1.
POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDING
DR;MANAL BEHERY
Professor OB &GYNE
2014

2.
DefDef
Postmenopausal bleeding is anyPostmenopausal 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

3.
Causes of postmenopausal uterineCauses 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%

4.
Atrophic VaginitisAtrophic Vaginitis
It is 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.

5.
Cervical polypCervical polyp
It is the second mostIt is the second most
common cause ofcommon cause of
postmenopausalpostmenopausal
bleedingbleeding

6.
Hormone replacement therapy(HRTHormone replacement 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

7.
Endometrial hyperplasia &EndometrialEndometrial hyperplasia &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

8.
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.

9.
InvestigationsInvestigations
HistoryHistory
Clinical examinationClinical examination
Cervical cytology (if appropriate(Cervical cytology (if appropriate(
Ultrasound scanUltrasound scan
Saline infusion sonographySaline infusion sonography
Outpatient hysteroscopyOutpatient hysteroscopy
Endometrial biopsyEndometrial biopsy

10.
HistoryHistory

11.
11--Duration and severityDuration and severity
No evidence of
association with pattern of
bleeding and malignancy
eg: one off bleed vs regular
bleeding

12.
--22--Associated symptomsAssociated symptoms

13.
Hormonal treatementHormonal treatement

14.
Past medical and surgical historyPast medical and surgical history
•FHistory of colorectal, endometrial or other cancers
associated with hereditary non-polyposis colorectal
cancer Lynch ll syndrome

15.
Clinical examinationClinical examination
•General:
•obesity?
•thyroid? pallor?
•pulse? Cachexia?

16.
Abdominal and pelvicAbdominal and pelvic
examinationexamination

17.
Speculum examination of the cervixSpeculum examination of the cervix

18.
Bimanual examinationBimanual examination

19.
Cervical smearCervical smear

20.
ColposcopyColposcopy

21.
Ultrasound scanUltrasound scan

22.
Transvaginal ultrasound (TVUSTransvaginal ultrasound (TVUS((
•Thickened (>5mm( endometrial stripe in postmenopause ALWAYS needs
further evaluation.

23.
Normal TVUS with endometrialNormal 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.

24.
Saline infusion sonographySaline infusion sonography

25.
SonohysterographySonohysterography
TVS may miss small polypsTVS may miss small polyps
Difficult to distinguish from thickenedDifficult to distinguish from thickened
endometriumendometrium
SHG helps inSHG helps in
accurate diagnosisaccurate diagnosis

26.
normal cavitynormal cavity

27.
EndometrialEndometrial biopsybiopsy
 a tissue 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.

28.
Endometrial samplingEndometrial sampling
All women with persistent menorrhogiaAll women with persistent menorrhogia
To diagnose or excludeTo diagnose or exclude
endometrial carcinoma orendometrial carcinoma or
HyperplasiaHyperplasia

29.
Endometrial Suction CuretteEndometrial Suction 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

30.
Sampling HowSampling How??
 Endometrial aspirationEndometrial aspiration
 Conventional D&CConventional D&C
 Hysteroscopy & directed biopsyHysteroscopy & directed biopsy

31.
hysteroscopyhysteroscopy
The Gold Standard-The Gold Standard-
Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,

32.
Indication of hystroscopyIndication of 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.

33.
Endometrial hyperplasis&endometrial polypEndometrial hyperplasis&endometrial polyp

34.
Endometrial polyp

35.
Management of postmenopausalManagement of postmenopausal
bleedingbleeding

36.
General treatmentGeneral treatment::
In some 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

37.
Rapid restoration of bloodRapid 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

38.
It is according to theIt is according to the causecause::

39.
Atrophic vaginitisAtrophic vaginitis
treated by 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,,

40.
Endometrial PolypsEndometrial Polyps
Removed by hysteroscopyRemoved by hysteroscopy

41.
When patient presents with 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

42.
MRI early stage cancerMRI early stage cancer

43.
Endometrial hyperplasia andEndometrial hyperplasia 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

44.
SummarySummary
Vaginal atrophy: oestrogen daily 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.

45.
How to approach a case ofHow to approach a case of
abnormal Vaginal bleedingabnormal Vaginal bleeding
DR;MANAL BEHERY
Professor, Zagazig University
2014

