Postmenopausal bleeding

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Postmenopausal bleeding - Atrophic Vaginitis

Postmenopausal bleeding - Atrophic Vaginitis

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  • 1. Case of postmenopausalBleeding(Severe atrophic vaginitis)Dr. Shivraj Todkari 05/06/12 Dr. Shivraj Todkari 1
  • 2. History 62 year old postmenopausal widow presented with Intermittent bleeding p/v for 2 months Her obstetric career was uneventful, she had 3 normal deliveries Her husband died 10 years back due to an accident She had no history or family h/o Gynaecological malignancies. She had no history DM / HT 2 05/06/12Dr. Shivraj Todkari
  • 3. On examination She looked pale but hemodynamically stable. Pulse 86/min regular, BP was 130/80 There was no edema or icterus Her RS & CVA appeared normal. P/A exam revealed no abnormality Her breast & auxillae were normal. 3 05/06/12Dr. Shivraj Todkari
  • 4. On pelvic examination… Her external genetalia appeared atrophic. Slight bleeding was noticed coming from vagina. On P/V exam, I could pass my one finger with difficulty. Vaginal walls were edematous, inflamed, non-elastic, bled on touch. Cervix was small flushed with vagina. On bimanual exam uterus was small mobile, non tender , no adenexal mass felt. P/S exam was not possible. 4 05/06/12Dr. Shivraj Todkari
  • 5. Investigations Her Hb was 8.5 g %, BT CT was normal Blood sugar were within normal limits. Urine exam showed few pus cells. With cytobrush vaginal scrapings were sent for cytology. Cytology report showed plenty RBCs, pus cells & parabasal cells. No maligant cells were seen. 5 05/06/12Dr. Shivraj Todkari
  • 6. Diagnosis: • With these findings diagnosis of severe atrophic vaginitis was done 6 05/06/12Dr. Shivraj Todkari
  • 7. Treatment Given Oral Tab Premarin (Conjugated estrogens 0.625 mg ) 1 tds X 2 week 1 bid X 2 weeks 1 OD X 2 months Antibiotics Ofloxacin with ornidazole X 5 days Haematinics: Iron + Bplex + Calcium & vit D3 X 3 months 7 05/06/12Dr. Shivraj Todkari
  • 8. Follow-up After 2 weeks of Tab Premarin, she started showing subjective improvements, her bleeding stopped completely. On completion on three months I could pass my two fingers easily, vagina was looking more healthy & moist. Her Hb was 12.5 g % Gradually I stopped her Oral Premarin. I advised her Vaginal Estradiol tablets 25 micrograms once weekly for 3 months. She was advised to continue taking calcium + vit D3 supplements She was called for follow-up after 3 months. 8 05/06/12Dr. Shivraj Todkari
  • 9. Discussion Severe atrophic vaginitis 9 05/06/12Dr. Shivraj Todkari
  • 10. Prevalence • About 40% of postmenopausal women have symptoms related to vaginal atrophy, most of whom require treatment. • However, only about 25% of symptomatic women seek medical attention 10 05/06/12Dr. Shivraj Todkari
  • 11. Symptoms • Dryness • Pruritus • Dyspareunia • Thin discharge • Bleeding p/v • Post-coital bleeding 11 05/06/12Dr. Shivraj Todkari
  • 12. Vaginal Epithelium Four layers of vaginal wall. • Stratified squamous epithelium • Basal Layer • Smooth muscle layer • Adventatia Note that there is no muscularis mucosa. The vagina wall has no glands. 12 05/06/12Dr. Shivraj Todkari
  • 13. Vaginal Epithelium 13 05/06/12Dr. Shivraj Todkari
  • 14. Vaginal Epithelium 14 05/06/12Dr. Shivraj Todkari
  • 15. Types of Vaginal Epithelial CellsParabasal CellsIntermediate CellsSuperficial Cells 15 05/06/12Dr. Shivraj Todkari
  • 16. Pathophysiology • In the hormone-deprived state of menopause, the urogenital epithelial and subepithelial tissues undergo atrophic change. • The connective tissue components of the vaginal mucosa, including collagen, elastin, and smooth muscle, all degenerate. • Vaginal length and diameter shrink, the vaginal fornices disappear, and the rugal folds of the vagina are lost. • Blood flow to the vagina is reduced, causing decreased transudation during sexual arousal and increased tissue susceptibility to trauma 16 05/06/12Dr. Shivraj Todkari
  • 17. Pathophysiology(cont.) • Vulvar sensitivity to pressure and light touch declines. • The vaginal mucosa becomes thinner and less cellular, and glycogen production declines, decreasing the colonization of lactobacilli and thus lactic acid production. • The usual acidity of the vagina, which serves as a potent defense mechanism, is lost, leading to an overgrowth of enteric organisms • Smokers may be at higher risk. 17 05/06/12Dr. Shivraj Todkari
  • 18. Pathophysiology(cont.) Postmenopausal women need to be asked about the symptoms of urogenital aging. Many women will not spontaneously report urogenital symptoms unless directly questioned, and will therefore needlessly suffer in silence. 18 05/06/12Dr. Shivraj Todkari
