Introduction:
If you're past menopause and haven't had a period for several months --
then start having minor bleeding once a month or so -- you should
probably see a doctor.
"Abnormal bleeding in a woman is always cause for concern,
"But if a woman didn't have a menses for nine months and then she bled,
[a doctor] would always evaluate thatA pelvic exam, [ultrasound], and
possibly a biopsy might be necessary to determine if it is endometrial
[uterine] cancer or pre-endometrial cancer, called hyperplasia.
Post menopausal bleeding can originate from other problems such as:
• Hormone replacement therapy
• Uterine (endometrial) polyps
• Cervical Cancer
• Cuts or lesions on the outside of the vagina
• Sex
Menopause: The process in a woman's life when ovaries stop functioning and menstruation stops.
Post-menopausal bleeding is a vaginal bleed that occurs after the
menopause (after a woman’s periods have stopped for at least 12 months).
The menopause usually happens between the ages of 45 and 55. Usually,
periods gradually become irregular and scanty before they stop
completely. However, a sudden menopause may occur in women who have had
surgery to remove the ovaries and in women who have had treatment for
breast cancer.
Post Menopausal Bleeding (PMB)
Vaginal bleeding occurring after 12 months of amenorrhoea, in a woman of the age where the menopause can be expected.
It does not apply to a young woman, who has had amenorrhoea from
anorexia nervosa, or a pregnancy followed by lactation. However, it can
apply to younger women following premature ovarian failure or premature
menopause.
Risk factors For Endometrial Cancer
• It is likely to occur if exogenous oestrogens are taken.
• Polycystic ovary disease increases risk.
• Hereditary non-polyposis colorectal carcinoma
• Obesity combined with diabetes
• Use of combined oral contraceptives decreases risk.
Etiology
• Non-gynecological causes including trauma or a bleeding disorder.
• Use of hormone replacement therapy
• Vaginal atrophy A thinning of the uterine lining (endometrial atrophy)
• Endometrial carcinoma usually presents as PMB, but 25% occur in premenopausal women.
• Endometrial polyps or cervical polyps
• Carcinoma of cervix; remember to check if the cervical smear is up to date
• Uterine sarcoma; this is rare
• Ovarian carcinoma, especially estrogen-secreting (theca cell) ovarian tumors
• Vaginal carcinoma is very uncommon.
• Carcinoma of vulva may bleed, but the lesion should be obvious.
• Infection of the uterus or cervix
• Chronic medical conditions (for instance, thyroid problems)
• Use of some medications
Polyps (no cancerous growths that develop from tissue such as that
lining the inside of the uterus) Endometrial hyperplasia (a condition in
which the lining of the uterus grows too much; if left untreated for a
long time, it may lead to cancer) simple, complex, and atypical
Management
History and examination may possibly indicate cause, but it is generally
accepted that postmenopausal bleeding should be treated as malignant,
until proved otherwise. This requires referral to a gynaecologist with
an appointment within 2 weeks.3
Investigations & Diagnosis
To diagnose abnormal bleeding, your doctor will review your personal and
family health history. You will have a physical exam and may have blood
tests. Give your doctor as much information as possible: how long has
the bleeding been going on, how heavy it is, how often it has occurred
and if you are taking HRT.
Other tests may be needed based on your symptoms:
• Endometrial biopsy: Using a catheter (tube), a small amount of tissue
is gently scraped from the lining of the uterus. It is then looked at
under a microscope.
• Ultrasonography: Sound waves are used to create a picture of the
pelvic organs. The device may be placed on the abdomen or in the vagina.
• Sonohysterography: A small amount of fluid is injected into the
uterus, and sound waves are used to create a picture of the pelvic
organs to detect abnormal changes in the uterus.
• Hysteroscopy: A thin device is inserted through the vagina and cervix to view the inside of the uterus.
• Dilation and curettage (D&C): Procedure in which the opening of
the cervix is widened. Tissue is then gently scraped or suctioned from
the lining of the uterus. It is examined under a microscope.