46.
DefinitionDefinition
Any uterine bleeding that is excessive inAny uterine bleeding that is excessive in
amount ,duration or frequancyamount ,duration or frequancy

47.
Characteristics of Normal MenstruationCharacteristics of Normal Menstruation

48.
Regulation of NormalRegulation of Normal
MenstruationMenstruation

49.
How do hormones workHow do hormones work??

50.
Why EP withdrawal bleeding
is self limited?
Why EP withdrawal bleeding
is self limited?

51.
33reasonsreasons
1-It is a universal endometrial event
Menstrual changes occurs simultaneously
in all segments of endometriaum

52.
33reasonsreasons
2-the endometrium is structurly stable,
Randome breakdown of tissue is avoided

53.
33reasonsreasons
Factors involved in stopping of menses
Waves of vacoconstriction
Vacular stasis
Endometrial collapse
Clotting factors

54.
0246810121416182022242628
Hormone
Level
Estradiol
Progesterone
FSH
LH
Menstrual Cycle Day
Ovulation
Endometrial
Thickness
0246810121416182022242628
Normal
Menstrual
Cycle

55.
Hormone
Level
Estradiol
Progesterone
Endometrial
Thickness
024681012141618
20
024681012141618
20Weeks
Breakthrough
Withdrawal
Anovulatory
Bleeding in PCOS
Lower limit
of normal

56.
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

57.
classificationclassification
OrganicOrganic
–SystemicSystemic
–Reproductive tract diseaseReproductive tract disease
–IatrogenicIatrogenic
DysfunctionalDysfunctional
–OvulatoryOvulatory
–AnovulatoryAnovulatory

58.
Systemic EtiologiesSystemic Etiologies
Coagulation defectsCoagulation defects
LeukemiaLeukemia
ITPITP
Thyroid dysfunctionThyroid dysfunction
Liver diseaseLiver disease

59.
Reproductive Tract CausesReproductive Tract Causes
Gestational eventsGestational events
MalignanciesMalignancies
BenignBenign
– AtrophyAtrophy
– LeiomyomaLeiomyoma
– PolypsPolyps
– Cervical lesionsCervical lesions
– Foreign bodyForeign body
– InfectionsInfections

60.
Most Common Causes ofMost Common Causes of
Reproductive Tract AUBReproductive Tract AUB
Pre-menarchalPre-menarchal
–Foreign bodyForeign body
Reproductive ageReproductive age
–Gestational eventGestational event
Post-menopausaPost-menopausall
–AtrophyAtrophy

61.
Iatrogenic Causes of AUBIatrogenic Causes of AUB
Intra-uterine deviceIntra-uterine device
Oral and injectable steroidsOral and injectable steroids
Psychotropic drugsPsychotropic drugs

62.
Dysfunctional causesDysfunctional causes
DUB is the mostDUB is the most
After pubertyAfter puberty
Before menopauseBefore menopause
After labor or abortionAfter labor or abortion

63.
““Doctor, I’m bleeding funnyDoctor, 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?

64.
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

65.
))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

66.
))Step 3) investigationStep 3) investigation
 TVSTVS to assess endometrial thicknessto assess endometrial thickness
 SonohystrographySonohystrography
 endometrial aspirateendometrial aspirate
 HysteroscopyHysteroscopy
 CT ,MRI for endometrial invasionCT ,MRI for endometrial invasion

67.
Consider those investigations ONLY 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

68.
))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

69.
Step 5 When to 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

70.
Surgery treatment ofSurgery treatment 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

71.
hystrectomyhystrectomy

72.
Other modalities of treatmentOther modalities of treatment
Levonorgesterol releasing IUCD (MirenaLevonorgesterol releasing IUCD (Mirena((

73.
22..Endometrial ablationEndometrial ablation
Hysteroscopic methodsHysteroscopic 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

74.
ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION
Uterine balloon therapyUterine balloon therapy Roller-ball endometriaalRoller-ball endometriaal
ablation ustingablation usting
resectoscoperesectoscope

75.
Abnormal Uterine Bleeding inAbnormal Uterine Bleeding in
Women of Childbearing AgeWomen of Childbearing Age

76.
Abnormal postmenopausal bleeding PAbnormal postmenopausal bleeding P
BleedingBleeding

77.
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