undergraduate

1. Prepared by:
Hedi Hameed

2. Menopause:
Is cessation of menstrual cycle for 12 consecutive
months.
Normal age for menopause(49_55)
Mean age 51.
Postmenopausal bleeding:
Is unscheduled vaginal bleeding that occurs after 12
months of amenorrhea in a woman of postmenopausal age.

3. Causes
1. Vaginal atrophy (60_80%)
2. Hormone replacement therapy(15_25%)
3. Endometrial hyperplasia (5_10%)
4. Endometrial carcinoma 10%
5. Endometrial or cervical polyp.(2_12%).

4. Vaginal atrophy
Is thinning, drying and inflammation of the vaginal walls because of
having less estrogen
Clinical features:
In addition to postmenopausal bleeding: Vaginal dryness , burning
sensation, discharge, itching with increased frequency, urgency ,
incontinence and urinary tract infections.
Treatment:
1.Vaginal moisturizers
2. Estrogene either in form of creams, ring or tablet.

5. 2.Hormone replacement therapy
A. .Estrogen- cyclical progsetrone :
Estrogene will be given everyday.
Progestrone will be given for the last (12_14) days .
Bleeding is considered normal if bleeding starts after the nineth
day of progesterone use or soon after the progestogen phase.
B. Combined estrogen-progestrone therapy:
Breakthrough bleeding is common in the first 3-6 months ,
Evaluation of the endometrium is recommended during the first
year, if bleeding is heavy, prolonged or if any bleeding occurs
after one year of use.

6. Endometrial hyperplasia
Is an abnormal proliferation of the endometrium (glands).
It accounts for 5_10 % of PMB.
It occurs due to excessive estrogen stimulation.
More than 4mm is significant.
classification:
1. Hyperplasia without atypia.
2. Hyperplasia with atypia
(premalignant)

7. TREATMENT
_ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA:
medroxyprogestrone acetate
Continous: 10mg daily for 3_6 months
cyclical:10 mg for 12 days each month
Repeat biopsy in (3_6) months.
Endometrial hyperplasia with atypia:
Hysterectomy with or without bilateral salpingo-
oopherectomy.

8. Endometrial carcinoma
2nd most common gynecological cancer.
Is mainly adenocarcinoma arising from the lining of the
uterus and is an estrogen-dependent tumor.
Accounts for 10% of postmenopausal bleeding.
90% of patients with endometrial cancer will present with
bleeding.
Has 4 stages:
I. Confined to uterine body
II. Involves cervix
III. Outside uterus but inside the pelvis
IV. Extended to blader or rectum.

9. .
Risk factors :
1. Early menarche
2. Late menopause
3. Nulliparity
4. Chronic anovulation(P.C.O.S)
5. Obesity (conversion of steroids to oestrone in their peripheral fat)
6. Diabetes mellitus
7. Unoppsed estrogen therapy
8. Tamoxifen therapy (ESTROGENIC ACTIVITY ON ENDOMETRIUM)
9. Personal or family history of:
endometrial, ovarian, breast or colon cancer.

10. Treatment
1. Stage 1 and 2 :
total abdominal hysterectomy + bilateral
salpingoopherectomy.
2. Stage 3 and 4 :
If resectable surgery followed by chemotherapy or
radiotherapy
If its not resectable neoadjuvant radiotherapy followed by
surgery.
3. High dose of progestin if unfit for surgery.(paliative)

11. Management
I. History
II. Examination
III.investigations

12. History:
1. Details of the bleeding(onset, duration, amount, color,
presence of clot,whether it was related to trauma or not).
2. Associated symptoms such as pain, fever or changes in
bladder or bowel function might suggest an infective process
such as pyometra or the bleeding may be arising from the
bowel or bladder .
3. exclude risk factors of endometrial carcinoma.

13. Examination
1. General examination: general condition, obesity.
exclude signs of malignancy ( weight loss, pale
2. Abdominal examination: for any palpable mass.
3. pelvic examination:
inspection of the vulva and vagina, particularly looking for
atrophy( The vaginal skin looks thin, red and inflamed with areas
of pinpoint bleeding).
A speculum examination (cervical polyp and cancer)
A bimanual examination to evaluate uterine size, mobility
and the adnexae.
4. Per rectal examination: to exclude colorectal problems.

14. Investigations
1. Complete blood count
2. Coagulation studies
3. LFT, RFT
4. CHEST XRAY .
specific investigations:
I. Ultrasound (T.A.U , T.V.U)
II. CA125
III. Pippelle smear
IV. Dilitation and curetage with biopsy
V. Hysterescopy with endometrial biopsy

16. References
• https://fafpf.files.wordpress.com/2012/11/pla
ton-pmb-capsule-comment-final.pdf
• http://onlinelibrary.wiley.com/doi/10.1002/tr
e.84/pdf