POSTMENOPAUSAL VAGINALBLEEDING PROF. M.C.Bansal. Founder Principal & Controller Jhalwar Medical College and Hospital Jhalwar. Ex . Principal& Controller Mahatma Gandhi Medical College and Hospital ., Sitapura , Jaipur.
Atrophic Vaginitis Senile Vaginitis is incorrect term . It is due to menopausla deficiency of estrogen ; resulting in thinning of vaginal epithelium (basal and 2-3 layered Para basal layer ) lacking in glycogen content hence defiance mechanism provided by lacto bacilli and acidic pH make this atrophic vaginal epithelium vulnerable for inflammation and infection by opportunistic common inhabitant bacteria . Slightest trauma even coital dabbing oneself dry may result in bleeding due to atrophic changes. P/S examination will reveal blood stained unhealthy vaginal discharge and puncted hemorrhagic spots on vaginal wall. Removal of any foreign body, local estriole vaginal cream(1%) and anti biotic cream containing soframycin / povidine and metronidazole therapy for a week will be sufficient . Oral estrogen can be given but carry the risk of endometral stimulation. Local estradiole is poorly absorbed systemically. Exclusion of neoplastic causes of RT& UT are necessary.
Atrophic Endometritis Endometrial thinning<4mm and inflammation that occurs as a result of estrogen deficiency.. Is called atrophic Endometritis. It may result in spotting or even bleeding more so in hypertensive women . This diagnosis is done after exclusion of more serious causes of postmenopausal bleeding from uterus ; being excluded by hysteroscopy and biopsy . Other extra uterine cause also need their exclusion by thorough history , local and syststemic examination and pelvic USG. Oral estrogen therapy and broad spectrum antibiotics are given with a caution of endometrial hyperplasia and other side effects of HRT.
Uterine Polyp Uterine polyps are common cause of postmenopausal bleeding .Polyps maybe endometrial , myomatous , carcinomatous or sarcomatous . TVS / saline sonohysterography and Hysteroscopy , their removal and HP Reporting is must . Blind D7C may miss its removal specially when it is pedunculated and mobile .
Endometrial Hyperplasia Hyperplasia means thickened endometrial lining >4mm in post menopausal women . HPR –classification 1. simple hyperplasia (risk of malignancy <1 %) 2. Complex Hyperplasia (3% risk of malignancy 3. Simple Hyperplasia with Atypia ( 8% risk ) 4. Complex Hyperplasia with atypia (30% of malignancy)
Endometrial Hyperplasia--- These hyperplasia without atypia; can safely treated by oral progesterone (medroxy, didrogesterone 10-30mg /day ) therapy for 3months ; followed by repeat D&c and HPR . If hyperplasia has reverted to normal , progesterone therapy is continued till next 9months ---TVs examination if needed D&c should be done in follow up at the interval of 3months . If hyperplasia persist / worsen in its grade/ atypia is present hysterectomy is the best option . In absence of H/O un opposed estrogen therapy given, endogenous source like small grannulosa cell tumor in ovary must be searched. Assessing estrogen and inhibit –A level ,TVS and palpable ovary in menopausal women will help in its detection .
Endometrial Neoplasisa. Endometrial neoplasia ; its type and grade is diagnosed by HP Reporting of endometrial tissue obtained by fractional D&c. It has to be managed according to its grading , staging done and appropriate investigations. Follow up , rehabilitation after surgery , chemo / radiotherapy is equally important.
Exogenous Intake ofEstrogen(ERT) of “ womens Health Initiative After2003 , with release “and “ Million Women Study “ results , the use of HRT has decrease significantly . Before this exogenous estrogen therapy was commonest cause of postmenopausal bleeding . Missed dose of drug and failure to follow the advised schedule for HRT resulted in increased i9ncidences of Endometrial hyperplasia and neoplasia . Tomoxifen therapy With its paradoxical estrogen like effect on endometrium can also cause bleeding episode. Such women need regular follow up by TVS , hysteroscopy and D&C (HPR ) ; incase the patient report with bleeding P/V.
Miscellaneous causes bleeding from Genital tract Intrauterine foreign body like forgotten IUCD or its broken , retained piece may cause pyometra. Cervical lesion such as infected ectropion, cervicitis, erosion, cervical polyp , post coital trauma and carcinoma may result in postmenopausal bleeding . the lesions are visible and easily identifiable on speculum examination . If there is no active bleeding Pap smear should be taken cervicoscopy to visualize cervical canal and colposcopy will also be done. Obvious infection and contact bleeding should be treated by local antibiotic creams and later followed by Colposcopy, Papsmear is to be done to exclude carcinoma situ or dysplasia.
