Postmenopausal bleeding for undergraduate


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undergraduate course lectures in Obstetrics&Gynecology prepared by Dr Manal Behery .Professor OB&Gyne .Faculty of medicine ,Zagazig University

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  • 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.
  • Postmenopausal bleeding for undergraduate

    2. 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. 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. 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. 5. Cervical polypCervical polyp It is the second mostIt is the second most common cause ofcommon cause of postmenopausalpostmenopausal bleedingbleeding
    6. 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. 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. 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. 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. 10. HistoryHistory
    11. 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. 12. --22--Associated symptomsAssociated symptoms
    13. 13. Hormonal treatementHormonal treatement
    14. 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. 15. Clinical examinationClinical examination •General: •obesity? •thyroid? pallor? •pulse? Cachexia?
    16. 16. Abdominal and pelvicAbdominal and pelvic examinationexamination
    17. 17. Speculum examination of the cervixSpeculum examination of the cervix
    18. 18. Bimanual examinationBimanual examination
    19. 19. Cervical smearCervical smear
    20. 20. ColposcopyColposcopy
    21. 21. Ultrasound scanUltrasound scan
    22. 22. Transvaginal ultrasound (TVUSTransvaginal ultrasound (TVUS(( •Thickened (>5mm( endometrial stripe in postmenopause ALWAYS needs further evaluation.
    23. 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. 24. Saline infusion sonographySaline infusion sonography
    25. 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. 26. normal cavitynormal cavity
    27. 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. 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. 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. 30. Sampling HowSampling How??  Endometrial aspirationEndometrial aspiration  Conventional D&CConventional D&C  Hysteroscopy & directed biopsyHysteroscopy & directed biopsy
    31. 31. hysteroscopyhysteroscopy The Gold Standard-The Gold Standard- Allows Direct Visualisation Of Uterine Cavity,Allows Direct Visualisation Of Uterine Cavity,
    32. 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. 33. Endometrial hyperplasis&endometrial polypEndometrial hyperplasis&endometrial polyp
    34. 34. Endometrial polyp
    35. 35. Management of postmenopausalManagement of postmenopausal bleedingbleeding
    36. 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. 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. 38. It is according to theIt is according to the causecause::
    39. 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. 40. Endometrial PolypsEndometrial Polyps Removed by hysteroscopyRemoved by hysteroscopy
    41. 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. 42. MRI early stage cancerMRI early stage cancer
    43. 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. 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 treated as cancer.
    45. 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. 46. DefinitionDefinition Any uterine bleeding that is excessive inAny uterine bleeding that is excessive in amount ,duration or frequancyamount ,duration or frequancy
    47. 47. Characteristics of Normal MenstruationCharacteristics of Normal Menstruation
    48. 48. Regulation of NormalRegulation of Normal MenstruationMenstruation
    49. 49. How do hormones workHow do hormones work??
    50. 50. Why EP withdrawal bleeding is self limited? Why EP withdrawal bleeding is self limited?
    51. 51. 33reasonsreasons 1-It is a universal endometrial event Menstrual changes occurs simultaneously in all segments of endometriaum
    52. 52. 33reasonsreasons 2-the endometrium is structurly stable, Randome breakdown of tissue is avoided
    53. 53. 33reasonsreasons Factors involved in stopping of menses Waves of vacoconstriction Vacular stasis Endometrial collapse Clotting factors
    54. 54. 0246810121416182022242628 Hormone Level Estradiol Progesterone FSH LH Menstrual Cycle Day Ovulation Endometrial Thickness 0246810121416182022242628 Normal Menstrual Cycle
    55. 55. Hormone Level Estradiol Progesterone Endometrial Thickness 024681012141618 20 024681012141618 20Weeks Breakthrough Withdrawal Anovulatory Bleeding in PCOS Lower limit of normal
    56. 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. 57. classificationclassification OrganicOrganic –SystemicSystemic –Reproductive tract diseaseReproductive tract disease –IatrogenicIatrogenic DysfunctionalDysfunctional –OvulatoryOvulatory –AnovulatoryAnovulatory
    58. 58. Systemic EtiologiesSystemic Etiologies Coagulation defectsCoagulation defects LeukemiaLeukemia ITPITP Thyroid dysfunctionThyroid dysfunction Liver diseaseLiver disease
    59. 59. Reproductive Tract CausesReproductive Tract Causes Gestational eventsGestational events MalignanciesMalignancies BenignBenign – AtrophyAtrophy – LeiomyomaLeiomyoma – PolypsPolyps – Cervical lesionsCervical lesions – Foreign bodyForeign body – InfectionsInfections
    60. 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. 61. Iatrogenic Causes of AUBIatrogenic Causes of AUB Intra-uterine deviceIntra-uterine device Oral and injectable steroidsOral and injectable steroids Psychotropic drugsPsychotropic drugs
    62. 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. 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. 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. 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. 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. 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. 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. 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. 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. 71. hystrectomyhystrectomy
    72. 72. Other modalities of treatmentOther modalities of treatment Levonorgesterol releasing IUCD (MirenaLevonorgesterol releasing IUCD (Mirena((
    73. 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. 74. ENDOMETRIAL ABLATIONENDOMETRIAL ABLATION Uterine balloon therapyUterine balloon therapy Roller-ball endometriaalRoller-ball endometriaal ablation ustingablation usting resectoscoperesectoscope
    75. 75. Abnormal Uterine Bleeding inAbnormal Uterine Bleeding in Women of Childbearing AgeWomen of Childbearing Age
    76. 76. Abnormal postmenopausal bleeding PAbnormal postmenopausal bleeding P BleedingBleeding
    77. 77. THANK YOU