  ““Doctor, I’m bleedingfunnyDoctor, I’m bleeding funny”” What is your first question?What is your first question? How do you help her defineHow do you help her define “bleeding“bleeding funny”?funny”? How do you quantify her bleeding?How do you quantify her bleeding?
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  A practical approach(step1) HISTORYA practical approach (step1) HISTORY •11--AgeAge(before puberty, reproductive age ,PM(before puberty, reproductive age ,PM(( •22--Pattern of bleedingPattern of bleeding: cyclic or a cyclic: cyclic or a cyclic •3Marital state3Marital state: complication of pregnancy: complication of pregnancy •44Drug intakeDrug intake ,hormonal ttt, HRT,hormonal ttt, HRT •::55previousprevious treatmenttreatment
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  ))Step2) Physical examinationStep2)Physical examination • AbdomenAbdomen: palpable mass?: palpable mass? • PelvisPelvis: cervical or vaginal lesion?: cervical or vaginal lesion? • Bimanual exaBimanual exam:uterine sizem:uterine size • SpeculumSpeculum :cervical lesion:cervical lesion • PRPR: rectum or parametrium: rectum or parametrium
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  ))Step 3) investigationStep3) investigation  TVSTVS to assess endometrial thicknessto assess endometrial thickness  SonohystrographySonohystrography  endometrial aspirateendometrial aspirate  HysteroscopyHysteroscopy  CT ,MRI for endometrial invasionCT ,MRI for endometrial invasion
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  Consider those investigationsONLY IFConsider those investigations ONLY IF –cervical smearcervical smear if sexually active and lastif sexually active and last smear more than 1 year agosmear more than 1 year ago –CBCCBC if menorrhagiaif menorrhagia –Thyroid function, coagulation profile onlyThyroid function, coagulation profile only when history suggestivewhen history suggestive
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  ))Step4) medical tttStep4)medical ttt For women under 40 with no suspicion ofFor women under 40 with no suspicion of organic lesions eitherorganic lesions either Hormonal (for irregular bleeding as well asHormonal (for irregular bleeding as well as menorrhagiamenorrhagia(( –combined OCcombined OC –progestogen only (21 days neededprogestogen only (21 days needed(( Non-hormonal (for menorrhagiaNon-hormonal (for menorrhagia(( –NSAIDNSAID –antifibrinolytic agentantifibrinolytic agent
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  Step 5 Whento referStep 5 When to refer??  No response to medical treatmentNo response to medical treatment  Over the age of 40Over the age of 40  Uterus > 10 week size or irregularUterus > 10 week size or irregular  High risk of endometrial Cancer (obesity, DM,High risk of endometrial Cancer (obesity, DM, PCOD)PCOD)  Cervical pathology suspectedCervical pathology suspected
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  Surgery treatment ofSurgerytreatment of AUBAUB – Dilation and CurettageDilation and Curettage quickest way to stop bleeding in patientsquickest way to stop bleeding in patients who are hypovolemicwho are hypovolemic appropriate in older women (>35)to excludeappropriate in older women (>35)to exclude malignancy but is inferior to hysteroscopymalignancy but is inferior to hysteroscopy follow with medroxyprogesterone acetate,follow with medroxyprogesterone acetate, OCP’s, or NSAID’s to prevent recurrenceOCP’s, or NSAID’s to prevent recurrence
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  hystrectomyhystrectomy
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  Other modalities oftreatmentOther modalities of treatment Levonorgesterol releasing IUCD (MirenaLevonorgesterol releasing IUCD (Mirena((
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  22..Endometrial ablationEndometrial ablation HysteroscopicmethodsHysteroscopic methods – Endometrial laser ablationEndometrial laser ablation – Electrosurgical endometrial ablationElectrosurgical endometrial ablation – Loop endometrial ablationLoop endometrial ablation – Roller-ball endometriaal ablation usting resectoscopeRoller-ball endometriaal ablation usting resectoscope Nonhysteroscopic methodsNonhysteroscopic methods – Radio-frequency-induced thermal endometrial ablationRadio-frequency-induced thermal endometrial ablation – MicrowaveMicrowave endometrial ablationendometrial ablation – Uterine balloon therapyUterine balloon therapy – 3.Hysterectomy3.Hysterectomy
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  ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION Uterineballoon therapyUterine balloon therapy Roller-ball endometriaalRoller-ball endometriaal ablation ustingablation usting resectoscoperesectoscope
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  Abnormal Uterine BleedinginAbnormal Uterine Bleeding in Women of Childbearing AgeWomen of Childbearing Age
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  Abnormal postmenopausal bleedingPAbnormal postmenopausal bleeding P BleedingBleeding
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