This document discusses the evaluation of post-menopausal bleeding (PMB). It lists the most common and less common causes of PMB which include atrophic vaginitis, hormone replacement therapy, endometrial hyperplasia, and genital malignancy. The objectives, history, examination, and investigations are described. For investigations, non-invasive methods like ultrasound and endometrial biopsy are recommended initially. Invasive methods like hysteroscopy may be used if initial findings are abnormal. Transvaginal ultrasound can help determine if the endometrium is thickened or thin to guide further evaluation and sampling.

1. EVALUATION OF A CASE OF
POST MENOPAUSAL BLEEDING
Kabilan. S

2. CAUSES
MORE COMMON LESS COMMON
Atrophic vaginitis
HRT
Senile Endometritis
Genital malignancy
Endometrial hyperplasia
Retained IUD
Uterine polyps
Cervical polyps
TB Endometritis
Urethral caruncle
Decubitus ulcer

3. OBJECTIVES
• History
• Examination
• Laboratory investigations

4. HISTORY

5. PRESENTING COMPLAINTS
• Bleeding per vaginum
• Vaginal discharge
• Pain in lower abdomen
• Bladder irritation symptoms
• Cachexia
• Mass descending per vaginum

6. • MENSTRUAL HISTORY
• MARITAL HISTORY
• OBSTETRIC HISTORY
• PAST HISTORY
• FAMILY HISTORY
• PERSONAL HISTORY

7. EXAMINATION

8. GENERAL EXAMINATION
• Built
• Jaundice
• Lymph nodes
• Breast
• Blood pressure

9. • ABDOMEN EXAMINATION
• INSPECTION OF PERINEUM
- If uterus is outside introitus

10. - Vulval growth
- Warts
- Discharge
• PALPATION
- Check urethral meatus for any caruncle or
polyps or mucosal prolapse

11. • SPECULUM EXAMINATION
- Visible cervical growth - Biopsy
- Apparently normal - Cervical smear to exclude CIN
• BIMANUAL EXAMINATION
- Palpable adnexal mass

12. INVESTIGATIONS

13. NON INVASIVE METHODS :
• Ultrasonography (Transvaginal)
• Sonohysterography
• CT, MRI
INVASIVE METHODS :
• Endometrial Sampling
- Biopsy (Pipelle)
- Fractional curettage
• Cervical cytology
• Hysteroscopy
• Hysterosalpingography

14. ULTRASONOGRAPHY
• Transvaginal (with color Doppler)
• Endometrial thickness < 5mm – Atrophy
• Endometrial thickness > 9mm, Irregular, Fluid in uterus – Further evaluation
- Saline infusion sonography

15. ENDOMETRIAL BIOPSY
• Pipelle endometrial sampling
- Aspiration cytology

16. CERVICAL CYTOLOGY
PAP smear
Positive Negative
Colposcopy guided cervical biopsy

17. FRACTIONAL CURETTAGE
• When cervical cytology is negative
• At fundus, body and isthmus of the uterus

18. HYSTEROSCOPIC EVALUATION

19. • Hysterosalpingography to diagnose uterine polyps
• CT and MRI

20. PMB
Hx, Examination
Atrophic Vaginitis/Endometritis HRT Malignancy IUD Polyps Urethral cause
TVUS, EB, Cervical cytology
TVUS
Thick endometrium (>5mm) Thin endometrium (<4mm)
Repeat Endometrial sampling Atrophic endometritis

21. SUMMARY

22. THANK YOU