Miscellaneous causes ------ Adnexal mass arising from ovary / tube may be benign / malignant –can also present as postmenopausal bleeding by virtue of functional ovarian tumor producing estrogen , associated with pelvic congestion and increased uterine vascularity in cases of large nonfunctional ovarian tumors. Endometrial tuberculosis is also not uncommon in this age group., in Indian subcontinent. Rarely uterine sarcoma/ mixed mullerian tumors may present with postmenopausal bleeding . Trauma to private parts– fall on sharp object , bull horn injury and offense on females may cause PMB
Systemic bleeding disorders It may be superimposed over atrophic vaginitis / endometritis. Common varieties of these disorders - Thrombocytopenia Leukaemia. Pancytopenia from immunosuppression , chemotherapy marrow suppression Anti coagulant ( iatrogenic ) therapy specially when high International normalized Ratio (INR ) is required . Secondary Coagulopathy due to liver dysfunction . High degree of suspicion is needed to diagnose these conditions as a cause of PMB.
Non Vaginal Bleeding Non vaginal bleeding often may be mistaken by women to be of vaginal origin . Surrounding structures and problems that need to be considered are from urogenital part of perineum --- Urethral carbuncle urethral prolapse Hematuria , bleeding is usually painless , noticed by women on toilet seat. Similarly rectal bleeding may also be mistaken for vaginal bleeding .
Initial Evaluation AndStabilization Assessment of blood loss In some cases the blood loss may be excessive ,rapid and possibly life threatening . Rapid restoration of blood volume ,vital parameters is followed by local examination to find out the site and source of bleeding . Tears need to be sutured. bleeding from cervical malignancy can effectively stopped by tight vaginal packing. Bleeding from uterine cavity need therapeutic D&C and quick ,bed side USG ; tissue obtained is collected in saline for HPR. Haemostatic agents like extracts of miocronised flavonoids , Tranexemic acid / anti PGs agents ---N-saids ( mefanic acid ) should be initiated.
Initial Evaluation AndStabilization---- In some circumstances when bleeding from uterus is not controlled , large doses of androgenic progestogens are needed. , intra uterine temponade may also be put in; by using foley’s catheter and blowing its balloon to appropriate volume . Uncontrolled life threatening bleeding unresponsive to the above measures ; may require uterine artery embolisation / internal artery ligation on either side. There is risk of DIC.
Initial evaluation and Stabilizatio. Acute life threatening Non life Threatening blood loss Blood loss History Initiate resuscitation General examination Ascertain source of bleeding Abd. Examination. Associated DIC, check FDC Pelvic examination Control bleeding and Rx Bimanual Examination TVS and color Doppler , SalineHysteroscopy , Biopsy Cx , D&C, HPReporting Suture tear , Vaginal packing If end –thickness < 4mm - Discharge Papsmear , colposcopy hysteroscopy. Androgenic Progestogens, Counseling Uterine Temponade, Uterine Cause of Bleeding artery embolisation , Bilateral Management Options Internal artery ligation , emergency Hysterectomy Explain Prognosis outline follow up plan
Diagnostic Approach History Go0d and detailed history will reveal details of pattern of bleeding , is it post coital or other precipitating factor present? The premenopausal menstrual history gives useful back ground information. H/o pre existing fibroids. CIN , HRT , systemic bleeding disorders , tamoxifen therapy or local estrogen cream application . It is necessary to establish whether bleedi9ng is from vagina / rectum or urethra.
Diagnostic Approach---- Examination General physical examination ; whether patient is Haemodynamically stable or not . Is it a case of acute bleeding ? Immediate resuscitation is to be started . Vircow’s Lymphadenopathy , palpable liver with irregular margin and hard nodular surface indicating distance metastasis , palpable lump in supra pubic area may be noted . Pelvic examination starts with speculum examination in good spot less bright light . A pap smear to be taken , colposcopy , cervical biopsy , office hysteroscopy , TVS and If required D7C at the same sitting will help nit only in reaching the diagnosis but help in control of bleeding .
Diagnostic Approach----- On bimanual examination uterine fibroids, adnexal mass , enlarged uterus < bulky without fibroids and adenomyosis is seldom present in menopausal woman ; indicating the possibility of existing pyometra / uterine body carcinoma . Cervical cancer is easily picked up on speculum examination , probe test and punch biopsy.
Diagnostic Approach--- Investigations 1. TVS– measure the endometrial thickness / presence of homogeneity, polyps , sub mucus fibroid , adnexal mass –provide very useful clue. 2. Saline hysterosonography --- useful when intra cavity polyps , fibroid s are suspected. Endometrial calcification indicates tuberculosis . 3. Full blood count – necessary to assess blood loss and if operative intervention is required . 4. Hysteroscopy—Intrauterine pathology is directly visualized . 5. Pap smear , colposcopy , Cx Biopsy , Fractional – curette ---tissue --- HPR
Future Management After initial assessing Patient and her relatives are counseled to alley anxiety and fear , explain about possible cause , out lining management plan , explain prognosis and help the women to take informed decision about her health . This help in long term treatment and follow ups. Those women with malignancy , it forms the basis of further treatment plan , management, support as suitable to individual woman .