• CT scan of the pelvis may help evaluate any pelvic masses.
• Blood tests such as a full blood count to check for anaemia, and clotting tests if you are taking anti-coagulants.
These tests can be done in the doctor's office or in an out-patient surgery center with pain relief.
Cautions
Most women with PMB will not have significant pathology but the dictum remains that:
Postmenopausal bleeding is cancer until proved otherwise.
• PMB in women on HRT still needs investigation.
• An obvious lesion like atrophic vaginitis does not exclude another lesion.
• Many women are unable to distinguish between vaginal and urinary
bleeding and some are unable to distinguish rectal bleeding. One paper
found that in women presenting with PMB the prevalence of bladder
tumours was 1.07% and of bladder cancer was 0.7%.
Treatment
Treatment for postmenopausal bleeding will depend on the problem and its
cause. If the endometrium is growing too much, progesterone may be
used.
• If the bleeding is caused by HRT, no treatment is necessary.
• Vaginal atrophy can be treated with local application of an oestrogen cream or oral HRT.
• Surgery is usually necessary for post-menopausal bleeding caused by
cancer. The uterus, cervix, ovaries, and fallopian tubes may all be
removed depending on the location of the cancer. Oestrogen producing
tumours elsewhere in the body will also need to be removed.
• A hysterectomy may be considered if post-menopausal bleeding is unexplained and cannot be controlled by other treatment.
Finally.
If you have any bleeding after menopause, see your doctor.
Postmenopausal bleeding has a number of causes, including cancer. The
earlier the cause of postmenopausal bleeding is found, the better it can
be treated.
Differential Diagnosis
The differential diagnosis of post-menopausal bleeding is classified according the organ involved:
Uterine disorders:
• Endometrial carcinoma
• Endometrial Atrophy
Cervical disorders
• Cervical carcinoma
• Cervical polyp
Vaginal disorders
• Vaginal carcinoma
• Vaginal atrophy
Vulval disorders
• Vulval atrophy
• Vulval carcinoma
Other
• Hormone replacement therapy
If you're past menopause and haven't had a period for several months --
then start having minor bleeding once a month or so -- you should
probably see a doctor.
"Abnormal bleeding in a woman is always cause for concern,
"But if a woman didn't have a menses for nine months and then she bled,
[a doctor] would always evaluate thatA pelvic exam, [ultrasound], and
possibly a biopsy might be necessary to determine if it is endometrial
[uterine] cancer or pre-endometrial cancer, called hyperplasia.
Post menopausal bleeding can originate from other problems such as:
• Hormone replacement therapy
• Uterine (endometrial) polyps
• Cervical Cancer
• Cuts or lesions on the outside of the vagina
• Sex
Menopause: The process in a woman's life when ovaries stop functioning and menstruation stops.
Post-menopausal bleeding is a vaginal bleed that occurs after the
menopause (after a woman’s periods have stopped for at least 12 months).
The menopause usually happens between the ages of 45 and 55. Usually,
periods gradually become irregular and scanty before they stop
completely. However, a sudden menopause may occur in women who have had
surgery to remove the ovaries and in women who have had treatment for
breast cancer.
Post Menopausal Bleeding (PMB)
Vaginal bleeding occurring after 12 months of amenorrhoea, in a woman of the age where the menopause can be expected.
It does not apply to a young woman, who has had amenorrhoea from
anorexia nervosa, or a pregnancy followed by lactation. However, it can
apply to younger women following premature ovarian failure or premature
menopause.
Risk factors For Endometrial Cancer
• It is likely to occur if exogenous oestrogens are taken.
• Polycystic ovary disease increases risk.
• Hereditary non-polyposis colorectal carcinoma
• Obesity combined with diabetes
• Use of combined oral contraceptives decreases risk.
Etiology
• Non-gynecological causes including trauma or a bleeding disorder.
• Use of hormone replacement therapy
• Vaginal atrophy A thinning of the uterine lining (endometrial atrophy)
• Endometrial carcinoma usually presents as PMB, but 25% occur in premenopausal women.