  • 19. Hormone receptor • The female introitus, vagina, bladder, and urethra are all derived from the primitive urogenital sinus, so it is not surprising that these structures possess hormonal sensitivity and demonstrate hormone receptor activity. • At the introitus, estrogen and progesterone receptors have been identified and are predominantly vaginal in location,whereas the majority of androgen receptors are found in the vulva. 19 05/06/12Dr. Shivraj Todkari
  • 20. Estrogen Receptors Two types • ERα • ERβ 20 05/06/12Dr. Shivraj Todkari
  • 21. Estrogen Receptors - α The ERα is found in • Vagina, pelvic floor muscles, Lower urinary tract, endometrium & ovarian stroma • Also in breast cancer cells and hypothalamus 21 05/06/12Dr. Shivraj Todkari
  • 22. Estrogen Receptor - β The ERβ has been documented kidneys, brain, bone, heart, lungs, intestinal mucosa, endothelial cells. 22 05/06/12Dr. Shivraj Todkari
  • 23. Binding affinities for alpha and beta ERs • 17-beta- estradiol binds equally well to both receptors. • Estrone and raloxifene bind preferentially to the alpha receptor. • Estriol and genistein to the beta receptor. 23 05/06/12Dr. Shivraj Todkari
  • 24. Cytology – Vaginal Atrophy 24 05/06/12Dr. Shivraj Todkari
  • 25. Cytology – Vaginal Atrophy 25 05/06/12Dr. Shivraj Todkari
  • 26. Vaginal Maturation Index Vaginal scrapings are used to determine maturation index The maturation index determines the ratio of parabasal, intermediate, and superficial cells and gives us rough idea about status of vaginal walls. Premenopause: 0-40-60 Perimenopause: 30-40-30 Postmenopause: 75-25-0 26 05/06/12Dr. Shivraj Todkari
  • 27. Diagnosis • Pelvic examination • Cytological examination • Biopsy may be required. 27 05/06/12Dr. Shivraj Todkari
  • 28. Differntal Diagnosis •Atrophic vaginitis •Malignancies Mostly squamous cell carcinomas, rarely adenocarcinomas, Clear cell carcinoma, Malignant melanoma and sarcomas •Vaginal adenosis (women exposed to DES in utero) •Vaginal lichen planus •Vaginal candidiasis 28 05/06/12Dr. Shivraj Todkari
  • 29. Vaginal cancer Vaginal cancer is rare and accounts for only about 2% to 3% of cancers of the female reproductive system. 29 05/06/12Dr. Shivraj Todkari
  • 30. Management of Vaginal Atrophy North American Menopause society Guidelines (NAMS) 05/06/12 Dr. Shivraj Todkari 30
  • 31. Management of Vaginal Atrophy (NAMS Guidelines March 2007) The primary goals of vaginal atrophy management are to relieve symptoms and reverse atrophic anatomic changes. 31 05/06/12Dr. Shivraj Todkari
  • 32. Management of Vaginal Atrophy (NAMS Guidelines March 2007) First-line therapies for women with vaginal atrophy include nonhormonal vaginal lubricants and moisturizers. 32 05/06/12Dr. Shivraj Todkari
  • 33. Management of Vaginal Atrophy (NAMS Guidelines March 2007) For symptomatic vaginal atrophy that does not respond to nonhormonal vaginal lubricants and moisturizers, prescription therapy may be required. 33 05/06/12Dr. Shivraj Todkari
  • 34. Management of Vaginal Atrophy (NAMS Guidelines March 2007) Randomized controlled trials in postmenopausal Women have shown that low-dose, local, prescription vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy while limiting systemic absorption. 34 05/06/12Dr. Shivraj Todkari
  • 35. Management of Vaginal Atrophy (NAMS Guidelines March 2007) All low-dose vaginal estrogen products like Estradiol vaginal cream, CE vaginal cream, the estradiol vaginal ring, and the estradiol hemihydrate vaginal tablet are equally effective. The choice is dependent on clinical experience and patient preference. 35 05/06/12Dr. Shivraj Todkari
  • 36. Management of Vaginal Atrophy (NAMS Guidelines March 2007) Progestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy. 36 05/06/12Dr. Shivraj Todkari
  • 37. Management of Vaginal Atrophy (NAMS Guidelines March 2007) If a woman is at high risk for endometrial cancer, is using a greater dose of vaginal ET, or is having symptoms (spotting, breakthrough bleeding), closer surveillance may be required. There are insufficient data to recommend annual endometrial surveillance in asymptomatic women using vaginal ET. 37 05/06/12Dr. Shivraj Todkari
  • 38. Management of Vaginal Atrophy (NAMS Guidelines March 2007) Vaginal ET should be continued as long as Distressful symptoms remain. 38 05/06/12Dr. Shivraj Todkari
  • 39. Management of Vaginal Atrophy (NAMS Guidelines March 2007) For women treated for non-hormone-dependent cancer, management of vaginal atrophy is similar to that for women without a cancer history. For women with a history of hormone-dependent cancer, management recommendations are dependent upon each woman`s preference in consultation with her oncologist. 39 05/06/12Dr. Shivraj Todkari
  • 40. Management of Vaginal Atrophy (SOGC Guidelines Feb 2006) Continued regular vaginal coitus provides protection from urogenital atrophy, presumably by increasing the blood flow to the pelvic organs. Masturbation has also been shown to increase genital blood flow in menopausal women and may help maintain urogenital health. 40 05/06/12Dr. Shivraj Todkari
  • 41. Thanks! 41 05/06/12Dr. Shivraj Todkari