Post-Menopausal Bleeding

1. Post-Menopausal Bleeding

2. PMB is when woman starts bleeding after a one year without period or other bleeding. .

3. Not all cases of PMB are caused by a medical problem. Sometime lifestyle and stress have an effect on the body, causing bleeding to occur.like dramatic weight loss can lead to estrogen normally stored in the fatty tissues being released into the blood stream leading to bleeding

4. The main differential diagnosis of PMB • 1.( 30% ) HRT • 2.(30%) atrophic endometritis / vaginitis • 3.(15%) endometrial cancer • 4.(10%) endometrial polyps or cervical polyps • 5.(5% )endometrial hyperplasia (simple, complex, and atypical), .

5. other uncommen causes include: 6-Vulval dermatitis, Vulval trauma& vulval cancer. 7. -Vaginal trauma,Vaginal polyps,Foreign body(especially pessary)&vaginal cancer. 8.ovarian cancer(theca cell, granulose cell tumors. 9.fallopian tube cancer.

6. 10. Overuse of anticoagulant medications such as aspirin, heparin, and warfarin. 11. Abnormalities of the hematologic system leukemia or a blood dyscrasia. 12.Other sites of origin include the bladder, urethra, rectum & anus which are often described by patients to be per vagina in origin.

7. Risk assessment Benign conditions is most frequent causes of PMB but endometrial cancer is the most serious potential underlying cause

8. . Probability of having endometrial cancer associated with PMB in women (Risk factors):

9. 1.Early menarche(< 10 years). 2.Late menopause(>55 years). 3.Null parity. 4.history of chronic anovulation. 5.tamoxifen use. 6.Unopposed estrogen therapy.

10. 7.Bleeding moderate or severe. 8.Obesity. 9.Hypertension. 10.diabetes mellitus 11.Persistent/ recurrent bleeding. 12.a family history of Lynch type II syndrome (hereditary nonpolyposis colorectal, ovarian, or endometrial cancer).

11. Management. History& examination is the most important step in assessing women with PMB.

12. So general examination forpallor,catchaxia, lymphadenopathy. Ex. Of the breast for possible tumor. Ex. of the chest for possiblemetastasis. a

13. . Local examination: May help in the diagnosis of vulval, vaginal, cervical or pelvic pathology. Senil atrophic vaginitis, cervical polyps or ulceration from a ring pessary can be directly visualized. Further more an indication of the patients general health can be obtained which is important before considering general anesthesia.

14. Ex. of the abdomen for organomegally, or palpable masses. Local ex. of the vulva for any lesion suggests malignancy. Then speculum ex. Of the vagina &cervix look for any polyp, atrophic changes, infection, or lesion suggestive of malignancy. Then before removal of the speculum take smear.PMB is an indication for cervical cytology (Pap smear). Endometrial cancer may be detected by

17. Investigation. 1. Complete blood count (CBC) and platelet count. 2. Cytologic smears from the vagina may be obtained. 3. A Pap smear and biopsy of the cervix will be obtained.

18. 4. Tests performed to identify abnormalities of the uterus, the main aim of these investigations are to exclude both endometrial cancer &atypical hyperplasia.

19. these investigation include:A.Outpatient investigations -Trans-vaginal ultrasound TVS for (endometrial thicknessL<5mm,& visulization of the ovaries). -Endometrial sampling (Pipelle, vabra, sharman curatte).safe cheap,easy to be done,but pathology can be missed sometime. -Office outpatient sonohysteroscopy directed endometrial biopsy .

20. B.In patient investigations. 1. Dilatation& curettage 2. Dilatation& fraction curettage. 3.Hysteroscopy directed endometrial biopsy(gold standard).

21. Vaginal ultrasonography. • Hydrosonography. • Endometrial biopsy. • Office biopsy. • D/C biopsy. • Hysteroscopic guided biopsy.

22. Vaginal ultrasound

23. saline-infusion sonography The introduction of intrauterine fluid (saline-infusion sonography) during transvaginal ultrasound .

24. At transvaginal ultrasonography, the finding of a thickened central endometrial complex,with or without cystic changes, is often nonspecific.

25. The Thickened endometrium may be a polyp CYST POLYP With polyps the endometrial-myometrialinterface is preserved well-defined, homogeneous, isoechoic to the endometrium

26. The Thickened endometrium may be a polyp catheter POLYP With polyps the endometrial-myometrialinterface is preserved

27. The Thickened endometrium may be a Submucosal leiomyomas With myomas the endometrial-myometrialinterface is distorted broad-based, hypoechoic,

28. Endometrial cancer Endometrial cancer is typically a diffuse process,but early cases can appear as a polypoid mass

29. Other specific investigation .MRI. has been advocated in the diagnosis of endometrial cancer.

30. Treatment 1. Postmenopausal bleeding due to bleeding from the vagina or vulva can be treated with local application of estrogen (hormone replacement therapy-HRT). 2. Removal of tissue from the inside of uterus (curettage) may be all that is necessary to relieve postmenopausal bleeding. 3. Removal of polyps (polypectomy) will correct bleeding associated with their presence.

31. 4.Cyclic progestin may be administered for treatment of overgrowth of the endometrium (simple endometrial hyperplasia), for up to 3 months. At completion of progestin therapy, a repeat D&C or endometrial biopsy will be performed to verify absence of hyperplasia.

32. 5.Hysterectomy may be necessary to treat the following condition. (1.) Endometrial hyperplasia with atypical cells. (2. )cancer of the uterus (endometrial). (3.) bleeding that does not resolve with treatment (refractory) causing anemia due to chronic blood loss.

33. Treatment. According to the cause, recurrent uterine bleeding should have repeated investigation in some time hysterectomy considered if the diagnosis cannot be made

34. Thank you