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.
11. 11--Duration and severityDuration and severity
No evidence of
association with pattern of
bleeding and malignancy
eg: one off bleed vs regular
bleeding
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
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.
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
28. 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.
29. 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
30. 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
33. 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.
37. 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
38. 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
40. 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,,
42. 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
44. 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
45. 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.
46. How to approach a case ofHow to approach a case of
abnormal Vaginal bleedingabnormal Vaginal bleeding
DR;MANAL BEHERY
Professor, Zagazig University
2014
58. 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
62. 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
63. Iatrogenic Causes of AUBIatrogenic Causes of AUB
Intra-uterine deviceIntra-uterine device
Oral and injectable steroidsOral and injectable steroids
Psychotropic drugsPsychotropic drugs
64. Dysfunctional causesDysfunctional causes
DUB is the mostDUB is the most
After pubertyAfter puberty
Before menopauseBefore menopause
After labor or abortionAfter labor or abortion
65. ““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?
66. 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
69. 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
70. ))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
71. 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
72. 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
Normal menstrual bleeding due to postovulatory estrogen-progesterone withdrawal is stable and precisely regulated. It is generally agreed that the normal menstrual cycle will be between 24 and 35 days in length, measured from the first day of menstrual flow of once cycle to the first day of the next cycle. The usual duration of menstrual flow is 4-6 days, but many women may have a flow for as little as 2 days or as much as 7 days.
Normal menstruation also tends to be consistent in the amount of blood that is lost. The usual volume of menstrual blood loss is 30 mL, and a menstrual flow greater than 80 mL is considered abnormal. In practice, however, it is virtually impossible for either the patient or her clinician to estimate menstrual volume of blood loss accurately.
Normal human menstrual function is dependent upon an intricate series of hormonal actions linking the neuronal nuclei of the hypothalamus to the pituitary gland, which subsequently stimulates the ovaries to produce sex-steroids that act upon the endometrial lining of the uterus. This pathway is known as the hypothalamic-pituitary-ovarian (HPO) axis. Along the HPO axis there is a complex system of positive and negative feedback signals that allow the end-organs to communicate with the higher centers.
Late in the menstrual cycle, the arcuate nucleus of the hypothalamus generates carefully timed pulses of gonadotropin-releasing hormone (GnRH), which stimulates cells of the anterior pituitary gland to produce follicle-stimulating hormone (FSH) and, to a smaller extent, luteinizing hormone (LH). In the right proportion, FSH will recruit a cohort of ovarian follicles for development. At the same time, pituitary FSH/LH circulates back to the hypothalamus, exerting a negative feedback control on pulses of GnRH to limit recruitment of additional follicles.
From this cohort of ovarian follicles, a dominant follicle is selected by the seventh day of the next menstrual cycle. This one follicle matures and proceeds to ovulation, usually on the 14th day. While maturing, the dominant follicle secretes increasing amounts of estradiol, which initiates ovulation through positive feedback by causing a massive and sudden release of LH from the pituitary (LH surge).
In the endometrial lining, rising levels of estradiol produced by the follicle stimulate proliferative growth of epithelial and stromal elements. This phase of growth is termed the proliferative phase and, under the influence of estradiol, the endometrium grows in height and becomes rich in progesterone-receptors.
Once the LH-surge occurs, the ovum is released, and the follicle collapses to become the corpus luteum. The corpus luteum is a sub-organ within the ovary with a lifespan of approximately 10 days that produces large amounts of progesterone. Under this progestagenic influence the endometrium enters the secretory phase. Endometrial growth stops, and the stroma becomes more compact and stable. The glandular epithelium develops glycogen vacuoles to prepare for implantation of an embryo. If implantation fails to occur, then the corpus luteum undergoes involution and production of progesterone is withdrawn. Upon progesterone-withdrawal, the endometrial lining collapses, resulting in menstruation.
Once levels of progesterone and estradiol decline, the hypothalamus and pituitary escape the influence of negative feedback, and FSH values rise again for the subsequent cycle.