• Endometrial polyps or cervical polyps
• Carcinoma of cervix; remember to check if the cervical smear is up to date
• Uterine sarcoma; this is rare
• Ovarian carcinoma, especially estrogen-secreting (theca cell) ovarian tumors
• Vaginal carcinoma is very uncommon.
• Carcinoma of vulva may bleed, but the lesion should be obvious.
• Infection of the uterus or cervix
• Chronic medical conditions (for instance, thyroid problems)
• Use of some medications
Polyps (no cancerous growths that develop from tissue such as that
lining the inside of the uterus) Endometrial hyperplasia (a condition in
which the lining of the uterus grows too much; if left untreated for a
long time, it may lead to cancer) simple, complex, and atypical
Management
History and examination may possibly indicate cause, but it is generally
accepted that postmenopausal bleeding should be treated as malignant,
until proved otherwise. This requires referral to a gynaecologist with
an appointment within 2 weeks.3
Investigations & Diagnosis
To diagnose abnormal bleeding, your doctor will review your personal and
family health history. You will have a physical exam and may have blood
tests. Give your doctor as much information as possible: how long has
the bleeding been going on, how heavy it is, how often it has occurred
and if you are taking HRT.
Other tests may be needed based on your symptoms:
• Endometrial biopsy: Using a catheter (tube), a small amount of tissue
is gently scraped from the lining of the uterus. It is then looked at
under a microscope.
• Ultrasonography: Sound waves are used to create a picture of the
pelvic organs. The device may be placed on the abdomen or in the vagina.
• Sonohysterography: A small amount of fluid is injected into the
uterus, and sound waves are used to create a picture of the pelvic
organs to detect abnormal changes in the uterus.
• Hysteroscopy: A thin device is inserted through the vagina and cervix to view the inside of the uterus.
• Dilation and curettage (D&C): Procedure in which the opening of
the cervix is widened. Tissue is then gently scraped or suctioned from
the lining of the uterus. It is examined under a microscope.
• CT scan of the pelvis may help evaluate any pelvic masses.
• Blood tests such as a full blood count to check for anaemia, and clotting tests if you are taking anti-coagulants.
These tests can be done in the doctor's office or in an out-patient surgery center with pain relief.
Cautions
Most women with PMB will not have significant pathology but the dictum remains that:
Postmenopausal bleeding is cancer until proved otherwise.
• PMB in women on HRT still needs investigation.
• An obvious lesion like atrophic vaginitis does not exclude another lesion.
• Many women are unable to distinguish between vaginal and urinary
bleeding and some are unable to distinguish rectal bleeding. One paper
found that in women presenting with PMB the prevalence of bladder
tumours was 1.07% and of bladder cancer was 0.7%.
Treatment
Treatment for postmenopausal bleeding will depend on the problem and its
cause. If the endometrium is growing too much, progesterone may be
used.
• If the bleeding is caused by HRT, no treatment is necessary.
• Vaginal atrophy can be treated with local application of an oestrogen cream or oral HRT.
• Surgery is usually necessary for post-menopausal bleeding caused by
cancer. The uterus, cervix, ovaries, and fallopian tubes may all be
removed depending on the location of the cancer. Oestrogen producing
tumours elsewhere in the body will also need to be removed.
• A hysterectomy may be considered if post-menopausal bleeding is unexplained and cannot be controlled by other treatment.
Finally.
If you have any bleeding after menopause, see your doctor.
Postmenopausal bleeding has a number of causes, including cancer. The
earlier the cause of postmenopausal bleeding is found, the better it can
be treated.
Differential Diagnosis
The differential diagnosis of post-menopausal bleeding is classified according the organ involved:
Uterine disorders:
• Endometrial carcinoma
• Endometrial Atrophy
Cervical disorders
• Cervical carcinoma
• Cervical polyp
Vaginal disorders
• Vaginal carcinoma
• Vaginal atrophy
Vulval disorders
• Vulval atrophy
• Vulval carcinoma
Other
• Hormone replacement therapy
